[ [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