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.