HYSTERIA Aside from a group of special features, which will he sufficiently emphasized in the present chapter, hysteria in childhood does not differ essentially from the same disease in adults. The same difficulty is encountered in defining the limits of this "great neurosis" which separate it from the adjoining territories of epilepsy and neurasthenia. It there fore becomes a duty which requires no further justification to begin by defining what we mean by hysterical symptoms, since there is no generally accepted definition that explains the intimate nature of the disease. Investigations by Charcot and his pupils have shown that most of the apparently somatic symptoms of hysteria are really psychic. Mobius expressed this thought in precise terms as follows: "Hysterical symptoms are those which are caused by concepts, including among concepts not only intellectual, but especially emotional states of excite ment." According to this view "all hysterical phenomena take the form of suggestions; but some of them, judged by their content are not suggested and represent merely a morbid reaction to emotional stimuli (movements)." This definition of hysteria has now been accepted by most authors, among them especially L. Bruns, who is an authority on hysteria in childhood, although rejected as too narrow by some, as for example, Binswanger. Charcot himself appears to take a. broader view of hysteria and "recognizes in hysteria, in addition to psychic manifestations of disease, other equivalent morbid phenomena which he attributes to nervous or dynamic disturbances" (quoted from Binswanger).
While we do not wish to lose ourselves in a profitless discussion of these controversial questions, we wish, in order to present this subject in as clear a manner as possible, to state at the outset that, in determin ing what is hysterical and what is not, we adopt the viewpoint of Mobius and refer all "dynamic" disturbances caused by concepts, to the depart ment of neurasthenia, as explained in the chapter devoted to that disease.
By the term concept, let it be repeated once more, we understand not only a clearly- defined intellectual mental process but also and chiefly- the emotional states.
For the purpose of practical diagnosis it is well to remember that the expression "due to psychic causes'' is approximately equivalent to "capable of being simulated." Whatever cannot be effeeted by exertion of the " will," even after repeated practice or under the influence of intense emotion, is not hysterical. It follows from this definition that
there is a lower age limit for the occurrence of hysterical disturbanees. After the occurrence of typical hysteria before the age of puberty had been recognized as not altogether rare, certain French authors (Chaumier, 011ivier and others) eontended that hysterieal manifestations may be observed even in infancy. Among these hysterical manifestations there are mentioned emotional symptoms, such as violent maniacal outbursts of rage, syncope, convulsions, conditions resembling meningitis, absence of the conjunctival and pharyngeal reflexes, strabismus, nystagnius, disturbances of respiration, palsies, contractures and the like. Admitting the functional nature of all these phenomena, we must insist that the most important of them, aeeording to our view, belong to neurasthenia and not to hysteria, and that, although Pitres has demonstrated that many children who present symptoms of this kind during infancy later develop hysteria this does not prove the contention. We are justified in regarding the end of the first period of childhood, or say the beginning of the third year of life, as the lowest age-limit for the appearance of hysterical symptoms. It is true that at this early age hysteria is rare and that it gradually increases in frequency after that period. It seems questionable, however, whether this period also is eapable of being subdivided into definite stages, especially as it has been maintained that the frequency of the disease undergoes a rapid increase when the child begins to go to school. It certainly- cannot be proved by existing statistics because they do not take sufficient account of certain forms of hysteria, which are particularly frequent in childhood and which we shall describe in detail later on. At all events, there are more important faetors than school work and increasing age in the etiology of juvenile hysteria. No attempt will be made to give statistics in regard to the frequency of hysteria in the two sexes for the same reasons that none are given for the different periods of life. It may be positively stated, however, that there is a slight preponderance in girls which becomes more marked as puberty approaches and gradually approximates the conditions obtaining among adults.