THE NERVOUS CHILD
PUBLISHED BY THE JOINT COMMITTEE OF
HENRY FROWDE, HODDER & STOUGHTON
17 WARWICK SQUARE, LONDON, E.C. 4
THE
NERVOUS CHILD
BY
HECTOR CHARLES CAMERON
M.A., M.D.(CANTAB.), F.R.C.P.(LOND.)
PHYSICIAN TO GUY'S HOSPITAL AND PHYSICIAN IN CHARGE OF
THE CHILDREN'S DEPARTMENT, GUY'S HOSPITAL
"RESPECT the child. Be not too much his parent. Trespass not on
his solitude."--EMERSON.
LONDON
HENRY FROWDE HODDER & STOUGHTON
OXFORD UNIVERSITY PRESS WARWICK SQUARE, E.C.
1920
_First Edition_ 1919
_Second Impression_ 1930
PRINTED IN GREAT BRITAIN
BY MORRISON & GIBB LTD., EDINBURGH
PREFACE
To-day on all sides we hear of the extreme importance of Preventive
Medicine and the great future which lies before us in this aspect of
our work. If so, it follows that the study of infancy and childhood
must rise into corresponding prominence. More and more a considerable
part of the Profession must busy itself in nurseries and in schools,
seeking to apply there the teachings of Psychology, Physiology,
Heredity, and Hygiene. To work of this kind, in some of its aspects,
this book may serve as an introduction. It deals with the influences
which mould the mentality of the child and shape his conduct. Extreme
susceptibility to these influences is the mark of the nervous child.
I have to thank the Editors of _The Practitioner_ and of _The Child_,
respectively, for permission to reprint the chapters which deal with
"Enuresis" and "The Nervous Child in Sickness." To Dr. F.H. Dodd I
should also like to offer thanks for helpful suggestions.
H.C.C.
_March_ 1919.
CONTENTS
CHAP. PAGE
I. DOCTORS, MOTHERS, AND CHILDREN 1
II. OBSERVATIONS IN THE NURSERY 16
III. WANT OF APPETITE AND INDIGESTION 50
IV. WANT OF SLEEP 64
V. SOME OTHER SIGNS OF NERVOUSNESS 73
VI. ENURESIS 89
VII. TOYS, BOOKS, AND AMUSEMENTS 96
VIII. NERVOUSNESS IN EARLY INFANCY 104
IX. MANAGEMENT IN LATER CHILDHOOD 117
X. NERVOUSNESS IN OLDER CHILDREN 131
XI. NERVOUSNESS AND PHYSIQUE 145
XII. THE NERVOUS CHILD IN SICKNESS 160
XIII. NERVOUS CHILDREN AND EDUCATION ON SEXUAL MATTERS 169
XIV. THE NERVOUS CHILD AND SCHOOL 182
INDEX 191
THE NERVOUS CHILD
CHAPTER I
DOCTORS, MOTHERS, AND CHILDREN
There is an old fairy story concerning a pea which a princess once
slept upon--a little offending pea, a minute disturbance, a trifling
departure from the normal which grew to the proportions of intolerable
suffering because of the too sensitive and undisciplined nervous
system of Her Royal Highness. The story, I think, does not tell us
much else concerning the princess. It does not tell us, for instance,
if she was an only child, the sole preoccupation of her parents and
nurses, surrounded by the most anxious care, reared with some
difficulty because of her extraordinary "delicacy," suffering from a
variety of illnesses which somehow always seemed to puzzle the
doctors, though some of the symptoms--the vomiting, for example, and
the high temperature--were very severe and persistent. Nor does it
tell us if later in life, but before the suffering from the pea arose,
she had been taken to consult two famous doctors, one of whom had
removed the vermiform appendix, while the other a little later had
performed an operation for "adhesions." At any rate, the story with
these later additions, which are at least in keeping with what we know
of her history, would serve to indicate the importance which attaches
to the early training of childhood. Among the children even of the
well-to-do often enough the hygiene of the mind is overlooked, and
faulty management produces restlessness, instability, and
hyper-sensitiveness, which pass insensibly into neuropathy in adult
life.
To prevent so distressing a result is our aim in the training of
children. No doubt the matter concerns in the first place parents and
nurses, school masters and mistresses, as well as medical men. Yet
because of the certainty that physical disturbances of one sort or
another will follow upon nervous unrest, it will seldom happen that
medical advice will not be sought sooner or later; and if the
physician is to intervene with success, he must be prepared with
knowledge of many sorts. He must be prepared to make a thorough and
complete physical examination, sufficient to exclude the presence of
organic disease. If no organic disease is found, he must explore the
whole environment of the child, and seek to determine whether the
exciting cause is to be found in the reaction of the child to some
form of faulty management.
For example, a child of two or three years of age may be brought to
the doctor with the complaint that defæcation is painful, and that
there has existed for some time a most distressing constipation which
has resisted a large number of purgatives of increasing strength.
Whenever the child is placed upon the stool, his crying at once
begins, and no attempts to soothe or console him have been successful.
It is not sufficient for the doctor in such a case to make an
examination which convinces him that there is no fissure at the anus
and no fistula or thrombosed pile, and to confine himself to saying
that he can find nothing the matter. The crying and refusal to go to
stool will continue after the visit as before, and the mother will be
apt to conclude that her doctor, though she has the greatest
confidence in him for the ailments of grown-up persons, is unskilled
in, or at least not interested in, the diseases of little children.
If, on the other hand, the doctor pursues his inquiries into the
management of the child in the home, and if, for example, he finds
that the crying and resistance is not confined to going to stool, but
also takes place when the child is put to bed, and very often at
meal-times as well, then it will be safe for him to conclude that all
the symptoms are due to the same cause--a sort of "negativism" which
is apt to appear in all children who are directed and urged too much,
and whose parents are not careful to hide from them the anxiety and
distress which their conduct occasions.
If this diagnosis is made, then a full and clear explanation should be
given to the mother, or at any rate to such mothers--and fortunately
they are in the majority--who are capable of appreciating the point of
psychology involved, and of correcting the management of the child so
as to overcome the negativism. To attempt treatment by prescribing
drugs, or in any other way than by correcting the faulty management,
is to court failure. As Charcot has said, in functional disorders it
is not so much the prescription which matters as the prescriber.
But the task of the doctor is often one of even greater difficulty.
Often enough there will be a combination of organic disturbance with
functional trouble. For example, a girl of eighteen years old suffered
from a pain in the left arm which has persisted on and off since the
olecranon had been fractured when she was two years of age. She was
the youngest of a large family, and had never been separated for a day
from the care and apprehensions of her mother. The joint was stiff,
and there was considerable deformity. The pain always increased when
she was tired or unhappy. Again, a girl had some slight cystitis with
frequent micturition, and this passed by slow degrees into a purely
functional irritability of the bladder, which called for micturition
at frequent intervals both by day and night. In such cases treatment
must endeavour to control both factors--the local organic disturbance
must if possible be removed, and the faults of management corrected.
It is a good physician who can appreciate and estimate accurately the
temperament of his patient, and the need for this insight is nowhere
greater than in dealing with the disorders of childhood. It can be
acquired only by long practice and familiarity with children. In the
hospital wards we shall learn much that is essential, but we shall not
learn this. The child, who is so sensitive to his environment, shows
but little that is characteristic when admitted to an institution.
Only in the nursery can we learn to estimate the influences which
proceed from parents and nurses of different characters and
temperaments, and the reaction which is produced by them in the child.
The body of the child is moulded and shaped by the environment in
which it grows. Pure air, a rational diet, free movement, give
strength and symmetry to every part. Faults of hygiene debase the
type, although the type is determined by heredity which in the
individual is beyond our control. Mothers and nurses to-day are well
aware of the need for a rational hygiene. Mother-craft is studied
zealously and with success, and there is no lack of books to give
sound guidance and to show the mean between the dangerous extremes of
coddling and a too Spartan exposure. Yet sometimes it has seemed as if
some mothers whose care for their children's physical health is most
painstaking, who have nothing to learn on the question of diet, of
exercise, of fresh air, or of baths, who measure and weigh and record
with great minuteness, have had their attention so wholly occupied
with the care of the body that they do not appreciate the simultaneous
growth of the mind, or inquire after its welfare. Yet it is the
astounding rapidity with which the mental processes develop that forms
the distinguishing characteristic of the infancy of man. Were it not
for this rapid growth of the cerebral functions, the rearing of
children would be a matter almost as simple and uneventful as the
rearing of live stock. For most animals faults of environment must be
very pronounced to do harm by producing mental unrest and
irritability. Thus, indeed, some wild animal separated from its
fellows and kept in solitary captivity may sicken and waste, though
maintained and fed with every care. Yet if the whole conditions of
life for the animal are not profoundly altered, if the environment is
natural or approximately natural, it is as a rule necessary to care
only for its physical needs, and we need not fear that the results
will be spoiled by the reaction of the mind upon the body. But with
the child it is different; airy nurseries, big gardens, visits to the
seaside, and every advantage that money can buy cannot achieve success
if the child's mind is not at rest, if his sleep is broken, if food is
habitually refused or vomited, or if to leave him alone in the nursery
for a moment is to evoke a fit of passionate crying.
The grown-up person comes eventually to be able to control this
tremendous organ, this brain, which is the predominant feature of his
race. In the child its functions are always unstable and liable to be
upset. Evidence of mental unrest or fatigue, which is only rarely met
with in grown persons and which then betokens serious disturbance of
the mind, is of comparatively common occurrence in little children.
Habit spasm, bed-wetting, sleep-walking, night terrors, and
convulsions are symptoms which are frequent enough in children, and
there is no need to be unduly alarmed at their occurrence. In adult
age they are found only among persons who must be considered as
neuropathic. To make the point clear, I have chosen examples from the
graver and more serious symptoms of nervous unrest. But it is equally
true that minor symptoms which in adults are universally recognised to
be dependent upon cerebral unrest or fatigue are of everyday
occurrence in childhood. Broken and disturbed sleep, absence of
appetite and persistent refusal of food, gastric pain and discomfort
after meals, nervous vomiting, morbid flushing and blushing, headache,
irritability and excessive emotional display, at whatever age they
occur, are indications of a mind that is not at rest. In children, as
in adults, they may be prominent although the physical surroundings of
the patient may be all that could be desired and all that wealth can
procure. It is an everyday experience that business worries and
responsibilities in men, domestic anxieties or childlessness in women,
have the power to ruin health, even in those who habitually or grossly
break none of its laws. The unstable mind of the child is so sensitive
that cerebral fatigue and irritability are produced by causes which
seem to us extraordinarily trivial. In the little life which the child
leads, a life in which the whole seems to us to be comprised in
dressing and undressing, washing, walking, eating, sleeping, and
playing, it is not easy to detect where the elements of nervous
overstrain lie. Nor is it as a rule in these things that the mischief
is to be found. It is in the personality of mother or nurse, in her
conduct to the child, in her actions and words, in the tone of her
voice when she addresses him, even in the thoughts which pass through
her mind and which show themselves plainly to that marvellously acute
intuition of his, which divines what she has not spoken, that we must
seek for the disturbing element. The mental environment of the child
is created by the mother or the nurse. That is her responsibility and
her opportunity. The conduct of the child must be the criterion of her
success. If things go wrong, if there is constant crying or
ungovernable temper, if sleep and food are persistently refused, or if
there is undue timidity and tearfulness, there is danger that seeds
may be sown from which nervous disorders will spring in the future.
There are many women who, without any deep thought on the matter, have
the inborn knack of managing children, who seem to understand them,
and have a feeling for them. With them, we say, the children are
always good, and they are good because the element of nervous
overstrain has not arisen. There are other women, often very fond of
children, who are conspicuously lacking in this power. Contact with
one of these well-meaning persons, even for a few days, will
demoralise a whole nursery. Tempers grow wild and unruly, sleep
disappears, fretfulness and irritability take its place. Yet of most
mothers it is probably true that they are neither strikingly
proficient nor utterly deficient in the power of managing children. If
they lack the gift that comes naturally to some women, they learn from
experience and grow instinctively to feel when they have made a false
step with the child. Although by dearly bought experience they learn
wisdom in the management of their children, they nevertheless may not
study the subject with the same care which they devote to matters of
diet and hygiene. It is the mother whose education and understanding
best fits her for this task. In this country a separate nursery and a
separate nursery life for the children is found in nearly all
households among the well-to-do, and the care for the physical needs
of the children is largely taken off the mothers' shoulders by nurses
and nursemaids. That this arrangement is advantageous on the whole
cannot be doubted. In America and on the Continent, where the children
often mingle all day in the general life of the household, and occupy
the ordinary living rooms, experience shows that nerve strain and its
attendant evils are more common than with us. Nevertheless, the
arrangement of a separate nursery has its disadvantages. Nurses are
sometimes not sufficiently educated to have much appreciation of the
mental processes of the child. If the children are restless and
nervous they are content to attribute this to naughtiness or to
constipation, or to some other physical ailment. Their time is usually
so fully occupied that they cannot be expected to be very zealous in
reading books on the management of children. Nevertheless, in
practical matters of detail a good nurse will learn rapidly from a
mother who has given some attention to the subject, and who is able to
give explicit instructions upon definite points.
It is right that mothers should appreciate the important part which
the environment plays in all the mental processes of children, and in
their physical condition as well; that they should understand that
good temper and happiness mean a proper environment, and that constant
crying and fretfulness, broken sleep, refusal of food, vomiting, undue
thinness, and extreme timidity often indicate that something in this
direction is at fault.
Nevertheless, we must be careful not to overstate our case. We must
remember how great is the diversity of temperament in children--a
diversity which is produced purely by hereditary factors. The task of
all mothers is by no means of equal difficulty. There are children in
whom quite gross faults in training produce but little permanent
damage; there are others of so sensitive a nervous organisation that
their environment requires the most delicate adjustment, and when
matters have gone wrong, it may be very difficult to restore health of
mind and body. When a peculiarly nervous temperament is inherited,
wisdom in the management of the child is essential, and may sometimes
achieve the happiest results. Heredity is so powerful a factor in the
development of the nervous organisation of the child that, realising
its importance, we should be sparing in our criticism of the results
which the mothers who consult us achieve in the training of their
children. A sensitive, nervous organisation is often the mark of
intellectual possibilities above the average, and the children who are
cast outside the ordinary mould, who are the most wayward, the most
intractable, who react to trifling faults of management with the most
striking symptoms of disturbance, are often those with the greatest
potentialities for achievement and for good. It is natural for the
mother of placid, contented, and perhaps rather unenterprising
children, looking on as a detached outsider, seeing nothing of the
teeming activities of the quick, restless little brain, and the
persistent, though faulty reasoning--it is natural for her to blame
another's work, and to flatter herself that her own routine would have
avoided all these troublesome complications. The mother of the nervous
child may often rightly take comfort in the thought that her child is
worth the extra trouble and the extra care which he demands, because
he is sent into the world with mechanism which, just because it is
more powerful than the common run, is more difficult to master and
takes longer to control and to apply for useful ends.
It is through the mother, and by means of her alone, that the doctor
can influence the conduct of the child. Without her co-operation, or
if she fails to appreciate the whole situation, with the best will in
the world, we are powerless to help. Fortunately with the majority of
educated mothers there is no difficulty. Their powers of observation
in all matters concerning their children are usually very great. It is
their interpretation of what they have observed that is often faulty.
Thus, in the example given above, the mother observes correctly that
defæcation is inhibited, and produces crying and resistance. It is
her interpretation that the cause is to be found in pain that is at
fault. Again, a mother may bring her infant for tongue-tie. She has
observed correctly that the child is unable to sustain the suction
necessary for efficient lactation, and has hit upon this fanciful and
traditional explanation. The doctor, who knows that the tongue takes
no part in the act of sucking, will probably be able to demonstrate
that the failure to suck is due to nasal obstruction, and that the
child is forced to let go the nipple because respiration is impeded.
The opportunities for close observation of the child which mothers
enjoy are so great that we shall not often be justified in
disregarding their statements. But if we are able to give the true
explanation of the symptoms, it will seldom happen that the mother
will fail to be convinced, because the explanation, if true, will fit
accurately with all that has been observed. Thus the mother of the
child in whom defæcation is inhibited by negativism may have made
further observations. For example, she may have noted that the
so-called constipation causes fretfulness, that it is almost always
benefited by a visit to the country or seaside, or that it has become
much worse since a new nurse, who is much distressed by it, has taken
over the management of the child. To this mother the explanation must
be extended to fit these observations, of the accuracy of which there
need be no doubt. Fretfulness and negativism with all children whose
management is at fault come in waves and cycles. The child, naughty
and almost unmanageable one week, may behave as a model of propriety
the next. The negativism and refusal to go to stool are the outcome of
the nervous unrest, not its cause. Again, the nervous child, like the
adult neuropath, very often improves for the time being with every
change of scene and surroundings. It is the _ennui_ and monotony of
daily existence, in contact with the same restricted circle, that
becomes insupportable and brings into prominence the lack of moral
discipline, the fretfulness, and spirit of opposition. Lastly, the
conduct of the nervous child is determined to a great extent by
suggestions derived from the grown-up people around him. Refusal of
food, refusal of sleep, refusal to go to stool, as we shall see later,
only become frequent or habitual when the child's conduct visibly
distresses the nurse or mother, and when the child fully appreciates
the stir which he is creating. The mother will readily understand that
in such a case, where constipation varies in degree according as
different persons take charge of the child, the explanation offered is
that which alone fits with the observed facts. A full and free
discussion between mother and doctor, repeated it may be more than
once, may be necessary before the truth is arrived at, and a line of
action decided upon. Only so can the doctor, remote as he is from the
environment of the child, intervene to mould its nature and shape its
conduct.
If the doctor is to fit himself to give advice of this sort, he must
be a close observer of little children. He must not consider it
beneath his dignity to study nursery life and nursery ways. There he
will find the very beginnings of things, the growing point, as it
were, of all neuropathy. A man of fifty, who in many other ways showed
evidence of a highly nervous temperament, had especially one
well-marked phobia, the fear of falling downstairs. It had never been
absent all his life, and he had grown used to making the descent of
the stairs clinging firmly to the stair-rail. Family tradition
assigned this infirmity to a fall downstairs in early childhood. But
all children fall downstairs and are none the worse. The persistence
of the fear was due, I make no doubt, to the attitude of the parents
or nurse, who made much of the accident, impressed the occasion
strongly on the child's memory, and surrounded him thereafter with
precautions which sapped his confidence and fanned his fears.
In what follows we will consider first the subject of nursery
management, searching in it for the origin of the common disorders of
conduct both of childhood and of later life. I have grouped these
nursery observations under the heads of four characteristic features
of the child's psychology--his Imitativeness, his Suggestibility, his
Love of Power, and his acute though limited Reasoning Faculties. I
feel that some such brief examination is necessary if we are to
understand correctly the ætiology of some of the most troublesome
disorders of childhood, such as enuresis, anorexia, dyspepsia, or
constipation, disorders in which the nervous element is perhaps to-day
not sufficiently emphasised. Finally, we can evolve a kind of nursery
psycho-therapeutics--a subject which is not only of fascinating
interest in itself, but which repays consideration by the success
which it brings to our efforts to cure and control.