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Procaine injection therapy of painful conditions
A
PRACTICAL
VOL. LXXX11
JOURNAL
BUILT
OCTOBER,
1951
ON
MERIT
NUMBER
FOUR
lhlitoeial PROCAINE INJECTION THERAPY OF PAINFUL CONDITIONS SELECTION
OF PATIENTS
S
INCE the publrcations of Leriche,’ Lewis,2 KeIIgren,3 Steinbrocker,4 Livingston,5 TraveIl,B GorrelI’ and others have appeared, the procaine injection treatment of painful mus&loskeIetaI conditions has become widely used. The technic, especiaIIy as compared with intravenous procaine therapy, is safe, rapid and comparativeIy simpIe. Sufficient stress has not been pIaced upon the proper seIection of patients. When patients 1LERICHE, R. The Surgery of Pain. Baltimore, 1939. Williams & Wilkins Co. 2 LEWIS, T. Pain. New York, MacmiIlan Co. * KELLGREN, J. H. Observations on referred pain arising from muscle. Clin. SC., 3: 175, 1938. 4 STEINBROCKER, 0. Arthritis in Modern Practice. PhiIadeIphia, 1941. W. B. Saunders Co. ~L~VINGSTON,W. K. Pain Mechanisms. New York, 1943. MacmilIan Co. 6 TRAVELL, J. Management of pain due to muscle spasm. New York State J. Med., 45: 2085-2o97, 1945; Rapid relief of acute stiff neck. M. Womans’ J., 4: 89_ 95, 1949; Basis for muItipIe uses of IocaI b&k of somatic trigger areas. Mississippi Valley M. J., 71: 23, 1949; Pain and disability of shouIder and arm. J. A. M. A., 120: 417-422, 1942; Treatment of painfuI disorders of skeIeta1 muscIe. New York State J. Med., 48: zogo2059, 1948. r GORRELL, R. L. The nupercaine treatment of Iumbago. Tri-State M. J., I I : 2223, 1939. Local anesthetics in precordia1 pain. Clin. Med., 46: I I, 1939. Treatment of skeleta1 pain with procaine injections. Am. J. Surg., 63: 102-104, 1944. MuscuIofasciaI pain, treatment with procaine injection. J. A. M. A., 142: 557-562, 1950. 413
are not seIected properly, poor resuIts foIIow and the technic is bIamed rather than the Iack of cIinica1 judgment. After seeing many dramatic resuIts with procaine injections one becomes enthusiastic and tends to hurry through the history and physica examination in order that one may begin the injection. One shouId not inject any patient who gives a history of a nervous breakdown, who compIains of symptoms from head to toes, who is receiving compensation and enjoying it, who cannot accurately IocaIize the pain, who does not honestly want relief of pain, who gives a clinica impression of having a psychopathic personality or of being constitutionaIIy inferior. The norma person wants as IittIe to do with physicians as possibIe. He consults one onIy when driven by pain, worry or fear. He appreciates a carefu1 history, a compIete physica examination and a fundamenta1 Iaboratory examination. He is happy when told that no or a minor abnormaIity is found. He does not want an operation or other painful procedure unIess he is sure that it is necessary. Such a person can be toId that an injection wiII reIieve his pain. The person who has something to gain by continuance of pain and other symptoms is happy when told of abnormalities. Such a
414
EditoriaI
person shouId not be injected or operated upon but shouId have a careful Iife history taken and possibIe psychiatric study: If the patient is Iooking for sympathy from friends and famiIy, for a vacation, for an excuse to avoid the distastefu1, i.e., coitus, for continuance or increase of pension or compensation, he should not be injected. Such patients do not really seek reIief and wiI1 not admit it, if obtained. They wiI1 rather seize upon the injection as another cause of pain. The stoIid type of person may deceive the physician into beIief that IittIe or no pain is present. The individual who drives himseIf on without regard to pain and who does not worry about pain may be suffering from seriqus painfu1 disease and yet give no outward indication. Superficial pain in skin, muscIe and fascia can often be IocaIized and described fairly accurateIy. Deep pain cannot be IocaIized we11 or described, e.g., the burning beneath the sternum of a coronary thrombosis, the painfu1 pressure of a brain tumor or the hungry distress of a peptic uIcer. Pain cannot be ruIed out, by a laboratory test or physica examination. WoIff and Wolf’s* study indicates that a11 heaIthy persons with intact, functioning nervous systems have the same capacity for perceiving pain, i.e., their pain threshoId is roughIy the same. What the person’s reaction is varies with his previous experience with pain, his menta1 baIance with Iife’s situations, his knowIedge about and worry concerning the significance of pain and disease, and his desire to keep on with his work. “Pain perception needs onIy a simpIe, primitive nerve connection. Pain reaction is modified by higher centers. What does the sensation mean to that person in the Iight of past experience?” Unlike the threshoId for pain perception, the reaction varies wideIy for different individuals and even for the same individua1 under different circumstances.* Itching is induced by stimuli beIow the intensity needed to cause pain. Tickling may resuIt from even weaker stimuli. Other sensations may be confused with pain or may be mingled with it. If pain is present, there wiI1 be interference with the patient’s menta1 or physica activities or both. MiId pain may be overIooked during 8 WOLFF, H. G. and WOLF, S. Pain. SpringfieId, III., 1949. CharIes C Thomas, PubIisher.
activity which keeps the mind away from the discomfort. This is the reason for pain becoming more noticeable during the night or other period of inactivity. Pain caused by abnormaIity of the muscuIoskeIeta1 system wiI1 be intensified by certain motions or positions, wiI1 be reIieved by rest, activity or heat, according to its type. It wiI1 be relieved by such therapies as massage, anaIgesics, procaine injection, sympathetic nerve bIock or ethy1 chIoride spray. If severe pain is present, the patient wiI1 not be able to sIeep weI1. Also, the patient wiI1 not object to an injection or other transientIy uncomfortable treatment to obtain reIief. Severe pain is not relieved by one or two aspirin tabIets. Severe pain coIors menta1 processes and causes them to return to the pain. TYPICAL
SYNDROMES
Two errors occur when one attempts to cIassify patients into groups. First, a known syndrome may be overIooked because it does not fit the usua1 pattern and may superficiaIIy resembIe another condition, e.g., gout may be confused with rheumatoid arthritis.* The second error is to force a11 patients into diagnostic syndromes regardIess OT minor differences in symptoms and signs. The patient with Iow back pain may receive different diagnostic workups atid therapy if he or she happens to consuIt the gynecoIogist, orthopedist, genera1 practitioner, surgeon or uroIogist. Low back pain and sciatica .are considered aImost diagnostic of protruded intervertebra disc by many orthopedic and neurologic surgeons. The orthopedist tends to focus his attention on the x-rays and to beIieve that bony abnormalities are the cause of pain. The gynecoIogist tends to incriminate the infected cervix, the peIvic tumor and the retroverted uterus. The uroIogist looks for renal, ureteral, bIadder or urethral disease. AI1 physicians must Iearn the importance of the physioIogic as opposed to the pathologic Iesion, i.e., the temporary changes in muscle and fascia and their bIood supply which produce pain but do not cause any aIteration in x-rays or Iaboratory studies. In such cases the history and physica examination are the diagnostic procedures. SuccessfuI therapy at this stage prevents the deveIopment of physica and 9HENCH,
P. S. Gout. J. A. M. A,
116: 453,
1941.
American Journal of Surge y
EditoriaI psychic changes. If pain is reIieved or covered up by saIicyIates or other anaIgesics, both physician and patient are misIed into beIieving that the underIying condition has been cured. Many syndromes not yet described are presented by patients. Such patients shouId not be forced into existing cIassifications. As one studies hundreds of patients with pain, one becomes aware of the trapezius syndrome, the deltoid syndrome, the stiff neck syndrome of TraveIP and many others. A number of cases of musculoskeletal pain are apparentIy due to imbaIance of the autonomic nervous system. The injection of nicotinic acid, histamine or tetraethyl ammonium chIoride or procaine block of the sympathetic nerve suppIy to the area dramaticaIIy reIieves the pain. Even the cocainization of the sphenopaIatine gangIion lo has been cIaimed to reIieve Iow back pain. The pain of sinusitis has been shown to be caused by fibrositis of the muscIes inserting 10AMSTER, J. L. Treatment of low back pain. New York State J. Med., IOO: 2475, 1948.
October, IgyI
415
around the occiput. Fibrositis is now being used as a synonym for any type of connective tissue pain on a rheumatic basis, and especiaIIy if noduIes can be feIt. InterestingIy enough the procaine injection of a sympathetic nerve may resuIt in the patient feeIing stronger. This has aIso been noted by Karnosh’l from the CIeveIand CIinic. SUMMARY
One must know something about the patient as a person before one can treat any condition satisfactoriIy and this is especiaIIy true of pain. Certain persons do not wish to be reIieved of pain. One must avoid the tendency to force patient’s signs and symptoms into preconceived groups or diagnostic pigeonhoIes. One must Iearn if pain is present and its characteristics. RALPH GORRELL, M.D. I1 KARNOSH, L. Sympathetic block. Cleveland Clin. Bull., 24: IIO, 1948.
PRACTICAL
VOL. LXXX11
JOURNAL
BUILT
OCTOBER,
1951
ON
MERIT
NUMBER
FOUR
lhlitoeial PROCAINE INJECTION THERAPY OF PAINFUL CONDITIONS SELECTION
OF PATIENTS
S
INCE the publrcations of Leriche,’ Lewis,2 KeIIgren,3 Steinbrocker,4 Livingston,5 TraveIl,B GorrelI’ and others have appeared, the procaine injection treatment of painful mus&loskeIetaI conditions has become widely used. The technic, especiaIIy as compared with intravenous procaine therapy, is safe, rapid and comparativeIy simpIe. Sufficient stress has not been pIaced upon the proper seIection of patients. When patients 1LERICHE, R. The Surgery of Pain. Baltimore, 1939. Williams & Wilkins Co. 2 LEWIS, T. Pain. New York, MacmiIlan Co. * KELLGREN, J. H. Observations on referred pain arising from muscle. Clin. SC., 3: 175, 1938. 4 STEINBROCKER, 0. Arthritis in Modern Practice. PhiIadeIphia, 1941. W. B. Saunders Co. ~L~VINGSTON,W. K. Pain Mechanisms. New York, 1943. MacmilIan Co. 6 TRAVELL, J. Management of pain due to muscle spasm. New York State J. Med., 45: 2085-2o97, 1945; Rapid relief of acute stiff neck. M. Womans’ J., 4: 89_ 95, 1949; Basis for muItipIe uses of IocaI b&k of somatic trigger areas. Mississippi Valley M. J., 71: 23, 1949; Pain and disability of shouIder and arm. J. A. M. A., 120: 417-422, 1942; Treatment of painfuI disorders of skeIeta1 muscIe. New York State J. Med., 48: zogo2059, 1948. r GORRELL, R. L. The nupercaine treatment of Iumbago. Tri-State M. J., I I : 2223, 1939. Local anesthetics in precordia1 pain. Clin. Med., 46: I I, 1939. Treatment of skeleta1 pain with procaine injections. Am. J. Surg., 63: 102-104, 1944. MuscuIofasciaI pain, treatment with procaine injection. J. A. M. A., 142: 557-562, 1950. 413
are not seIected properly, poor resuIts foIIow and the technic is bIamed rather than the Iack of cIinica1 judgment. After seeing many dramatic resuIts with procaine injections one becomes enthusiastic and tends to hurry through the history and physica examination in order that one may begin the injection. One shouId not inject any patient who gives a history of a nervous breakdown, who compIains of symptoms from head to toes, who is receiving compensation and enjoying it, who cannot accurately IocaIize the pain, who does not honestly want relief of pain, who gives a clinica impression of having a psychopathic personality or of being constitutionaIIy inferior. The norma person wants as IittIe to do with physicians as possibIe. He consults one onIy when driven by pain, worry or fear. He appreciates a carefu1 history, a compIete physica examination and a fundamenta1 Iaboratory examination. He is happy when told that no or a minor abnormaIity is found. He does not want an operation or other painful procedure unIess he is sure that it is necessary. Such a person can be toId that an injection wiII reIieve his pain. The person who has something to gain by continuance of pain and other symptoms is happy when told of abnormalities. Such a
414
EditoriaI
person shouId not be injected or operated upon but shouId have a careful Iife history taken and possibIe psychiatric study: If the patient is Iooking for sympathy from friends and famiIy, for a vacation, for an excuse to avoid the distastefu1, i.e., coitus, for continuance or increase of pension or compensation, he should not be injected. Such patients do not really seek reIief and wiI1 not admit it, if obtained. They wiI1 rather seize upon the injection as another cause of pain. The stoIid type of person may deceive the physician into beIief that IittIe or no pain is present. The individual who drives himseIf on without regard to pain and who does not worry about pain may be suffering from seriqus painfu1 disease and yet give no outward indication. Superficial pain in skin, muscIe and fascia can often be IocaIized and described fairly accurateIy. Deep pain cannot be IocaIized we11 or described, e.g., the burning beneath the sternum of a coronary thrombosis, the painfu1 pressure of a brain tumor or the hungry distress of a peptic uIcer. Pain cannot be ruIed out, by a laboratory test or physica examination. WoIff and Wolf’s* study indicates that a11 heaIthy persons with intact, functioning nervous systems have the same capacity for perceiving pain, i.e., their pain threshoId is roughIy the same. What the person’s reaction is varies with his previous experience with pain, his menta1 baIance with Iife’s situations, his knowIedge about and worry concerning the significance of pain and disease, and his desire to keep on with his work. “Pain perception needs onIy a simpIe, primitive nerve connection. Pain reaction is modified by higher centers. What does the sensation mean to that person in the Iight of past experience?” Unlike the threshoId for pain perception, the reaction varies wideIy for different individuals and even for the same individua1 under different circumstances.* Itching is induced by stimuli beIow the intensity needed to cause pain. Tickling may resuIt from even weaker stimuli. Other sensations may be confused with pain or may be mingled with it. If pain is present, there wiI1 be interference with the patient’s menta1 or physica activities or both. MiId pain may be overIooked during 8 WOLFF, H. G. and WOLF, S. Pain. SpringfieId, III., 1949. CharIes C Thomas, PubIisher.
activity which keeps the mind away from the discomfort. This is the reason for pain becoming more noticeable during the night or other period of inactivity. Pain caused by abnormaIity of the muscuIoskeIeta1 system wiI1 be intensified by certain motions or positions, wiI1 be reIieved by rest, activity or heat, according to its type. It wiI1 be relieved by such therapies as massage, anaIgesics, procaine injection, sympathetic nerve bIock or ethy1 chIoride spray. If severe pain is present, the patient wiI1 not be able to sIeep weI1. Also, the patient wiI1 not object to an injection or other transientIy uncomfortable treatment to obtain reIief. Severe pain is not relieved by one or two aspirin tabIets. Severe pain coIors menta1 processes and causes them to return to the pain. TYPICAL
SYNDROMES
Two errors occur when one attempts to cIassify patients into groups. First, a known syndrome may be overIooked because it does not fit the usua1 pattern and may superficiaIIy resembIe another condition, e.g., gout may be confused with rheumatoid arthritis.* The second error is to force a11 patients into diagnostic syndromes regardIess OT minor differences in symptoms and signs. The patient with Iow back pain may receive different diagnostic workups atid therapy if he or she happens to consuIt the gynecoIogist, orthopedist, genera1 practitioner, surgeon or uroIogist. Low back pain and sciatica .are considered aImost diagnostic of protruded intervertebra disc by many orthopedic and neurologic surgeons. The orthopedist tends to focus his attention on the x-rays and to beIieve that bony abnormalities are the cause of pain. The gynecoIogist tends to incriminate the infected cervix, the peIvic tumor and the retroverted uterus. The uroIogist looks for renal, ureteral, bIadder or urethral disease. AI1 physicians must Iearn the importance of the physioIogic as opposed to the pathologic Iesion, i.e., the temporary changes in muscle and fascia and their bIood supply which produce pain but do not cause any aIteration in x-rays or Iaboratory studies. In such cases the history and physica examination are the diagnostic procedures. SuccessfuI therapy at this stage prevents the deveIopment of physica and 9HENCH,
P. S. Gout. J. A. M. A,
116: 453,
1941.
American Journal of Surge y
EditoriaI psychic changes. If pain is reIieved or covered up by saIicyIates or other anaIgesics, both physician and patient are misIed into beIieving that the underIying condition has been cured. Many syndromes not yet described are presented by patients. Such patients shouId not be forced into existing cIassifications. As one studies hundreds of patients with pain, one becomes aware of the trapezius syndrome, the deltoid syndrome, the stiff neck syndrome of TraveIP and many others. A number of cases of musculoskeletal pain are apparentIy due to imbaIance of the autonomic nervous system. The injection of nicotinic acid, histamine or tetraethyl ammonium chIoride or procaine block of the sympathetic nerve suppIy to the area dramaticaIIy reIieves the pain. Even the cocainization of the sphenopaIatine gangIion lo has been cIaimed to reIieve Iow back pain. The pain of sinusitis has been shown to be caused by fibrositis of the muscIes inserting 10AMSTER, J. L. Treatment of low back pain. New York State J. Med., IOO: 2475, 1948.
October, IgyI
415
around the occiput. Fibrositis is now being used as a synonym for any type of connective tissue pain on a rheumatic basis, and especiaIIy if noduIes can be feIt. InterestingIy enough the procaine injection of a sympathetic nerve may resuIt in the patient feeIing stronger. This has aIso been noted by Karnosh’l from the CIeveIand CIinic. SUMMARY
One must know something about the patient as a person before one can treat any condition satisfactoriIy and this is especiaIIy true of pain. Certain persons do not wish to be reIieved of pain. One must avoid the tendency to force patient’s signs and symptoms into preconceived groups or diagnostic pigeonhoIes. One must Iearn if pain is present and its characteristics. RALPH GORRELL, M.D. I1 KARNOSH, L. Sympathetic block. Cleveland Clin. Bull., 24: IIO, 1948.