The pronounced theatrical element which characterizes these forms of delirium as well as the stuporous states and the hysterical forms of somnambulism--..mally renders the diagnosis clear at once. In the main these sevzre forms of hysteria in older children, not excepting the occa sional prominence of sexual and erotic concepts, so closely resemble the manifestations of hysteria in the adult that a separate description appears to be superfluous in this place.
Among disturbances of the special senses, deafness and blindness of one or both eyes are the most frequent in childhood, but they are absolutely rare manifestations of hysteria at that period of life. For one who is acquainted with these phenomena in the adult no special description is necessary.
In connection with the forms of hysteria which imitate nervous diseases brief mention may be made of a few manifestations simulating surgical diseases of the bones, joints, muscles, tendons, etc. Con tractures of the muscles of the front and back of the neck, when uni lateral, may simulate torticollis, and when bilateral, cervical spondylitis. Elevation of one shoulder, rigidity or kyphoscoliotic curvature of the vertebral column, in which attempts at reduction arc accompanied by fixation of one hip-joint as in beginning coxitis, and many other symptom complexes of the same kind may be produced by hysterical muscular spasms. The diagnosis in practically' every case can be made on general grounds, particularly on the sudden onset after some insignificant physi cal injury or psychic insult, the "massivity" of the pains, and the absence of any cause for a corresponding organic disease.
The hysterical pictures which simulate diseases of the respiratory organs as a rule develop from corresponding organic affections hy auto imitation, as above briefly described, or as a permanent manifestation of the antecedent disease. Although they have only recently begun to be properly appreciated (Thiemich), and we have only a few isolated reports from earlier Hines, they are well worthy- of careful attention on the part of the physician. For example, if a child has ever suffered front tachypncea and dyspncea as the result of extensive bronchitis.. it may later, whenever it has the slightest catarrh, exhibit the sante symptoms either as psychic phenomena or through an hysterical reproduction of its former diseased state. In an entirely.similar manner a spasmodic cough, possibly with violent striclor, an asthmatic attack and the like may be reproduced hysterically. In order to recognize this change in the con
dition of affairs, which is particularly difficult for the attending physician who has seen and treated the patient during the primary organic disease, a painstaking objective examination must be made, bearing in mind the general diagnostic features of hysteria. The importance of making a correct diagnosis from the therapeutic standpoint will be referred to later.
Hysteria in children is not infrequently localized in the digestive tract and associated organs. Anorexia, vomiting, carcliospasm, diarrhcea, constipation, meteorism, incontinence of feces, prolapse of the anus and the like may be due to hysteria. The anorexia, which is probably primarily- produced by some organic disturbance, may in severe cases (Soltrnann, Kissel, Bruns and others) go on to an alarming state of inani tion threatening the child's life. In many- cases the refusal to take food can be overcome by simply placing a tray in front of the child instead of trying to force it to eat. When the child finds it is not under observation it will satisfy its hunger of its own accord. In other cases gavage will not only prevent the extreme effects of starvation but also affect a prompt cure of the anorexia through suggestion. Hysterical vomiting is usually recognized at once by the ease with which the act is performed, just like a volitional act. Merely awakening the ehild in time for school or a harsh word may suffice to bring on the vomiting. The prompt result which follows a single introduction of the stomach tube for diag nostic purposes confirms the diagnosis of hysteria. An instructive case of cardiospasm in a child two years old, which was also promptly cured by passing a tube, was observed in the Breslau Children's Hospital (Freund). Psychic diarrhma, that is to say, evacuation of feces, normal except for their frequency, sometimes persists a long time after the subsidence of an organic intestinal disease. It resists all astring ent remedies but yields at once to faradization of the abdomen, a pro cedure which has been soberly recomtnended as a treatment for diarrheea although it cannot act in any- other way than by suggestion. Constipa tion may develop in the same way, or rather may become a fixed habit from psychic causes, even aside from those eases in which the child has simply forgotten how to evacuate its bowels spontaneously.