The authors present a review of 146 patients who underwent 181 percutaneous cervical cordotomies for intractable pain. In addition, an anatomical-clinical correlation was carried out for 29 of these patients. It was found that the fibers subserving pain sensation in the C-2 segment lie in the anterolateral funiculus between the level of the denticulate ligament and a line drawn perpendicularly from the medial angle of the ventral gray-matter horn to the surface of the cord. The best analgesic results have been obtained by creating lesions that extend 5.0 mm deep to the surface of the cord and destroy about 20% of the hemicord. There is a somatotopic organization with sacral fibers running ventromedially and cervical fibers running dorsolaterally. The authors believe that the ascending fibers subserving the distinct sensations of pain induced by tissue damage and pinprick, although mixed (overlapping) in the anterolateral funiculus of the spinal cord, are physiologically distinct from one another. Whereas some cordotomies, both in the current series and as reported in the literature, may affect these functions differentially, optimum pain relief seems to be obtained only when pinprick sensation is also abolished in the affected segments. Evoked pain sensation is not abolished by cordotomy, but its threshold is greatly raised. When pathological pain is completely abolished, so is pinprick sensation. However, in a number of cases where pathological pain was only partially alleviated, pinprick sensation remained intact. The significance of these and other cases reported in the literature is discussed. The importance of clinically distinguishing between pain caused by tissue damage and pinprick sensation is emphasized, as well as that between return of pre-existing or new tissue-damage pain and painful dysesthesia.

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In 1931 Alpers described a condition in which there was a peculiar form of degeneration of the cerebral grey matter. Subsequently other examples of this disorder in association with epilepsy, spasticity, myoclonus and dementia in early life have been published. These 24 cases, together with eight of their own, have been summarized by Wolf and Cowen (1954) under the name of 'diffuse progressive cerebral cortical atrophy', although the cerebellum and basal ganglia were also involved. As the condition is uncommon it was thought worth while to record five cases, occurring in three families, in which cerebral biopsy was performed; on the four which subsequently died, histological and chemical examination of the brain was carried out.Case Reports Case 1. The health of the parents had been good. There was no known family history of epilepsy or mental illness. An only sibling constitutes the second case of this report.This full-term male infant was the product of the mother's first pregnancy and weighed 6i lb. (2-9kg.). The membranes ruptured 48 hours before delivery and labour lasted 24 hours. The child was shocked at birth and appeared cyanotic one hour later; oxygen was administered. He was apparently well when discharged from hospital on the tenth day. Diphtheria-pertussis inoculations were given at 6, 7 and 8 months, and vaccination was carried out at 10 months, without complications.At 10 months of age the child broke a femur and was in hospital for six weeks. There was no apparent head injury.The parents thought that the child developed normally until the age of 15 months. He sat at 6 months if supported. At 10 months he could form simple phrases but was unable to crawl. However, the clinicians considered from a review of home movies, that motor retardation had begun at about 8 months of age.The first convulsion, which occurred at 15 months, began with extension of the right hand in a claw position; the child 'shivered', fell forward limp and remained unconscious for four hours; clonic movements of the extremities then occurred. The patient was observed in hospital for 10 days; temperature and cerebrospinal fluid were normal. During the next two months the patient became less active and more irritable. A second convulsion, similar to the first, occurred at 17 months, and subsequently there were progressively more frequent episodes ofjerking of the extremities with hyperextension of the back, without loss of consciousness.At 23 months of age focal seizures began. These were characterized by loss of consciousness and twitching of the left side of the face and left arm, each lasting 30 to 60 seconds. These occurred with increasing frequency, being almost continuous when the patient was admitted to hospital.The patient was admitted to the National Hospital, Queen Square, at the age of 24 months, on January 13, 1958, under the care of Dr. E. A. Carmichael. He was a physically well-developed child who was inattentive to his surroundings, did not speak, and was unable to maintain the sitting position. There were frequen...

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After high cervical percutaneous cordotomy for pain in malignant disease, 12 patients died during sleep at postoperative intervals between 1 and 8 days. Nine died after a first cordotomy and three after a second (contralateral) procedure. All except one had known pulmonary disease before operation. The operated segment of the spinal cord (C2) was studied histologically after death. Superposition of lesion outlines made it possible to determine those parts of the lesioned areas common to all unilateral and bilateral cases respectively. All cases dying of presumed respiratory dysfunction syndrome had lesions involving the region of the anterolateral funiculus in the C2 segment containing "pain" fibres activated from the second to fifth thoracic dermatomes.