The role of the cerebral cortex in the conscious appreciation of pain has interested neurologists for many years. Head and Holmes (1911) considered that pain entered consciousness at thalamic level, and more recently Penfleld (1947) stated that 6. . .no removal of cortex anywhere can prevent pain from being felt and only very rarely does a patient use the word pain to describe the result of cortical stimulation ", and, he goes on, " it is obvious therefore that the pathway of pain conduction reaches the thalamus and consciousness without essential conduction to the cortex ". Adrian (1941) found that no impulses reached the sensory cortex in response to noxious or thermal stimulation at the periphery in the rabbit, cat, and monkey. On the other hand, a considerable body of evidence would suggest that there is central representation of pain in the cortex, and this work has been summarized recently by Marshall (1951) who, in presenting further evidence from 11 cases of cortical wounds followed by impairment of pain and temperature sense, advanced the hypothesis that the final elaboration of sensory impulses depends on mutual activation of thalamus and cortex.Electrical stimulation of the cortex has yielded equivocal results. In Cushing's (1909) two cases stimulation of the post-central gyrus was painless, and Foerster (1936) reported paraesthesiae but seldom pain. Penfield and Boldrey (1937) recorded only 11 instances out of well over 800 responses to electrical stimulation where the word " pain" had been used by the patient to describe the cortical sensation. Recently, however, Horrax (1946) stimulated the post-central gyrus in four patients suffering from painful states and elicited pain in three. To explain the apparent discrepancy between his results and those of Penfield and Boldrey, Horrax concluded that he was probably using too strong a current, since in the motor cortex the same current caused convulsions. Stone (1950) also recorded one case where stimulation of the sensory cortex produced pain in the phantom leg.In this paper we wish to record three cases in which partial resection of the post-central gyrus was undertaken for the relief of pain. In the first patient the pain developed during an unusual, prolonged, sensory painful aura in traumatic epilepsy, the second patient had intractable pain in a phantom foot, and the third had a painful thigh stump. In all three, electrical stimulation of the appropriate area of the post-central gyrus reproduced the pain complained of by the patient and relief followed the removal of this area of cortex.
Results of StimulationThe operations were conducted under local analgesia. Monopolar stimulation was used. The stimulator gave negative square pulses of current, the strength, frequency, and duration of which could be independently controlled. The position of the motor cortex was first identified by stimulation and then the post-central gyrus was explored. With varying parameters, different thresholds of stimulation in the motor and sensory cortex were established. ...