Ways and Means of the Surgery of Pain
A large number of operative approaches have been worked out and tested against uncontrollable pain. As in every other branch of medicine the large number and variety of methods is little more than evidence for their unsatisfactory nature. The point of view of the surgeon launching out into the fight against pain can be subdivided as follows: he tries either to interrupt the nervous pathway, or to change the conditions in order to decrease the sensitivity of the patient and so affect the pain threshold and the reaction to pain. The latter may finally change the quality of the perceived pain, and the behaviour and attitude of the patient to pain in general. One could call the first method a primitive, roughly physical-anatomic method, the second approach is a physiological one, and the third now goes under the label of psychosurgery. The individual ways and means of these three basic groups can be listed as follows
I. Physical-anatomical ways and means
A. Operative procedures on the first neuron.
1. Section of the peripheral sensory nerve (peripheral neurotomy).
2. a) Section of the sensory spinal roots (rhizotomy,
posterior radicotomy).
b) Section of the spinal connexions (ramicotomy).
c) Alcohol infiltration of the spinal roots.
B. Operative procedures on the second neuron.
3. Section of the spinal pathways carrying pain information.
a) Spinothalamic tracts in the anterolateral columns of the cord (anterolateral chordotomy).
b) spinothalamic tracts, at the site of crossover (in the anterior grey matter of the chord) myelotomy of the posterior commissure.
4. Section of the spinothalamic tracts in the medulla oblongata (supraolivary bulbar tractotomy).
5. Section of the spinothalamic tracts in the midbrain (mesencephalic tractotomy).
6. Interruption of the sensory pathway in the posterior nuclei of the thalamus (posterior thalamotomy).
II. Physiological approaches
A. Manipulation of the internal milieu.
1. Manipulation of the level of blood calcium.
a) Operative procedures on the parathyroids
b) Bone implantation.
2. Changing the function of the adrenals 1 (this belongs also to group B).
3. A change in the function of the sexual glands.
4. A change in the function of the thyroid.
5. Manipulation of hormonal effects in some painful states associated with malignant cancer.
B. Manipulation of vaso-motor balance.
1. Procaine
a) Infiltration i. Into vessels, ii. into the sympathetic chain, plexuses and ganglia,
b) intra-arterial injection,
c) intravenous injection.
2. Periarterial sympathectomy.
3. Resection of the sympathetic chain.
4. Removal of the sympathetic plexus.
III. Psychosurgery (Operative procedures „on the third neuron”)
1. Frontal lobotomy (leucotomy).
2. Removal of the temporal and supraorbital cortices.
3. a) Thalamotomy.
b) Hemispherectomy.
4. Postcentral gyrectomy.