The symptomatology of hysteria is not only variegated but abso lutely inexhaustible; "typical" disease pictures are rare in comparison with " atypical" forms. A few characteristic features are common to nearly all cases of hysteria. Familiarity with these features is of great value in the diagnosis because it is a kind of key to the otherwise enigmatical and contradictory observations.
The first thing to be pointed out in this connection is that hysteria in childhood frequently presents itself as a monosymptomatic affection. By this we mean not only the presence of a single symptom but the absence of the somatic stigmata which are so familiar in the hysteria of adults. This behavior, particularly in the ease of young hysterical children is not aecidental; it is merely the expression of the relatively na1ve imagination of the child and is comparable to a similar behavior observed by Krell] among the unedueated agricultural classes in Thuringen and Pommerania. An hysterical child., as Bruns has pointed out, is satisfied with a single symptom and refuses to meet the physician half way when he looks for stigmata. We agree with Strfirupe11, 13runs, Ifellpach and others that the stigmata, such as antesthesia of a paralyzed arm and the like, usually do not dot-clop until they are sought after, in other words, that they are suggested by the examiner and by the act of examination. "The lay mind of the adult hysterical patient uncon sciously reasons that 'a cotnpletely paralyzed arra must also be bereft of sensation. If the doctor is looking for sensory disturbances he evi dently expects to find them; they belong, so to speak, to the other symptoms which I present,' and aecordingly, he actually fails to per ceive the pain irritant when it is applied to the arm" (Bruns). The unsophisticated child, on the other hand, is not capable of such a proeess of reasoning and the paralyzed arm therefore shows 110 antesthesia. This dependence of the stigmata on suggestion on the part of the ex aminer, whether actual or apparently unintentional, is well shown in another group of stigmata, the hysterogenic and hysterofrenic zones and pressure points in paroxysmal forms of hysteria. A convulsive seizure may be produced or inhibited by irritating any part of the body, not only the ovarian region or the testicles, provided the physician has previously predicted the occurrence in a casual remark addressed to other persons in the room. This phenomenon is seen in children old
enough to go to school, in whom other stigmata such as, for example, concentric contraction of the visual field, is still difficult to determine and in whom the tests for sensation are uncertain.
The more carefully we examine the more frequently shall we find stigmata, particularly- in older children; but the diagnosis must be made without them, because they are, as a matter of fact, frequently absent.
In many cases the picture of the monosymptom itself is of aid in making the diagnosis. It is often characterized by what the Freneh call "massivity"—a gross, exaggerated manifestation of the functional disturbance, which the child, so to speak, thrusts upon the physician's notice. A patient suffering from aphasia at least makes some attempt to speak, while a child with hysterical deaf-mutism does not utter a sound; when asked to speak it fails to make even the faintest movements of the lips. In organic palsy the child is still able to perform a few movements, in hysteria the paralyzed member is absolutely dead and motionless. In a similar manlier hysterical pains are characterized by their exaggerated, "insane" intensity, as shown for example when an attempt is made to overcome a contracture by passive movements.
Often the sudden onset of a disease which, when due to an organic lesion, develops more slow-1y, and its unmistakable origin in some psychic shock (fright, fear) or insignificant bodily injury, suggests the correct diagnosis.
In other cases, the symptoms betray their psychic origin by their contradictory nature with respect to the anatomical conditions. Bruns makes this clear by a number of examples. For example, a paralysis instead of affecting the muscle groups which correspond to its peripheral, spinal or cerebral localisation, as in Erb's plexus paralysis or in a cerebral hemiplegia, involves an entire extremity or a segment of the extremity, a hand or a leg, and affects all its movements. Sensory disturbances, instead of exhibiting a segmental character, have a "sleeve-like" dis tribution which would not be possible in an organic lesion. Everywhere the patient's naive conceptions of anatomy are revealed.