108 Clin. Lectures on Diseases of the Nervous System, London, 1882.
The diagnosis of hysterical paraplegia from diffused myelitis is governed practically by the same rules which serve in subacute myelitis of the anterior horns, with some additional points. In diffused myelitis, in addition to the motor, trophic, vaso-motor, electrical, and reflex disorders of myelitis of the anterior horns, affections of sensibility from involvement of the sensory regions of the cord will also be present. Anæsthesia and paræsthesia will be present.
Acute ascending paralysis, the so-called Landry's paralysis, particularly when it runs a variable course, might be mistaken sometimes for hysterical paralysis. In one instance I saw a fatal case of Landry's paralysis which had been supposed to be hysterical until a few hours before death. In Landry's paralysis, however, the swiftly ascending character of the disorder is usually so well marked as to lead easily to the diagnosis. In Landry's paralysis the loss of power begins first in the legs, but soon becomes more pronounced, and passes to the arms, and in the worst cases swallowing and respiration become affected.
Spinal hemorrhage and spinal tumors, giving rise to paralysis, may be mistaken for hysterical paralysis, partly because of the contractures. Reactions of degenerations are usually features of this form of organic paralysis. The contractures of hysterical paralysis can be promptly relieved by deep, strong pressure along supplying nerve-trunks; this cannot be accomplished in the organic cases. Severe localized pains in the limbs, sometimes radiating from the spinal column, are present in the organic cases. Pain may be complained of by the hysterical patient, but close examination will show that it is not of the same character, either as regards severity or duration.
Hysterical locomotor ataxy is usually readily distinguished from posterior spinal sclerosis, although the phenomena are apparently more marked and more peculiar than those exhibited as the result of organic changes. Hysterical ataxic patients often show an extraordinary inability to balance their movements, this want of co-ordinating power being observed even in the neck and trunk, as well as the limbs. In hysterical cases a certain amount of palsy, often of an irregular type, is more likely to be associated with the ataxia than in the structural cases. The knee-jerk, so commonly absent in true posterior spinal sclerosis that its absence has come to be regarded as almost a pathognomonic symptom of this affection, in hysterical motor ataxy is present and exaggerated. In hysterical locomotor ataxy other well-marked symptoms of general hysteria, such as hysterical convulsions, aphonia, etc., are present.
In the diagnosis of spastic spinal paralysis from hysterical paraplegia great difficulties will sometimes arise. A complete history of the case is of the utmost importance in coming to a conclusion. If the case be hysterical, usually some account of decided hysterical manifestation, such as aphonia, sudden loss and return of sight, hysterical seizures, etc., can be had. Althaus holds that a dynamometer which he has had constructed for measuring the force of the lower extremities will, at least in a certain number of cases, enable us to distinguish between the functional and spinal form of spastic paralysis. In the former, although the patient may be unable to walk, the dynamometer often exhibits a considerable degree of muscular power; while in the latter, more especially where the disease is somewhat advanced, the index of the instrument will only indicate 20° or 30° in place of 140° or 160°, and occasionally will make no excursion at all.
The diagnosis of multiple cerebro-spinal sclerosis from hysteria occasionally offers some difficulties. Jolly goes so far as to say that it can only with certainty be diagnosticated in some cases in its later stages and by the final issue—cases in which the paralytic phenomena frequently alter their position, in which paroxysmal exacerbations and as sudden ameliorations take place, and convulsive attacks and disturbances of consciousness of a like complicated nature as in hysteria are met with. Disorders of deglutition and articulation, also characteristic of multiple cerebro-spinal sclerosis, are now and again observed in the hysterical. Recently, through the kindness of J. Solis Cohen, I saw at the German Hospital in Philadelphia a patient about whom there was for a time some doubt as to whether the peculiar tremor from which he suffered was hysterical or sclerotic. At rest and unobserved, he was usually quiet, but as soon as attention was directed to him the tremor would begin, at first in the limbs, but soon also in the head and trunk. If while under observation he attempted any movement with his hands or feet, the tremor would become violent, and if the effort was persisted in it would become convulsive in character. The effort to take a glass of water threw him into such violent spasms as to cause the water to be splashed in all directions. The fact that this patient was a quiet, phlegmatic man of middle age, that his troubles had come on slowly and had progressively increased, that tremor of the head and trunk was present, that cramps or tonic spasms of the limbs came and went, indicated the existence of disseminated sclerosis. The knee-jerk was much exaggerated, taps upon the patellar tendon causing decided movement; when continued, the leg would be thrown into violent spasm.
Spondylitis, or caries of the vertebræ, is sometimes difficult to distinguish from hysterical paraplegia or hysterical paraplegia from it, or both may be present in the same case. Likewise, painful paraplegia from cancer or sarcoma of the vertebræ may offer some difficulties. A woman aged forty-four when two years old had a fall, which was followed by disease of the spine, and has resulted in the characteristic deformity of Pott's disease. She was apparently well, able to do ordinary work, until about five years before she came under observation, when her legs began to feel heavy and numb, and with this were some pain and slight loss of power. These symptoms increased, and in three months were followed by a total loss of power in the lower extremity. She was admitted to the hospital, and for about three years was unable to move the legs. She went round the wards in a wheeled chair. The diagnosis was made of spondylitis, curvature, and paralysis and sensory disorders depending on compression myelitis, and it was supposed she was beyond the reach of remedies. One day one of the resident physicians gave her a simple digestant or carminative, soon after which she got up and walked, and has been walking ever since. She attributes her cure entirely to this medicine.
What is the lesson to be learned from this case? It is, in the first place, not to consider a patient doomed until you have made a careful examination. There can be much incurvation of the spine without sufficient compression to cause complete paralysis. In this patient organic disease was associated with an hysterical or neuromimetic condition. This woman had disease of the vertebræ, the active symptoms of which had subsided. The vertebral column had assumed a certain shape, and the cord had adjusted itself to this new position, yet for a long time she was considered incurable from the fact that the conjunction of a real and a mimetic disorder was overlooked.