Infantilism

INFANTILISM, infantilismus (from Latin infantilis - childish), retardation of physical and psychological development. The name was first proposed by Lasegue. In 1871, Lorain described under this name a specific type of persons with delayed general development who retain all youthful features in terms of growth, body proportions, and psychology (Lorain's type). Loren attributed great importance to tuberculosis, congenital syphilis, malaria, and pellagra in the etiology of the disease. A further stage in the study of I. was the work of Brissaud, who in 1894 gave a description of another infantile type (see Brissaud's disease), retaining as a result of halted development not youthful, but childlike body proportions and psyche (Brissaud's type). Brissaud and especially Hertoghe considered the etiological basis of these diseases to be hypofunction of the thyroid gland and classified them as abortive forms of myxedema. Further research showed that the causes and clinical picture of I. can be very diverse. I. can be hereditary and acquired as a result of various diseases of early childhood, as well as unfavorable external environmental conditions ('dystrophic I.'). In addition, Brissaud, Meige, Gandy, and others introduced the concept of late I. - the appearance of the I. syndrome with the disappearance of secondary sexual characteristics and restoration of childlike features in a previously normal adult. Anton proposed a rather extensive classification of infantilism, distinguishing between general and partial infantilism. General infantilism includes: a) infantilism with myxedema and cretinism; b) mongolism; c) I. due to absence or hypoplasia of sexual organs; d) I. with primary disease of other endocrine glands, mainly adrenal, thyroid, and pancreatic; e) dystrophic I., which includes: 1) I. in hypoplasia of blood vessels; 2) I. in primary brain diseases; 3) I. in congenital syphilis; 4) I. in alcoholism and other intoxications of parents (lead, mercury, etc.); 5) I. as a result of various diseases and metabolic disorders acquired in early age (tuberculosis, chlorosis, heart defects, pellagra); 6) I. on the basis of poor hygienic living conditions and starvation of children. Partial I. includes: a) underdevelopment of sexual organs; b) I. in defects of the cardiovascular system; c) I. of the voice and vocal organs; d) absence of beard and body hair in a person with fully proportional build; e) psychological infantilism. Peritz distinguishes: 1) I. on the basis of disease of endocrine glands (Brissaud's type); 2) dystrophic I. in diseases of other organs (Loren's type) and 3) psychological I. Peritz includes in endocrine I.: a) dysthyrogenic I. due to insufficiency of the thyroid gland, b) dysgenital I. in underdevelopment of sexual organs and c) pluriglandular I., depending on multiple disease of various endocrine glands. Borchardt considers infantilism as a developmental delay (subevolutionism) and includes in it cases in which by a certain age the corresponding average degree of development is not achieved. Accordingly, he divides general I. into 1) hereditary I. (on the basis of a pathologically altered growth stimulus); 2) I. due to damage to the embryo (alcohol, lead, X-rays, etc.); 3) endocrine I.: a) dysthyrogenic, b) hypophyseal and c) pluriglandular; 4) dystrophic I. on the basis of: a) early (often intrauterine) infection with syphilis, tuberculosis, leprosy, malaria, pellagra, echinococcus; b) nutritional disorders; c) early intoxication (alcohol) and d) congenital or early-developing heart defect. Based on a broad understanding of I., some authors also included clinical pictures such as eunuchoidism, dystrophia adiposo-genitalis, cases of dwarf growth regardless of the presence or absence of other symptoms of I. But already Falta speaks against such confusion of essentially different clinical forms, limiting I. to those cases in which the halt of development at the childhood stage and growth retardation are accompanied by underdevelopment of sexual organs, lymphatic apparatus, delayed development of bone nuclei, non-closure of epiphyseal zones, preservation of childlike proportions of limbs and mental retardation. Recent authors (Molchanov, Hegler) include in I. only cases of general developmental retardation, isolating growth retardation into a separate form of nanism and requiring that for the diagnosis of I. at least the main symptoms of general developmental retardation be present, namely - growth retardation, mental retardation and sexual maturation. In addition, Molchanov proposes to isolate endocrine forms with more or less definite localization of lesion from the general concept of I. and speaks in these cases of hypothyroidism, or thyrogenic nanism, etc. Zondek adheres to the same opinion, but points out that there are cases of thyrogenic I. which, in their habitus, development of sexual organs and psyche, present all signs of I., but without any obvious symptoms of hypothyroidism. In view of the insufficiently clarified function of individual endocrine glands and their undeniable connection with each other and with the nervous system, the definition of I. as 'general retardation of development of the entire organism (subevolutionism, according to Borchardt), in which the arrest of development of the skeleton, sexual organs, blood and lymph circulation apparatus, hematopoietic organs, nervous system and psyche represent coordinated phenomena' (Lederer) still fully retains its significance. Both infantile types - Loren's type and Brissaud's type - have the following common symptoms: growth retardation, underdevelopment of sexual organs, absence of secondary sexual characteristics (beard, mustache, hair on the pubis and armpits) and underdevelopment of psyche. In other respects, Loren's type differs significantly from the endocrine Brissaud's type. Many transitional forms are also encountered. Loren's type, with very small overall body size, is distinguished by proportionality of its individual parts, slenderness and delicacy of build; the chest is narrow, bones are long, thin; the skin is delicate, smooth, without signs of edema; the voice is high, childish; epiphyses are often fused; bone and muscle protrusions are clearly visible due to the absence of covering fat. Psychically, they sometimes show greater or lesser degrees of retardation and childishness, but often are almost completely normal. For Brissaud's type, with small height, there is disproportionately large head, round fleshy face, thick protruding lips, puffy eyelids, sparse eyelashes and eyebrows, flattened nose. The trunk is cylindrical with a large protruding abdomen; the navel is located low; the lower extremities are short, the fatty layer is abundantly developed. The skin is puffy; bone nuclei are underdeveloped, epiphyseal zones remain closed for a long time; proper eruption of teeth is disturbed. The thyroid gland is mostly reduced. Metabolic processes, including gas exchange, are decreased. The psyche is childish; patients are either frivolous, fearful, irritable and tearful or are sluggish, drowsy, inattentive and inactive (see below - psychological infantilism). The female infantile type is characterized by underdevelopment of mammary glands and the entire sexual apparatus; the waist indentation is barely outlined, hips are narrow; menstruation is absent. In Loren's type I., hair is long, thin, silky; eyelashes are long. For thyrogenic I., changes in bones toward osteoporosis or rickets are characteristic, and in hypophyseal I., growth retardation comes to the fore; the psyche mostly corresponds to age. In hypophyseal I., all body dimensions are very small, but proportional; the skin is normal or slightly flabby (so-called geroderma), bone nuclei and epiphyseal lines correspond to age (Breitman). Sexual maturation sometimes proceeds normally, but often sexual organs and their function remain underdeveloped. Pluriglandular I. is distinguished by variety of symptoms depending on the degree of participation of one or another gland and on the age at which the disease occurred. Hunt, Fletcher, and others described cases of 'renal I.' in which, along with developmental retardation, there was chronic interstitial inflammation of the kidneys; during life in these patients, increased thirst, polyuria with slight albuminuria and low specific gravity of urine and changes in the skeleton resembling late rickets were observed. These children are very unstable and easily die from infections. At autopsies, in addition to changes in kidney tissue, mild arteriosclerosis, slight hypertrophy of the heart and decalcification of long bones were found. 'Hepatic I.' has been described by many authors (Tissier, Lereboullet, Falta, Pfaundler); in these cases, various organic diseases of the liver lie at the basis, causing profound disorders of its function. In 'pancreatic I.', which some associate with intestinal I., in addition to general developmental retardation, chronic diarrhea and meteorism are observed.

Under the name of primary infantilism, some authors distinguish cases where development stops completely unexpectedly and without any visible causes in children of any age ('atelleiosis,' according to Gilford). In such patients, the face and even in mature age retains childish features and expression, the head is comparatively large, the lower extremities are short, and gradually all the typical signs of infantilism develop. A separate group of mental infantilism includes cases where mental retardation is the only symptom, not accompanied by a delay in physical development. In rare cases, infantilism is combined with symptoms of premature aging and withering. Almost all infantilics show signs of anemia and a slight lymphocytosis; blood pressure is low. The prognosis in infantilism is not particularly favorable; in general, the life span of infantilics is short, as they are easily influenced by external harmful factors and poorly tolerate infections. Treatment for dystrophic forms consists of improving nutrition and general hygienic living conditions. As for endocrinological infantilism, a therapeutic effect is obtained only in those comparatively rare cases when infantilism develops entirely on the basis of hypothyroidism or diseases of the pituitary gland and pancreas. Organotherapy with thyroid gland preparations gives favorable results. The effect of other preparations is less reliable. Intestinal infantilism, or Herter-Heubner disease (celiac disease), was first described by the Scottish physician Gee in 1888 under the name coeliac affection, i.e., 'disease of the abdomen,' and was thoroughly studied by Herter and Heubner. The disease is rare, affecting mainly children aged 2-4 years; after 6 years it is almost never encountered. The basis of the disease is the body's inability to digest and assimilate food, mainly fats and carbohydrates. The causes of this weakness of the digestive organs are still unclear. Herter attributes intestinal infantilism to microbial diseases and sees the cause of the disease in the abnormality of the intestinal flora, which retains the characteristics of the flora of an infant longer than the normal period. Heubner considers the main cause to be a congenital constitutional weakness of the digestive apparatus. Patho-anatomical changes present nothing characteristic; they consist of atrophy of all digestive and endocrine glands. Symptoms. The disease either begins suddenly with unexpected diarrhea or develops gradually, often following some acute illness. In the latter case, the child becomes listless, capricious, irritable, insomnia appears, sometimes muscle twitching; he loses weight, becomes pale, the skin and muscles lose their elasticity, and finally diarrhea appears. The stools are not frequent, 2 times a day, but extremely abundant; sometimes the total amount significantly exceeds the daily amount of food. The stool is usually mushy, foamy, with a sharp odor (putrid or sour, depending on the food), containing a lot of undigested fats, and sometimes carbohydrates as well. The abdomen noticeably increases in volume, showing signs of false ascites during diarrhea due to the intestines being filled with fluid. From the very beginning of the disease, weight stops increasing, and with the appearance of diarrhea, a sharp drop in weight is sometimes observed; at the same time, there is a complete stop or a noticeable delay in growth. Appetite is sometimes completely absent, sometimes abnormally increased. Temperature can remain normal all the time. At times the child's condition improves, diarrhea stops, weight increases somewhat, appetite and strength return. Then unexpectedly a relapse occurs (diarrhea and a sharp drop in weight), and such alternation of improvements and deteriorations is observed throughout the entire disease. Gradually the patient acquires a characteristic appearance: with very small stature and a pale, slightly puffy face, a huge protruding abdomen, thin, emaciated legs, pale flaccid skin, atrophic musculature. The immediate cause of the disorder is poor absorption and disturbance of metabolism in the form of poor assimilation of fats and carbohydrates; proteins are assimilated better. The disease is often accompanied by various complications, most often tetany, less often-edema, osteoporosis, and avitaminoses (scurvy, xerophthalmia); it lasts for many months, sometimes years. The prognosis, however, is quite favorable. In most cases, relapses gradually become less frequent and weaker, and the child recovers; but such children often remain weak and incomplete people for their entire lives. In treatment, it is necessary to primarily ensure adequate nutrition. Most authors agree on the exclusion of cow's milk, fats, soluble carbohydrates, and cellulose from the diet as much as possible. Food should consist mainly of proteins and flour (insoluble carbohydrates). Cottage cheese, eggs, vegetarian soups, vegetable and fruit, carefully pureed, crackers, white bread, flour porridges, meat are allowed. Of fruits, bananas are best tolerated. In the most severe cases, even in older children, it is necessary to return to mother's milk. Enzyme therapy is recommended (as in the closely related pancreatic infantilism)-pancreatin, takadiastase.

r, lunts. Infantilism in women. I. - a concept whose scope and content are not yet fully established; therefore, its definition varies among different authors. -I. is apparently observed more frequently among women than among men, which led Mates to speak of a 'physiological predisposition of women to pathological infantilism.' In obstetrics and in gynecological diseases, I. plays a major role and often manifests itself through a series of important general clinical symptoms and serious consequences. The general morphological signs of an infantilized woman are as follows: small stature, semi-childish features, a small (bluntly shaped) nose, a naive facial expression, a delicate and fragile build, thin bones throughout the skeleton and particularly of the pelvis, poorly expressed secondary sexual characteristics (absence of typical female fat deposits in certain areas, sparse hair in the armpits and on the pubis, underdeveloped mammary glands, an underdeveloped, usually uniformly shallow pelvis). There may be deviations from this typical habitus, for example, women of tall stature and robust build, but with signs of partial and specifically sexual I., or their bodies are covered with long, thick, light-colored hair (with atypical distribution), which here is explained at all not by an intersexual tendency, but by the preservation of a fetal characteristic (lanugo hair). The characteristic features of the sexual apparatus of an infantilized woman are as follows. In the presence of the aforementioned sparse hair on the external genitalia - noticeable underdevelopment of them; a narrow vaginal entrance, shortness, narrowness and inelasticity of the entire vagina, poorly expressed vaults, a poorly developed portio vaginalis uteri; generally a small, underdeveloped uterus, with its cervix being relatively larger than the body contrary to the norm; the uterus is usually sharply bent forward (acute-angle anteflexion), with a very narrow, as if stenosed, internal os; underdeveloped ovaries and Fallopian tubes, which are difficult to palpate; the ovaries are often located very high, which corresponds to the embryonic state when their descent has not yet occurred, and the Fallopian tubes are highly convoluted, which also indicates a halt in development at embryonic stages. Of course, various disorders of all sexual functions are also associated with the aforementioned deficiencies of the sexual apparatus. Due to the late maturation of the entire organism, menstruation sets in late, does not establish itself for a long time, remains scanty and very painful; besides oligomenorrhea and dysmenorrhea, in some cases prolonged amenorrhea can be observed, while in other cases, on the contrary, polymenorrhea and profuse menorrhagia. The infertility observed in I. often depends less on the aforementioned anatomical peculiarities of the uterus, which to some extent impede the penetration of spermatozoa, than on the reduced ability of the ovaries to produce mature eggs or even on the complete absence of ovulation. It is also well known that infertility and myomatous degeneration of the uterus relatively frequently coincide. If pregnancy does occur in cases of not sharply expressed infantilism, it often proceeds with a series of complications: all symptoms of pregnancy often have a pathological character, such toxicoses as intractable vomiting are not uncommon, spontaneous abortions and premature births are quite frequent. If pregnancy does end in timely delivery, the unreliability of the uterus as a contractile and expulsive organ is clearly evident in all stages of labor and afterward. The complications associated with this are as follows: poor (weak, infrequent and short) contractions in both the first and second stages of labor; their often protracted nature requires therapeutic as well as operative intervention; the atonic state of the uterus is particularly noticeable in the third stage of labor, leading to retention of the placenta and dangerous atonic hemorrhages. Atonicity of the uterus in the postpartum period leads to its subinvolution, which also contributes to infectious diseases. Finally, the generally narrowed pelvis, typical of sharply expressed I., often requires one or another operative intervention, as the soft parts of the birth canal in an infantilized woman often turn out to be rigid and inelastic and therefore offer considerable resistance, so operative deliveries, and often spontaneous ones, are associated with the danger of significant trauma to the cervix, vagina and (usually high) perineum. To this is added the weakness of the abdominal press musculature, which of course hinders the normal course of the act of delivery, and later leads to enteroptosis with all its diverse consequences. I. of the mother directly or indirectly affects the offspring: all the aforementioned complications sometimes lead to its premature appearance; severely proceeding labors can end in stillbirths or the birth of children with low viability; finally, infantilized women, due to underdevelopment of the mammary glands, are often poor wet nurses. All that has been said applies only to first motherhood, as an infantilized woman, who has successfully passed through all the trials and dangers associated with it, usually, as clinical experience shows, develops to the norm both morphologically and functionally. Apparently, hypertrophic and hyperplastic processes associated with pregnancy, which stimulate the activity of all organ systems without exception and train them, indeed contribute to the maturation of the infantilized female organism to a normal level. Among other manifestations of sexual I., which are comparatively rarer, one can mention a certain predisposition 1) to ectopic pregnancy due to the convoluted nature of infantilized Fallopian tubes, 2) to tuberculosis of the sexual organs, noted by some authors, 3) to a comparatively more severe course of all inflammatory processes in general, and 4) to an anomaly of position in the form of congenita retroversio-flexio uteri or ante-flexio retroposita. The peculiarities of the psyche of infantilized women are interesting, for which, as well as for their somatic sphere, typical features of childhood age and character are typical (psychic I.). Associated with this are the following peculiarities of the psychological makeup: usually a mobile character, a sanguine temperament, instability (lability) of mood, light, lively reactions to all impressions of the external world; all this is sometimes strikingly evident at first glance at the face of an infantilized woman. Upon more detailed observation, certain typical properties of childish psychology attract attention. Since an infantilized woman is generally insufficiently differentiated in a sexual sense, it is not surprising that her sexual psyche is also underdeveloped; she reacts comparatively weakly to all psychosexual stimuli. This phenomenon probably finds explanation in the reduced production of hormones, those 'libidogenic substances,' which stimulate the main psychosexual center. Coitus usually does not give her the fullness of sensations characteristic of a normal woman, all the more so as it often turns out to be painful for purely mechanical reasons. After a successfully completed pregnancy, the phenomena of psychic I. and sexual indifference usually become considerably smoothed out. Since the basis of I. is anatomical deficiency, the prognosis and treatment of sharply expressed cases would seem to be discouraging. However, even old physicians empirically recommended marital life and pregnancy for chlorosis and hysteria. And indeed life experience convinces us that already under the influence of normal sexual life in chlorotic, infantilized and asthenic-infantilized girls, a more distinct manifestation of all secondary sexual characteristics and maturation of the lagging organism is observed. Of course, in severe cases of I., pregnancy (if it occurs at all, which seems unlikely) cannot play the role of a 'therapeutic agent,' as it is associated with great dangers for such a low-value, poorly fit for motherhood organism and can therefore further worsen the situation. In mild cases of I., pregnancy undoubtedly proves to be a powerful therapeutic factor.

e. Kurdinovsky. Mental infantilism is characterized by a halt in the development of the psyche at a child stage. Phenomena of mental infantilism may also occur in a child, in whom characteristics of childhood typical of an earlier age are observed. Clinically, the mind of an infantilistic person appears as follows: perceptions are superficial; what is seen and heard is usually reproduced imperfectly; attention is more attracted by external stimuli, and therefore is extremely unstable; the ability to remember, according to Pende, amounts to ²/3 of the norm; the formation of concepts in an infantilistic person is insufficient in both quantity and quality; general concepts are vague and unclear; the essential and the accidental are not sufficiently separated from each other; the knowledge of an infantilistic person is meager; newly acquired material is usually associated along the lines of emotionally colored memories; judgment is superficial, hasty, and often stands in close dependence on firmly grasped representations and on experienced moods. In his reasoning, the infantilistic person is prone to invalid generalizations, for which reason his entire worldview differs from childish naivete and narrowness of outlook; there often exists a kind of fear of the new, unknown, untested. The behavior of the infantilistic person proceeds within the framework of reactions of an underdeveloped subject. On the one hand, it is insufficiently serious, i.e., carefree and frivolous; in addition, crude egoism, vanity, boasting, and a tendency to capriciousness are revealed; on the other hand, the infantilistic person is resentful, timid, shy, unsure of his abilities, and prone to fears. In his actions, he lacks independence, readily follows the suggestion and example of those around him, and adapts with difficulty to new people and situations. He reacts to unpleasantness with tears; he easily falls into a depressed state. The infantilistic person, generally speaking, is little capable of regular serious work, loves to spend time in amusements, strives for pleasures and for a change of impressions. Serious life tasks are beyond his power; rarely does he occupy an independent place in society; his attempts to work are unorganized and disorderly; most often, throughout his life, he remains dependent on his family. The infantilistic person, however, knows how to relate to himself critically, to recognize and evaluate his weak sides. Often he deeply suffers from the feeling of his own inadequacy, and sometimes the awareness of inferiority pushes him to produce a series of hypercompensatory formations and fantasies. The infantilistic person is prone to distortion of the surrounding reality. Here both the childish tendency to fantasy and boasting and the tendency to replace unattainable aspirations with fiction play a role. The above-mentioned tendency to follow others, including bad examples, often leads the infantilistic person to frivolous behavior and to conflict with the law, but he usually does not go as far as pronounced antisocial actions. Often, in contrast to the above-mentioned characteristics, individual traits of character can be seen in the infantilistic person that also occur in a mature subject, for example, punctuality in the performance of his duties and especially of others' prescriptions, increased neatness and pedantry in relation to clothing, handwriting, manner of speaking. The speech of the infantilistic person often sounds like a lesson memorized in class, due to artificial intonations. Among psychotic phenomena, hysterical reactions and obsessive formations are characteristic of the infantilistic person. As the infantilistic person approaches the age of sexual development, he begins to differ more and more sharply from the normal subject. He remains alien to the entire sum of moods and mental changes characteristic of the pubertal period. Sexual desire may be diminished or may be absent altogether; often it manifests itself in a perverted form. The absence of secondary sexual characteristics in the pubertal period leads to a deepening of the already mentioned feeling of inadequacy. Kronfeld and Hirschfeld proposed the concept of psychosexual infantilism, meaning a delay in the development of sexuality in such a subject at the infantile stage. Besides general mental infantilism, Kraepelin proposed the concept of partial mental infantilism. Here the question is of a halt at the child stage of development of individual properties of the psyche (especially in hysteria, paranoia, and other psychopathies). Mental infantilism may be the only manifestation of developmental delay, but much more often it goes hand in hand with somatic infantilism. Individual traits of mental infantilism are also characteristic of the endocrine forms of developmental delay of the Brissot type, but here along with infantilism there are also obvious defects of the psyche, one or another degree of feeble-mindedness, which, generally speaking, does not in itself belong to the concept of mental infantilism.

t. Simeon.