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 Cholera