Hyperaesthesia

“ The early return of sensation is a favourable sign, and in this relation the development of hyperæsthesia, whether preceded by anæsthesia or no, points to the maintenance of continuity of, and a moderate degree of damage to, the nerve. The early return of sensation, even if modified in acuteness, was always a very hopeful sign; also the production of formication in the area of distribution of the nerve on manipulation of the injured spot. As in the case of nerve injuries of every nature, the disposition and temperament of the patient exerted considerable influence on the course of the cases. ”

“ Entire abolition of reflexes in lower limbs and trunk. Hyperæsthesia was present in both upper extremities, with a zone of hyperæsthesia around the chest. The patient suffered greatly for some weeks from pain in the hyperæsthetic area, he developed severe cystitis and later incontinence of urine. A large trophic sacral bed-sore steadily increased in depth and size. ”

“ Deep injuries [16] to the posterior columns of the spinal cord are always followed by a degree of hyperæsthesia greater than after the laying bare of the nervous centres—hyperæsthesia which appeared in all parts of the body behind the place injured.... Before the operation in rabbits the most energetic pinching of the skin produces agitation but no shrieking; after the operation, on the contrary the least pinching produces shrieking and a much greater agitation. Sometimes the hyperæsthesia is so considerable that the least pressure upon the skin makes the animal shriek. ”

“ Nor is it only as a dissecting agent that hysteria can aid our research. There are in hysteria frequent acquisitions as well as losses of faculty. It is not unusual to find great hyperæsthesia in certain special directions—of touch, hearing, perception of light, etc.—combined with hysterical loss of sensation of other kinds. This subject will be more conveniently{53} treated along with the hyperæsthesia of the hypnotic trance. ”

“ The motor nerves are more involved than the sensory ones, there being rarely complete anaesthesia, but rather a blunting of sensation as though a piece of cloth were interposed between the examining instrument and the skin. At first there is weakening of the muscle power as shown by the grip of the hand or weakness of foot muscles. In more advanced cases we may have foot and wrist-drop. Hyperaesthesia of the muscles is prominent, especially that of the calf muscles. The unsteadiness of gait is not true ataxia as the patient does not clearly show the Romberg sign. ”

“ Since then he has been paralyzed in the right arm and leg, with anæsthesia in the leg almost complete, and hyperæsthesia in the arm. I have not the slightest doubt that paralysis is due to pressure on the angular gyrus of the left side of the brain, and am about to trephine immediately. ”

“ Thus injury to a single nerve, or to a complex of two or more, was far more common than one implicating the whole plexus. Again, while complete paralysis might affect one set of nerves, another might simply exhibit signs of irritation in the form of hyperæsthesia or pain. ”

“ But no precautions were taken against hyperaesthesia further than enclosing the card in a second envelope. There is a power possessed by a certain number of people, of naming a card drawn by them or held in the hand face downwards, so that there is no normal knowledge of its suit and number. Few thorough trials have been made; but it seems to point to some kind of hyperaesthesia rather than to clairvoyance; in the Richet experiments even if the envelopes excluded hyperaesthesia of touch on the part of the medium, there may have been subliminal knowledge on Prof. ”

“ In the hysterical variety of both hyperæsthesia and paræsthesia general treatment is of more value than local measures. General tonics, moral support, such as will be secured if we can convince the patient that there is really no serious trouble with the organ, but that it is only a morbid sensation, will be of the greatest value. In these cases change of climate, change of occupation, diversion by new associations, with expectation of recovery on the part of the patient, often bring about the most satisfactory results. ”

“ Some weeks or months after the injury, the patient complains of increasing hyperaesthesia and of neuralgic pains in the course of the nerve. The nerve is very sensitive to pressure, and, if superficial, may be felt to be swollen. The associated muscles are wasted and weak, and are subject to twitchings. There are also trophic disturbances. It is rare to have complete sensory and motor paralysis. The disease is commonest in the nerves of the upper extremity, and the hand may become crippled and useless. ”

“ In the skin, in addition to the fugitive heats, we often have a peculiar pricking, itching, or stabbing sensation, and various kinds of hyperaesthesia, frequently associated with disturbances of tactile sensation. We observe also muscular twitchings, and general weakness of the organs of locomotion. ”

“ He has pain in the back on making any movement, and there is a diffuse tenderness or hyperæsthesia along the spine. There is weakness of the limbs, sometimes attended with numbness, and he is easily fatigued by walking. ”

“ Among other wounds, one track entered 1 inch to the right of the second lumbar spinous process, and emerged 1 inch internal to the right anterior superior iliac spine. There were signs of wound of the kidney, and in addition, retention of urine, incontinence of fæces, complete motor and sensory paralysis of the right lower extremity, and total absence of all reflexes. Anæsthesia existed over the whole area of skin supplied by the nerves of the sacral plexus, hyperæsthesia over that supplied by the lumbar nerves. ”

“ Pain in the back, corresponding to the seat of the disease, is rarely absent, and all movements of the trunk are extremely painful. When the exudation is sufficient to compress the nerve-roots, the pain will extend to the trunk and the limbs, and other signs of irritation, such as a feeling of constriction by a tight girdle, and tingling, numbness, and cutaneous hyperæsthesia in the limbs, will be observed, varying in situation according to the seat of the lesion. In some cases the compression of the cord may be sufficient to cause paraplegia. ”

“ When breathed for anæsthetic purposes the skin becomes livid, the blood pressure raised, and unconsciousness follows. It acts first upon the higher nerve centres, then upon the spinal cord, medulla, and heart. If pushed too far it causes death by asphyxia. In ordinary use for anæsthesia, the latter is rapidly produced, and recovery follows quickly when the administration is stopped. It has peculiar effects upon certain people, who may not only show the symptoms of hilarity, but, in some cases, become extremely violent. ”

“ Whatever muscular contractions may be produced for the time, they are harmless, and need not be noticed. Wherever the electro-vital fluid is in excess, producing hypersthenia—too much vital action—the part is morbidly positive; and, excepting sometimes in the stomach and bowels, the B D current, of medium force, directed to that part under the negative pole, will produce sharp pain. But where a current of full medium strength can not be felt under the negative pole, there is a morbidly negative state—a deficiency of vital action—a condition of at least partial paralysis—anæsthesia. ”

“ The SYMPTOMS attributed to hyperæmia of the spinal membranes are pain in the back extending to the legs, with numbness and tingling of the toes, sensation of weight in the limbs, muscular weakness, appearing suddenly without fever and usually of transient duration. There is no evidence that it gives rise to paralysis. ”

“ The swelling of the feet makes the patient think—sometimes at the suggestion of his physician—of kidney trouble or heart trouble, and sometimes it is hard to persuade him that there is nothing serious the matter with these important organs. The disturbance of the circulation further leads to numbness, to some anesthesia, and to paresthesia. Corns and especially callouses grow more readily between the toes, and patients who are prone to read about such ailments may conclude that they are suffering from hypesthesia {420} and hyperesthesia due to some serious progressive organic nervous disease. ”

“ There was anesthesia to pain and heat, as well as in bones and joints, along with the tactile anesthesia. There was a hyperesthetic region on the right side, corresponding with the distribution of the fourth dorsal root. All the cutaneous reflexes up to the abdominals were gone; but defense reflexes could be brought out in foot and leg by skin, bone or joint stimulation. The deep reflexes of the legs were also lost, whereas those of the arms were increased. Retention of urine without incontinence; no retention of feces. ”

“ Among the advantages, aside from the number of assistants required and the discomfort immediately following the administration of a general anesthesia, are the absence of remote ill effects of the invasion throughout the entire system of a noxious chemical substance and its direct deleterious effects on many large organs such as the lungs, heart, kidneys, and liver, and the assurance, when a proper drug, dosage, and technic are employed, that death cannot be ascribed to the anesthetic. ”

“ During the period of the attack the whole right side becomes anaesthetic to all forms of sensations, kinaesthesis included, so that he is not even aware of the spasms unless he actually observes the affected limbs.
The affected limbs, previously normal, also become paretic. After the attack has subsided, the paresis and anaesthesia persist (as sometimes happens in true idiopathic epilepsy) for a few days, after which the patient’s condition remains normal until the next attack. After his last attack, however, the anaesthesia and paresis continued for about three weeks. ”

“ The gait disorder sometimes amounted to a real astasia-abasia. The left leg became stiff and was dragged behind. There was a paresis demonstrable in dorsal decubitus, of the left side, especially of the leg, without atrophy. There was a hypesthesia of the whole left side of the body, with the exception of the head. Hyperesthesia of the left leg, hip and upper sacrum. The left corneal reflex was diminished. Moody, hypochondriacal, lachrymose. The general attitude of the patient was affected and theatrical. Paradoxical innervations were frequently found on test. ”

“ In general terms, it may be stated that when anæsthesia is due to lesions of peripheral nervous endings, of nerve-trunks, and of the posterior root system of the spinal cord, reflexes are diminished or lost.
It is often stated that anæsthesia causes ataxia of movement. This, from the results of experiments on animals and from clinical study, we believe to be a gross error. In animals and in man loss of sensibility gives rise to awkwardness or uncertainty in movement (increased if the eyes be closed) which is properly to be classed as a special variety of inco-ordination ”

“ In some of these injuries, notably "drunkard's palsy," the disability appears to be due not to damage of the nerve, but to overstretching of the extensors of the wrist and fingers (Jones) . A similar form of paralysis is sometimes met with from the pressure of a tourniquet, from tight bandages or splints, from the pressure exerted by a dislocated bone or by excessive callus, and from hyper-extension of the arm during anaesthesia. ”

“ The movements of the diaphragm must be constantly watched as it is the first to become paralyzed when anesthesia is carried too far. The same care must be observed with the pupil for cerebral and the pulse for cardiac signs. Before giving this anesthetic the same preparations as for chloroform narcosis should be observed. The stomach should be empty, the nose and mouth smeared with vaselin, and the eyes protected with a towel.
At first the patient is given the ether with a considerable mixture of air, which should be lessened gradually. ”

“ Under ether anesthesia the damage to the nerve-cells is at least four times greater than under nitrous oxid. Inhalation anesthesia is, therefore, but a veneer— a mask that "covers the deep suffering of the patient." The cause of the exhaustion of the brain is the discharge of nervous energy in a futile effort to energize the paralyzed muscles in an attempt to escape from the injury just as if no anesthetic had been given. ”

“ Though the patient may be convinced that he will suffer no pain, the mental attitude toward the local anesthesia, together with fear, may operate so strongly as to constitute a shock to the nervous system so great that a general anesthetic should be used and the local method abandoned, even were it apparently indicated.
Again, the injection of anesthetic drugs in cicatrical and inflamed tissues is quite difficult of accomplishment and because of the peculiarity of these tissues, diffusion throughout a given area is imperfect, hence insensibility is not complete. ”

“ If the traumata under inhalation anesthesia are sufficiently strong and are repeated in sufficient numbers, the brain-cells are finally deprived of their dischargeable nervous energy and become exhausted just as exhaustion follows such strenuous and prolonged muscular exertion as is seen in endurance tests. Whether the energy of the brain be discharged by injury under anesthesia or by ordinary muscular exertion, identical morphologic changes are seen in the nerve-cells. ”