Chemical Sympathectomy

The evolution of the best plan of treatment is still a matter for experiment, but the following method will be successful in most cases. The use of a local analgesic before the first treatment has been discontinued as unnecessary, and instead a sphygmometer cuff is applied to the amputation stump and inflated to over 200 mm. Hg. Within two or three minutes the tender scars and neuromata become less sensitive, and gentle hammering with a wooden mallet or by means of a mechanical vibrator can be started and continued with increasing vigour for about 10 minutes. The blows of the mallet are usually transmitted to the neuroma through a wooden applicator (see below). If the stump is too short for the sphygmometer cuff, hypalgesia of the neuromata can be obtained by prolonged pressure on them, and indeed the application of pressure is just as effective as hammering in abolishing the stump pain, as shown by the use of a golf-ball in Case 3. During percussion or pressure on the neuromata a great variety of sensations are referred to the phantom foot or hand. These gradually become less, and the part of the phantom affected becomes numb and painless in 5 to 10 minutes if the strength of percussion is correct. There are usually at least three neuromata in each stump, which should all be treated in the same way. Bruising of the stump should be avoided if possible, but if a bruise develops the next treatment can be applied to the nerve just above the neuroma. After treatment the patient should wear his artificial limb for as long as he wishes-the more the stump is exercised the better. Jactitation usually ceases to be troublesome after the first or second treatment. Treatment at first must be repeated at least twice daily, but before long one treatment a day is usually sufficient, and the patient soon learns to knock away his phantom pain whenever it becomes troublesome. A heavy mallet is required to treat neuromata buried under thigh muscles, but in other instances a light mallet may be adequate. Repeated pressure is often useful, as in Case 2, while in a few instances the application of a sphygmometer cuff at a pressure of 200 mm. Hg for half an hour rendered the stump comfortable for many hours. This method, however, is probably not suitable for frequent use. The patients soon learn the optimum period of percussion, and should each be provided with a suitable mallet and a wooden applicator with a smooth metal cap. For the applicator, half the handle of a hammer with a " dome-ofsilence" on one end is very suitable if the rough edges of wood are filed smooth. The patients should continue treatment once or twice a day for several weeks ; thereafter the duration and severity of treatment required should be ascertained by experiment in each case. Adequate information regarding the necessary duration of treatment is not yet available. During percussion of the neuromata, but before the onset of general numbness in the stump, many sensations appear in the phantom that are of great physiological interest. Among these are, first, the reappearance of long-sincevanished parts of the phantom, and secondly the reappearance, as in Case 7, of pre-amputation sensations of the type described by Henderson and Smyth (1948). Finally, it seems probable that some other painful conditions, such as tender scars. are just as easily relieved by this method of treatment.