THE CATARRHAL CHILD L .A. NICHOLS, M.R.C.S., L.R.C.P. Sidcup In general practice, illnesses involving the upper and lower respira- tory tracts account for almost 50 per cent of all attendances of children. They are the most time consuming cases, with the necessity for complete physical examination on each occasion. They originate most incommodious calls. Over 25 per cent of all cases referred to paediatric departments of hospitals are cases of sino- bronchitis. (Kempton, J. J., 1954). In a recent symposium on research Professor Robert Platt (1957) stated, " The measles report was interesting in that nobody could agree what a catarrhal child was, but yet it came out quite clearly that any child classified as such by his doctor, was more liable to develop complications ". It seemed pertinent to me to enquire why this syndrome remained difficult to define and resistant to specific therapy. The mothers of these catarrhal children appeared to me to display anxiety dis- proportionate to the severity of the condition. In order to find out how far this was true the child's reaction to his illness was obtained; or, at special sessions out of surgery hours, individual psychotherapy was entered into with the mother. Thus a new approach became possible. Definition Catarrh is fluid flowing from a mucous membrane. The catarrhal child therefore shows an excessive response of the mucous mem- branes to disturbing factors. The eyes, ears, nose, throat, lungs, and bowels may be affected. Most commonly, colds, ear-aches, sore throats, and stomach pains are manifested. Each child responds by producing one individual specific syndrome. Always, for instance, the same painful left ear, without any apparent redness of the drum, or sore throat, or headache, as his own reaction pattern. In addition, the history reveals additional different manifestations throughout the first decade. Multiple stools from birth, snuffles at four months, and convulsions ushering in severe pyrexias from the first year. Before the second year diarrhoea is common. At the time the child begins to be clean, elimination difficulties are noticed. At 21 the onset of colds, with ear-aches begin: the parents are up all night and aspirin is most efficacious. By four the colds are really frequent, the child has stomach-ache with emotional difficul- ties and loss of sphincter control until the age of six. In the first school year, frequent colds, headaches, ear-aches, cause repeated J. COLL. GEN. PRACT., 1959, 2, 43 44 L. A. NICHOiS absences from school: stomach pains, nausea and vomiting, and periodic abdominal migraine may be related to obvious stress: pertussis, measles and chicken-pox are always picked up. Secondary infection causes complications in lungs and ears. At seven his illnesses are fewer and shorter in duration. Headache when tired and muscular pains are common, and he may still attend school despite his colds. Through the next two years his health improves remarkably until, at ten, his attendances at surgery are rare. Many children present these features, yet they are rarely presented to the doctor. Witness the children going to school coughing and spluttering with running noses, but still happy and laughing. There are two groups of catarrhal children. One finds its way to the practitioner, reattending with each new manifestation; the other smaller group may receive home treatment only, or be ignored. The attitude of the parents determines into which group the child falls. The utilization of the child's illnesses by the parents or the child must be the determining factor in our classification of the case as a member of the catarrhal group. The catarrhal child as seen in practice has attached to it a parent with free, floating anxiety, ostensibly related to the child's condition. Utilization of the Illness When a patient attends the surgery, he presents himselfnot because of anatomical or physiological disturbance but for alleviation of his suffering. He offers his practitioner symptoms and signs which are interpreted and translated according to the knowledge, interests, and ability of the individual doctor. When an adult patient is brought by somebody else, we already suspect an abnormal emotional attitude to the illness, in either person or both. This is not so interpreted in paediatric cases. The usual routine is to take a case history from the mother, make a physical examination of the child, and then discuss the case with the mother. The child is rarely asked about his symptoms directly and the meaning of the illness and what it does to and for him is never elicited. This is practice common to both general practitioners and paediatric specialists alike. In dealing with the problem of enuresis, Nichols (1956) found that discussion of the problem openly, with both parents and child resulted in a lessening of tension of the whole family. Reassurance and suggestion to the child, with simple psychotherapy to the mother, could cure the condition. In our assessment of diseases of children care must be taken to differen- tiate between the sufferings of the child and the suffering of the mother. The acceptance of the mother's overt anxiety as a direct result of the child's condition and the neglect of her own emotional problems result in reattendances. Her related, deeper anxieties- THE CATARRHAL CHILD 45 unconscious like her guilt-remain unrecognized and, indeed, neglected. " The child is the prese'nting symptom of the mother" (Balint, 1957). Aetiology A clinical and bacteriological study of respiratory illness was carried out in families of the same size and structure (two parents and three children) living in various types of houses in a working class area of London. The study, which lasted two years, included regular visits by a paediatrician or nurse, who, besides making clinical and social observations, took fortnightly throat and pernasal swabs from all members of the family. Of some twelve social and envirornental factors examined-for example maternal care, range of outside contacts, and dampness of the house-only overcrowding, and with less certainty, inadequate clothing were found to be related to the incidence of acute coryza and chronic catarrh. (Brimblecome et al. 1958). Climate, exposure (especially of the feet to cold), digestive disturb- ances with emphasis on excessive carbohydrate intake, and clothing have at different times been blamed by varying authorities. Research on family infections, dietary habits, social and economic factors have so far failed to show a true causal relationship to the inception of these catarrhal conditions. In countries of temperate climates, a child will be sick ten times as often with colds as with all other illnesses combined. From the age of 2j to 6 the frequency, severity, duration, and sequelae increase; thereafter the incidence falls and fades in the years preced- ing puberty. Despite lack of evidence of any infective process in the chest, nose, throat, and ears, these catarrhal children are the most frequently referred to hospital, and end with tonsillectomy and adenoidectomy, " a prophylactic ritual carried out for no particular reason with no particular result" (Medical Research Council, 1938). The Physical Picture The infants with snuffles, who vomit when forced to feed, and the croupy, wheezy babies give way to the toddlers with sore throats, ear-ache and running noses. The attacks are sudden, dramatic in their onset, with or without high temperature. The child is running about one minute and the next is prone, and cries for help. In pre-school days, snuffles and mouth breathing with some degree of deafness are the usual manifestations. Coughing at night, disturbing the parents' rest brings the change over to mother's bed. Headaches are common with the rise in temperature and the flushed faces. A persistent, ineffective, irritating cough becomes the commonest presenting symptom. The cervical glands are more or less permanently enlarged, irrespective of any acute attacks. Indigestion, bilious attacks, and interference with normal sleep follow mixing with other children at school. Coughs and colds become the excuses for absences. He reaches a new phase in 46 L. A. NICHOLS physical development, shooting up in stature. The associated fevers-measles and pertussis-tend to cause recurrences and re- crudescences of all symptoms, and complications and prolonged bed rest and tardy convalescences are marked. Complaints of poor sleep, poor appetite, and failure to gain weight are now common. He is described as easily tired; is often a mouth breather with a heavy mucoid or mucopurulent nasal discharge; has nausea in the mornings (especially Mondays) sickness and abdominal pain. Examination may show pallor, thin anxious facies, a body with poor musculature, a poorly developed chest and generalized mild hypotonia. There may be a congested nasal mucosa with discharge, large tonsils without obvious infection, small cervical glands palp- able, and a complete inability to breathe through or sniff through either nostril. The chest shows poor shape and expansion, and crepitations which disappear on coughing are audible at both bases. But often the mother's description of the child is belied by its appear- ance. The impression gained is that no organic lesion is present. This is confirmed by x ray, E.S.R., haemoglobin estimation, blood counts and Heaf's puncture, at the insistence of the parents. Examples of the later stages when secondary infection has reached the sinuses are rarely seen today in practice. The child is listless, pale, kypho-scoliotic, underdeveloped, with an open mouth, and said to be perpetually tired and subject to fretfulness. The tonsils and adenoids are permanently enlarged and ear-aches, obstructed breathing, snoring, and sore throats occur with the changing seasons. Chronic posterior nasal discharge may have led to infective episodes in the chest leading to segmental collapse. In the prepubertal stage spontaneous recovery occurs. Gone are complaints of the upper respiratory tract. Recovery occurs irres- pective of any treatment undertaken, and often despite it-whether subjected to the sacrifice of the lymphoid tissues of tonsils and adenoids, the illogical taking of cough mixtures, antibiotics and anti-histamines, throat paints, lozenges, nasal drops, exercises and holidays by the sea and movement by the family to other parts of the country. Case Management On each occasion that a child is presented to me with a cold or manifestations of the catarrhal syndrome, I demand answers from the child himself to the following questions: How does he feel at the moment? What does the illness do to and for him? Does he enjoy his rest in bed? Does he envy his brothers and sisters going off to school? What would he do if mother did not insist on bed rest? Does he find his tiredness more apparent in the morning rather than at TV time? Given encouragement and allowed time THE CATARRHAL CHILD 47 THE CATARRHALCHILD ~~~~~~~~47 to reply the child ably responds. The greatest difficulty is to avoid the mother attempting to answer for him. Often the child is able to give the clue to the problem and the mother should see that her problem and anxiety is not entirely shared by the child. If the mother still reattends with increasing frequency especially in the first school year, I offer her an appointment outside of surgery hours to discuss her specific problems. None have refused to attend for at least one session. Psychotherapy commences. Illustrative Cases Case 1. Mrs P. W. aged 32; boy aged 6. They had been on my list for six months, during which time the boy had suffered from repeated colds, high temperatures, and running noses. Pertussis and some weeks later measles had produced innumerable calls to the house at all hours. Psychotherapy was started when the child in its second week of convalescence after measles was not allowed to return to school. Complaints of his tiredness, his thinness, his inability to eat were belied by his appearance and statements. The child was always well dressed; the house spotless. The mother's history was as follows: her father was a naval captain who had left a wife and four children to marry, bigamously, her mother with whom he lived eighteen years before returning to his legal wife. During this time five more children were borne to him and he spent six months in a mental hospital suffering from depression. The patient's mother then became a barmaid and took to drink. Mrs. P. W. married at the age of 19 a sailor who was due to be posted to the Far East. " Everybody said he was the least likely person they would have thought I would have married ". Her approved-of boy friend was away with the Royal Marines, and never returned. A few months after her marriage her father died. Within a year of her husband's return from the forces she gave birth to a baby girl. The child left hospital with green stools, and when she had asked if the condition was serious, she was assured that it was normal. After she had stayed in her sister's house for six days, her sister's ten-week old infant was taken to hospital with 'pneumonia', and it died there ten days later. In the meantime she had persuaded her doctor to readmit her own child to the hospital where gastro-enteritis led to its rapid demise. She blamed herself for the death of her sister's child and the hospital doctors and nurses for the death of her own. She refused to leave the house, remained unwashed and unkempt, and could not be persuaded to have medical care. This period of depression lasted some four months; then she resumed work as a model. At this time she thought she was suffering from tuberculosis and visited doctor after doctor for reassurance. In 1950 she found herself unwantedly pregnant. Martin was bom in hospital after a difficult labour, and she was readmitted six weeks later for curettage for retained placental products. In hospital she learned that tuberculosis was now curable and decided that her aches and pains must be due to cancer. She felt compelled to listen to all her neighbours and customers' complaints and intro- spected these. She had only to hear of a case of cancer of the breast to feel a lump in her own. She said that if a cure were found for cancer she would develop a fear of polio. She visited the doctor with every minor illness that the boy developed. After some fifteen sessions her anxiety, agitation, guilt and depression were relieved. Since treatment was started I have never had to attend the boy. As she told me recently " Martin is so changed you would never recognize him ". I see the lad frequently in the street and of course his appearance is unchanged. She knows that she can return to me for further treatment when she desires; I am sure that she will. The last two years have amply repaid the 15 hours spent; and on the balance in time spent I have gained. Case 2. Mrs R. F.: Girl aged 8, boy aged 5. The mother made repeated attendances with the boy who had rhinitis and a muco-purulent nasal discharge 48 L. A. NICHOI5s and was a snoring, poor sleeper. At school he was dull and apathetic. The mother admitted that there was trouble at home with the father who was an accountant and had been offered a post abroad, but she was unwilling to accom- pany him. Soon after her marriage, against which she had been warned by his mother, they had spent some two years in the Far East. She was often beaten without apparent reason, and he had acquired a girl friend. She described herself as frigid and her husband as sexually cruel. She took the boy to bed with her whenever he had a cold. Due to the influence of her sister she left her husband, taking the children with her. The subsequent quarrels and open fighting led to court actions and the threat of divorce, and to his twice attempting suicide, first by taking massive doses of aspirin and then by throwing himself under his father's car. He had memories of being locked in his bedroom as a child while his mother was being assulted by his father. Divorce proceedings are in abeyance, but this unhappy marriage of the masochistic, depressive girl and the hysterical, psychopathic man exists only in name. They live apart and he has promised to go abroad alone for three years-the solution of their problem to be left until he returns. The children have been in excellent health and free from colds since his departure. Case 3. Mrs E. C. aged 49. Boy aged 14, girl aged 7. The girl was an unwanted pregnancy early during which there was a threatened miscarriage of unknown cause. The child was born with talipes and the mother was depressed for months. Teething difficulties, innumerable colds, exaggerated reactions to all immunizations, and attendances at the orthopaedic clinics were so numerous that the child was never out of the doctor's sight. She was pampered, fussed over and spoilt, over-clothed and over-fed. She was never allowed out in the rain and was put to bed with the slightest symptom. Psychotherapy helped to relieve this mother's guilt in a few sessions, and the child has entered a new phase. Case 4. Mrs P. D. aged 35 with two adopted, unconnected children, a boy aged 8 and a girl aged 5i, who both presented identical pictures of the catarrhal child. There were fevers lasting for five days, with moist sounds all over the chest and they were often wheezy. The children never looked ill, and there was no response to sulphonamides or antibotics; belladonna and ephedrine in no way altered the course of the illnesses. The children were car sick and feverish at the start of holidays. The infertile marriage was attributed to the removal of a testicle for tuberculosis in adolescence. He was an athlete and could not believe that he was unable to produce a child. The mother attended for one session only and we discussed superficially her unconscious resentment: when offered a further appointment she excused herself. I received no more calls however until her husband was turned down for a life insurance policy to enable them to move down to the coast. The girl was sick " She's got it again, doctor." This child by now loved her rest in bed and the additional comforts she received. Her mother said: " I can do nothing with young John now ", but in the girl she had a most wel- come partner. Case 5. R.F.D. aged 5. This was a case of recurrent pyrexias of 1040F. + with hard dry coughs and recurrent headaches. There was nothing to be found on examination. I was never called until the third day of the fever when I would find a worried father sitting by the bed and a nearly tearful mother. The child looked at me almost defiantly. The onsets of his attacks were the sequels of his father losing his temper and striking the child, and despite the father's contrition during the next and subsequent days, the fever never seemed to clear until my Mist. Aspirin had been dispensed. The father knew that the child goaded him into the attack but despite his efforts at self-control the beatings continued, THE CATARRHAL OULD 49 Discussion The emotional picture takes cognizance of reactions of both mother and child. The child's reaction to his own illness; the factors precipitating it; the warmth and comfort of bed; the attempts at spoiling; the singling out from the siblings for extra favours; and the holding up of the parents to ransom are all concerned, even when the inner need for retributive punishment is causative and the child hates the enforced rest these factors may be elicited. The mother's overt anxiety is accepted as a direct result of the child's condition and leads to neglect ofher own emotional problems. Her continuous anxiety, despair, guilt, and agitation become trans- ferred to the practitioner. In my own practice the primary reason for my referral and admission to hospital of children with varying phases of sino-laryngo-tracheo-bronchitis is my own anxiety about prognosis. The amount of anxiety is related more to the agitation and despair of the parents, than to the course of the illness. This seeking of further advice and treatment-this dilution of responsi- bility-is resorted to so as to relieve the child, the parents, and the doctor from an accumulated tension. Most of these children belong to the over-protected type: the over-indulged child, the result of the mother attempting to make up for what she missed in her own unhappy childhood; or the child towards whom the mother is basically hostile, but proves otherwise to the outside world by spoiling overlove. Again, the mother uses the child as her love object, concealing her unconscious estrange- ment from her husband and producing if she can, the timid, depend- ent, clinging child. The emotionally insecure and immature, unable to face responsi- bility as parents, punctuate their description of the child's illness with self blame. " I let him go out without his overcoat ". The mother in attempting to mould the child according to her own complexes must inevitably meet resistance as the child reaches out for independence. If she succeeds the child may even enjoy his dependency and sickness. The child's growing-up problems, his natural development, his reaching out for independence occur at this period. Can it be pure coincidence that the incidence of catarrhal infections increases throughout the pre-Oedipal phase to reach maximum intensity in the Oedipal phase, and diminishes to complete disappearance in the prepubertal? Not all cases of catarrhal children are seen by the doctor. At least half of the cases at risk may be seen at varying phases before commencing school. It is then possible to assume that the number of catarrhal children in a practice exceeded by far the non-catarrhal, so L. A. NIC'H'OLS and to postulate that the catarrhal child is a normal child, passing through a phase of development. The fact that the maximum incidence of demands for treatment of the symptoms and signs of this phase occur at the first year of school life has led to the accept- ance and widespread belief that they are caused by infections, " germs " passing from child to child. But where lie the pathogens? Not in the sore throat, and not in the tonsils nor adenoids. Nor in the running nose of the child that neither sniffs nor blows. What is the family doctor expected to treat? A natural hypertrophy? Mechanical, irritative, and obstructive features of the upper respiratory tract? This happens at the time of the Oedipal situation, when the child's growing up problems, his jealousies, fears, difficul- ties of adjustment, his search for independence, and his loves and hates are disturbing him. These stress symptoms are the child's natural method of conversion of his anxiety to focus attention or to hide his problem. Those cases of catarrhal children who are repeatedly brought to the doctor and whose parents agitate for more and more treatment are those in which the so-called illness of the child is utilized to focus attention on the mother's own free, floating anxiety. Her underlying guilt and depression remain unrecognized and indeed neglected. The mother in effect is pleading with the doctor to be helped; " I am this child; relieve my despair, and save me ". Her unintelligible plea, the guilt it arouses in the doctor, leads to the final sacrifice, the removal of the tonsils and adenoids. The child, whose symptoms have already been caused by his guilt, suffers the punishment and finds relief just at the time when the cycle of normal development was taking him into a quiescent phase pre- paring him for puberty. The result of operation relieves the mother very temporarily and the assessment of improvement is mainly of her own condition. This is so often seen with the mother's later attendances for psychosomatic complaints when the child is well. If, then, these symptoms do occur universally and are normal how can the time factors of incidence, maximum intensity and evanescence be explained? Cycles of behaviour occur in children when placidity gives way to aggression in their drive to independence. At 24 the child appears to demand that he stand on his own feet. At six there is a definite turning away from mother and he shows his defiance openly. By the age of nine, independent of both parents, boys especially begin to formulate a new relationship, of co-opera- tion and understanding tolerance. If tears are universally accepted as a sign of unhappiness, why cannot a running nose be conceded an indication of tension? The child, with an anxiety-prone mother who attempts to mould THE CATAR.RHAL CmLD 51 him -according to her own immature needs and complexes, must of necessity pass through more stormy passages than the child of a more mature adult. His attempts to break away to independence causes tension. Expiation and relief come through his symptoms. Conclusions It is postulated that the catarrhal child is a normal child, whose symptoms are no encumbrance to him. The signs and symptoms however are utilized by parents with free-floating anxiety and guilt in an attempt to focus attention to their own problems. These are unconscious in the main and amenable to psychotherapy. A small group of children have reactions from disturbances of their own psyche. A secondary hypothesis is formulated that the attacks align themselves at the periods of development when the child attempts to assert himself, and in particular turns away from the mother. It is these positive facts rather than the negative findings of research into the aetiology of the condition which must be considered in our attempts at cure. Symptomatic treatment for the relief of pain, and discussion of the child's difficulties with the mother combined with psycho- therapy have produced satisfactory results. The resultant lessening of tension in the mother, and the relief of pressure on the child has led not only to amelioration of the child's symptoms but also to a positive healthier attitude to life by the whole family. The undoubted lengthy time required for treatment (hourly interviews at weekly intervals) has been adequately compensated for later, by a gross diminution of attendances for many other psychogenically-determined complaints. Summary The aetiology of the catarrhal child reveals no positive evidence of allergy, infection, dietetic errors, social, geographical or environ- mental factors. The clinical picture is ofheadache, ear-ache withtransient deafness, nasal catarrh, sore throat and cough. Vomiting in infancy with elimination difficulties are common associates. No specific treat- ment avails. The natural history shows onset at 2j, reaching a maximum incidence of attacks in the first school year, 5 to 6. The attacks fade by the eighth year, and the child is free before puberty. All children pass through these phases, yet 50 per cent are constant attenders at the general practitioner's surgery. There is a definite correlation between the frequency of attendances and the amount of anxiety expressed by the mother. This free-floating anxiety is readily accepted as a result of the child's indisposition, and deeper 52 L. A. NICHOLS unconscious mechanisms are ignored. The cases can be managed by discussion with the child andmother and specialpsychotherapeutic sessions to allow her relief through expression. Translation affords her opportunity towards emotional maturity, avoidance of pressure on the child and relief from later psychogenic symptoms. The theory is supported that the syndrome formation is psycho- genically determined at phases of the child's development when he attempts assertion and independence.

REFERENCES Kempton, J. J. (1954), Refresher course for general practitioners, B.M.A. Lond., vol. 2, p. 344. Platt, Robert (1957), Research Newsletter, 4, 149. Nichols, L. A. (1956), Lancet, 2, 1336. Balint, M. (1957), The doctor, the patient andhis illness. Lond. p. 32. Brimblecombe, et al., (1958) Brit. med. J., 1, 119. Medical Research Council (1938). Spec. Rep. Series No. 227. H.M.S.O. Lond.

A Survey of Accidents in Old Age. J. F. FLEETWOOD, M.B., D.P.H., Journal of the Irish Medical Association. (October 1958) 43, 292. A series of 380 accidents to people over 65 years old was collected from general practice and hospital sources. The results were ana- lysed to determine the social, personal and family elements involved. The following recommendations were made: that adequate fire- guards are needed; that motorists realize that old people are as un- predictable as children; that thorough physical examination is needed of any old person who falls for no obvious reason; that heights and cycling should be avoided by those whose reflexes are slow, or who are liable to syncope; that adequate nursing super- vision is needed by the bed-bound aged, both at home and in in- stitutions; and that non-slip floor coverings are best. These simple precautions would prevent most of the accidents that occur to old people.