Hyperesthesia

“ There was a quadriparesis, more marked, however, on the left; walking with falls to the left; astasia with left foot; double facial paresis; inability to whistle and to close eyes completely; intestinal and bladder paralysis; nocturnal emissions non-pleasurable; partial anesthesia of right leg, of [531] arm and of hand, with hyperesthesia of thigh, of forearm and of the posterior aspect of the upper arm; anesthesia of the left side, including thorax and abdomen, excepting that the arm was hypesthetic only. Face hyperesthetic. Complete anesthesia of nipple and testis; hypesthesia of neck ”

“ Tremor of hands, head, body, ceasing during voluntary movements. Episodically he had spells of dizziness followed by absent-mindedness, whereupon he wandered aimlessly about, of a sudden becoming aware of being in a place, but not knowing how he came there.
Special senses intact. Several points of cutaneous hyperesthesia, particularly mammary and pseudo-ovarian on the left, pressure whereon provoked a lively emotional reaction with acceleration of pulse, redness, lacrimation. Knee reflexes lively, cutaneous reflexes normal, except the plantar which were very lively. ”

“ 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. ”

“ 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. ”

“ At first the pulse is slightly stronger and fuller than the normal, but it soon loses its strength and volume and becomes more rapid. The pupils are at first dilated, and as narcosis is induced, contract. Should they contract after this, during operation, it is a danger signal not to be neglected. Death may come on suddenly.
If the patient struggles violently under early anesthesia, as is often seen in alcoholics and athletes, it is not advisable to push the chloroform nor should total muscular relaxation be effected. The arrest of reflex movement is all that is required. ”

“ 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 minor or trivial affairs the elimination of pain is not to be considered lightly, for every patient, even the strongest, will appreciate [Pg 235] anything which will expedite a cure and at the same time will relieve him of suffering. Rather than lose time from their work or suffer the nausea and dangers of general anesthesia, these patients often bear for years conditions which could easily be cured by operations under local anesthesia. In this class one must first think of hemorrhoids; of cysts; of fatty tumors; of foreign bodies in the hands and feet; of verruca and of ingrown nails. ”

“ 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. ”

“ 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 rapid recovery from anesthetics seems to indicate that it is not neurons, or essential nerve cells, that are so deeply affected, but some extraneous, and less important, mechanism within the brain. The neuroglia theory explains this very well and does away with the difficulty. Certain curious phenomena of hysteria are easily explained on this theory. When there is anesthesia in a member because of hysteria, this anesthesia does not follow the distribution of certain nerves, but is limited by a line in the shape of a cuff drawn round the limb. ”

“ 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. ”

“ The same system of muscles comprising those of the thorax, abdomen and perinaeum, performs consentaneously the acts of respiration, vomiting, defecation and micturition. When the spinal cord suffers injury above the origin of the phrenic nerve, immediate death supervenes, owing to a cessation of the respiratory act. Considering, however, the effect of such an injury upon the pelvic organs alone, these may be regarded as being absolutely excluded from the pale of voluntary influence in consequence of the paralysis of the diaphragm, the abdominal and perinæal muscles. ”

“ According to Babinski’s figure, the organic factor acts as a bait for the hysterical symptoms. According to the Salpêtrière experience, hysteria is incapable of producing a real superficial and deep anesthesia such as is mentioned for this case. For example, no hysterical patient in the Charcot clinic, according to Sicard, could undergo a scalpel operation without some general or local anesthetic. When, therefore, a true deep anesthesia occurs, Sicard’s conception would be that the anesthesia is not a truly hysterical one but belongs to the group of physiopathic phenomena. ”

“ Anæsthesia, not of a high degree nor at all coextensive with the paralysis of the muscles—sometimes, indeed, confined to very circumscribed areas—may be said to exist always in multiple neuritis—a fact of great diagnostic value. Hyperæsthesia of the skin is frequently seen. Hyperalgesia and analgesia are sometimes observed. Hyperæsthesia of the muscles is a very marked symptom in almost every case, and shows itself not only upon direct pressure being made, but also in the pain elicited by passive movements of the parts affected. ”

“ 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. ”

“ 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. ”

“ 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. ”

“ The choice of the anesthetic is of great importance as to the outcome of the operation. The Basedow’s type with predominating nervous, myasthenic and psychic symptoms is best operated on under general anesthesia, the other cases under local anesthesia. 5. Operation is contraindicated in status lymphaticus; if it can not be avoided, a local anesthetic should be employed. 6. In many cases the operation only lays the foundation for successful internal treatment. 7. The most unfavorable time for operation is that of increasing intensity of the disease ”

“ Such patches of anæsthesia, hyperæsthesia, or paræsthesia sometimes indicate foci of disease in the spinal cord (and brain?) ; as, for example, the pains, etc. of posterior spinal sclerosis. These patches may also occur in consequence of [p. 39] interference with local circulation of peripheral parts; and we meet with them in such conditions as hysteria, neurasthenia, alcoholism, etc.
(g) Universal hyperæsthesia, paræsthesia, and anæsthesia may be observed. The last condition, in the insane, is very apt to give rise to delusions of non-identity and death of the body. ”

“ The right hand was found markedly congested and 1.5 cm. larger in circumference. The fingers and hand were especially weak. There was a marked tremor of the arm. Electric excitability normal. The sensory disorder was in glove form. Hypesthesia to touch reached the elbow, analgesia to a point three fingers’ breadth below the elbow, and anesthesia to cold to a point two fingers’ breadth still lower, a sort of stepwise dissociation of sensibility resembling what is found in spinal lesions. The case was presented as one of local traumatic hysteria. ”

“ 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. ”

“ 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. ”

“ It usually occurs in patients who have had prophylactic injections of anti-tetanic serum, the toxins entering the blood being probably neutralised by the antibodies in circulation, while those passing along the motor nerves are unaffected.
When it occurs in the _limbs_, attention is usually directed to the fact by pain accompanying the spasms; the muscles are found to be hard and there are frequent twitchings of the limb. A characteristic reflex is present in the lower extremity, namely, extension of the foot and leg when the sole is tickled. ”

“ 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. ”

“ 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. ”