The Catarrhal Child L .A

THE CATARRHAL CHILD L .A. NICHOLS, M.R.C.S., L.R.C.P. Sidcup In general practice, illnesses involving the upper and lower respiratory 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 difficulties 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.

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