PH YCII80-iESTHKSIA(cold hknkationh),

AND PSYCHUO-ALGIA(COLD I'AINk).

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CIIABLKB L. DANA, M. D.,VklUnic rbyalHut lo IMUtu* HoaplUl; l*tnliß Hml Hmm

IHMW. Ikllnw IluaplUl M«Ur*l Colbr*.

RKinuNTRi) num tub

Well) Yovte i«rHfc«l Journalfur Fritruary tti, Uf9S.

Reprinted from the Netr York Medical Journalfor February 26, 1898.

PSYOIIUO-J2STIIESIA (COLD SENSATIONS),AND PSYOHRO-ALGIA (COLD PAINS)*

IW CHARLES L. DANA, M. D.,VIHITINU I’IIYHIOIAN TO HRI.I.RYUR HOArtTAL ;

OUORKHMOII or NKUVOI'M DI'KAHKH, lIKI.I.RVIR HOM’tTAL MROK Al. (01.1.R0K.

Intkoductouy.—ln a recently written article on thesubject of panesthceia f I have tried to show with somenew emphasis the significance and relationship of thissymptom. I venture to quote here some of my introduc-tory paragraphs:

Paresthesia is the name given to a number of sub-jective sensations, such as prickling, numbness, creepingsensations, tickling, and burning. It includes, in fact,nearly all the subjective sensations of the skin, exceptthose of pain. It is a condition which is, therefore, ex-tremely common, and in its mildest and most trivialcharacter is much more often experienced than pain.When these sensations fix themselves in a certain local-ity, following the tract of the nerve, or fastening them-selves upon the hand or foot, they take on a certain clini-cal picture, and deserve to have the name of a diseaseto just the same extent that a neuralgia does. Para?s-thesia, in almost all cases, implies simply a lower grade

* Road before the Now York Neurological Society, October ft, 1597.f Ttvf liook of Nrrvoim Dimunri, fourth edition, p, 152,

Oorriuuiir Ihuh, uv I). Aoomto* a>o Oompakt

PSYCIIHO-yfcSTIIKSIA AND PBYCIIHO-ALGIA.2

of irritation of the nerve fibres than occurs in neural-gia, and is a kind of ghostly simulacrum of that disease.It very often precedes or accompanies attacks of pain.There is sometimes a tingling of the teeth or burning inthe face which has a shadowy likeness to a toothache ortrigeminal neuralgia. In the same way, one finds par-cesthesias affecting the head, causing sensations of pres-sure and constriction, of burning, and general undefin-ablc discomfort, which arc entirely comparable to head-aches.

In conditions of neurasthenia, panesthesias of thehead are more common even than the headaches. Par-a'sthesia sometimes follows the course of a nerve, aswhen one feels numbness of the hand if the ulnar ispressed upon at the elbow, or numbness in the footwhen the sciatic is pressed upon, as when the legs arecrossed.

There is also pancsthcsia affecting one of the inter-costal nerves or one of the crural nerves. On the otherhand, panesthesia may affect all four extremities, so thatthey feel entirely benumbed or prickling. There is, 1repeat, a very close analogy between these groups ofpanesthesias and neuralgias.

Panesthesia affects single ccrcbro-spinal nerves justas neuralgia docs, or it may be more generally distrib-uted. In the latter case it affects most the feet andhands, and it is called acro-parceslhesia.

We meet then with:1. Cephalic panesthesias, comparable to diffuse head-

aches.2. Local panesthesias, comparable to local neural-

3. Acro-panesthesia, involving the feet or hands orboth diffusely.

The cephalic panesthesias are usually symptoms ofneurasthenic or litha?mic states. Among eighty-fivecases of local and acro-panesthcsife, not symptomatic ofother and organic nerve disease, 1 found that there wereof the local forms thirty-five cases, of acro-panesthesiafifty cases. The local panesthesias affected tlio arms in

PSYCIIKO-JCSTHESIA AND PSYCHRO-ALGIA. 3

eighteen cases, next the thigh ami leg nerves in twentycases, and, last, the trigeminal nerve in three cases.

The following analysis of eighty-five cases of parnes-thesia occurring in my practice shows something of thecause and local development of the malady. The mostfrequent causes I find to be those concerned with occu-pation, I‘anesthesia, in its general manifestations, maylie considered almost an occupation neurosis. The listof cases may he put down as follows;Occupation 10Kheumatism 10Alcoholism AInfection ASenility. A

Keflex irritation 2Hysteria 8(Mimnoleric change 2Various causes, such as neuras-

thenic state, puerperium, etc. 12

Among 85 cases there were 50 males and 19 females:

The special nerves affected were:Trigeminal 4 Sacral Ilirncliin) R Sciatic 1Ulnar 7 Plantar * IIKadial 1Orural 4Peroneal 1

The commoner form of panesthesia is simply that ofa sensation of prickling numbness or of a part beingasleep. A more rare form is that accompanied by sensa-tion of heat, and hero (he perverted feeling verges closelyupon pain. In fact, the sensation of heat is often so

Males. Kcmaln. Total.

11 an<Im hihI foot, or lioth, nffcotod B 11 1718ft 12

Foot and 10 10 204 4

14 12 26

86 49 85

4 PSYCHRO-.KSTHESIA AND PSYCHRO-ALdIA.

distressing that the patient considers it to all practicalpurposes a pain, although it may not correspond to thestrictly technical psychological definition.

Psychro-asthesia.—Among the rarer forms of par-esthesia are those of sensations of cold (psychro-esthesia,from cold). These sensations are felt quiteapart from any actual lowering of the temperature ofthe body and without any objective evidences of vascu-lar change in the allectcd part. Cold paresthesias arenot usually very distressing, and, although they aresometimes described as cold pains, they are not so akinto pain as are the heat sensations. The term psychro-a?sthcsia was first used by Pollaisson (Lyon medical,1887). Later it was adopted by Silvio {La Hiformamedica, February 17 and 18, 1890), and these authorshave reported several cases of this kind, A case wasalso reported recently by Dr. L. G. Guthrie in Brain,spring and summer number, 1897. These two later arti-cles have drawn renewed attention to this interestingsymptom. A number of cases have occurred in my ex-perience, and it seemed to me that it might bo worthwhile to report a few of them in hopes that a fullerknowledge of the rctiology and pathology of the condi-tion might be obtained.

Case I.—Dora C., aged fifty-three years; Ireland;washerwoman. The patient for three years had hadconstant tinnitus aurium, especially in the right car,troubling her most at night. She had disease of bothinternal ears and chronic middle-car catarrh, and bothexternal canals were almost filled by soggy epithelialscales. Such was the report of her condition by Dr.A. M. Fanning. Her special complaint was of the coldsensation which she felt continuously in the foreheadduring all this period of three years. This annoyedher so much that she thought she could not get along

PSYCIIIIO-yKSTIIKSI A AND PSYCH RO-ALGIA. 5

without a bandage over her forehead to keep it warm.Tlio sensation was bilateral and involved the upper partof the forehead, like a brow headache; the skin was notcold or in any way changed to the sight or touch. Shehad some of the ordinary parsesthesias in the hands andfeet of the prickling pms-and-needles kind. She wasslightly nervous and slept badly. There was no dyspep-sia, and the bowels were regular. She drank a good dealof tea—five or six cups a day. Examination showed noamesthesia in any form and no signs of organic nervousdisease.

Hero was a case of cold para?sthesia of the forehead,associated with the ordinary paresthesias which occur inmiddle-aged women who do a great deal of washing anddrink a good deal of tea and, perhaps, alcohol.

Cahu ll.—Francis L. L., aged fifty-six years; mar-ried; United States; mechanic. Family history good;no syphilis; habits temperate. His occupation com-pelled him to stand all day. The patient had somechronic bronchial trouble, and a year and a half agoho began to have paresthesia of the legs below the knees.Ho said the trouble came on at two in the morning.Very soon after this he began to have sensations of cold-ness in the feet, which were always worse in the morningand lasted until the middle of the afternoon. Duringthis time he felt as if standing upon ice, and he wouldtry by heat and rubbing to get rid of the discomfort.Toward three o’clock the cold sensations changed to burn-ing sensations, which lasted until night. He had sometremor, the pulse was rather rapid, and he showed signsof arterial sclerosis. The lungs, heart, and sexual or-gans were normal; digestion normal, and a physical ex-amination showed absolutely no amesthesia of the affect-ed parts and no change in the vascularity. The reflexeswere slightly exaggerated.

Here, again, we have a case of cold parasthesia asso-ciated with heat and the ordinary prickling paresthesia,

PSYCHRO-iESTHESLA AND PBTCHUO-ALOIA.

due probably to exposure, to defective venous circulationdependent on the man’s habits of standing at his work,and probably to some rheumatic influences.

Case lll.—lxjwis S., aged forty-two years; mar-ried ; butcher by occupation. Family and previoushistory negative. The patient was a healthy-lookingman, who came to the clinic complaining of a sensa-tion of coldness over the left thigh, especially markedon its anterior surface. This had lasted for six months,and had been gradually increasing. During the previ-ous year he had had the same sensation in the rightthigh, but this had disappeared, lie denied syphilisand rheumatism. Ho drank, but not to excess. Exam-ination showed absolutely no objective signs. Sensationwas normal as to temperature, touch, and pain. Thetongue was thickly coated, and there was some historyof dyspepsia. On questioning him I found that in hisoccupation his thigh was constantly brought into con-tact with the edge of a table or counter; in other words,there was constant slight trauma. Dr. (Jcorgc It. Elliott,who examined his urine, concluded that there was a tox-aemia from digestive disorder.

Case IV.—James 0., aged sixty-two years; Ireland;married; occupation, clerk. The patient had sufferedseveral years from bronchitis. For three weeks previousto being seen by me he had been suffering from someprickling panesthesia of the fingers and in the lower ex-tremities, and, at the same time, ho had sensations ofcold in these parts. He had dyspepsia, poor appetite,and constipation. Examination showed nothing ob-jective in the hands and feet; the knee-jerks were pres-ent : there was no loss of power in the legs, and no nnirs-thesia over the affected parts. The sensations of coldwere not due to actual vascular changes, but were sub-jective. The patient had no signs of tabes dorsalis.

Case V.—.Jeremiah H., aged forty-nine years; mar-ried; Ireland; laborer. The patient had always been ahealthy man and did not drink intoxicating liquors.For four successive winters ho had suffered during the

PSYCIIRO-ifiSTIIESIA AM) PBYCHRO-ALGIA. 7

wliolo of the cold weather from a sensation of coldnesson the left leg, on the outer side just above the ankle.The affected area was sharply mapped out and measuredabout eight by four inches. It was not exactly painful,but gave him a great deal of annoyance and apprehen-sion. The sensation disappeared as the summer /eathercame on. There were no other complaints. Examina-tion showed nothing abnormal in touch, sensation, orpain, nor were there any objective changes to be seen inthe part affected. A careful general examination wasmade without discovering any signs of organic disease.The patient described his symptoms vividly, and he wasshown to my class ns a case of cold panesthesia, due tosome irritation of (he peripheral filaments of the externalpopliteal nerves.

Cash Vl.—Elizabeth J., aged forty-one years; Ire-land; domestic. For about a year the patient had suf-fered from some pains in the right ankle, togetherwith prickling sensations which ran down to the toesand up to the knees. The part from the knee down alsofelt constantly cold, and this cold sensation was asso-ciated with para?sthcsia and prickling. The patient de-nied ever having had rheumatism, and also denied drink-ing and other had habits. Her general health was good,and there were no objective symptoms connected with thepart affected. The legs and feet were not tender, norwas there any redness or swelling. The knee-jerks werepresent, and there was no particular weakness of the ex-tremities. The patient complained of the coldness, butperhaps even more of the prickling and pain.

Cast. VII, Mr. ('. C., aged forty-four years;United States; married; occupation, business. Familyhistory good. The patient had had syphilis twenty yearsbefore, with secondary symptoms afterward. lie was awell-nourished man and apparently in good health, ex-cept for the particular symptom complained of. Thisconsisted of a sensation of intense coldness over theleft hip on its lateral surface. The area was limited,and extended from the knee about two thirds of the way

PSYCHRO-.ESTIIESIA AND PSYCHRO-AUiIA.8

up the thigh, mostly in the distribution of the exter-nal cutaneous nerve. Tic felt, he said, as though it hadbeen painted with menthol. Warmth and exercise madeit disappear for a time, but it returned. The part af-fected looked and felt to the touch perfectly normal.There was no anaesthesia of touch, pain, or temperature.A careful examination failed to reveal any trouble withthe general bodily functions. The urine, digestion,heart, and lungs were normal. The pulse was 08, Afurther careful examination was made for tabes, but hoshowed no signs of this. There was no loss of knee-jerks;no eye symptoms; no bladder symptoms. The patientsimply suffered from this continual sensation of coldnessof the thigh.

The foregoing cases all occurred in patients in whomit was impossible to detect any absolute signs of organicdisease of the central or peripheral nervous system. Ihave under observation now at the Montcfiorc Homo twopatients, one of whom is certainly suffering from syrin-gomyelia in an advanced stage. The other probably hassyringomyelia in an early stage. In both cases the pa-tients complain of a sensation of coldness over the upperextremities. This sensation is felt from the hands up tothe elbows, and is simply a cold feeling not associatedwith pain. Both patients have some slight sensory dis-turbances, such as thermo and pain amesthosia, but theseare not marked. They are not accompanied with sensa-tions of prickling or of heat, or with the ordinary panes-thesias.

I have presented the foregoing clinical data verymuch condensed, for the reason that I know that myhearers are familiar with cases of this kind, and it doesnot seem to mo necessary tc go into elaborate detail to il-lustrate further their character.

Analysis of Symptoms.—We have apparently two

rSYCHKO ifCSTIIKSIA AND rSYCHRO-ALGIA. 9

classes of cold parassthesia. In one the symptom is notdefinitely limited to certain areas, but involves a wholeextremity or all four extremities, and is associated withother paresthesias or with pain, and often with evidenceof vasomotor disturbance.

The other class of cold paresthesia, psychro-nesthesiaproper, is a disorder in which the sensation is quite anisolated one. The patient suffers from a feeling ofcold exclusively, or almost so, having with it no prick-ling or numbness and not always any distinct pain, al-though it may amount to such. Furthermore, this formof paresthesia is limited to some special area, oftenestupon the thigh or buttock, but sometimes upon the calfor upon the face, and more or less closely following thedistribution of a nerve.

The sensation is purely dermal and superficial. Themind refers it to the external world, so that it seems likean objective sensation similar to a touch. The patientfeels as though some cold object were lying upon thepart.

The sensation may disappear in warm weather orunder exorcise.

In some instances it is not so much a cold sensationas a cold pain or psychro-algia, and it may be obstinateand distressing, especially in quite elderly and senile per-sons.

Pathogeny .—The psychro-avdbegins of the first ormixed typo are met with oftenest in mild forms of neu-ritis, such as may bo caused by alcohol, or such as occursin sciatica; they are also observed in locomotor ataxia.Among thirty-six cases care fully examined for this symp-tom by Dr. Joseph Friinkcl, he found two persons whospontaneously complained of sensations passing up and

10 PSTCHRO-wESTHESIA AND PSYCHRO-ALOIA.

down the back like waves of cold, or alTecting the logsin a similar manner. The symptom also occurs in theearly stage of syringomyelia, as noted in my two cases.Mixed psychro-a?sthesia is thus usually due to neuriticirritation, but may indicate a lesion higher up. Yet inpractically all cases it means a lesion of the peripheralsensory neurone at one part or another of its course. *

The exciting causes are usually alcohol, lithtemia, ex-posure, and toxic agents that lead to nerve degeneration.

The purer types of cold sensation and cold pain arefound more often in men, and almost always in personsover forty years. The trouble is caused sometimes bytrauma, combined with exposure and a rheumatic tend-ency. A neuropathic constitution favors its develop-ment. Polaisson attributes some cases to varicose veinsand to uterine disease.

So far as clinical experience and reading go, the coldparaesthesia of syringomyelia is less intense and lesssharply limited than those in the cases described. Thepatients have simply a sensation of general coldness,but not of the same sharp smarting coldness complainedof by the patients whose history I have reported. Thesensation is really subjective, is like that felt in diffuseneuritis, and is perhaps due to vasomotor disturbances.

Pathology.—There arc both special cold and specialheat nerves distributed to the skin and some of the mu-cous membranes. The fibres carrying these thermal im-pulses run in the ccrebro-spinal nerves mingling withother sensory nerves. They separate again in the spinalcord, as shown in cases of syringomyelia and central-cordlesions, but apparently run very difTusedly in the brain

* Dr. William H. Thomson reports n rase of psychro-nsthesia due toa cerebral lesion. Such cases are unique.

AND I*SV(’HUO-ALOIA.

axis and capsule, for local lesions here do not cause adifferentiation of heat and cold anajsthesia. Hence(apart from psychical states) we must place the seat ofthe lesion in psychro-sesthesia practically almost alwaysin the peripheral nerves. Its presence may, however,indicate a beginning syringomyelia or some other cen-tral cord lesion •; and also, in rare cases, locomotorataxia.

Treatment.—In most cases the treatment is that ofan underlying neuritis or neuritic irritation. Antir-rheumatic drugs, mix vomica,exercise, and electricity areindicated. Locally, a liniment containing a little mus-tard oil is useful. Warm applications and friction some-times give relief. In very obstinate cases the questionof syringomyelia should bo investigated. Where thereare pain and evidences of decided neuritis, as in sciatica,rest is necessary.

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