It must be pointed out, however, that constipation, as well as anor rexia and vomiting for that matter, may be caused by an imperative idea or, in other words, may be due to psychic but not hysterical causes. Thus, the fear of being poisoned is often present in anorexia. In two cases of retention of feces, observed by Neumann in young boys, the cause was found to be disgust and loathing of the act of defection. "It is nasty to do Aa" said a little patient aged threm who would never tell the nurse when his bowels needed to be moved and would not evacuate when told to do so except at night when the inhibitory concept 1N:as in subjection.
Hysterical meteorism of a pathologic degree results either from swallowing air—in which ease there is always a suspicion of simulation— or from nervous tonic spasm of the diaphragm, and is particularly apt to be mistaken for peritonitis when it is associated with marked sensi tiveness of the abdomen. Cases due to spasm of the diaphragm (pseudo tympanite nerveuse ou ventre en accordion, Bernheirn), may be recog nized by the fact that the abdomen collapses under chloroform amethesia, without the escape of gas from the mouth or anus as when the condition is due to swallowing air.
The recurrence of prolapse of the anus as the result of some fixed idea, which in children is usually quite transparent, has also been observed in a number of well-authenticated cases in children about the age of three.
Finally we have two disturbances in the genito-urinary apparatus that are frequently hysterical: Pollakiurio, that is, the evacuation of urine at abnormally frequent intervals, and diurnal and nocturnal enuresis. As both symptoms may be due to a number of organic dis eases. affecting the nervous system, metabolism and the genito-minary system, these causes must first be excluded by a careful physical and urinary examination. But even after the functional nature of the dis turbanee has been established by exclusion, the diagnosis of hysteria is not justifiable without further proof.
This subject, which has been extensively studied in the past few years, is sufficiently important to justify a niore detailed diseussion. While French authors (Janet, Guinon and othem) had long recognized and insisted upon a psychic etiology in enuresis, the majority of German authorities (see for example the text books of Ilenoch and Baginsky) regarded the eondition as a 1oeal neurosis of the bladder, and the only controversial point was the mechanism of the disturbances or its mode of onset. Czerny's school was the first in C.lermany to insist upon the psychogenic origin of enuresis as well as of pollakiuria, and the analogous disturbance of incontinenee of feces, which they explain as hysterical symptoms. This is undoubtedly true in a eertain proportion of eases of enuresis and is proven by the occasional sudden occurrence of enuresis or pollakiuria in children who had not been subject to it in infancy. In these cases there is evidently a definite cause, as for example, in one of Reinaeh'.s, as is shown by the prompt and permanent result which followed antihysterical treatment (see page 378). In the same eategory belong all the cases of psychic infection, in children who had previously been free from enuresis, by other children in the same class or boarding school who are affected with the disease, and the promptness with whieh eases of this kind due to unconscious' imitation recover, is a strong argument in favor of the hysterical nature of the disturbanee. Pfister, on the other hand, advaneed a different view in an important paper on the subject in whieli he cited a number of eases of enuresis. He has, in addition to the cases clue to organie eauses, a group in which the nocturnal enuresis represents an abortive or unnoticed attack of epilepsy. This group is eharacterized by the fact that the enuresis occurs "quite sporadically, possibly for a short period every night in succession, with intervals of irregular duration, front several days to many weeks or even longer when the ehild is quite free from the disturbance." On careful
examination other signs of nocturnal epileptic explosions are always discovered in adults and usually also in children (he refers to chil dren of at least five years of age or older). Among these signs are biting the tongue, falling out of bed, sometimes pronounced lassitude on waking up in the morning, and the like. This form of enuresis with a suggestion of epilepsy is also mentioned by Binswanger and others. In Pfister's second group the enuresis begins in infancy and the children can never be trained to eleanly habits; or it begins some time between the third and sixth or seventh year of life mith frequent and usually nightly evacuations at different hours of the night. In addition to the nocturnal evacuation, for which it is frequently impossible to discover any special cause (possibly dreams?), there is usually also some diurnal enuresis which, however, is much more rare and is brought on only by fright or inattention when the child is busily engaged in play. This variety of enuresis, which is extremely variable and is often associated with pollakiuria and other functional disturbances of urination or even incontinence of feces, and which obstinately resists all educational therapeutic measures, is regarded by Pfister as a sign of functional degeneration and an hereditary- neuropathic stigma. The arguments which he advances in support of his theory, the details of which are extremely ingenious, are too lengthy to be reproduced in this place; but it seems desirable, in order to throw light on the pathogenesis of enuresis and related disturbances, to mention at least his main proposition, the general neuropathic etiology and significance of the affection. If this is borne in mind, all other causal factors that have been mentioned, such as adenoid vegetations, the drinking of large quantities of fluid in the evening, cold beds and consequent chilling of the abdomen, slight affec tions of the bladder (Rey) or changes in the composition of the urine (Lawrence and others) assume at most an accidental significance. While it seems to us that Pfister in his character of psychiatrist has exaggerated the frequency of the severe, degenerative CaSCS, his writings nevertheless represent a distinct advance in therapeutics. He has shown us the necessity of differentiating our cases more accurately. Whenever there is any- reason to suspect epilepsy, the corresponding treatment and supervision of the patient must be begun at once. On the other hand, in functional disturbance of the bladder in which epilepsy can be posi tively excluded antihysterical treatment must be instituted as rapidly and energetically as possible in a manner to be presently described, and in this way prompt and permanent results will be obtained in a great many cases. Nevertheless one must not be surprised if the treatment fails at least partially in a great many cases. These will be put down as belonging to the degenerative form, in which general hygienic and educational measures must be tried, although time and the gradual bodily and mental development of the child will in the end prove the most potent factors in bringing about a cure. Accordingly we may dis pense with a mere enumeration of all the various infallible remedies which have been recommended without the slightest attempt at dis ethnination. There is no specific remedy. All methods of treatment act either by suggestion or not at all, including epidural injections (Kap sammer), which are so greatly lauded by Cathelin. Even the results of hypnotic suggestion are neither better nor worse than the results obtained by any other form of psychic treatment (Hack!ander).