The diagnosis of subacute myelitis of the anterior horns from hysterical paraplegia is often of vital importance. “A young woman,” says Bennett,107 “suddenly or gradually becomes paralyzed in the lower extremities. This may in a few days, weeks, or months become complete or may remain partial. There is no loss of sensation, no muscular rigidity, no cerebral disturbances, nor any general affection of the bladder or rectum. The patient's general health may be robust or it may be delicate. She may be of emotional and hysterical temperament, or, on the contrary, of a calm and well-balanced disposition. At first there is no muscular wasting, but as the disease becomes chronic the limbs may or may not diminish in size. The entire extremity may be affected or only certain groups of muscles. Finally, the disease may partially or entirely recover, or remain almost unchanged for years.” This is a fair general picture of either disease.
107 Lancet, vol. ii. p. 842, November, 1882.
Two facts are often overlooked in this connection: first, that poliomyelitis is just as liable to occur in the hysterical as in the other class; and, secondly, that the symptoms of hysterical paraplegia and poliomyelitis may go hand in hand.
The history is different in the two affections. Frequent attacks of paralysis in connection with hysterical symptoms are very suggestive, although not always positive. In poliomyelitis the disease may come on with diarrhœa and fever; often it comes on with vomiting and pain. The patellar reflex is retained, often exaggerated, and rarely lost, in hysteria, while it is usually lost in poliomyelitis. Electro-muscular contractility is often normal in hysterical paralysis, although it is sometimes slightly diminished quantitatively to both faradism and galvanism: the various muscles of one limb respond about equally to electricity: there are no reactions of degeneration in hysterical paralysis as in poliomyelitis. In poliomyelitis reactions of degeneration are one of the most striking features. The cutaneous plantar reflex is impaired in hysterical paraplegia; bed-sores are usually absent, as are also acute trophic eschars and the nail-markings present both in generalized subacute myelitis and diffused myelitis. True muscular atrophy is also wanting in hysterical paraplegia, although the limbs may be lean and wasted from the original thinness of the patient or from disuse. The temperature of the limbs is usually good. There is no blueness nor redness of the limbs, nor are the bowels or bladder uncomfortably affected.
Buzzard108 gives two diagrams (Figs. 16 and 17), which I have reproduced. They are drawn from photographs. They show two pairs of feet, which have a certain superficial resemblance. In each the inner border is drawn up into the position of a not severe varus. They are the feet of two young women who were in the hospital at the same time. A (Fig. 16), really a case of acute myelitis, had been treated as a case of hysteria; and B (Fig. 17), really a case of hysteria, came in as a paralytic. In these cases the results of examination into the state of the electrical response and of the patellar-tendon reflex was sufficient to make a diagnosis clear. In the organic case the electrical reactions were abnormal and the patellar-tendon reflex was abolished. These conditions were not present in the hysterical case.
FIG. 16.
FIG. 17.