The Nervous Child Part 5

And so with children! Parents must take it for granted that they will display all the virtues they desire in them. They must trust to their honour always to speak the truth, and always to do their best in work or play whether they are with them or not. Again and again the children will fail and their patience will be tried to the utmost.

They must explain how serious is the fault, and for the time being their trust may have to be removed; but with the promise of amendment it must again be fully restored and the lapse completely forgotten. If the child feels he is not trusted he ceases to make any effort, and lapse will succeed lapse with increasing frequency.

In efforts at moral training there is often too great an emphasis laid upon negative virtues. It is wrong to do this: to do that is forbidden. Children cannot progress by merely avoiding faults any more than a man may claim to be an agreeable companion at table because he does not eat peas with a knife or drink with his mouth full. There must be a constant effort to achieve some positive good, to acquire knowledge, to do service, to take thought for others, to discipline self, and the parent will get the best result who is comparatively blind to failure but quick to encourage effort and to appreciate success. When the child knows well that he is doing wrong, exhortation and expostulation are usually of little avail if repeated too often, and serious talks should only take place at long intervals.

We know how effective the so-called "therapeutic conversation" may be in helping some overwrought and nervously exhausted man or woman to regain peace of mind and self-control. After an intimate conversation with a medical man who knows how to draw from the patient a free expression of the doubts, anxieties, and fears which are obsessing him, many a patient feels as though he had awakened in that instant from a nightmare, and pa.s.ses from the consulting-room to find his troubles become of little account. Not a few patients return to be rea.s.sured once more, and derive new strength on each occasion. Yet visits such as these must be infrequent or they will lose their power.

Now, just as the physician is well aware that his intervention if too frequently repeated will lose its effect, so the parent must be chary of too frequent an appeal to the moral sense of the child. At long intervals opportunity may be taken with all seriousness to set before the child ideals of conduct, to-speak to him of the meaning of character and of self-discipline, and of the standards by which we judge a man or woman to be weak and despicable, or strong and to be admired. The effect of such an intimate conversation, never repeated, may persist throughout life. Constantly reiterated appeals, on the other hand, do more harm than good. To tell a child daily that he is "breaking mother's heart," or that he is "disappointing his father,"

is to debase the moral appeal and deprive it of its strength.

For everyday use it is best to cultivate a manner which can indicate to the child that he is for the moment unpopular, but which at the same time denies to the small sinner the interest of attempting his own defence. On the other hand, should the child be reasonably in doubt as to the nature of his offence we must spare no trouble in explaining it to him. Punishment will be most effective when the child is convinced that he is rightly convicted. If it is to act as a real deterrent, he must agree to be punished--a frame of mind which, if it can be produced, may be welcomed as a sure sign that training is proceeding along the right lines.

By physical training, mental training, and moral training the child's character is formed and self-discipline is developed. With the child of neuropathic disposition and inheritance matters may not proceed so smoothly. Reasoning and conduct may be alike faulty, and the nervous disturbances may even cause detriment to the physical health. Not that the nervous child requires an environment different from that of the normal child. The difficulties which the parents will encounter and the problems which must be solved differ not in kind but in degree. An error of environment which is without effect in the normal child may be sufficient to produce disastrous results in the neuropathic.

It must be granted that there are some unfortunate children in whom the moral sense remains absent and cannot be developed--children who steal and lie, who seem dest.i.tute of natural affection, or who appear to delight in acts of cruelty. These moral degenerates need not be considered here. Serious errors of conduct, however, in children who are not degenerate or imbecile, frequently arise directly from faults of management and can be controlled by correcting these faults.

Suppose, for example, that a child is found to have taken money not his own. The action of the parents faced with this difficulty and disappointment will determine to a great extent whether the incident is productive of permanent damage to the child's character. The peculiar circ.u.mstances of each case must be considered. For example, the parent must bear in mind the relation in which children stand to all property. The child possesses nothing of his own; everything belongs in reality to his father and mother, but of all things necessary for him he has the free and unquestioned use. Unless his attention has been specially directed to the conception of ownership and the nature of theft, he may not have reasoned very closely on the matter at all. Very probably he knows that it is wrong to take what is not given him, but he does not regard helping himself to some dainty from a cupboard as more than an act of disobedience to authority. He may have imbibed no ideas which place the abstraction of money from a purse belonging to his parents on a different plane, and which have taught him to regard such an action as especially dishonourable and criminal. Finally, a child who, undetected, has more than once taken money belonging to his father and mother, may pa.s.s without much thought to steal from a visitor or a servant. To deal with such a case effectively, to ensure that it shall never happen again, requires much insight. If the father, shocked beyond measure to find his son an incipient criminal, differing in his guilt in no way from boys who are sent to reformatories as bad characters, convinces the child that although he did not realise it, he has shown himself unworthy of any further trust, untold harm will be done. Almost certainly the child will act in the future according to the suggestions which are thus implanted in his mind. If the household eyes him askance as a thief, if confidence is withdrawn from him, he sees himself as others see him and will react to the suggestions by repeating the offence. The seriousness of what he has done should be explained to him, and after due punishment he must be restored completely and ostentatiously to absolute trust. Only by showing confidence in him can we hope to do away with the dangers of the whole incident. To inculcate good habits and encourage good behaviour we must let the child build up his own reputation for these virtues. It need not make him priggish or self-satisfied if parents let him understand that they take pride in seeing him practise and develop the virtue they aim at. For example, it is desired above all that he should always speak the truth. Then they must ostentatiously attach to him the reputation of truthfulness and show their pride in his possessing it. If he falls from grace they must remember that he is still a child, and that if that reputation is lightly taken from him and he is accused of a permanent tendency towards untruthfulness, he is left hopeless and resigned to evil. Let any mother make the experiment of presenting to her child in this way a reputation for some particular virtue. For example, if an older child shows too great a tendency to tease and interfere with the younger children, let the mother seize the first opportunity which presents itself to applaud some action in which he has shown consideration for the others. Let her comment more than once in the next few days on how careful and gentle the older child is becoming in his behaviour to the little ones, and in a little the suggestion will begin to act until the transformation is complete. If, on the other hand, the mother adopts the opposite course and rebukes the child for habitual unkindness, she will be apt to find unkindness persisted in.

The criminal records of the nation show too often the truth of the saying that "Once a thief always a thief." Deprived of his good repute, man loses his chief protection against evil and his incentive to good.

The inability of a child--and especially of a nervous and sensitive child--to form conceptions of his own individuality except from ideas derived from the suggestions of others, gives us the key to our management of him and to our control of his conduct. He has, as a rule, a marvellously quick perception of our own estimate of him, and unconsciously is influenced by it in his conception of his own personality, and in all his actions. Parents must believe in his inherent virtue in spite of all lapses. If they despair it cannot be hid from the child. He knows it intuitively and despairs also. It is then that they call him incorrigible. If it happens that one parent becomes estranged from the child, despairs of all improvement, and sees in all his conduct the natural result of an inborn disposition to evil, while the other parent holds to the opinion that the child's nature is good, and to the belief that all will come right, then often enough the child's conduct shows the effect of these opposite influences. In contact with the first he steadily deteriorates, affording proof after proof that judgment against him has been rightly p.r.o.nounced. In contact with the other, though his character and conduct are bound to suffer from such an unhappy experience, he yet shows the best side of his nature and keeps alive the conviction that he is not all bad.

The force of suggestion is still powerful to control conduct and determine character in later childhood. The impetus given by the parents in this way is only gradually replaced by the driving power of his own self-respect--a self-respect based upon self-a.n.a.lysis in the light of the greater experience he has acquired.

CHAPTER X

NERVOUSNESS IN OLDER CHILDREN

In older children the line which separates naughtiness, fractiousness, and restlessness from definite neuropathy begins to be more marked.

The nature of the young child, taking its colour from its surroundings, is sensitive, mobile, and inconstant. With every year that pa.s.ses, the normal child loses something of this impressionable and fluid quality. With increasing experience and with a growing power to argue from ascertained facts, character becomes formed, and if tempered by discipline will come to present a more and more unyielding surface to environment, until finally it becomes set into the stability of adult age.

We may perhaps, with some approach to truth, look upon the adult neurotic as one whose character retains something of the impressionable quality of childhood throughout life, so that, to the last, environment influences conduct more than is natural.

All the emotions of neurotic persons are exaggerated. Disappointments over trifles cause serious upsets; grief becomes overmastering.

Violent and perhaps ill-conceived affection for individuals is apt to be followed by bitter dislike and angry quarrelling. On the physical side, sense perception is abnormally acute, and many sensations which do not usually rise up into consciousness at all become a source of almost intolerable suffering. To these most unhappy people summer is too hot and winter too cold; fresh air is an uncomfortable draught, while too close an atmosphere produces symptoms of impending suffocation.

In some neurotics there is an excessive interest in all the processes of the life of the body, and when attention is once attracted to that which usually proceeds unconsciously, symptoms of discomfort are apt to arise. Thus so simple an act as swallowing may become difficult, or for the time being impossible. To breathe properly and without a sense of suffocation may seem to require the sustained attention of the patient; or again, the voice may be suddenly lost.

More commonly, perhaps, neuropathy exhibits itself in an undue tendency to show signs of fatigue upon exertion of any sort, mental or physical. Sustained interest in any pursuit or task becomes impossible. Nameless fears and unaccountable sensations of dread establish themselves suddenly and without warning, and may be accompanied on the physical side by palpitation, flushing, headache, or acute digestive disturbances.

All these manifestations are best controlled by selecting a suitable environment, and as a rule the character of the environment is determined by the temperament and disposition of those who live in close contact with the patient. Like the tiny children with whom we have dealt so far, the behaviour of neuropathic persons is subject wholly to the direction of stronger and more dominant natures. With faulty management at the hands of those around them, no matter how loving and patient these may be, the conduct of the neurotic tends to become abnormal.

In children beyond earliest infancy we recognise a gradual approach to the conditions of adult life. Fractiousness and naughtiness, ungovernable fits of temper, inconsolable weeping and inexplicable fears should disappear with early childhood even if management has not been perfect. If they persist to older childhood we shall find in an increasing percentage of cases evidence of definite neuropathic tendencies which urgently call for investigation and for a precise appreciation of the nature of the abnormality. It may be that the only effective treatment is that which we recognise as essential in the grosser mental disturbances--removal from the surroundings in which the abnormal conduct has had free play, and separation from the relatives whose anxiety and alarm cannot be hidden.

In young nervous children fear is the most prominent psychical symptom. The children are afraid of everything strange with which they come in contact. They are afraid of animals, of a strange face, or an unfamiliar room. Older children usually manage to control themselves, suppress their tears, and prevent themselves from crying out, but it is nevertheless easy to detect the struggle.

Often we find those distressing attacks to which the name "night-terrors" has been given. The child wakes with a cry,--usually soon after he has gone to sleep,--sits up in bed and shows signs of extreme terror, gazing at some object of his dreams with wide-open startled eyes, begging his nurse or mother to keep off the black dog, or the man, or whatever the vision may be. Even after the light is turned up and the child has been comforted, the terror continues, and half an hour may elapse before he becomes quiet and can be persuaded to go back to bed. In the morning as a rule he remembers nothing at all.

Phobias of all sorts are common in nervous children, and result from a morbid exaggeration of the instinct for self-preservation. Some cannot bear to look from a height, others grow confused and frightened in a crowd; dread of travelling, of being in an enclosed s.p.a.ce such as a church or a schoolroom, or of handling sharp objects may develop into a constant obsession. I have known a little girl who was seized with violent fear whenever her father or mother was absent from the house, and she would stand for hours at the window in an agony of terror lest some harm should have befallen them. As if with some strange notion of propitiating the powers of darkness these children will often constantly perform some action and will refuse to be happy until they have done so. The same little girl who suffered such torments of anxiety in her parents' absence would always refuse to go to bed unless she had stood in turn on all the doormats on the staircase of her home. Other children feel themselves forced to utter certain words or to go through certain rhythmical movements. They fully understand that the fear in their mind is irrational and devoid of foundation, but they are unable to expel it. Often it is hugged as a jealous secret, so that the childish suffering is only revealed to others years afterwards, when adult age has brought freedom from it. We will do well to try by skilful questioning to gain an insight into the mental processes of a child when we find him showing an uncontrollable desire to touch lamp-posts or to stand in certain positions; or when he develops an excessive fear of getting dirty, or is constantly washing his hands to purify them from some fancied contamination.

The treatment of all these symptoms calls for much insight. The child's confidence must be completely secured, and he must be encouraged to tell of all his sensations and of the reasons which prompt his actions. The nervous child has a horror of appearing unlike other children, and will suffer in silence. If his troubles are brought into the light of day with kindness and sympathy they will melt before his eyes. Even night-terrors are, as a rule, determined by the suppressed fears of his waking hours. If they are provoked by his experiences at school, by the fear of punishment or by dismay at a task that has proved beyond his powers, he should be taken away from school for the time being. Night-terrors are said to be aggravated by nasal obstruction due to adenoid vegetations. Clothing at night should be light and porous, and particular attention should be paid to the need for free ventilation.

We have spoken in an earlier chapter of the trouble sometimes experienced in inducing a nervous child to go to sleep. In older children insomnia is common enough. Even when sleep comes it may be light and broken, as though the child slept just below the surface of consciousness and did not descend into the depths of sound and tranquil slumber. We have often noticed how different is the estimate of the patient from that of the nurse as to the number of hours of sleep during the night. The sick man maintains that he has hardly slept at all, whilst the nurse, drawing us aside, whispers in our ear that he has slept most of the night. In estimating sleep we have to consider not only its duration, but also its depth, and the patient who denies that he has slept at all has lain perhaps half the night with an active restless brain betwixt sleep and wakefulness. Often enough when he comes to consider in the morning the problems that vexed his soul at midnight, he is quite unable to recall their nature, and recognises them as the airy stuff that dreams are made of.

Although in a sense asleep he may have retained a half-consciousness of his surroundings and a sense of despair at the continued absence of a sounder sleep.

With nervous children we are apt to find sleep which is of little depth and which constantly shows evidence of a too-active brain. The body is tossed to and fro, words are muttered, and the respiration is hurried and with a change in rhythm, because there is no depth of anaesthesia. The body still responds to the impulses of the too-active brain. From the nature of his dream--as shown by chance words overheard--we may sometimes gather hints to help us to find where the elements of unrest in his daily life lie. Sleep-walking is only a further stage in this same disorder of sleep, in which the dream has become so vivid that it is translated into motor action.

If a child begins to suffer from active sleeplessness we must not make the mistake of urging him to sleep. He is no more capable than we are ourselves of achieving sleep by an effort of will power. To urge him to sleep is likely to cause him to keep awake because we direct his attention to the difficulty and make him fear that sleep will not come. If he understands that all that he needs is rest, he will probably fall asleep without further trouble.

Day-dreams also may become abnormal, and tell of an unduly nervous temperament. Any one who watches a little child at play will realise the strength of his power of imagination. The story of Red Riding Hood told by the nursery fire excites in the mind of the child an unquestioning belief which is never granted in later life to the most elaborate efforts of the theatre. All this imaginative force is natural for the child. It becomes abnormal only when things seen and acts performed in imagination are so vivid as to produce the impression of actual occurrences, and when the child is so under the sway of his day-dreams that he fails to realise the difference between pretence and reality. Imagination which keeps in touch with reality by means of books and dolls and toys is natural enough. Not so imagination which leads to communion with unseen familiars or to acts of violence due to the organisation of "conspiracies" or "robber bands" amongst schoolboys.

If evidence of abnormal imagination appears, the child must be kept in close touch with reality. We must give him interesting and rational occupation, such as drawing, painting, the making of collections of all sorts, gardening, manual work, and so forth. In older children we must especially supervise the reading.

In many nervous children we find a faulty contact with environment, so that instead of becoming interested in the thousand-and-one happenings of everyday life and experiences, they become introspective and self-conscious. As a result, sensations of all sorts, which are commonly insufficient to arouse the conscious mind, attract attention and, rising into consciousness, occupy the interest to the exclusion of everything else. The conscious mind is not capable of being occupied by more than one thing at a time. If attention is concentrated upon external matters, bodily sensations, even extreme pain, may pa.s.s altogether unnoticed. The Mohawk, Lord Macaulay tells us, hardly feels the scalping-knife as he shouts his death song. The soldier in the excitement of battle is often bereft of all sense of pain. On the other hand, the patient who is morbidly self-conscious becomes oblivious of his surroundings while he suffers intensely from sensations which are usually not appreciated at all. Self-conscious children will complain much of breathlessness and a sense of suffocation, of headache, of palpitation, of intolerable itching, of the pressure of clothing, or of flushing and a sense of heat.

Excessive introspection influences their conduct in many ways. At children's parties, for example, they will be found wandering about unhappy, dazed and unable to feel the reality of the surroundings which afford such joy to the others; or they may be anxious to join in play, but finding themselves called upon to take their turn are apt to stand helplessly inactive, or to burst into tears. At school, though they may be really quick to learn, they will often be found oblivious of all that has gone on around them, not from stupidity, but from inability to dissociate their thoughts from themselves and to concentrate attention upon the matter in hand. In such a case we must aim at developing the child's interest to the exclusion of this morbid introspection. Taking advantage of his individual apt.i.tude, we must strengthen his hold upon externals in every way possible, and we must explain to him the nature of his failing and teach him that his salvation lies in cultivating his capacity for paying attention to things around him and developing an interest in suitable occupations.

Fainting fits are not uncommon amongst nervous children from about the sixth year onwards, and are apt to give rise to an unwarranted suspicion of epilepsy. In other cases fears have been aroused that the heart may be diseased. In children who faint habitually the nervous control of the circulation is deficient. We notice that when they are tired by play, or when they are suffering from the reaction that follows excitement of any sort, the face is apt to become pale, and dark lines may appear under the eyes. Yet there may be no true anaemia present: it is only that the skin is poorly supplied with blood for the moment. After a little rest in bed, or under the influence of a new excitement, the colour returns, and the tired look vanishes. If children of this type are made to stand motionless for any length of time, and if at the same time there is nothing to attract their interest or attention--a combination of circ.u.mstances which unhappily is sometimes to be found during early morning prayers at school--the want of tone in the blood vessels may leave the brain so anaemic that fainting follows. The first fainting attack is a considerable misfortune, because the fear of a recurrence is a potent cause of a repet.i.tion. Standing upright with the body at rest and the mind vacant, the circulation stagnates, the boy's mind is attracted by the suggestion, he fears that he will faint as he has done before, and he faints. Schoolmasters are well aware that if one or two boys faint in chapel and are carried out, the trouble may grow to the proportion of a veritable epidemic. It is important that this habit of fainting should be combated not only by general means to improve the tone of the body and circulation, but also by taking care that the child understands the nature of the fainting fit, and the part which a.s.sociation of ideas plays in producing it. Disease of the heart seldom gives rise to fainting.

The same vasomotor instability which shows itself in the tendency to syncopal attacks is apparent in many other ways. Sudden sensations of heat and of flushing, equally sudden attacks of pallor, coldness of the extremities, abundant perspiration,--raising in the mind of the anxious mother the fear of consumption,--and excessive diuresis are common accompaniments. A further group of symptoms is provided by the extreme sensibility of the digestive apparatus. Dyspepsia, hyperaesthesia of the intestinal tract, viscero-motor atonies and spasms, and anomalies of the secretions, whether specific like that of the gastric juice or indifferent like that of the nasal, pharyngeal, gastric, and intestinal mucus, are all of common occurrence. Whenever the nervous child is subjected to any exhausting experience, any excitement, pleasurable or the reverse, or any undue exertion, whether mental or physical, one may note the subsequent gastro-intestinal derangement, including even a coating of the tongue. The slightest deviation from the usual diet, the most trivial fatigue, a chill of the body, even a change in the temperature of the food may set loose the most extreme reactions in the gastro-intestinal tract--motor, sensory, or secretory. It is not an accident that so often the mucous diarrhoea, which may have afflicted an excitable child in London for many months, and which a visit to the seaside, with all its healthy activities, may seem to have completely cured, relapses within a day or two of the return to the restricted environment and uninteresting routine of life in London. The child who was happy and busy and at peace with himself, at play in the open air, resents the sudden cessation of all this, and the nervous unrest returns. To attempt treatment by dietetic restrictions alone is to deal only with a symptom. The gastro-intestinal reactions are so violent that the parents are generally voluble on the subject of the many foods which cannot be taken and the few which are not suspect. To prescribe rigid tables of diet is to add to the alarm of the mother, and to sustain her in the belief that the child is in daily danger of being poisoned by a variety of common articles of diet. Only by lowering the excitability of the nervous system, by occupying the mind and giving strength to the child's powers of control can we effectively combat the hyperaesthesia. If necessary the personnel of the management of the child will have to be altered. There may be no other way to achieve certain and rapid improvement in a condition which is causing grave danger to the child and very genuine distress and suffering to the parents. A violent reaction to intoxications of all sorts is a further stigma of nervous instability. Sudden and even inexplicable rises of temperature are frequent complaints, and the const.i.tutional effects of even trivial local infections are apt to be disproportionately great.

Fatigue is easily induced and is exhibited in all varieties of activity--mental, physical, or visceral. Mental work may produce fatigue with extreme readiness even although the quality of the work may remain of a high standard. To Darwin and to Zola work for more than three hours daily was an impossibility, and yet their work done under these restrictions excites all men's admiration. The palpitation and breathlessness which follows upon trivial exertion, such as climbing a flight of stairs, is a good example of visceral fatigue.

Among adult neuropaths we recognise the harm which may be done by unwise speeches on the part of relatives, or still more on the part of doctors. A chance word from a doctor or nurse off their guard for the moment will implant in the minds of many such a person the unyielding conviction that he or she is suffering from some gastric complaint, from some cardiac affection, or from some constriction of the bowel.

It may take the united force of many doctors to uproot this pathological doubt which was implanted so easily and so carelessly.

The medical student is notoriously p.r.o.ne to recognise in himself the symptoms of ailments which he hears discussed. Little children, too, are apt to suffer in the same way. How much illness could be avoided if mothers would cease to erect some single manifestation of insufficient nervous control into a local disorder which becomes an object of anxiety to the child and to the whole household.

Undue liability to fatigue, irritability, instability, lack of control over the emotions, extreme suggestibility, prompt and exaggerated reactions to toxins of all sorts, excessive vasomotor reactions and anomalies of secretion, weakness of the gastro-intestinal apparatus--these, and many other symptoms, are of everyday occurrence in the nervous child. To discuss them more fully would be to pa.s.s too far from our nursery studies into a consideration of psychological medicine.

CHAPTER XI

NERVOUSNESS AND PHYSIQUE

It has already been said that symptoms of nervousness are often accompanied by faults in the physical development of the child. The defects may a.s.sume so many forms as to make any attempt at description very difficult. Nevertheless, certain types of physical defect present themselves with sufficient frequency, in combination with neurosis, to merit a detailed description. For example, we recognise a type of nervous child which is marked by a persistence into later childhood of certain infantile characteristics of the build and shape of body.

Further, we meet with a group characterised by a special want of tone in the skeletal muscles, by lordosis, by postural alb.u.minuria, and by abdominal and intestinal disturbances of various sorts. We recognise also the rheumatic type of child with a tendency to ch.o.r.ea, and in contrast to this a type with listlessness, immobility, and katatonia.

Lastly, in a few children, in boys as well as in girls, we may meet with cases of hysteria.[3]

[Footnote 3: If we accept as hysterical all symptoms which are produced by suggestion and which can be removed by suggestion, we may correctly speak of a physiological hysteria of childhood, which includes a very large number of the symptoms discussed. The term is used here in its older more limited sense.]

(1) A GROUP WITH PERSISTENCE OF CERTAIN INFANTILE CHARACTERISTICS

During the first year or eighteen months of life, the rounded infantile shape of body persists. The limbs are short and thick, the cheeks full and rounded, the thorax and pelvis are small, the abdomen relatively large and full. The great adipose deposit in the subcutaneous tissue serves as a depot in which water is stored in large amounts. In the healthy child of normal development by the end of the second year a great change has taken place. The shape of the body has become more like that of an adult in miniature. The limbs have grown longer and slimmer. The thorax and pelvis have developed so as to produce relatively a diminution in the size of the abdomen. The body fat is still considerable, but no longer completely obliterates the bony prominences of the skeleton. Delay in this change, in this putting aside of the infantile habit of body, is commonly a.s.sociated with a corresponding backwardness in the mental development. Such children walk late, talk late, learn late to feed themselves, to bite, and to chew effectively. Watery and fat, they carry with them into later childhood the infantile susceptibility to catarrhal infections of the lung, bowel, skin, etc., and they are apt to suffer, in consequence, from a succession of pyrexial attacks. Nasal catarrh, bronchitis, ot.i.tis media, enteritis, eczema, urticaria papulata, are apt to follow each other in turn, giving rise in many cases to a persistent enlargement of the corresponding lymphatic glands. The effect upon the different tissues of the body of these repeated infections is very various. We are probably not wrong in attributing the failure to develop and the persistently infantile appearance to a prejudicial effect upon the various ductless glands in the body. The condition is a.s.sociated with an excessive retention of fluid in the body, secondary in all probability to alterations in the concentration and distribution of the saline const.i.tuents of the body. A rapid excretion of salts may be followed by a correspondingly speedy dehydration of the body, a retention of salts by a sudden increase of weight. The parathyroid glands are probably closely concerned in regulating the retention and excretion of salts, and especially of calcium, a circ.u.mstance which becomes of significance when we remember how frequently rickety changes, tetany, and other convulsive seizures form part of the clinical picture which we are now considering. While it is difficult to determine the effect of repeated infections upon the functions of the endocrine glands, we have clear evidence of the deleterious influence upon almost all the tissues of the body, the functioning of which it is more easy to estimate. For example, the cells of the skin and of the mucous membranes which happen to be visible to the eye show clear evidence of diminished vitality and increased vulnerability. Physiological stimuli, incapable of producing any visible reaction in healthy children, habitually determine widely spread and persistent inflammatory reactions. For example, the licking movements of the tongue at the corners of the mouth produce the little unhealthy fissures which the French call _perleche_. The physiological stimulus of the erupting tooth is capable of causing a painful irritation of the gum, so that the child is said to suffer from teething, accompanied, it may be, and the a.s.sociation is significant, by "teething convulsions." The irritation of the urine produces rawness and excoriation of the skin of the prepuce, contact with intestinal contents not in themselves very abnormal, an intractable dermat.i.tis of the b.u.t.tocks or a persistent diarrhoea and enteral catarrh. Improvement in the general health, the result of the cessation for the time being of the recurrent infections, perhaps consequent upon improved hygienic conditions, always determines the rapid disappearance of all these accompaniments of the general diminution of tissue vitality.

The muscular system and the bones are commonly also involved, so that rickety changes are often found in these infantile and watery children. In early childhood the processes of calcification and decalcification proceed side by side and with great rapidity, and in health there is always a balance on the side of the constructive process. In the children whom we are now considering, saturated as they are, from time to time, with the toxins resulting from repeated infection, ossification may be so interfered with as to cause softening and bending, with the evolution of a state of rickets.

Between bone and muscle, too, we find a close relationship. We do not find powerful muscles with softened bone, nor flabby muscle with rigid and well-formed bone.