Chapter 11

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 assume 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 albuminuria, and by abdominal and intestinal disturbances of various sorts. We recognise also the rheumatic type of child with a tendency to chorea, 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 depôt 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 associated 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, otitis 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 associated with an excessive retention of fluid in the body, secondary in all probability to alterations in the concentration and distribution of the saline constituents 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 circumstance 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 _perlèche_. 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 association 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 dermatitis of the buttocks 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.

In the nervous system, the conditions are somewhat different. In skin, in bone, and in muscle new cell elements are constantly being formed, and the life of the individual cell is relatively short. In the nervous system, on the other hand, the individual cells are long lived. Their life-history may even be coterminous with that of the individual, and if destroyed they are not replaced. Nevertheless, they do not escape undamaged in the general disturbance. In a deprivation of calcium we have, in all probability, the explanation of the increased irritability of peripheral nerves and of the tendency to convulsive seizures of all sorts which is a common accompaniment of the condition. Convulsions, laryngismus stridulus, tetany, or carpopedal spasm are all frequently met with. In crying, the children hold their breath to the point of producing extreme cyanosis, ending, as the spasm relaxes, with a crowing inspiration, which resembles and yet differs in tone from both the whoop of whooping-cough and the crowing inspiration of croup.

Apart, however, from this tendency to convulsive seizures the nervous system of these children is abnormal. As a rule they are excitable, and develop late the power to control their emotions. Lagging behind in physical development and in the capacity to interest themselves in the pursuits of normal children, their emotional state remains that of a much younger child. In the infant classes at schools they are recognised as dullards, learning slowly, speaking badly, and lacking co-ordination in all muscular movements.

The clinical picture so depicted is encountered with extreme frequency among the children of the poor in our large cities. To find a name for the condition is no easy matter. To call it "rickets" is to place an undue emphasis upon the bony changes which, though common, are by no means invariable. Elsewhere I have suggested the name status catarrhalis, on an analogy with the name status lymphaticus, which in the post-mortem room is used to describe the secondary overgrowth of lymphatic tissue which is found in these catarrhal children. In the present connection it is of interest to us to note how commonly the nervous system is involved in the general picture and the frequency both of convulsive disorders and of neuropathy.

The nervous symptoms of both sorts are to be allayed only by improving the general hygiene of the child and raising its resistance against infection. A sufficiency of fresh air and of sunlight, and a management which encourages independence of action in the child, are both necessary. The diet is of the first importance. It should be sufficient, and no more than sufficient, to cover the physiological needs of the child for food. The majority of these children have enormous appetites, and excess of food, and especially of carbohydrate food, plays some part in the production of the disturbance. We must guard against overfeeding, against want of air and want of exercise, and against those errors of management described in previous chapters, which produce the maximum of disturbance in this type of child.

(2) A GROUP WITH MUSCULAR ATROPHY, LORDOSIS, AND POSTURAL ALBUMINURIA

At an older age, in children from the fifth year onwards, a second type of physical defect associated with pronounced nervous disturbance presents itself with some frequency. The body is thin and badly nourished, and the muscular system especially poorly developed and very lax in tone. The most striking feature is the extreme lordosis, accompanied usually by a secondary and compensatory curve in the cervico-dorsal region, so that the shoulders are rounded, with the head poked forward. Viewed from in front the abdomen is seen to be prominent, overhanging the symphysis pubis, while the shoulders have receded far backwards. The scapulæ have been dragged apart, as though by the weight of the dependent arms, with eversion of their vertebral borders and lowering of the points of the shoulders. The position which they adopt is that into which the body falls when it ceases to be braced by strong muscular support. The muscular system is here so weakly developed and so toneless that the posture is determined by the bony structure and its ligamentous attachments.

The lordosis resembles the similar deformity which develops in cases of primary myopathy, when the spinal muscles have undergone complete atrophy. As in myopathy the movements are very uncertain. The children are apt to fall heavily when the centre of gravity is suddenly displaced, because their upright posture is maintained by balancing the trunk upon the support of the pelvis. The frequency and severity of the falls which these children suffer is a common complaint of the mother. The faulty posture is often associated with slight albuminuria. Its appearance is very capricious, but it is dependent to a great extent upon the assumption of the erect posture. There has been much discussion as to its explanation. It has been argued that the lordosis itself produces the albuminuria by mechanical compression of the renal vein, and it is said that albuminuria can be produced, even in the prone position, by placing the child in a plaster jacket applied so as to maintain the position of lordosis. Other observers, however, have not obtained this result. It seems most likely that the albuminuria is due to defective tone in the vasomotor musculature, comparable in every way to the defective tone in the muscles of the skeleton. We have often further evidence of vasomotor weakness. Fainting attacks are so common as to be the rule rather than the exception. Again, mothers are likely to complain of the child's pallor and of dark lines under the eyes, especially after exertion or in the reaction which follows excitement of any sort. As a rule a blood count will not show any very striking evidence of true anæmia. The pallor is of vasomotor origin, determined by faults in the distribution of the blood from vasomotor weakness and not by deficient blood formation. Circulatory and vasomotor disturbance probably also accounts for the dyspeptic pains and vomiting which commonly accompany any emotional excitement, or follow any unusual exertion or fatiguing experience. Constipation is a common, and mucous diarrhoea an occasional, symptom. The abdomen is often pigmented. The hands and feet are usually cold and cyanosed.

The extreme nervousness of the children is the point upon which most stress may be laid in the present connection. The association of albuminuria with neurosis in childhood has been noticed by many observers. The gastric and intestinal symptoms are especially characteristic. If the condition of the children is not materially improved, and if the symptoms, both of the physical defect and of the nervous disturbance, are not cut short, we may predict that in adult age their lives will be made miserable by a variety of abdominal symptoms dependent both on the vasomotor disturbance and upon the accompanying neurosis. Now that surgery forms so large a part of our therapeutic proceedings, they may not reach middle life without being submitted to one or more surgical operations. With good management both on the physical side and on the moral or psychological side they can be made into strong and useful members of society.

The treatment of these cases may be summed up as follows:

_(a)_ We must search for any source of infection, a source which is often to be found in the condition of the tonsils. Enucleation may then be indicated as the first step in treatment.

_(b)_ Massage and gymnastic exercises calculated to improve the muscular tone, while every effort is made to secure for the child as perfect hygiene in the environment as possible.

_(c)_ The stimulating effect of cold douches is often very evident in improving the vasomotor tone. These children, however, will not stand well the abstraction of heat from their thin and chilly little bodies, so that it is a good plan before the colder douche to immerse the child in a hot bath and to return again to the bath momentarily afterwards. With these precautions children will often enjoy a cold spray, the temperature of which may be constantly lowered as they become used to it. Prolonged hot bathing has a correspondingly prejudicial effect.

_(d)_ We must be on the watch to prevent the development of further postural deformities, such as scoliosis. If a child of strong muscular tone and good physique habitually adopts some posture, curled up, it may be, in some favourite easy-chair, there is little likelihood that its constant assumption will produce deformity. When the muscular system is lax and weak, on the other hand, deformity such as scoliosis is very readily caused. It is important, for example, to see that the child does not habitually incline to one side in reading or writing. When there is little energy for free and energetic play the children are apt to become great bookworms. If there is shortsightedness, the dangers are correspondingly increased. A special chair may be made with a well-fitting back and the seat a little tilted upwards so as to throw the child's trunk on to the support of the back. Lastly, a desk, the height of which can be regulated at will, can be swung into the proper position. The child, sitting straight and square, with the weight supported by the foot-rest and back as well as by the seat of the chair, should be taught to write with an upright hand, avoiding the slope which leads to sitting sideways with the left shoulder lowered.

(e) Malt extract, cod liver oil, Parrish's food, and other tonics may be of undoubted service.

(3) RHEUMATISM AND CHOREA

It is certain that there is a close association between rheumatism in childhood and the common nervous affection known as chorea. We are still ignorant of the precise nature of the infection which we know as rheumatism. There is much to suggest that in rheumatism we have to deal only with a further stage in those catarrhal infections to which so much infantile ill-health is to be attributed, and that endocarditis and arthritis, when they arise, signalise the entry of these catarrhal, non-pyogenic organisms into the blood stream, overcoming at last the barrier of lymphoid tissue which has hypertrophied to oppose their passage. Certainly the connection of rheumatism with catarrhal infections of the mucous membranes and adenoid enlargements of all sorts is a close one. Whatever its nature, the rheumatic infection in childhood is more lasting and chronic than in adult life. Rheumatism in childhood is not manifested by acute and short-lived attacks of great severity so much as by a long-continued succession of symptoms of a subacute nature, a transient arthritis, perhaps, succeeding an attack of sore throat with torticollis, to be followed by carditis, to be followed again by another attack of tonsillitis. And so the cycle of symptoms revolves. In most cases the child grows thin and weak; in most cases he becomes restless, irritable, and unhappy; often there is definite chorea. Of this cerebral irritability chorea is the expression. In adults, chorea is perhaps more obviously associated with mental stress of all sorts and with states of excitement and agitation. In the case of little children it is often only the mother who really appreciates how radical an alteration the child's whole nature has undergone, and how great the element of nervous overstrain has been before the chorea has appeared.

Of the treatment of chorea there is no need to speak. It is purely symptomatic. Isolation, best perhaps away from home, as might be expected, gives the best results. If there are pronounced rheumatic symptoms, the salicylates will be needed; if there is anæmia, arsenic and iron; if there is sleeplessness and great restlessness, bromides or chloral. Hypnotism is often almost instantly successful, but, apart from hypnosis, curative suggestions proceeding from the attendants form the principal means at our disposal.

(4) EXHAUSTION AND KATATONIA

A large number of children, in convalescence from infective disorders, when the nutrition of the body has fallen to a low ebb, show as evidence of cerebral exhaustion a group of symptoms which in a sense are the reverse of those which characterise cerebral irritation and chorea. The healthy child is a creature of free movement. The children we are now considering will sit for a long time motionless. The expression of their faces is fixed, immobile, and melancholy. If the arm or leg is raised it will be held thus outstretched without any attempt to restore it to a more natural position of rest for minutes at a time. The posture and expression remind us at once of the katatonia which is symptomatic of dementia præcox and other stuporose and melancholiac conditions in adult life. Symptoms of this sort are especially common in children with intestinal and alimentary disturbances of great chronicity.

The symptom is so frequently met with that it is strange that it should have attracted so little attention as compared with the contrasting condition of chorea. And yet it is of more serious significance, more difficult to overcome, and with a greater danger that permanent symptoms of neurasthenia will result. In early childhood a careful dietetic régime, suitable hygienic surroundings, and a stimulating psychical atmosphere will often effect great improvement. As in chorea, however, relapses are frequent, and there are cases which for some unexplained reason are peculiarly resistant to all remedial influences.

(5) HYSTERIA

In hysteria, in contrast to the types previously described, the infective element may be completely absent. Except in some special features of minor importance the symptoms of hysteria do not differ from those of adults, and, as in adult age, the condition of hysteria may be present although the physical development may be perfect. We cannot here speak of any physical characteristics which are associated with the nervous symptoms.

The third or fourth year represents the age limit, below which hysterical symptoms do not appear. Thereafter they may be occasionally met with, with increasing frequency. At first, in the earlier years of childhood, there is no preponderance in the female sex. As puberty approaches, girls suffer more than boys.

It may be said to be characteristic of hysteria in childhood that its symptoms are less complex and varied than in adult life. The naive imagination of the child is content with some single symptom, and is less apt to meet the physician half-way when he looks for the so-called stigmata. Similarly mono-symptomatic hysteria is characteristic of oases occurring in the uneducated or peasant class. In children, hysterical pain, hysterical contractures or palsies, mutism, and aphonia are the most usual symptoms. Hysterical deafness, blindness, and dysphagia are manifestations of great rarity in childhood.