The degree of intelligence necessary for the simulation of hysterical symptoms is by no means high, while it is true that many hysterical children arc more intelligent and vivacious than average children of their own age, and accustomed by their constant association with arlults to observe and form judgments in a way not usual with children—in short, are what is generally known as old-fashioned. Hysterical dis turbances nevertheless occur in children of very slender mental gifts and in imbeciles. An interesting fact in this connection which was brought out by Bruns and which we have also been able to confirm is that the grossest, most "massive" forms of hysteria occur chiefly in country children who have a very limited mental horizon.
There is but little to add about the diagnosis of hysteria. The frequency with which hysterical traits are associated with organic dis eases is a warning to use the greatest care in the objective examination of the patient. Thus in many forms of brain tumor (glioma with peri odical bleeding, intraventricular cysticerei and the like) the clinical picture may be very deceptive and closely resenible that of hysteria. Failure to recognize an hysterical symptom as such and accordingly to apply the proper treatment greatly diminishes the chance of recovery by confirming the parents and attendants in their belief that the child is suffering from a grave disease. For the physician himself the mistake is serious only when another physician or even a quack is called in and by recognizing the true state of affairs rapidly brings about a cure. Conversely, parents will never forgive a physician if Ile fails to recognize an organic lesion and calls it hysteria, because in the lay mind this word always has in it an offensive element of simulation or of over anxiety that need not be taken seriously.
The prognosis of hysteria in children is in the main favorable, not only as regards the individual manifestation, which is often quite easy to cure, but also the psychic constitutional anomaly as a whole. This inaportant distinction between hysteria in the adult and the same dis ease in children was first established by Bruns, who kept his patients under continual observation after their recovery. He states distinctly, however, that complete permanent recovery is effected only when the first hysterical symptom is recognized as early as possible and removed by appropriate treatment or as he says, extirpated. As the result of
numerous unsuccessful therapeutic experiments the first symptom be comes inveterate or the psychic anomaly so firmly rooted that it never disappears altogether. Even if the individual symptom is ultimately rentoved, other symptoms sooner or later make their appearance and betray- the fact that the hysterical change of character is permanent. The prognosis is undoubtedly most favorable in the hysterias which are produced by imitation or p.sychie contact infection. These forms are sometimes epidemic in schools as, for example, hysterical chorea (Hol wede), hysterical tremor (Demmer). The children who are attacked secondarily always recover rapidly in such cases.
Treatment. follows from what has been said that the treatment of hysteria in childhood is purely psychic. The physician IS rarely able to prevent the development of the constitutional disposition, which is due to heredity; but Ile can often see to it that the child is separated from its hysterical mother, either permanently or at least during her attaeks, or that the governess, if she has hysteria, is dismissed. But above all Ile must, by refraining from every kind of treatment that is not absolutely necessary, guard against fostering hypochondriac intro spection and self-indulgence which lead to hysterical manifestations. He must also exercise an advisory control of the child's education.
The treatment of pronounced hysterical symptoms offers to the physician a wide field for tbe exercise of whatever he may possess of ingenuity' and sagacity, as well as tact and sympathy'. We strongly reeommend Bruns' comprehensive and stimulating writings on this subject and are content in this place to indicate merely the proper lines which must be followed in the treatment. In young children, who are in the main credulous and used to obeying, the treatment may- be purely or, as Strilmpell says, unclisguisedly psychical. Thus, in a case of astasia-abasia the child may be simply set on its feet with the brief injunction "now walk" or the like. But in most eases the physician finds himself compelled to mask the psychic effect of his treatment by employing physical methods. The most effective are those which have a strong suggestive action, such as pain or, on the other hand, whatever must appear mysterious and wonderful to the child and thereby render it susceptible to suggestion.