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Summary Seventy patients with intractable pain underwent hypothermic saline spinal subarachnoid injection. Thirty-three patients had pain due to benign conditions and thirty-seven to neoplastic diseases. In all patients, pain was relieved for several days after saline injection. In the thirty-three patients with benign conditions, pain was relieved for one to three months in 50 per cent and for seven months in less than 20 per cent. In twenty-eight of the thirty-seven patients with neoplasm who were dead at the time of this evaluation, 75 per cent of the twenty-eight patients had excellent to fair pain relief after hypothermic saline injection until the time of death. The mechanism of pain relief by hypothermic subarachnoid saline injection is not clear; nevertheless, the low morbidity warrants its consideration for pain relief in patients with neoplastic diseases.

Patients who develop metastatic lesions in the spinal column from breast carcinoma do suffer a great deal of pain. When spinal cord compression causes paralysis of limbs or sphincters, the quality of life deteriorates although they may live for many months. Decompressive laminectomy alone does not significantly alter their outlook. We have found that hypophysectomy either alone or in combination with laminectomy allows regression of these tumours in some cases. We have described six patients who have been submitted to hypophysectomy and only three of these have had decompressive laminectomy. The most important result of endocrine ablation has been the relief of intractable pain. Four paralysed patients began to walk again and the improvement in the quality of their life made the surgery well worth while.

Bilateral anterior cingulectomies were performed on 23 patients for the relief of intractable pain. 19 patients suffered from pain due to metastatic disease, 3 from arachnoiditis and 1 from a phantom limb syndrome. Of those patients suffering from pain due to metastatic disease, 10 (52.1%) obtained pain relief. Among the patients suffering from arachnoiditis, 1 obtained pain relief. The case of phantom limb syndrome also obtained relief from pain. Combining all the patients, we were able to relieve the pain symptoms in only 12 out of the 23 patients (52.2%). We cannot recommend this operation for the relief of pain.

25 patients with hemiparesis and without overt mirror movements were examined. EMG needle electrodes were inserted into the opponens pollicis and abductor digiti minimi muscles of the affected hand and the EMG recording was filmed during opposition of the thumb and abduction of the fifth finger of the intact hand. In 10 patients action potentials were recorded from both examined muscles. The study shows that muscle contractions equivalent to overt mirror movements are a frequent finding in hemiplegia.

This is a report of the occurrence of nystagmus retractorius, inferior quadrantanopia of optic tract or geniculate origin, and paresis of conjugate gaze, following localized stereotactic lesions in the central nervous system of man. These ocular phenomena were observed after the lesions were placed in the region of the pallidum or thalamus for the relief of tremor and rigidity in extrapyramidal diseases and for the relief of intractable pain. Report of Cases Case 1. —This 72-year-old white woman developed intractable postherpetic neuralgia following herpes zoster ophthalmicus on the right in August, 1958. Protamine, x-ray therapy, avulsion of the right supraorbital nerve, and undermining of the affected skin failed to produce relief. Because of persistence of the pain, she was admitted to Duke Hospital in July, 1960, for stereotactic thalamotomy. Neurological examination revealed a complete anesthesia in the distribution of the first division of the right trigeminal nerve; otherwise, it was

The common causes for intractable pain are presented. Minor and major neurosurgical procedures for its relief are listed. Table VIII Table VIII. Death within fourteenth days after various neurosergical procedures for the relief of intractable pain Operations No. No. of Deaths Cause of Deaths Chordotomy Unilateral 14 0 Bilateral 20 0 Rhizotomy Unilateral 7 0 Bilateral 9 0 Chordotomy and Rhizotomy 2 1 Bronchopneumonia (12 days) Rhizotomy, 5th and 9th cranial, C1, C2, C3 3 1 Postoperative shock (18 hr.) Medullary spinothalmic tractotomy 2 2 Medullary softening (24 hr.) cardiac metastasis with hemopericardium (6 days) Mesencephalic spinothalamic tractotomy 1 0 Sympathectomy 4 0 Total 62 4 (6.4%) The advantages and disadvantages of subarachnoid and paravertebral alcohol injections are compared with those of chordotomy, rhizotomy and sympathectomy. Fifty-seven cases of intractable pain in which operation was performed by the authors are then presented in the following groups: (1) malignancies, nasopharynx and neck, paraveretbral, gastrointestinal, pelvic and skeletal; (2) vascular: neurosyphilis with and without tabetic crises, causalgia with and without phantom pain, cardiac (angina); (3) miscellaneous: tuberculosis of the bladder, arachnoiditis, herpes zoster and fracture of the thoracic vertebra; (4) unknown etiology with neurosis. The relief of pain, mortality from operations and complications, are listed in tables. Each group is then analyzed and the results compared with those published by others. Conclusions were then made as to the relative merits of the various procedures and contraindications to their use. The possibilities of recent procedures such as resection of the sensory cortex and prefrontal lobotomy are discussed.

Rarely should a defeatist attitude toward intractable pain be entertained without an investigation of the possibilities of relief by means of surgery. This applies especially to patients with incurable cancer because to them the actual and potential penalties involved are insignificant when compared with the relief of pain which they may expect from surgical treatment. In this country alone, cancer takes 160,000 lives each year. Of this number of patients passing through the terminal stages of the disease, comparatively few require neurosurgery. Local treatment of the growth, together with other measures such as x-ray therapy and the administration of analgesic drugs, tides the majority of patients over until there are complications causing rapid failure or until cerebral metastases occur which may not only raise the threshold of pain but also make the patient indifferent to his condition. It is in those patients with intractable pain, whether this comes early or late in the course of a malignant neoplasm...

During a twelve year period from June 1958 through June 1970, forty-two patients underwent surgical procedures for chronic pancreatitis and its complications at the John Cochran Veterans Administration Hospital, St Louis, Missouri. Indications for operation were an epigastric mass in thirty-one patients, recurrent intractable pain in eight and upper gastrointestinal bleeding in three. Fourteen patients required a total of twenty-eight reoperations. Multiple postoperative complications were encountered after all operative procedures. Only thirteen patients had good or excellent results. Seven patients died after either primary or secondary operations.

M ANY patients with malignancies of the head and neck survive for long periods of time, even though their disease has not been controlled by surgical or radiation therapy. They usually die slowly of the Iocal effects of the disease rather than from distant metastases to the central nervous system, the liver or the lungs. Many of these unfortunate people have severe pain, and this symptom may date either from the onset of the disease or from the first sign of its recurrence. In some instances, the pain may be markedly increased by swallowing and, as a result, the patient may deteriorate rapidly because of an inadequate intake of food. The physician caring for these patients has a choice of several plans of therapy. Local excision or radiation may be very helpfuI in relieving pain. The removal of a radionecrotic mandible may give surprising relief of pain. However, in many patients Iocal therapy is not possibIe. The physician may decide to accept the situation and relieve the patient with narcotics. In many cases, this approach may be justified or at least the only one possible. Unfortunately, however, quite a few of the patients so treated outlive the relief given by the drugs and then have, in addition to pain, the problems of addiction to and dependency on narcotics. Alternatively, a neurosurgica1 approach to the problem may be eIected. With this approach one accepts the fact that nothing further can be done about the disease itself, but that some form of symptomatic relief can be achieved either by altering the patient’s response to pain or by preventing the sensation of pain from reaching conscious levels. In any long term illness, proper pIanning of therapy is important; insofar as operations for the relief of pain are concerned, this planning is speciahy important. There would seem to be a proper time to perform a pain-reheving operation in relationship to the amount of pain experienced, the patient’s physical state, his life expectancy and other possible forms of therapy. Local procedures, if reasonable, should be tried first. If these fail, a delinite decision as to further management should be made. The probIem of what constitutes pain, and especially intractable pain, is an individual matter. Beecher [2] has recentIy written that “Pain cannot be satisfactorily defined, except as man defines it introspectively for himself.” He has further stated that “No convincing demonstration has yet been given that the pain threshold is a constant from man to man, or from one time to another in a given man.” It is my impression that pain-relieving operations provide the best results when performed early, certainly before the patient has received any quantity of narcotics. They should also be performed at such a time that the patient’s convalescence will not probably take up the major part of his life expectancy. It is diflicult for many physicians to advise a surgical procedure knowing that it will only give symptomatic relief and that the patient will probably succumb, if not to the operation, to the primary disease. This attitude leads to procrastination at the best, and at the worst to addiction. Patients who have received any amount of narcotics, usuaIIy do badly and are diflicult to manage if painrelieving operations are later attempted; although they may be relieved of the primary pain, they will still feel the need for narcotics for any other discomfort. It has seemed to me that the best results have been achieved in patients somewhere between the aspirin and

A method is suggested for relieving intractable pain due to cancer or other conditions by a simple procedure which accurately places a minimal amount of alcohol at the posterior root ganglion. There do not appear to be any harmful effects from the procedure. It may be useful also in peripheral vascular diseases of the lower extremity in which pain and vasospasm are factors without harmful complications. 35 In one case of osteoarthritis of the spine in which 1 2 m. of alcohol was used at D-12 and L-1, 2 and 3, there was not only relief of pain but also a hot, dry extremity indicating sympathetic paralysis on this side. The increase in skin temperature was 4 degrees over that of the opposite foot. This sympathetic paralysis persisted for over a month.

The mobilization of lecithin from the tissues into the blood stream with the production and retention of degredation products such as choline and its derivatives may well explain the thrombotic tendency, capillary bed disturbance, claudication and intractable pain in thromboangiitis obliterans. The capillaries are involved in the pathological process as well as the large and small vessels. The capillary lesions may be divided into three stages: (1) the irritative and vasomotor disturbances; (2) paralysis of the capillariomotor mechanism with marked dilatation of the capillaries resulting in rubor and stasis; (3) pregangrenous or gangrenous stage, in which there is capillary thrombosis and endovasculitis. Treatment executed on the basis of the limitation of lecithin intake and the detoxication of choline derivatives by the intravenous use of activated sulphur gave most promising and lasting results.

Two patients with Charcot disease of the spine who failed to respond to the usual conservative treatment of rest and braces have had relief of back pain after surgical arthrodesis of the involved area. Each of these patients had additional lower-extremity joint lesions which complicated the end result. Spine fusion was solid in both patients, after the usual length of time and postoperative management. Roentgenograms show arrest of the destructive and disintegrating processes of the vertebrae after surgical arthrodesis and solid fusion of the diseased portion. There was no evidence of further destruction in the five and seventeen years, respectively, that these patients were followed. Not all patients with Charcot disease of the spine require surgery. The authors feel that fusion is indicated in patients with intractable pain, signs of marked instability of the spine, or nerve-root and spinal-cord irritation who have failed to respond to braces. The chance for solid fusion in these patients seems satisfactory. With solid fusion, one can expect recovery from severe radiating pain, muscle weakness, paraplegia, and cessation of the destructive bone changes. In younger patients with an otherwise good life expectancy, it might be wise to perform this procedure as a prophylactic measure after a definite diagnosis of Charcot disease is made. The results of only three other spine fusions for Charcot disease of the spine have been reported. In all patients, a satisfactory result was obtained.

Percutaneous cordotomy has been performed twenty-seven times in twenty-three patients. Seventyfour per cent of these patients experienced satisfactory relief of pain. There were two deaths in the series, both from respiratory complications. Paresis, respiratory insufficiency, and urinary retention were significant complications. If factors such as pain on the opposite side, addiction, and other problems related to the disease are considered, cordotomy seemed worthwhile in approximately 50 per cent of our patients. However, it may be most helpful in the treatment of intractable pain due to malignant lesions, particularly if pain involves the brachial or lumbosacral plexus.

SPIEGEL, Wycis and their coworkers have adapted the Horsley-Clarke stereotaxic apparatus so that precisely localized lesions may be produced within the brain substance of humans. In this manner, they have been treating patients who have certain emotional disorders and intractable pain (1, 2). Consequently, a unique opportunity has been afforded the present authors to investigate the relationship of the thalamus and hypothalamus to the human metabolic economy. Patients so treated have been studied over a period of two years with a variety of tests, including those measuring the response of eosinophils to the stress produced by ACTH, epinephrine and insulin. This paper is limited to a report of changes observed with these latter procedures. METHODS AND MATERIAL Fifteen schizophrenic patients have been evaluated before and at intervals after bilateral lesions were produced in the thalamus and/or hypothalamus by Drs. Spiegel and Wycis. Several patients were operated on again and the lesions enlarged and/or se...

ALTHOUGH it has never been claimed that the phenothiazines have an analgesic action compar- able to that of the opiates, it is frequently inferred that they have some effect on pain. They are widely used to potentiate analgesic drugs in the management of intractable pain and have enjoyed great popularity in the treatment of the terminal stages of malignant disease. Apart from their anti-emetic effect, the rationale of the pre-operative use of the phenothiazines has never been clearly defined. Here they are usually administered in combination with analgesics and their sedative and tranquillizing properties are considered to be highly desirable. This popularity is evidenced by the marketing of the 'Tamer- gan" preparations which contain pethidine and promethazine. When these first became available the authors were evaluating a method of analgesi- metry, using pethidine 100 mg as the standard drug. It was expected thatPamergan P.100 (pethi- dine 100 mg and promethazine 50 mg) would produce a more marked and consistent degree of analgesia than pethidine alone. As will be shown later, this was not the case and this surprising finding led us to study the effects of promethazine 50 mg and the above mentioned mixture in more detail. This paper reports the results of this study and compares the findings with those reported for pethidine alone by Dundee and Moore (1960). For the sake of clarity, the mixture of pethidine 100 mg and promethazine 50 mg is referred to by its proprietary name of 'Tamergan P. 100". METHOD

(1960). The Hypnotic Control of Intractable Pain. American Journal of Clinical Hypnosis: Vol. 3, No. 1, pp. 3-8.

1. 1. Clinical observations following fifty intraspinal subarachnoid injections of 95 per cent alcohol ∗ demonstrate that the procedure is a practical and safe one when done properly. As shown experimentally, it is dangerous to life when done improperly. 2. 2. Used properly, alcohol usually relieves intractable pain, and may cause only partial anesthesia, but does not paralyze muscles. 3. 3. The fundamental principles of technique for the intraspinal subarachnoid injection of alcohol are given. 4. 4. Abstracts of 19 cases of cancer are given, as follows: Carcinoma of stomach 2 Carcinoma of cervix 5 Carcinoma of prostate 4 Carcinoma of rectum 4 Sarcoma of pelvic bones 2 Bronchiogenic carcinoma of lung 1 Sarcoma of tibia with x -ray ulceration 1 5. 5. The procedure when successful is invaluable in the relief of chronic, painful conditions. A single, subarachnoid alcohol injection may give relief for as long as eight months. It obviates the necessity for using narcotics in large doses, and diminishes the possibility of making drug fiends of chronic invalids. By relieving pain, it allows more intensive x -ray, radium, or other medical treatment to be given, and so tends to prolong life. 6. 6. There is some clinical evidence that sympathetic fibers are affected by 95 per cent alcohol when introduced into the subarachnoid space. This method therefore promises to be one of value in the treatment of diseases and disorders of the sympathetic nervous system.