The etiology of hysterical manifestations, the most important of which we have just described, might be given more briefly if we were better acquainted with the nature of hysteria, which is but imperfectly characterized by such expressions as limitation (narrowing) of con sciousness, increased susceptibility to suggestion, an abnormal tendency to exhibit somatic reactions to psychic influence and the like.
The most important etiologic factor, heredity, in itself gives us no information in regard to the disturbance that is going on in the mechan ism of the child's psychic life. The causal significance of environment and education is rather more intelligible, but here the question at once presents itself whether these injurious influences really produce the foundation of the malady, the hysterical alteration of the nervous sys tem, or whether they merely act as exciting causes—as "agents provo cateurs"—and bring the disease to the surface. The influence of somatic diseases also in this respect is by no means clear.
The fact that hysterical symptoms may appear as the result of inadequate causes forces upon us the theory of a latent condition. A correct understanding of this latent condition or at least of its psycho pathologic signs, would be of the greatest value; but that is as yet beyond our reach.
Numerous attempts to explain this condition have been made. The French, especially San Philippe and others, have described a hysterie latente and a hysterie naissante, but the conditions to which they refer are in the main neuropathic or genuine neurasthenic changes in char acter, such as we frequently observe as forerunners or concomitants of hysteria in children. Unfortunately these traits are often missed in the purest cases of hysteria.
On the other hand it seems quite justifiable to speak of an hysterical character, which consists in exaggeration of the emotional life, a lively imagination coupled with an unchildlike interest in the process and conditions of the body, egotism and an instinctive desire to appear important, to attract the attention and, if possible, excite the admiration of other persons. These traits of character help to explain the fantastic confabulations of hysterical children, and especially their mania to utilize their morbid symptoms in making trouble for persons whom they dislike as, for example, when they develop an hysterical palsy after they have had their ears boxed by a strict and exacting teacher. The hysterical
character may develop in the absence of any lack of conscious or un conscious education, and in these cases it must be assumed that the predisposition is unusually pronounced. As a rule, a vicious environ ment is at least partly responsible for its development. In many cases the hysteria can be shown to be due to direct imitation of diseases of the parents but the most important cause is the wrongly-directed, usually too indulgent and always capricious education of the child by hysterical or neuropathic parents. This point requires no further elucidation. In other cases external insults sueli as fright or fear are operative causes.
Thus we once observed a state of deaf-mutism lasting several weeks in a little boy of three who had been frightened by the sudden apparition of a cat on a dark stairway. Bruns, for example, observed unilateral convulsions resembling night terror coming on in the morning as the child was called to get up and go to school, and for which the child's fear of a strict teacher was responsible. The same authors cite examples of hysteria in children whose fathers were drunkards and abused their wife and children when intoxicated, and points out that in these cases the desire to escape the unhappy home life by being admitted to the hospital is also a factor in the etiology.
Autoimitation of organic diseases, which has been referred to repeat edly in this section, is absolutely fostered by unintelligent, overindulgent parents who let the child have its way while it is ill and gratify its most foolish wish, exhaust themselves in expressions of love and pity, ancl do everything to make sickness a condition to be greatly desired by the child. An hysterical disease in a child surrounded by such an environ ment has many points in common with conscious simulation or may, in fact, be nothing but shnulation. As physicians, however, we must remember that the simulation itself is a pathologic trait of character. A child that is psychically normal does not simulate disease.