Duty & Discipline | Essay No. 16

Essay No. 16

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Discipline and Training
in the Prevention of Nervous Diseases
BY
W. A. Marris, M.D.
(Late House Physician, National Hospital
for the Paralysed and Epileptic,
Queen Square, W.C.)

MUCH has been said and written about the increase of lunacy in our nation, and in the discussion as to whether the increase is apparent or real, recourse is naturally had to the statistics annually published by the Commissioners in Lunacy. Unfortunately, for the equally important discussion on the increase of lesser forms of mental weakness than those which come under the attention of the Commissioners, no such statistics are available, and we are driven back on the general impression of those best qualified to judge, namely, the general medical practitioners of this country, the home doctors.
These are the men who know the great prevalence of mental weakness, hysteria, hystero-epilepsy, nervous debility, neurasthenia, mental depression, excitability, weak nerves, with their disastrous effect upon individual character and upon the mental and moral stamina of our nation as a whole.
Whether these troubles are on the increase matters

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not for the moment, but that they are appallingly widespread cannot be denied by those of us who are in a position to know- Every doctor realises what a large proportion of his time and nervous energy is spent in allaying unnecessary fears, in fighting the depression produced in so many patients by the slighter ailments—a depression which his patients of a robuster nervous system, or, to put it bluntly, of a greater self-control, would be ashamed to show. As one doctor expressed it, "Half of a general practitioner's work consists in ' bucking up ' the weaklings." It is a commonplace of the novelist that the doctor's manner should be a mingling of authority, sympathy, and cheerfulness, inspiring confidence while he is in the sick-room, and leaving brightness and hope behind him. To the public this is the picture of the ideal doctor at times of critical and terrible illness. The doctor knows, however, that all his skill and tact in the judicious blending of sympathy, raillery, and authority are strained to the breaking point in dealing, not with cases of life and death, but with his list of weaklings who are overpowered by little troubles, or by no real troubles at all.
A little thought will show that this strain is not the doctor's alone. The whole family of the patient is affected. The adult members suffer by the constant demands on their sympathy, by the loss of the work which the patient should be able to do, and by the

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expenditure of the family funds on extra help in the house, repeated "changes of air," and doctors' bills, including all the modern expensive cures by massage, Weir-Mitchell rest cures, special diets, specialists' opinions, vibration and electrical treatment, etc.
The strain on the breadwinner of a middle-class family, should his wife belong to the army of nervous sufferers, through the expense, and through the lack of happy restfulness in his home life, is almost intolerable. On the other hand, when the breadwinner is the afflicted one, wife and children are permanently handicapped by the drain on the family resources. In the wealthier ranks of society the evil results may be even more morally serious. An incapacitated, complaining husband or wife easily serves as cause or excuse for the healthier partner to seek consolation from others, even to the breaking of the marriage vows-
It must ever be a matter of deepest thankfulness that out of these evil and often unnecessary conditions there emerges from time to time, to rejoice our hearts, the picture of the perfect saint ; the mother taking up the burden of money-earning and settling her boys in life in addition to performing her own true home work ; or the father who, in addition to his long day's work, returns home at night to take up endless domestic tasks and dreary nursing.
As with all the other ills of human life, this curse of unwholesome nerves cannot be cut short by, any

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drastic policy. It can, however, and it must be reduced far below its present extent, if the physical, moral, and economic position of our nation is to be maintained. Modern medicine, up till now, has expended its energies in two directions towards this end, firstly in a serious attempt to gain a scientific knowledge of the nature of the perversion of the nervous system underlying this trouble, and secondly in the invention of cures for the individual sufferers, as previously mentioned. It has almost forgotten in this connection its own old watchword, that "Prevention is better than cure."
It is on this line that most work needs to be done at the present time, and needs to be done by the family doctor.
In so far as the tendency to nervous ailments depends on heredity there is little scope for the doctor to work, under our present social code. The regulation of marriages is not yet, at any rate, a practical subject, though a word in season may occasionally be given to a young man or young girl who appears to be attracted by a partner of this most undesirable type. Advice is also asked at times from the family doctor on the marriage of cousins, and the probability of continuation of family weaknesses will not be forgotten by the wise practitioner.
The real scope for the doctor's powers of prevention, however, lies in the home, in the upbringing of the young children. Daily and hourly he is con-

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suited on the management of children, and by his own handling of little patients he can often give a practical lesson to the mother, nursemaid, or guardian.
Let it be laid down once and for all that hereditary weaknesses are not hopeless, but can often be cured and can always be mitigated by right treatment from the earliest years. Unfortunately, this is not admitted by vast numbers of parents. "He is such a nervous child ; I can do nothing with him," is a complaint that will be recognised by family doctors everywhere. According as the doctor passively acquiesces in this complaint, or can imbue the mother with further strength and help to battle with the child's weakness, so will be its future. In many cases the doctor can see for himself that the child is not naturally of nervous temperament, and that the natural excitability of youth has been mistaken by an over-anxious parent for evidence of "highly-strung nerves." The mistake once made, the home treatment resolves itself into a process of making life easy for the child; all scoldings are avoided, punishment is unheard of, and, worst of all, little ailments are magnified, and treated with the elaborate care and anxiety that would be suitable for illness involving danger to life. Is it to be wondered at that the child grows up fretful and distressed at every little jar in the routine of life ?
What sort of upbringing and training, then, is the doctor to advise for the general management of

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normal children and for the correction of many forms of nervous weakness in children ? Undoubtedly he should advise a stricter and sterner discipline than is now practised in many homes.
There is one motive which, above all others, enables both normal men and women, as well as the neurasthenic and the vacillating, excitable, nervous weakling, to look beyond their own sufferings and interesting feelings, and to fit themselves into the scheme of life around them. This motive is the sense of compulsion, of duty, of obedience, of " must." Amongst the labouring classes we see less of these forms of illness and moral failure, and the reason is clear. They have no time for it. They must go on working. Work must be done, and done immediately, that food may be provided- The husband must bring home wages, the wife must go and buy and cook the food. This forced participation in the daily life reduces to its minimum the duration of and the suffering from these nervous maladies and their evil effects on those around the patient.
Again, many of the best recoveries from such troubles as the mental depression that follows some attacks of influenza are seen amongst good Christian men and women who have trained themselves for years in unselfishness and obedience to duty, and have daily striven for the fulfilment of the prayer of the English Church : "Lord, make Thy chosen people j oyf ul

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For large numbers of patients in the middle and upper classes of society the immediate compulsion of work to be done is inoperative. Duties can be easily shirked or thrown on the shoulders of others, either servants, relatives, or business partners. To protect this class and aid them in their weaknesses, there must therefore be implanted in them, and cultivated in them, a strong sense of obedience to duty and a wholesome realisation of the laws of consequence. Surely the time to get this ingrained into the moral and mental fibre is during childhood ?
The practical difficulty lies in the fact that the natural trainers of the child are themselves often of unstable mental equilibrium, or of self-indulgent habits; and yet the medical man's help for the children must in most cases be given indirectly by urging on the parents, as frequently as tact will find opportunity, the necessity of firm moral control of their children.
A few of the practical points in which it is possible to give this advice will illustrate what is being urged here. It is hardly necessary to multiply instances of the endless opportunities that occur to medical men to give help in this matter.
To a young mother in an unnecessary fever of anxiety at the crying of her little baby but an hour or two old, a few cheerful words may convey the invaluable lesson that a baby's crying is not such a terrible thing that it must be stopped at all costs in the shortest possible space of time. Can she once

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assimilate the fact that babies cry over a thousand things that are very good for them, such as dressing and undressing, she will not be so desperately anxious in a year or two's time to keep the little child good by giving in to its every desire. The old nursery excuse that "Crying is so bad for children " has been responsible for untold evils. The rupture that is occasionally found in children who have cried excessively is due, not to the crying, but to the debilitated health that caused the excessive crying. In children about two years old, of strong desires, and also in placid children at a later age, there is at times a passionate sobbing when their will is—rightfully —thwarted, to which none but the most callous could listen unmoved, and which, if not harmful physically, is probably an unwise strain on their nervous system, and must be stopped. If a few moments of soothing, or of distraction of the attention—without a yielding of the original bone of contention between mother and child—is not successful, a sound smack of the hand on a harmless part of the body—never on the head—will enable the child to regain its lost self-control, and will leave the mother in a strong position of authority which will be of infinite value in the future. One of the best ways in which medical men can help the parents is by assuring them that, however painful to themselves, physical punishment is more than harmless--that it is often of great good for the child.

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When the home atmosphere is unresponsive to all promptings towards wholesome discipline and sustained regularity, the kindest advice that the doctor can give is one which many mothers hail with relief, though others have to have it urged on them over and over again, and that advice is to hand over the work of training the child to others, and to entrust it to them entirely. When circumstances permit, the institution of a governess of strong nerves and will, but of kindly disposition, who shall be given a free hand to carry out the task of regaining control of a spoilt or nervous child, is often the best solution of the trouble. In other cases it is the doctor's duty to press for an early resort to school—either day school or boarding school, according to the age and circumstances of the child—and no dread of overworking the young brain should be allowed for a moment to weigh against the value of the moral training of good school discipline. Overwork is easily guarded against by control of home work in the case of day school, and by half-term inspection in the case of boarding school ; and in younger children by forbidding all "playing at school " when at home. This last simple device will stop the "going over her lessons in her sleep " of which so many mothers complain.
In these and many similar ways the medical man can—and, one is glad to think, does—give help to parents and children alike. But I think it behoves

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us to look out for more frequent opportunities of speaking to parents about the upbringing of their families, and to urge on them the enormous advantages that are gained, both for normal children and for children with any tendency to nervous weakness, by a stricter discipline than that now in fashion.
It is not easy for a family practitioner in full practice to engage in public work, especially while so much of it involves partisanship ; but, by bringing all his weight and authority to bear in favour of a sturdier home life, every medical man may feel that he is doing his share for his country. He is helping to ward off the deterioration of our national life with which we are threatened, not only in the matter of bodily inches, but in the infinitely more serious matter of intellectual and moral vigour.

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