The Mother's Manual of Children's Diseases

APPENDIX
ON THE MENTAL AND MORAL FACULTIES IN CHILDHOOD, AND ON THE DISORDERS TO WHICH THEY ARE LIABLE

Any remarks on the ailments of children would be incomplete if no notice were taken of the mental and moral peculiarities of early life.

For want of giving heed to them, not only are grave mistakes made in the education of children, but in the management of their ailments, both by doctors and by parents: much needless trouble is given to the doctors, much needless distress to the child, much needless anxiety to the parents.

The common mistake committed by those parents who do not make their child an idol to fall down and worship, and thus turn him, to his own misery and theirs, into the most arbitrary of domestic tyrants, is to treat him as though he were in mind, as well as in body, a miniature man; feebler in intellect as he is inferior in strength, but differing in degree only, not in kind.

Now the child differs essentially from the adult in the three respects; that

1. He lives in the present, not in the future.

2. His perceptions are more vivid, and his sensibilities more acute; while the world, on which he has just entered, surrounds him with daily novelties.

3. He has less self-consciousness, less self-dependence, lives as a part of the world by which he is surrounded—a real practical pantheist.

The child lives in the present, not in the future, nor much even in the past, till the world has been some time with him, and he by degrees shares the common heritage of retrospect and anticipation. This is the great secret of the quiet happiness which strikes almost all visitors to a children's hospital.

No one can have watched the sick bed of the child without remarking the almost unvarying patience with which its illness is borne, and the extremity of peril from which apparently, in consequence of that patience, a complete recovery takes place. Much, indeed, is no doubt due to the activity of the reparative powers in early life, but much also to the unruffled quiet of the mind. No sorrow for the past, no gloomy foreboding of the future, no remorse, disappointment, nor anxiety depresses the spirits and enfeebles the vital powers. The prospect of death, even when its approach is realised—and this is not so rare as some may imagine—brings in general but small alarm. This may be from the vagueness of the child's ideas; it may be, as the poet says, that in his short life's journey, 'the heaven that lies about us in our infancy' has been so much with him, that he recognises more clearly than we can do

 
'The glories he hath known,
And that imperial palace whence he came.'
 

I dwell on this truth, because it is of great practical moment that we should bear in mind to how very large an extent the child lives only in the present; because it follows from it that to keep the sick child happy; to remove from it all avoidable causes of alarm, of suffering, of discomfort; to avoid, as far as may be, any direct struggle with its waywardness; and even if death seems likely to occur, to look at it from a child's point of view—not from that which our larger understanding of good and evil suggests to our minds—are duties of the gravest kind which weigh on the parent and the nurse, no less than on the physician.

But not only does the child live in the present far more than it is possible for the adult, but there are, besides, other important mental differences between the two. Not only is the mind of the child feebler in all respects than that of the adult, but, in proportion to the feebleness of his reasoning power, there is an exaggerated activity of his perceptive faculties, a vividness of his imagination. The child lives at first in the external world, as if it were a part of himself, or he a part of it, and the gladheartedness which it rejoices us to see is as much a result of the vividness with which he realises the things around him, as of that absence of care to which it is often attributed. This peculiarity shows itself in the dreams of childhood, which exceed in the distinctness of their images those which come in later life. It shows itself, too, in the frequency with which, even when awake, the active organs perceive unreal sounds, or in the dark, at night, conjure up ocular spectra; and then not merely colours, but distinct shapes, which pass in long procession before the eyes. This power fades away with advancing life; except under some conditions of disease, the occasional appearance of luminous objects in the dark is the only relic with most of us of the gift of seeing visions with which, at least in some degree, we were endowed in our early years. The child who dreads to be alone, and asserts that he hears sounds, or perceives objects, is not expressing merely a vague apprehension of some unknown danger, but often asserts a literal truth. The sounds have been heard; in the stillness of its nursery the little one has listened to what seemed a voice calling it; or, in the dark, phantasms have risen before its eyes, and the agony of terror with which it calls for a light, or begs for its mother's presence, betrays an impression far too real to be explained away, or to be met by hard words or by unkind treatment.

Impressions such as these are not uncommon in childhood, even during health. Disorder, direct or indirect, of the functions of the brain, more commonly the latter, greatly exaggerates them, and I have known them to outlast for many weeks all other signs of failing health after convalescence from fevers. The unreal sights are far more common than the sounds. The sounds are usually of the simplest kind—as the tinkling of a bell, of which we all remember the exquisite use made by Hans Andersen in one of his nursery tales; or the child's own name, at intervals repeated, just as the little watchful boy heard it in far off Judæa, when it was the prelude to a wondrous communication from the unseen world. It came to him as he woke from sleep, before the morning dawned, while the lamp, lighted overnight, was burning still; and still it is so far the same that these occurrences which suggest to us problems that we cannot attempt to solve, mostly take place at times of transition from the sleeping to the waking state.

The ocular spectra are usually far more vivid and detailed. Those which occur in the waking state are by no means always painful, though their strangeness not infrequently alarms the child, and his horror at the dark arises, not from his seeing nothing, but from his seeing too much.

Some imaginative children amuse themselves with these phantasms, and then, if encouraged to relate them, will constantly transgress the boundary line between truth and falsehood, and weave their little romance. When they happen on waking they are usually preceded by frightful dreams, but the image which the child sees then is not the mere recollection of the dream, but a new, distinct, though painful impression; generally of some animal to which the child points, as now here, now there. These night terrors from the very circumstantial character of the impressions which attend them, often, as I have already said, occasion needless anxiety as to the importance of the cause on which they depend.

Sleep-walking in its smaller degrees of getting out of bed at night, is by no means unusual in childhood; but the greater degrees of somnambulism are certainly rare; and I have always found them dependent on undue mental work; not always, indeed, on the tasks being excessive, but sometimes on the over-anxiety of the child to make progress. I have not yet known a poor person's child a somnambulist.

But not only are the perceptions more acute in childhood than in adult life, the sensibilities are more intense. The child's emotions, indeed, are often transitory—generally very transitory; but while they last they produce results far greater than in the grown person. In the case of the latter, recollection of the past, anticipation of the future, or even the duties of the present, control the overwhelming sorrow, or call forth the energies needed to bear it. The child lives in the present, and this present is but the reflection of the world around, its impressions uncontrolled by experience, ungoverned by reason.

The broken-heartedness of a child on leaving home is not the expression only of intense affection for its friends or relations, it is the shock of separation from the familiar objects which have surrounded it; and I have not infrequently seen children inconsolable when removed from homes that were most wretched, or from relations who were most unkind. Every now and then, indeed, I have been compelled to send children home from the hospital because no love nor care could reconcile them to the change from home; and they have refused to eat, and spent their nights in weeping. The feeling is an unreasoning one, like the home-sickness of the mountaineer.

But, moreover, sudden shocks may sometimes overthrow the whole moral equilibrium, and disarrange the balance of the nervous system so seriously as to cause the death of a child previously free from any important ailment. Thus, I remember a little boy five years of age who died sixteen days after his father's funeral. The strange sad scene overcame him, though there had been no special tie between him and his father. He shivered violently, became very sick, complained by signs of pain in the head, for he had lost his speech, which he regained by slow degrees in the course of four or five days. Improvement in other respects did not take place, he lay in a drowsy state save when he called for his mother, and at length the drowsiness deepened into stupor, and so he died. I suppose his mother was right; she said his heart was broken.

It behoves us to bear in mind that the heart may break, or the reason fail, under causes that seem to us quite insufficient; that the griefs of childhood may be, in proportion to the child's powers of bearing them, as overwhelming as those which break the strong man down. Every now and then we are shocked by the tale that some young child has committed suicide, and for reasons which to our judgment seem most trivial—from fear of punishment, or even from mere dread of reproof. These facts deserve special attention, they show how much more the susceptibility and sensitiveness of children need to be taken into consideration than is commonly done.

This keenness of the emotions in children displays itself in other ways, and has constantly to be borne in mind in our management of them. The child loves intensely, or dislikes strongly; craves most earnestly for sympathy, clings most tenaciously to the stronger, better, higher around it, or to what it fancies so; or shrinks, in often causeless but unconquerable dread, from things or persons that have made on it an unpleasant impression. Reason as yet does not govern its caprices, nor the more intelligent selfishness of later years hinder their manifestation. The waywardness of the most wilful child is determined by some cause near at hand; and those who love children, and can read their thoughts, will not in general be long in discovering their motives and seeing through their conduct.

One word more must be said with reference to that intense craving for sympathy so characteristic of the child. It is this which often underlies the disposition to exaggerate its ailments, or even to feign such as do not exist, and in such attempts at deception it often perseveres with almost incredible resolution. Over and over again I have met with instances where the motives to such deception were neither the increase of comfort nor the gratification of mere indolence; but the monopolising the love and sympathy which during some bygone illness had been extended to it, and which it could not bear to share again with its brothers and sisters. This feeling, too, sometimes becomes quite uncontrollable, and the child then needs as much care and as judicious management, both bodily and mental, to bring it back to health, as would be called for in the case of some adult hypochondriac or monomaniac.

A caution may not be out of place as to the importance of not ministering to this tendency to exaggerated self-consciousness by talking of children's ailments in their hearing, or by seeming to notice the complaints they make as though they were something out of the common way.

It will be observed that throughout I have dwelt more on disorders of the moral faculties than of the intellectual powers in childhood, and I have done so because I believe them to be the more common and the more important. In the feeble-minded the moral sense almost invariably participates in the weakness of the intellect; but it is by no means unusual for the former to be grievously perverted, while the intelligence is in no respect deficient. The moral element in the child seems to me to assert its superiority in this, that it is the most keenly sensitive, the soonest disordered—

 
'Like sweet bells jangled, out of tune, and harsh,'
 

and the discord is first perceived in the finest notes.

To a very great extent, a mixture of vanity and of a morbid craving for sympathy lie at the root of many of those perversions of character which excite a parent's anxiety. One of these consists in an over-scrupulousness with reference to the right or wrong of actions in themselves quite indifferent; in doubts as to whether the morning or evening prayer has been properly said, whether something was or was not absolutely true, whether this or that peccadillo was a grievous offence against God, and so on; and all these little cases of conscience are brought by the child several times a day to his mother or to his nurse for solution. If listened to readily the child's truthfulness becomes inevitably destroyed, and he grows up with a morbid frame of mind, which after-life will aggravate almost infinitely.

One knows indeed the history of child saints; but it must be remembered that one great characteristic of pre-eminent sanctity at all ages of life is reticence, while these little people are perpetually seeking to interest others in themselves, their doubts, and feelings. If wisely dealt with, not by direct ridicule, but by a wholesome neglect of the child's revelations, treating them as of no special interest or importance, and discouraging that minute introspection which, of doubtful good at any age, is absolutely destructive of the simplicity of childhood, this unnatural condition will soon pass away. It will help this object very much, if the child is sent on a visit to judicious friends, and change of scene, of pursuits, of playmates, and amusements will be of all the more service since these morbid states of mind seldom come on in children whose bodily health is robust.

Another mode in which the same perverted feelings display themselves is in the disposition occasionally noticed to exaggerate some real ailment, or to complain of some ailment which is altogether imaginary. So far is this from being rare that my experience coincides entirely with that of the French physician M. Roger, who has had larger opportunities than anyone else in France for observing the diseases of children, and who says, 'It must be borne in mind that simulated ailments are much more common in the children's hospital than in a hospital for adults.'

It is difficult to assign any sufficient reason for this conduct. Mere indolence seems sometimes to be the chief reason for it, oftener vanity; the sense of importance in finding everything in the household arranged with exclusive reference to itself appears to be the motive for it; and this may sometimes be observed to be very powerful even at an exceedingly early age. In many instances a morbid craving for sympathy is mingled with the love of importance, and both these sentiments are not infrequently exaggerated by the conduct of a foolishly fond mother. Real illness, however, in almost all these cases exists at the commencement, though the child persists in complaining of its old symptoms long after their cause has disappeared.

The great difficulty which the doctor meets with in the management of these cases arises from the incredulity with which his opinion is received. Candour is looked upon as so eminently characteristic of childhood, that deceit seems impossible; the case is thought by the parents to be an obscure one which the doctor does not understand; and therefore it is said, he, with want of straightforwardness and of kindness, throws doubts on the existence of disease, and on the truthfulness of a most loving, most suffering child. The vagaries of a hysterical girl, the fits, the palsy, the half-unconsciousness have all been assumed within my own observation by children from ten to fifteen years old, and I have more than once had to give place to the ignorant and impudent pretender who traded successfully on the feelings of the parents. Sometimes, one knows not why, except that the child has got tired of the part he was playing, the symptoms that had caused so much anxiety suddenly disappear, but even then the habit of mind left behind is anything but healthy. Indeed in all cases of this kind it is much less the state of the body than that of the mind which excites my apprehension. The constant watching its own sensations, the habit of constantly gratifying every wayward wish and temper under the plea of illness, and the constant indulgence which it too often meets with in this from the over-kindness of its parents, exert a most injurious influence on its character, and it grows up a juvenile hypochondriac.

A doctor is very unlikely to throw doubt recklessly on the reality of a child's illness. His hesitation should certainly not be attributed to unworthy motives; the parents should co-operate with him heartily in any course of observation which he desires to follow, and if necessary another medical man of experience should be associated with the first, and allowed to visit the child two or three times. One does not associate the idea of moral delinquency with hysteria; the child who shams belongs to the same class with the hysterical patient. It is only the strangeness of the occurrence in the eyes of non-medical people, that makes them fancy it something worse.

If now the suspicion is justified that the child is either greatly exaggerating or altogether feigning illness, it does not by any means always follow that he should at once be charged with it, since it is often of much importance that his self-respect should not be destroyed. It must be remembered that there is in all these cases a measure of real ailment underlying all the half-unconscious exaggeration, and that if spoiling and over-indulgence do much to foster it, sternness and punishment interfere with recovery. To turn the thoughts away from self, to occupy the mind with new scenes, new amusements, new pursuits, to call forth by degrees self-control, and to let the child perceive rather by your manner than by what is actually said that the parents have not been duped by all his past vagaries; such are the simple means by which the little one will be brought round again to health of mind and health of body. Unhappily, in the minds of too many people the idea of the doctor is associated with the administration of drugs and with nothing else; the treatment of disease is of much wider scope; and many of our best remedies are those which do not admit of being weighed or measured, and whose names are not inscribed on the drawers or bottles in Apothecaries' Hall.

Another phase of mental disorder in childhood sometimes presents itself as the result of overtasking the intellectual powers. This over-work too is by no means due in all cases to the parents' unwisely urging the child forward, but it is often quite voluntary on his part. The precaution too of limiting the hours of work is often inadequate from the want of some provision for turning the thoughts and energies during play hours into some perfectly different channel.

In many of these cases Nature happily takes matters into her own management. For a year or two, or more, the mind has grown apparently at the expense of the body; the parents take a fearful joy in their darling's acquirements; and if it should live, think they, of what remarkable talents will it not be the possessor! By degrees, the extreme quickness of intellect becomes less remarkable; but the body begins to increase in robustness; and a year will sometimes suffice to transmute the little fairy, so quick, so clever, but so fragile, into a very commonplace, merry, rosy, romping child. I may add that it is well to bear in mind the converse of this; to remember that body and mind rarely grow in equal proportion at one time; that the incorrigible little dunce, though not likely to prove a genius as he grows older, will yet very probably be found at twelve or fourteen to know as much as his playmates. A dull mind, and a sickly or ill-developed frame may make us anxious: but if the physical development is good, the mind will not be likely to remain long below the average standard.

But sometimes, the over-tasked mind leads to mischief which Nature cannot rectify; an attack of water on the brain destroys the child, or if not it sinks under almost any accidental disease. In other instances neither of these results takes place, but the whole nervous system seems profoundly shaken, and the moral character of the child seriously, and even permanently injured. I remember a quick and clever little girl aged five and a half years who was urged on by her governess to work which she delighted in, till at length the signs of over-taxed brain showed themselves in frequent extreme irritability, and occasional attacks of causeless fury amounting almost to madness. It was fully a year during which almost all mental work was suspended, while the child was sent to have complete change under most judicious management in the country, before her mind quite recovered its balance and she became able to resume her studies in a very moderate degree.

Cases such as this are instances of the slightest degree of a condition which if not remedied may pass into confirmed insanity. I believe the gradations to be almost imperceptible by which the one state passes into the other; and I have known instances in which the ungovernable temper and occasional fury of the child have passed in youth into abiding insanity which rendered the patient the inmate, and I fear the permanent inmate, of a lunatic asylum.

In whatever circumstances insanity comes on in childhood, and it does sometimes, though very seldom, come on independently of any obvious exciting cause, it always assumes the character of what has been termed moral insanity, or of that condition in which the moral system rather than the mental power is chiefly disordered.

Idiocy is unquestionably of much more frequent occurrence in childhood, than any of those forms of mental or moral disorder of which I have been speaking hitherto. The term idiocy, however, is a very wide one, including conditions differing remarkably from each other both in kind and degree, while not seldom it is misapplied to cases in which there is mere backwardness of intellectual power.

Backward Children.—Enfants arriérés—as the French call them—constitute a class by no means seldom met with. They generally attain their bodily development slowly, and the development of their mind is equally tardy. They cut their teeth late, walk late, talk late, are slow in learning to wash and dress themselves, are generally dull in their perceptions, and do not lay aside the habits of infancy till far advanced in childhood. When the time comes for positive instruction, their slowness almost wears out everyone's patience; and among the poor indeed the attempt at teaching such children is at length given up in despair, and growing up in absolute ignorance, it is no wonder that they should be regarded as idiots. Still, dull as such children are, there is between them and the idiot an essential difference. The backward child, unlike the idiot, does not remain stationary; his development goes on, but more slowly than that of other children, he is behind them in the whole course of their progress, and his delay increasing every day, places at length an enormous distance between him and them—a distance which in fact becomes insurmountable.

In some of its minor degrees even, this backwardness not infrequently excites the solicitude of parents. It is sometimes observed in children who had been ill-nourished in infancy or who had been weakened by some serious or protracted illness, even though unattended by any special affection of the brain; but it is also met with independent of any special cause. The distinction, however, between such a case and one of idiocy is this, that though at four years old the child may not seem to be intellectually superior to most children at two, yet in manners, habits, and intelligence it does agree with what might be expected from the child at two; less bright perhaps, less joyous, but still presenting nothing which if it were but younger would awaken apprehension.

It is well in all cases of unusual backwardness to ascertain the condition of the sense of hearing, and of the power of speech, for I have known the existence of deafness long overlooked, and the child's dulness and inability to speak referred to intellectual deficiency; and have also observed mere difficulty of articulation, dependent partly on malformation of the mouth, lead to a similar misapprehension. In both instances I have seen this inability to keep up ready intercourse with other children cast a shadow over the mind, and the little ones in consequence be dull, suspicious, unchild-like. I have already referred to a similar result as sometimes following serious illnesses. The child will for months cease to walk, or forget to talk, if these had been but comparatively recent acquirements; or will continue dull and unequal to any mental effort for weeks or months together, and then the mind will begin to develop itself once more, though slowly, possibly so slowly as never altogether to make up for lost ground.

Idiocy.—In idiocy, however, there is much more than the mere arrest of the intellect at any period. The idiot of eight years old does not correspond in his mental development to the child at six, or four, or two; his mind is not only dwarfed but deformed; while feebleness of will is often as remarkable as mere deficiency of power of apprehension. Even in earliest infancy there is usually a something in the child idiotic from birth which marks him as different from babies of his own age. He is unable to support his head, which rolls about from side to side, almost without an effort on his part to prevent it. Next it is perceived that the child, though he can see, does not notice; that his eye does not meet his mother's with the fond look of recognition, accompanied with the dimpling smile, with which the infant, even of three months old, greets his mother. Then it is found to have no notion of grasping anything, though that is usually almost the first accomplishment of babyhood; if tossed in its nurse's arms there seems to be no spring in its limbs; and though a strange vacant smile sometimes passes over its face, yet the merry ringing laugh of infancy or joyous chuckle of irrepressible glee is not heard. As time passes on, the child shows no pleasure at being put down 'to feel its feet,' as nurses term it; if laid on the floor it probably cries, but does not attempt to turn round, nor try to crawl about as other babies do. It does not learn to stand or walk till late, and then stands awkwardly, walks with difficulty, crossing its legs immediately on assuming the erect posture, an infirmity which it often takes years to overcome. Just, too, as the idiot is slow to notice, slow in learning to grasp anything, or to stand or walk, so he is late in learning to talk, he often acquires but few words, for his ideas are few. He learns even these few with difficulty, and employs the same to express many different things; he generally articulates them indistinctly, often indeed so imperfectly as to be almost unintelligible.

In other instances the evidences of idiocy are not present at birth, or at any rate are not then noticed, but succeed to some attack of convulsions or to some illness attended with serious affection of the brain. Sometimes too there is no point in the child's history which can be laid hold on as marking the commencement of the weakening of his intellect, but as the body grows the mind remains stationary, or its powers retrocede, until by degrees the painful conviction that the child has become idiotic forces itself upon the unwilling parents. Here we have sometimes the sad spectacle of the body perfectly developed, hale and strong, but the mind obscured; the child in constant unrest, perpetually chattering, laughing without cause, destroying its clothes, or the furniture of its room, for no purpose; or sitting silent, with a weird smile upon its face, looking at its spread-out fingers, or stroking a piece of cloth for a quarter of an hour together as though the sensation yielded it a kind of pleasure. It would be almost endless to describe the various degrees of mental weakness; from the slight silliness down to the condition in which the child is, and remains all life long, below the level of the brute.

Parents as a rule are anxious to persuade themselves, and to persuade the doctor that their idiot child was once as bright and intelligent as others; and that the mind was darkened by some grave illness. We have, however, the highest authority, that of Dr. Down, for saying that as a rule which has but few exceptions idiocy from birth is more amenable to training than that which comes on afterwards, that in fact it is more hopeful to have to do with an ill-developed than with a damaged brain.

The one great question which still remains is what can the parents do for best and wisest whom the affliction has befallen of having an idiot child.