Summary
The central neurone systems are dealt with, which are activated by painful stimulation of the skin or are influenced by the central effects of such stimulation. Pain is a central nervous manifestation. While there is no specific peripheral receptor system for pain, that system extending from spinal posterior horn to thalamus has a close relationship with the experience of pain. Many fibres of the spinothalamic tract run to the nuclei of the reticular formation of the medulla oblongata, of the pons, and of the midbrain from which nuclei secondary connections are made with thalamus and subthalamus. Through them the reticular activating system with its arousal effects can be stimulated. Collaterals to the periaqueductal grey matter could serve as a basis for the affective reactions to pain stimuli. In the region of the thalamus a sub-division occurs (a) in a cortical pain conduction over the small celled caudal ventral nucleus (V. c. pc) which when stimulated in man results in severe pain, to the koniocortex area 3 b of the posterior central gyrus, stimulation of which scarcely ever provokes typical pain, and (b) in a subcortical pain conduction over intralaminar nuclei of the thalamus, over the nucleus limitans and perhaps over the centromedian to the outer segment of the pallidum. In order to relieve intractable pain permanently by means of thalamic coagulation it is necessary to destroy both the cortically dependent pain nuclei of the thalamus and to coagulate the nuclei responsible for subcortical pain control. — Extirpation of both II. sensory area produces no reduction of the pain.
Prefrontal lesions or leucotomies reduce the capacity to experience pain because they lead to a personality change by disorganising the thalamo-prefrontal connections. But they also lead to a neglect of pain by interruption of the connections of the adversive systems of area 8 with the reticular formation and with the parietal and occipital lobes through the arcuate fasciculus. This tract is interrupted above the superior border of the claustrum in cases of pain asymbolia in the dominant hemisphere, and in cases of hemiagnosia dolorosa in the non-dominant hemisphere.
Stimulation of the skin by touch or noxious stimuli are under a tonic active central control of the reticular formation. If this control is cut off by disruption of the pathways or by narcosis, the sensory evoked potentials increase to a large size, although an experience of pain does not occur. — The skin receptors have a variable threshold of stimulation according to the tonus of the sympathetic system.
The combined emotional and the motor reactions to potentially painful stimuli are dependent on experiences with unpleasant stimuli having occurred at a conscious early stage of development. If such experiences are not encountered in early stage of development, the patterns of behaviour to painful stimuli remain disordered.
Résumé
Il est question ici des neurones centraux qui sont activés par la stimulation douloureuse cutanée et qui jouent un rôle dans l'élaboration centrale des messages douloureux. La douleur est une manifestation centrale, Alors qu'il n'existe pas de récepteurs périphériques spécifiques à la douleur, les fibres allant des corne? postérieures spinales au thalamus ont des relations intimes avec la douleur. De nombreuses fibres des faisceaux spinothalamiques vont aux noyaux de la substance réticulée du tronc cérébral, à partir desquels les connections s'établissent avec le thalamus et le subthalamus. Par elles la substance réticulée activatrice peut être excitée. Les collatérales qui gagnent la substance grise péri-épendymaire de l'aqueduc peuvent être à l'origine des réactions affectives qui accompagnent quelquefois les stimulations douloureuses.
A l'étage thalamique il y a lieu de faire la distinction entre a) la conduction corticale de la douleur, qui va du noyau ventral postérieur parvocellulaire (V. c. pc) dont la stimulation est douloureuse chez l'homme, à l'aire corticale 3 b du sillon central postérieur, dont la stimulation provoque rarement une douleur, et b) la conduction souscorticale de la douleur qui va des noyaux intralaminaires, du nucleus limitans et peut être du centre médian, au segment externe du pallidum. Pour améliorer une douleur résistante aux thérapeutiques de façon durable par coagulation thalamique, il faut détruire le noyau du thalamus qui intervient dans la conduction corticale de la douleur et le noyau responsable de la conduction souscorticale. L'extirpation bilatérale de l'aire sensitive II ne diminue pas la douleur.
La leucotomie frontale diminue la capacité de prendre conscience de la douleur parce qu'elle détermine un changement de la personnalité en désorganisant les connections préfronto-thalamiques. En outre, elle entraîne l'interruption des connections des systèmes adversifs de l'aire 8 avec la formation réticulée et avec les lobes pariétal et occipital par le faisceau arqué. Ce faisceau est interrompu au bord supérieur du Claustrum, dans les cas d'asymbolie à la douleur dans l'hémisphère dominant et dans les cas d'hémiagnosie douloureuse, dans l'hémisphère non dominant.
La stimulation tactile et nociceptive sont sous le contrôle central tonique de la formation réticulée. Si cu contrôle est aboli par suite de l'interruption des voies descendantes ou de l'anesthésie générale, les potentiels évoqués sensitifs augmentent beaucoup d'amplitude bien que l'expérience douloureuse ne soit plus vécue. Le seuil d'excitabilité des récepteurs cutanés varie en fonction du tonus sympathique.
Les réactions motrices et émotionelles aux stimuli douloureux dépendent du souvenir des expériences douloureuses antérieures. Si ces expériences ne sont pas faites dans l'enfance, le comportement aux stimuli douloureux demeure inadapté.
Riassunto
Viene fatta una trattazione del sistema di neuroni centrali che viene eccitato da stimolazioni dolorose cutanee o che influenza l'elaborazione centrale di questo eccitamento. Il dolore è una manifestazione nervosa centrale. Mentre perifericamente non vi è alcun sistema sensitivo specifico per il dolore, già dal corno posteriore al talamo queste vie hanno una propria individualità nel fenomeno della percezione del dolore. Moite fibre del tratto spino-talamico yanno ai nuclei della formazione reticolare, del midollo allungato, del ponte e del mesencefalo, dai quali nascono connessioni ascendenti col talamo e con il subtalamo. Pertanto può essere stimolato il sistema attivatore reticolare con il suo effetto risvegliante. Le collaterali alla sostanza grigia periacqueduttale, vanno interpretate come il substrato delle reazioni affettive allo stimolo doloroso. Nell'ambito del talamo è necessaria una distinzione: a) in una conduzione corticale del dolore dal nucleo ventrale caudale parvicellulare, la cui stimolazione nell'uomo origina un violento dolore, all'area 3 b della circonvoluzione centrale posteriore, la cui stimolazione può provocare raramente un dolore tipico, e b) in una conduzione sottocorticale del dolore dai nuclei della lamella mediale, dal nucleus limitans e forse dal centro mediano alla porzione pallidale esterna. Per abolire con coagulazioni talamiche in maniera durevole gli stati dolorosi non dominabili terapeuticamente, è necessario coagulare oltre al nucleo talamico connesso con la corteccia anche quei nuclei che partecipano alla conduzione sottocorticale del dolore. L'estirpazione della corteccia sensitiva parietale anteriore produce una ipoalgesia che però è spesso associata ad una iperpatia ed alla persistenza del dolore spontaneo. L'estirpazione bilaterale del campo corticale sensitivo II non dà luogo ad alcuna modificazione della percezione del dolore. Quest'ultima è invece realizzabile, con lesioni del sistema talamo-prefrontale, attraverso una modificazione della personalità. In realtà, la leucotomia prefrontale diminuisce la capacità a percepire il dolore anche per la ragione che con questo intervento vengono interrotte le connessioni del sistema adversativo dell'area 8 con la formazione reticolare e con i lobi parietale ed occipitale realizzata attraverso il fasciculus arcuatus. Questo fascio risulta interrotto a livello del margine superiore del claustrum, nei casi di asimbolia del dolore nell'ambito dell'emisfero dominante e nei casi di emiagnosia dolorosa nell'ambito dell'emisfero non dominante.
Le stimolazioni sensitive della cute sono sottoposte ad un efficiente controllo tonico centrale da parte della formazione reticolare. Se questa viene esclusa mediante interruzione di vie o con la narcosi, i potenziali evocati sensitivi risultano di maggior ampiezza, benchè non abbiano luogo delle risposte.
I recettori cutanei hanno una eccitabilità diversa a seconda del tono del sistema simpatico.
La reazione complessa, sensitiva e motoria, a stimolazioni dolorose dipende dalla esperienza fatta, in un precedente stadio di sviluppo, con le stimolazioni dannose. Se non si sono fatte tali esperienze nella prima infanzia, il comportamento di fronte agli stimuli dolorosi risulta alterato.
Resumen
Son tratados los sistemas neuronales centrales que son excitados en las estimulaciones dolorosa intensas de la piel o que influyen sobre la elaboración central de estas excitaciones. El dolor es un manifestatión nerviosa central. Mientras que no existe ningún sistema sensorial periférico específico para el dolor, el sistema astas posteriores a tálamo, tiene ya una estrecha relacción con el fenómeno doloroso. Muchas fibras del tracto espino-talámico, se dirigen a los núcleos de la formación reticular del bulbo, protuberancia y mesencefalo, de los cuales parten conexiones ascendentes para el tálamo y subtálamo. Por este mecanismo puede ser estimulado el sistema reticular activador con su función de vigilia. Las colaterales a la sustancia gris del acueducto pueden representar la base para las reacciones afectivas a los estímulos dolorosos. A nivel del talamo se verifica una bifurcación: a) hacia una conducción dolorosa cortical por medio del nücleo ventral y caudal de células pequeñas cuya estimulación en el hombre determina dolores muy intensos para alcanzar el area granular 3 b de la circunvolucion central posterior cuya estimulación raramente determina un dolor típico, y b) en una conduction dolorosa subcortical hacia los núcleos de la lamina medial, hacia el núcleo limitante y quizás hacia el centro mediano hasta la zona más externa del pallidum. Para eliminar de una forma duradera por medio de coagulaciones talámicas los estados dolorosos resistentes a la terapia habitual, es necesario coagular además de los núcleos dolorosos talámicos relacionados con la corteza, tambien los nucleos de la conducción dolorosa subcortical. Las extirpaciones de la corteza sensitiva y de la parte anterior del lóbulo parietal, determinan realmente una hipoalgesia, pero frecuentemente se une a esto una hiperpatía con persistencia de dolores espontaneos. La extirpación del II. campo sensitivo no da lugar a una restricción en la vivencia dolorosa. Esto último se efectúa sin embargo por una modification de la personalidad como consecuencia de la destrucción del sistema tálamo-prefrontal. Las leucotomías prefrontales disminuyen la capacidad de elaborar o vivenciar el dolor, pero tambien por medio de ellas se interrumpen las conexiones del sistema adversivo del area 8 con la formación reticular y con los lóbulos parietal y occipital por medio del fasciculo arqueado.
Este fascículo está interrumpido juntamente encima del margen superior del claustrum en los casos de asimbolia dolorosa del hemisferio dominante y en los de hemiagnosia dolorosa en el no dominante.
Las estimulaciones sensitivas de la piel permanecen bajo un control central tónicamente activo de la formación reticular. Si dicho control es liberado por medio de la ruptura de las vias o por la narcosis, entonces crecen en magnitud los potenciales sensitivos evocados, aun cuando cese su respuesta. Los receptores cutaneos poseen una excitabilidad distinta segun el estado de tono del sistema simpatico. Las reacciones globales sensitivas y motoras a los estímulos dolorosos dependen de que en un cierto estado precoz del desarrollo se produjeron experiencias con estimulaciones nociceptivas. Cuando tales experiencias no tuvieron lugar en la niñez precoz, permanece alterado el comportamiento frente a estimulos dolorosos.
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Nach einem Referat auf dem 1. Europäischen Neurochirurgen-Kongreß in Zürich, 16. Juli 1959.
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Hassler, R. Die zentralen Systeme des Schmerzes. Acta neurochir 8, 353–423 (1960). https://doi.org/10.1007/BF01405466
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DOI: https://doi.org/10.1007/BF01405466