One of the commoner forms of the grave phase of hysteria is paraplegia.153 Often muscular atrophy—which ensues from disuse—exaggeration of the deep reflexes, and retention of urine are added to the paraplegia and heighten the resemblance to an organic affection. Its development, though sometimes sudden, often occupies weeks or months, and may be preceded, exactly as in chronic myelitis, by weakness in the legs, and not infrequently by combined ataxia and weakness. It is much more difficult to discriminate here than is generally held or than is enunciated in textbooks. The sufferer from hysterical paraplegia does not always give other indications of the hysterical neurosis, and even if she did show a globus and tenderness at certain points, it is a question whether it could be called a scientific diagnosis which determined the case to be one of functional trouble on these signs alone. More than one error has been committed in this respect. In chronic myelitis retention of urine is less common than incontinence, which is the reverse of hysterical paraplegia. Pupillary symptoms do not occur with the latter affection. If there be sensory anæsthesias, they are bizarre in character or distribution, and do not usually harmonize with the distribution of the paralysis. In most cases moral influences can be exerted so as to increase the power of movement far beyond what would be possible in an organic disease; and while an electrical examination will not always yield positive results in chronic myelitis, yet no case of chronic myelitis with complete or nearly complete paraplegia but will show at least quantitative changes of such extent as to prove beyond doubt that the case is of an organic character.
153 I have observed for two years a stationary brachial diplegia, of undoubted hysterical origin, although the patient had never shown any ordinary hysterical manifestations, and had had no other hysterical symptom than chromatopsia, and that only for a short period. From its long duration, constancy, and the resulting atrophy of disuse it had been regarded as a case of peculiarly limited chronic myelitis.
There is one point in which spinal and cerebral disease involving the motor tract differs in the majority of cases, which may be utilized in distinguishing obscure affections of the former from those of the latter kind. In cerebral paralysis of any standing the superficial reflexes, such as the cremaster and abdominal reflexes, are usually diminished or abolished, while the deep or tendon reflexes are exaggerated. In spastic conditions due to spinal disease—say sclerosis of any kind affecting the lateral column and leaving the motor nuclei of the anterior cornua unaffected—the deep reflexes are similarly increased, but the cremaster reflex is increased also.154 This feature of the superficial reflexes is significant in the case of cerebral disease only when unilateral.
154 Attention has been called, I believe, by Westphal, to the fact that the cremaster reflex may not be demonstrable when reflex excitability is at its highest, because the cremaster muscle is already in extreme spastic contraction.
The initial period of diffuse sclerosis is sometimes confounded with rheumatism—an error less pardonable than in the case of tabes, inasmuch as in diffuse sclerosis the pains are not usually premonitory, but associated with motor paresis. It is erroneous to regard a pain as rheumatic because it is aggravated or relieved by changes in the weather. There are many subjects of myelitis who regard themselves as veritable barometers, and with more justice than most rheumatic patients.
In some cases of chronic alcoholism there are motor weakness and a gait much like that of diffuse sclerosis.155 It is to be remembered that the solar tickling reflex is very often abolished in alcoholic subjects, and profound diminution of the normal cutaneous sensibility of the leg and feet usually coexist. But unless there is peripheral neuritis—which is an exceptional and, when present, well-marked affection—the absence of profound nutritive changes of the muscle, the presence of the alcoholic tremor, the absence of sphincter and bladder trouble, and the great variation of the symptoms from week to week, and even from day to day, serve to distinguish the alcoholic spinal neurosis from myelitis.
155 Wilks' alcoholic paraplegia.
The Secondary Scleroses.
In studying the lesions underlying the symptoms of organic spinal disease, the occurrence of fascicular scleroses, secondary to such disease and due to the destructive involvement of nerve-tracts, was repeatedly noted. Türck may be regarded as the discoverer of these degenerations, and the reliability of this old observer may be inferred from the fact that one bundle of fibres liable to individual degeneration still goes by his name, and that, as far as he was able to discriminate between the various paths which secondary degenerations follow through the cerebro-spinal fibre-labyrinth, his statements have not been materially modified by more recent investigators, such as Bouchard, Vulpian, and Westphal.
The discovery by Meynert that the great cerebro-spinal tracts attain the white color which they owe to the development of myelin around their component axis-cylinders with advancing maturity, and that the tracts of noblest, and therefore most intelligent, function were the last to show this sign of maturity, was greatly extended by Flechsig, who found that each tract receives its myelin at a definite period of intra-uterine life, the lowest or the nerve-roots first; then the short or intersegmental or—as the physiologist may call them—the automatic tracts; then the long or controlling tracts; and last, the associating tracts of the cerebral hemispheres which mediate the complex relations underlying mental action. It was this discovery which gave a new impulse to the study of the secondary affections of the cord and brain. The accuracy with which secondary degeneration follows the lines marked out by the normal course of the tract is as great, diminishing when the tract diminishes, changing its position or direction and decussating where the latter changes its direction or position or decussates, that it constitutes not alone an interesting subject for pathological study, but has become one of the most reliable guides of the cerebral anatomist. It is of great importance to the pathologist to be able to differentiate between the primary disease and its secondary results, and, as the controversy concerning the so-called system diseases shows, even the most studious observers are uncertain in this direction in many cases.