As chief of neurosurgery for a small city hospital, I’ve never had a phone call at 2 a.m. bring me good news, and this night held true to form. The emergency room had just admitted a 22-year-old convenience store clerk, whom I will call Rachel. She had awakened several hours earlier with a rather annoying problem: She could not move her legs. According to the ER physician, Rachel noticed that she could not roll over in bed and, when the fog of sleep finally cleared, discovered that she had two lifeless logs where her lower extremities used to be.
She lived alone and, not wishing to disturb her parents living miles away, managed to crawl to her nightstand and phone directly for an ambulance. When I arrived, Rachel was still strapped to a spinal board, the right sleeve of her nightgown rolled up to allow for the intravenous line.
“Does anything hurt?” I asked.
“No,” she said, shrugging. “I really feel fine . . . except for this leg thing.”
“Are they numb?” I continued, stroking her bare shins with my index finger.
“Nah, I feel that. They just feel funny, you know, heavy. Do you think this is serious? When can I go home? I have to open the store at 6.” She smiled. “Gotta make the coffee!”
Further interrogation revealed little. Rachel was healthy, no illnesses, no medications, no surgeries. A smoker since age 14, she used marijuana sporadically, but there was no other history of drug use. No traumas, no chance of pregnancy (her boyfriend had abruptly dumped her six months earlier, and she still seethed when discussing him), no history of depression or other mental illness, no significant family history. She was in good health. Except for the “leg thing.”
In addition to lacking any obvious pathology, she also lacked health insurance. The ER had already set up an MRI of her entire spine and summoned the technician from home to do it. This might yield an answer—but I suspected the truth about her condition already, and I was reluctant to saddle this poor woman with thousands of dollars of expensive pictures. The tests would all be negative anyway.
A quick examination confirmed my suspicions. When I poked her foot with a pin, she yelped but didn’t move her legs. Yet her reflexes were normal, and the tone of her leg muscles was good. Finally, her Babinski sign—a neural reflex that causes the big toe to go down when the sole of the foot is stroked—was normal. These findings, coupled with a blasé attitude toward her paralysis (a mental state known in neurology as “la belle indifférence”), made me suspect a rather distasteful diagnosis: hysteria.
The word “hysteria” derives from the Greek word for womb, and for centuries the condition was thought to be a feminine affliction arising from bad uterine humors. Women hysterics outnumber men six to one for reasons yet unknown. What is known is that the womb plays no role. Many neurological conditions, including migraine and multiple sclerosis, afflict women disproportionately. The ovaries and the hormones they produce or the double X chromosomes are more likely culprits.
Today hysteria is known by the more palatable but still inaccurate moniker “conversion disorder.” It manifests acutely in the form of blindness, paralysis, even coma, with no apparent organic disease. Sigmund Freud believed that the hysterical mind converts some psychic trauma into a physical malady that will both garner sympathy and allow the sufferer to hide from her problems behind a shield of illness. Decades before Freud, the great French neurologist Jean-Martin Charcot suggested that hysteria was indeed an organic brain illness, not the product of a disturbed or demon-possessed mind, but Freud’s explanation gained wider acceptance.
Although many hysterics complain of mental distress (like Rachel’s boyfriend woes), recent neurophysiological evidence from PET scans and functional MRIs suggests that the malady may be akin to a seizure initiated by the frontal lobes, and so is a condition of the brain as well as the mind. Some people may have a vulnerability to this kind of response to stress. Thus Charcot was probably right (he usually was), and Freud was probably wrong (no surprise there either).
The cardinal sign of hysteria—indifference to an obviously crippling neurological predicament—is not entirely reliable. I once cared for a teenager who was suddenly struck blind. Because she seemed apathetic about her condition, she was mistakenly given a diagnosis of hysteria. In fact, she was both blind and apathetic because of a brain tumor. Nevertheless, indifference is still a useful clue, particularly when the physical examination is normal. Rachel’s preserved reflexes, good leg tone, downward Babinski sign, and preserved sensation were all inconsistent with known organic causes of sudden paraplegia (paralysis in both legs). Her lack of pain also made other causes like a ruptured disk, brain hemorrhage, or spinal abscess highly unlikely. Her nonchalance was simply icing on the diagnostic cake.
Conversion paralysis is very different from willful malingering because the hysterical patients really believe they cannot move. I have seen inexperienced physicians, anxious to expose a faker, injure people by placing clamps on their fingers or plunging needles deep into thigh muscles, only to be astounded and mortified when patients make no attempt to pull away. So I was gentle with Rachel, both physically and verbally.
I told her that most likely nothing serious was going on and that she probably had a “vitamin deficiency.” I instructed the nurses to infuse a liter of intravenous nutrients. The solution’s impressive amber hue suggests to the patient that some “real medicine” is being administered. This is one aspect of hysterical paralysis that still smacks of a psychiatric origin: Patients must be convinced that they are being treated as if they have an organic disease. Simply telling them they are imagining things doesn’t work very well.
There is an old adage: Neurology is what you do while you are waiting for the films to be developed. Physicians rely too heavily on imaging machines, and I saw no urgent need for scanning this patient. Her examination and history told her story well enough. True, the doctor must always rule out physical illness before diagnosing conversion syndrome, but in Rachel’s case, infusing some vitamins could be done in the time it took to fire up a cold MRI machine. By then I would know.
Twenty minutes after the infusion ended, Rachel’s legs roared to life, and she walked out the door. I went home, tired but happy in the knowledge that I hadn’t allowed a single freakish spasm of a young woman’s brain to land her in the poorhouse or in the psychiatric ward.