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Pain, Anxiety, and Grief
 PAIN, ANXIETY, A N D GRIEF

PHARMACOTHERAPEUTIC CARE OF
THE DYING PATIENT AND THE BEREAVED

Ivan K. Goldberg,
Austin H. Kutscher,
and Sidney Malitz,
editors
with the assistance of
Lillian G. Kutscher

Columbia University Press

Neiv York
1986
 Library of Congress Cataloging in Publication Data
M a i n entry under title:

Pain, anxiety, and grief.

( C o l u m b i a University Press/Foundation of Thanatology

series)
Includes bibliographies and index.
1. Terminal care. 2. Bereavement. 3. P a i n —
Chemotherapy. 4. A n x i e t y — C h e m o t h e r a p y . 5. Grief.
6. N e u r o p s y c h o p h a r m a c o l o g y . I. G o l d b e r g , Ivan K.,
1934- . II. Kutscher, Austin H. III. M a l i t z ,
Sidney, 1 9 2 3 - . IV. Series. I D N L M : 1. A n x i e t y -
d r u g therapy. 2. P a i n — d r u g therapy. 3. Palliative
Treatment. 4. Terminal Care. W B 310 P1441
R726.8.P34 1985 616'.029 85-9685

Library of Congress Cataloging in Publication Data

ISBN 0 - 2 3 1 - 0 4 7 4 2 - 8 (alk. paper)

C o l u m b i a University Press
New York G u i l d f o r d , Sunev
Copyright © 1986 C o l u m b i a University Press
A l l rights reserved

Printed in the U n i t e d States of A m e r i c a

This book is Smyth-sewn and printed o n permanent and durable acid-free paper
 Contents

Preface vii
Acknowledgment ix
I. Practical, Ethical, and Moral Issues Relating to
Pharmacotherapy
1. G e n e r a l S y s t e m s A p p r o a c h to the
P s y c h o p h a r m a c o l o g i c T r e a t m e n t o f t h e D y i n g Patient
IRWIN M. G R E E N B E R G 3

2. T h e N e e d s o f D y i n g Patients STEWART G. WOLF 15

3. Practical and P h i l o s o p h i c a l C o n c e p t s o f Pain C o n t r o l
WILLIAM R E G E L S O N 19

4. S o m e L i m i t s o f P s y c h o t r o p i c D r u g s in S u p p o r t i v e
T r e a t m e n t o f O n c o l o g y Patients
PATRICIA M U R R A Y 28

5. Psychological Hazards of D r u g Therapy

R I C H A R D S. B L A C H E R 34

6. D r u g s , Physicians, and Patients I R V I N G S. W R I G H T 38

7. Problems of Polypharmacy DAVID M. BENJAMIN 41
8. Suicide b y D r u g O v e r d o s e B R U C E L. D A N T O 53
II. Controlling the Dying Patient's Pain
9. Pain C o n t r o l in the T r e a t m e n t o f C a n c e r
I V A N K. G O L D B E R G 65

10. T h e U s e o f D i a m o r p h i n e in t h e M a n a g e m e n t of
T e r m i n a l C a n c e r (Historical amd Chronological
Evolution, 1971) R O B E R T G. T W Y C R O S S 70

11. T h e U s e and A b u s e o f N a r c o t i c Analgesics in

T e r m i n a l C a n c e r (Historical and Chronological
Evolution, 1974) R O B E R T G. T W Y C R O S S 79

12. C o n t i n u i n g a n d Terminal C a r e — O v e r v i e w of
Analgesia (Historical and Chronological Evolution,
1978) ROBERT G. T W Y C R O S S 105
vi Contents

13. Cancer Pain: A Comparison of Methadone,

Methadone-Cocaine, and Methadone-Amphetamine
MICHAEL WEINTRAUB, AMY VALENTINE AND
STEPHEN STECKEL 128

14. Utility of a Combination of Stimulant Drugs

with Opiates in the Production of Analgesia
W A Y N E O. E V A N S 142

15. Pharmacokinetic Aspects of Analgesia During

Palliative Care M . K E E R I - S Z A N T O 148
16. Relief for the Dying and the Bereaved: The Role
of Psychopharmacologic Agents and Analgesics
CHING-PIAU CHIEN, BALU KALAYAM, AND

R E U B E N J. SILVER 151

17. The Cancer Ward I R E N E Β. S E E L A N D 159

18. Pharmacologic Agents—Barriers or Tools?
S A M U E L C. K L A G S B R U N 164

19. Psychological Responses in the Dying Patient:

A Role for Behaviorally Active Peptide Hormones?
DANIEL CARR 169

III. Relieving the Grief and Anxiety of Bereavement

20. Acute Grief: A Physician's Viewpoint
R O B E R T G. T W Y C R O S S 177

21. Psychopharmacologic Treatment of Bereavement

R O B E R T K E L L N E R , R I C H A R D T. R A D A , AND
WALTER W. W I N S L O W 185

22. Tricyclic Antidepressants in the Treatment

of Depression in Conjugal Bereavement: A Controlled
Study PHILIP R. M U S K I N A N D A R T H U R R I F K I N 200
23. The Relevance of Psychopharmacologic Agents
for the Bereaved in a C o m m u n i t y Mental Health
Center (CMHC) A R L E E N I. S K V E R S K Y , R I C H A R D E
TISLOW, A N D A N T H O N Y E S A N T O R E 210

Index 215
 Preface

The advances in medical technology that have transformed life-

threatening diseases into long-term, chronic illnesses have yet to
deal definitively with the pain and anxiety of the dying patient
and the grief of the bereaved. Although the costs of protracted
illness are now measured in terms of dollars and cents, alloca-
tion of resources, and decreases in the social productivity of
individuals, they have a different significance when extension of
life means extension of suffering. In most life-threatening ill-
ness, pain and discomfort eventually impose a toll that affects
the quality of life of those, including both patients and their
family members, w h o have benefited—until the quest for cure
has become unrealistic.
Few would deny that, within the modalities offered the criti-
cally ill to ease suffering, there is a broad range of pharma-
cotherapeutic agents. But many would question how and when
these drugs are currently prescribed and administeted. The
British have introduced us to the hospice philosophy of total
care for the terminally ill patient—total care embracing the
physical, psychosocial, psychological, and spiritual nurturing
of an individual until the very end of life. If we have been
impressed enough to attempt to transplant the hospice system
from the Old World to our shores, many are still reluctant to
make the fullest necesssary use of the psychopharmacologic ar-
mamentarium as "fail safe" final measures to ease the passage of
the dying.
In this book, the pioneer work of Dr. Robert G. Twycross at
St. Christopher's Hospice in London has been chronicled in
several chapters of historical import. Regrettably, for all the
good intentions and high standards of our pain control experts,
vili Preface

the taboos against appropriate usage of narcotics and other

agents even for the care of the terminal patient have not been
eradicated and we have yet to eliminate our fears of these as
uncontrollable social hazards and substances of the highest
abuse potential. Although testimony is presented in this text on
behalf of the effectiveness of those drugs that are already ac-
cepted in our pharmacopoeias, many question whether these
drugs are used properly, in sufficient quantity, and at appropri-
ate time intervals.
As those w h o have shared in this effort acknowledge, pain is
more than a physical phenomenon: it is a complex of physical,
psychosocial, psychological, and spiritual disorders. Nor is
there any panacea capable of obliterating all of the suffering it
causes, although much relief has been achieved when caregivers
have cared enough. The thrust of pain emerges from different
sources and in different degrees as it confronts the dying and the
bereaved. That thoughtful, caring scientists are still not com-
pletely satisfied with what they can offer patients, that they are
constantly seeking new ways to understand the phenomena of
pain, that they continue to search for new concepts of pain
dynamics and management as well as new agents to accomplish
the tasks—these are the messages conveyed in this book.
Experience demonstrates that controlling the pain of the
dying and easing the grief and anxiety of the bereaved are issues
of practical, ethical, and moral significance. Experience also
assures us that what has been accomplished by our most diligent
researchers, academicians, and clinicians serves as a base for
future discoveries. What science gains, it rarely loses. So, as it
has come to pass that advances have been made in medical tech-
nology and disease control, it should some day come to pass
that death can be confronted with dignity and bereavement
borne with hopefulness.

The Editors
 Acknowledgment

The editors wish to acknowledge the support and encourage-

ment of the Foundation of Thanatology in the preparation of
this volume. All royalties from the sale of this book are assigned
to the Foundation of Thanatology, a tax exempt, not for profit,
public, scientific and educational foundation.
Thanatology, a new subspecialty of medicine, is involved in
scientific and humanistic inquiries and the application of the
knowledge derived therefrom to the subjects of the psychologi-
cal aspects of dying; reactions to loss, death, and grief; and
recovery from bereavement.
The Foundation of Thanatology is dedicated to promoting
en.ightened health care for life-threatened or terminally ill pa-
tients and their families. The Foundations orientation is a posi-
tive one based on the philosophy of fostering a more mature
understanding of life-threatening illness, the problems of grief,
and the more effective and humane management and treatment
of patients and family members in times of crisis.
Pain, Anxiety, and Grief
 I.
PRACTICAL, ETHICAL, AND
MORAL ISSUES
RELATING TO
PHARMACOTHERAPY
 1.
GENERAL SYSTEMS APPROACH TO
THE PSYCHOPHARMACOLOGIC
TREATMENT OF
THE DYING PATIENT

IRWIN M . GREENBERG

During the past two decades, there has been a noticeable shift in
the effort made by psychiatry, medicine, and allied fields to
deal with the intrapsychic and interpersonal aspects o f the
phenomenon o f death. M u c h o f the effort has gone into psycho-
therapeutic intervention with the dying patients and their fami-
lies, principally with people w h o had not had previous
psychiatric illness. Although relatively little was done systemat-
ically with respect to use o f psychopharmacologic agents in
treatment o f the elements o f the social system comprising the
dying patient's family, the groundwork for such investigation
was laid by overt expressions o f alterations in value system.
Stated otherwise, an axiom o f principle appears to have been
stated by those dealing with the psychosocial problems o f the
dying person—that there indeed existed a valid field o f study in
the psychological treatment o f the dying patient. In retrospect,
this was a radical departure from the classical concerns o f both
the psychodynamic and biological schools o f thought. T h e for-
mer, influenced strongly by Freud's emphasis, assiduously
avoided the problem o f death as a thing in itself. T h e latter was
much more concerned with the metabolic, electrophysiological,
and genetic processes underlying defined psychiatric disease.
4 Irwin M. G'eettberg

It is n o t a p p r o p r i a t e to m e n t i o n here, more than in passing, a

few of the m a n y possible reasons for this shift in the spirit of the
times w i t h respect to the treatment of dying people. The u n -
usual w i d e s p r e a d violence t h r o u g h o u t all of the w o r l d since the
beginning of this c e n t u r y has been an unavoidable fact to be
faced by all. T h o s e w h o w o u l d choose not to think of death if
they could were literally coerced to do so. As the world changed
politically after 1950, the h u m a n needs of m a n y people w h o had
hitherto been i g n o r e d or considered exploitable began changing
rapidly. T h e death or m i s e r y of those distant f r o m us in space or
b a c k g r o u n d b e c a m e less deniable. With these t w o p h e n o m e n a
of widespread violence and the new egalitarianism there arose a
new attitude t o w a r d religion and death in many diversified e t h -
nic and s o c i o e c o n o m i c g r o u p s . Salvation, w h e t h e r by grace or
works, appeared less possible and existentialism increased in
popularity, even to t h o s e w h o had never heard of it.
As a c o n s e q u e n c e of these three interrelated changes—one of
action, o n e of t h o u g h t , and one of feeling—there arose a change
of attitude a m o n g a few w o r k e r s in the biomedical and social
science professions. T h i s attitudinal change allowed these few to
seek the capability to treat death as an aspect of life. T h e r e
followed the discovery of new, or the rediscovery of old, m e t h -
ods of treating d y i n g patients and their families.
As the capability to treat such people appeared, some w o r k
was described b y Eissler (1955), Shneidman and Farberow
(1957). Feifel (1959). G r e e n b e r g (1964), and Greenberg and Alex-
ander (1962). Eissler was one of the first psychiatrists to describe
treatment of the d y i n g patient. Shneidman and Farberow were
interested principally in suicide. Feifel worked with a multi-
disciplinary a p p r o a c h , and Greenberg investigated reunion
fantasies. S o m e of the helpful earlier concepts of G r o t j a h n
(1960) and Z i l b o o r g (1943) were rediscovered in t e r m s of the
recognition of m o r t a l i t y as an i m p o r t a n t intrapsychic matter.
T h e q u e s t i o n i n g of older attitudes toward the dying person
grew, and Kiibler-Ross's (1969, 1975) ideas were very well dis-
seminated. Death, w h i c h was b e c o m i n g more depersonalized
with advances in technology, was repersonalized t h r o u g h
efforts such as hers. So widespread has the awareness of the
need to treat the d y i n g person b c c o m e (Becker 1973; G A P 1975)
General Systems Approach 5

that even courses for preparation of Psychiatric Board Examina-

tions provide equal time for this subject.

A Theoretical Approach

With increasing awareness of the need for psychological

treatment of the dying patient and the family, interest in psycho-
pharmacologic agents for these people also grew, but with
systematization.
Death clearly presents many physiological, as well as psycho-
logical and familial, problems. The treatment of all in a system-
atic manner, lending appropriate emphasis to one aspect or
another of intervention, required a more general theory than
those used by workers in the field. Von Bertalanffy's General
Systems Theory (1975) would appear to be a suitable framework
for developing such a theory, and it is this point that the re-
mainder of this presentation develops. The development in-
cludes a description of a form of General Systems Theory, with
emphasis on the recognition of primary and secondary sub-
system dysfunction as differentiated from critical subsystem
dysfunction. The concept is demonstrated to imply that treat-
ment may at times be directed to factors other than those of
primary etiology (Greenberg 1978). Clinical examples of such a
formulation are described for patients w h o are not dying, as well
as for the dying patient, particularly with reference to use of
psychotropic medication.
The role of the influence of social ideology is also reviewed,
for it appears to enter into treatment decisions wittingly or
otherwise. The necessity for clinicians to deal with their own
ideology and with those of others is demonstrated to be of
paramount importance and indeed to constitute one of the most
critical parts of the treatment process.

General Systems Theory

A brief description of von Bertalanffy's theory begins with

the a priori assumption that any given organization of a living
6 Irwin M. Greenberg

o r g a n i s m o r set o f o r g a n i s m s m a y be taken as an i n d e x s y s t e m .
For conventional purposes, the individual h u m a n being may be
taken as the i n d e x s y s t e m in this d i s c u s s i o n . T h e classical a n a -
t o m i c and p h y s i o l o g i c a l a p p r o a c h e s then have the o r g a n i s m ' s
subsystems defined by their f u n c t i o n s — f o r example, m u s -
c u l o s k e l e t a l , cardiovascular, h e m a t o p o i e t i c , c e n t r a l n e r v o u s
s y s t e m s . T h e classical a p p r o a c h then defines s u b s y s t e m s b y
o r g a n , tissue, cell, o r g a n e l l e s , e n z y m e s y s t e m s , and m o l e c u l a r
species. In n e u r o p s y c h i a t r y , a s u b d i v i s i o n o f t h e c e n t r a l n e r v o u s
s y s t e m is o f t e n used, as is d o n e later in this d i s c u s s i o n .
In classical p s y c h o l o g i c a l and s o c i o l o g i c a l t h e o r i e s , the h u -
m a n o r g a n i s m is usually c o n s i d e r e d as an e l e m e n t o f the n u c l e a r
f a m i l y s y s t e m and e x t e n d e d f a m i l y s y s t e m , as w e l l as o f a m o r e
e x t e n s i v e i n t e r p e r s o n a l field s y s t e m and o f the s o c i e t y - a t - l a r g e .
T h e last usually i n c l u d e s the o t h e r s y s t e m s as s u b s y s t e m s b u t
m a y represent an a n o m i e - g e n e r a t i n g s t r u c t u r e f o r c e r t a i n r e f e r -
e n c e — t h a t is, s o c i o c u l t u r a l g r o u p s o r social classes. In s o m e
s o c i e t i e s , there is a w e l l - d e f i n e d r e l a t i o n s h i p b e t w e e n the r e f e r -
e n c e g r o u p and s o c i e t y - a t - l a r g e s y s t e m s on the o n e h a n d and
caste s t r u c t u r e and f u n c t i o n on the other.
In using a G e n e r a l S y s t e m s a p p r o a c h , it is b e s t t o c o n s i d e r
first the a n a t o m i c c r s t r u c t u r a l i n t a c t n e s s o f each s u b s y s t e m o r
s u p e r s y s t e m , b e it a b i o l o g i c a l o r social entity. F o r e x a m p l e , is
there a b r o k e n h o m e o r d i s r u p t e d n u c l e a r family, o r is t h e r e
m y o c a r d i a l d a m a g e in the c a r d i o v a s c u l a r s y s t e m ? S e c o n d l y ,
f u n c t i o n s h o u l d b e c o n s i d e r e d . Is the s t r u c t u r a l l y intact n u c l e a r
f a m i l y f u n c t i o n i n g as a family, o r is it o n e in w h i c h c o m m u n i c a -
t i o n and a f f e c t i v e i n t e r c h a n g e are at a m i n i m u m ? S i m i l a r l y , is an
a n a t o m i c a l l y i n t a c t o r g a n a c t u a l l y f u n c t i o n i n g , o r is there a loss
o f f u n c t i o n ? T h i r d l y , the q u a l i t y o f f u n c t i o n s h o u l d be i n v e s t i -
gated. D o e s a n u c l e a r f a m i l y p r o v i d e o p t i m a l c a r e and s u p p o r t
t o its m e m b e r s o r d o e s it o n l y c a r r y out m o t i o n s ? D o e s the
cardiac o u t p u t m e e t the r e q u i r e m e n t s o f the o r g a n i s m ? D o e s the
social s u p p o r t s y s t e m really p r o v i d e a d e q u a t e i n s u r a n c e ? M a n y
o t h e r e x a m p l e s can be c o n s t r u c t e d at any level o f s y s t e m o r g a n i -
zation.
Fourthly, the t i m e r e l a t i o n s h i p s o f each s y s t e m m u s t b e c o n -
sidered. S u c h c o n s i d e r a t i o n s r a n g e , for e x a m p l e , f r o m p e r i s t a l -
General Systems Approach 7

tic activity or respiratory rate under different conditions to the

l o n g - t e r m evolution of a nuclear family or social group.
In addition to the considerations of structure, function, qual-
ity, and t i m e in each subsystem, there is the additional d i m e n -
sion of the interactions between systems. These interactional
processes are of as great a significance as the systems t h e m -
selves. T h e interactional processes also require examination of
structure, f u n c t i o n , quality, and time relations. Subsystems
within the same s y s t e m may interact, as in peristaltic activity
following a meal. Moreover, subsystems may interact across
systems, as in the respiratory compensation for metabolic acid-
osis or alkalosis. In family f u n c t i o n , one m e m b e r may b e c o m e
the active one to s u p p o r t the illness of another. Social s y s t e m s —
for example, day-care centers for children—may develop to re-
place d y s f u n c t i o n a l or structurally absent extended families.
In dealing w i t h the use of psychotropic medication, it is nec-
essary to inquire i n t o the subsystems of the central n e r v o u s
system and their interactions. Many, but not all, of these struc-
tures of the central n e r v o u s system were defined a century ago.
S o m e were functionally defined only recently. T h e interaction
between s u b s y s t e m s as i m p l e m e n t e d b y n e u r o t r a n s m i t t e r s is
currently u n d e r g o i n g extensive investigation.
For the p u r p o s e s of the neuropsychiatrist, the great classical
cerebellar and rolandic s e n s o r y - m o t o r subsystems hold the least
interest; they are the p u r v i e w of the neurologist. O f m u c h
greater interest are (1) the great subcortical structures; (2) the
temporal-parietal sensory, cognitive, and integrative structures;
and (3) the great f r o n t a l - p r e f r o n t a l organized m o t o r conceptual
structures. M a n y of the functions of these great cortical n e u r o -
psychological s u b s y s t e m s have been described by Luria (1973).
However, the subcortical structures are very frequently those
that the clinical psychiatrist m u s t also understand. Essentially,
aside f r o m the e x t r a p y r a m i d a l m o t o r i c system, these reduce to
the reticular arid limbic systems. T h e f o r m e r exerts its influence
by activation, inhibition, and integration. T h e latter deals w i t h
e m o t i o n , olfaction, recent memory, and h o r m o n e metabolism
and, by means of the h y p o t h a l a m u s , acts as the upper m o t o r
n e u r o n center for a u t o n o m i c functions.
θ Irwin M. Greertberg

Clinical n e u r o p s y c h i a t r i s t s , then, deal with reticular, limbic,

intrapsychic, familial, and interpersonal interaction systems. It
is always necessary f o r t h e m to discover w h i c h is of primary
etiological i m p o r t a n c e and which is of critical importance for
intervention. It is also necessary to ensure the significance of the
presence or absence of o t h e r system d y s f u n c t i o n .
P r i m a r y s y s t e m d y s f u n c t i o n refers to basic etiology. For ex-
ample, myocardial infarction is often secondary to arterio-
sclerotic c o r o n a r y artery disease. T h e ensuing heart failure is, in
turn, secondary to myocardial insufficiency. Treatment, h o w -
ever, is aimed at relief of pain and reduction of the heart's w o r k -
load b y reducing fluid v o l u m e . T h e latter constitutes critical
system i n t e r v e n t i o n . Similarly, partial complex seizures of t e m -
poral lobe epilepsy may result f r o m repeated febrile cerebral
insult. T h e p r i m a r y s y s t e m d y s f u n c t i o n lies within the irritable
electrical focus and is treatable w i t h anticonvulsant medication.
T h e critical s y s t e m d y s f u n c t i o n may lie in the family system and
in o b t a i n i n g a g r e e m e n t f r o m the family that the patient indeed
has the disease w e think is present. T h u s , the practice of clinical
p s y c h o p h a r m a c o l o g y is o f t e n aimed not only at the primary or
etiological system d y s f u n c t i o n ; it is often directed, in addition,
to the familial or intrapsychic systems, which often reflect atti-
tudes t o w a r d illness.
O f f r e q u e n t i m p o r t a n c e is the matter of side effects, w h i c h
may be consciously m o r e distressing to the patient than the
original illness. It w o u l d be difficult to obtain therapeutic c o m -
pliance for c h l o r p r o m a z i n e f r o m a sign painter exposed to the
sun. It w o u l d be equally difficult to obtain cooperation f r o m a
watch repairman w h o developed tremors with fluphenazine.
There are, of course, h i g h l y idiosyncratic familial responses to
side effects, such as parental objection to nasal congestion in an
aggressive child treated w i t h thioridazine.
What may be of greater i m p o r t a n c e in all these cases is the
internalized value s y s t e m , which is here considered to corre-
spond internally to w h a t Erikson has called ego-identity (1950).
T h e p r o p e n s i t y to d e n y the need for medication is extremely
c o m m o n a m o n g people w h o have learned that doing things for
oneself is one of the greatest of good things. T h e belief in free-
General Systems Approach 9

d o m o f the w i l l is, at t i m e s , so g r e a t that p a t i e n t s w i t h f r a n k

s e i z u r e d i s o r d e r o r m e t a b o l i c illness s u c h as d i a b e t e s find it
e x t r e m e l y d i f f i c u l t t o face i m p e r f e c t i o n s in t h e i r o r g a n i s m s and
b e l i e v e in their a b i l i t y to d o e v e r y t h i n g t h e m s e l v e s . T h e r e is the
a d d i t i o n a l n e g a t i v e v a l u e a t t a c h e d t o the n e e d f o r d e p e n d e n c y ,
e v e n w h e n realistic, in these p e o p l e .
T h e critical s y s t e m d y s f u n c t i o n , t h e n , b e c o m e s o n e o f atti-
tudes and belief, b o t h in the p a t i e n t and in the n u c l e a r f a m i l y in
m a n y instances. S u c h b e l i e f s are w i d e s p r e a d and c u l t u r a l l y r e i n -
f o r c e d in the W e s t e r n world.

Application of the Theory in Treatment of

Dying Patients and Their Families

T h e a s s e s s m e n t o f critical s y s t e m d y s f u n c t i o n in the case o f a

d y i n g p a t i e n t o f t e n e x t e n d s b e y o n d e v a l u a t i o n o f the p a t i e n t and
the b e r e a v e d to the t r e a t m e n t t e a m . A s an e x a m p l e , a case is
cited:

The patient was an upper-middle-class housewife of Mediterranean an-

cestry with advanced pulmonary carcinoma for whom psychiatric evalua-
tion was requested to ascertain whether a spinothalamic tractotomy for
pain relief was psychiatrically reasonable. In the referral request, the ques-
tion was raised concerning the possibility of "trouble at home" precipitat-
ing an episode of excessive reaction to pain. There was no evidence of
cerebral metastasis. O n interview, the patient appeared to be a remarkably
intact woman who understood the nature of her disease and who appeared
to be using every resource to remain alive. There was no evidence of
hysteria or other functional disorder, nor was there evidence of cerebral
dysfunction. There was no indication of "trouble at home" or of la belle
indifference. Interview with visitors corroborated the impression given by
examination of the patient. The consultant's opinion was that the patient
was functioning well intrapsychically and interpersonally and that there
was no psychiatric contraindication to the operation. However, the patient
died three days later.

It w a s e v i d e n t , on s y s t e m a n a l y s i s , that the p r i m a r y s y s t e m
d y s f u n c t i o n w a s d i r e c t l y related t o the a n a t o m i c and s y s t e m i c
e f f e c t s o f a s p r e a d i n g c a r c i n o m a , w h i c h , in t u r n , w a s c a u s i n g
pain, and b e c a u s e o f w h i c h the patient d i e d . T h e critical s y s t e m
IO Irwin M. Greettberg

d y s f u n c t i o n w a s , h o w e v e r , t o b e f o u n d in a n i m p o r t a n t e l e m e n t
o f t h e social s y s t e m — n a m e l y , in t h e t r e a t m e n t t e a m . It is e x c e l -
lent p r a c t i c e f o r a n e u r o s u r g e o n n o t t o o p e r a t e if t h e r e is a
p o s s i b i l i t y o f e q u a l l y e f f e c t i v e n o n s u r g i c a l — t h a t is, m e d i c a l o r
p s y c h i a t r i c — t r e a t m e n t . T h u s t h e value system o f t h e n e u r o -
surgeon w h o requested the consultation came to the forefront.
Moreover, the discrepancy between the surgeon's view of ap-
propriate reaction to pain and the actual reaction of the patient
w a s e v i d e n t ; t h i s d i s c r e p a n c y m i g h t b e s t b e d e s c r i b e d as a r i s i n g
f r o m c u l t u r a l d i f f e r e n c e s . Lastly, t h e n e u r o s u r g i c a l s e r v i c e in
question was a research service dealing principally with t e m -
poral lobe disorders and one that was n o t accustomed to dealing
with dying patients. As a consequence, the advanced stage of
t h e p a t i e n t ' s illness w a s n o t easily r e c o g n i z e d . T h e i n t e r a c t i o n o f
all t h r e e f a c t o r s led t o t h e r e q u e s t f o r p s y c h i a t r i c c o n s u l t a t i o n .
F u r t h e r s y s t e m a n a l y s i s o f t h i s case w o u l d reveal t h a t n o t o n l y
was there a cultural difference between the patient and the sur-
g e o n b u t a l s o t h e r e w a s an e v e n m o r e s i g n i f i c a n t r e f e r e n c e
g r o u p difference between the patient and the usual patient p o p -
u l a t i o n w i t h w h i c h t h e s u r g e o n dealt. H e w a s s i m p l y n o t u s e d
t o d e a l i n g w i t h d y i n g p a t i e n t s in p a i n , n o r w a s t h e r e s t o f t h e
staff. It is n o t s u r p r i s i n g t h a t t h e o r d i n a r y m e t h o d o f d e n i a l o f
d e a t h c a m e i n t o play h e r e .
T h u s , t h e e s s e n t i a l p o i n t i l l u s t r a t e d b y t h e case is t h e n e e d t o
e x p l o r e t h e a c c e p t a n c e o f t h e p a t i e n t ' s d e a t h b y t r e a t i n g staff. It
is v e r y d i f f i c u l t f o r p h y s i c i a n s , n u r s e s , a n d o t h e r s t o a c c e p t t h e
p a i n , m a l a i s e , fear, a n x i e t y , a n d d e p r e s s i o n o f t h e d y i n g p a t i e n t
w h e n t h e r e is n o t yet r e c o g n i t i o n t h a t t h e p a t i e n t is i n d e e d
d y i n g . O n c e t h e r e is t h e r e c o g n i t i o n , o n t h e p a r t o f t h e social
s y s t e m — t h a t is, t h e t r e a t m e n t s t a f f — t h a t t h e p a t i e n t is d y i n g ,
there should be such recognition on the part of the family. A
f o r m o f p s y c h o t h e r a p e u t i c i n t e r v e n t i o n s h o u l d o c c u r in t h e
staffs interactions with the patient's family to enable family
m e m b e r s a n d o t h e r b e r e a v e d p e o p l e t o h a n d l e t h e i r o w n , as well
as t h e p a t i e n t ' s f e e l i n g s . If i n d i c a t e d , p s y c h o t r o p i c m e d i c a t i o n
may be prescribed for the bereaved.
If t h e r e is i n d e e d r e c o g n i t i o n o f i m p e n d i n g d e a t h b y b o t h s t a f f
a n d f a m i l y , several n e w issues m u s t b e a d d r e s s e d , t h e f i r s t o f
General Systems Approach 11

which is to ascertain the meaning of death to the patient and to

essential staff and family members involved. In many instances,
a family physician, clergyman, or close friend can be very help-
ful in answering the questions for the patient and for some
family member. In other instances the clinician will have to find
o u t de novo.
A m o n g some important attitudes toward death are those
dealing with punishment for sin and with belief in salvation,
predestination, and reunion in the hereafter. Although it is evi-
dent that the patient's beliefs are of paramount importance, it is
also important to deal with family and staff beliefs. These be-
liefs strongly influence the choice of medication, psychotropic
and otherwise, to be administered to the patient.
As stated previously, the principal symptoms, other than
those of delirium or of chronic brain syndrome, in the psychi-
atrically intact dying patient are pain, malaise, anxiety, and de-
pression. These s y m p t o m s are usually treatable to some degree
if they are recognized as treatable symptoms. Probably pain is the
most distressing of all s y m p t o m s to a dying person. Frequently
both anxiety and depression are relieved when pain is relieved.
The use of analgesics, narcotics, and tricyclic antidepressant
agents is often indicated for pain. The questions of amount and
frequency of dosage are sometimes of greater importance than
the actual choice of medication. It is here that the value system
of staff influences the treatment regimen.

1. If there is denial o f the patient's nearness to death, there is also

the great possibility o f denial o f pain.
2. If there is a c k n o w l e d g m e n t o f the patient's nearness to death, the
unconscious values o f belief in punishment for sin and the moral value
o f suffering may influence staff members to avoid using appropriate
medication.
3. If there is neither denial nor conscious belief in puritanical moral-
ity, there may be an unrealistic expectation on the part o f staff, and
possibly of family, for independence on the part of the patient. This
may appear clinically as concern not to allow the patient to become
"dependent" on medication and is often as not rooted in cognitive
confusion. Such confusion equates a dying, often elderly, person with
a younger drug-dependent person with entirely different problems.
12 Irwin M. Greenberg

Here the Western ethic o f independence at any cost interferes with

appropriate treatment.
4. If there is recognition of the need for medication, there may be
insufficient dosage or frequency because o f lack o f awareness o f the
time effectiveness o f dosage. For example, the maximum effective
time for some analgesic or narcotic agents may wear off within three,
and not four hours, so that it might be much wiser to administer the
medication every three hours.

To recapitulate, medication a d m i n i s t r a t i o n may not be o p t i -

mal, because of (1) intrapsychic reasons (for example, denial);
(2) value system reason (for example, belief in punitive m o r a l -
ity); (3) cognitive confusion (for example, lack of recognition of
the difference between d r u g d e p e n d e n c y in the dying patient
and in the younger, physically healthy patient); (4) incomplete
k n o w l e d g e (as in the failure to recognize o p t i m a l activity levels
of analgesic drugs).
There are, indeed, s o m e patients w h o m i g h t prefer to experi-
ence pain if the treatment of such pain reduces their cognitive
and relational capacities. Even in these cases, w h e n the clinician
has ascertained that the patient is not c o m p l y i n g w i t h conscious
or unconscious staff or family d e m a n d s , b o t h p h a r m a c o l o g i c
and psychological interventions are possible. For example, di-
p h e n y l h y d a n t o i n may alter peripheral nerve c o n d u c t i o n , as well
as alter thalamic conduction, and t h u s relieve pain sensation
w i t h o u t inducing loss of awareness. It may be particularly use-
ful in conjunction with tricyclic antidepresent medication.
Hypnosis may often be of benefit to rcducc pain in suitable
patients, so that no medication may be a p p r o p r i a t e at times.
To return to the p h a r m a c o l o g i c t r e a t m e n t of family a n d other
bereaved people, it is very i m p o r t a n t to bear in mind that such
people are not always psychiatrically intact but may suffer f r o m
any psychiatric disorder simply by chance. Simple reassurance,
supportive psychotherapy, and the use of anxiolytic agents
(GAP 1975) will not always be h e l p f u l . It is necessary t o assess
the psychiatric status of any i m p o r t a n t family m e m b e r and treat
accordingly. Such p r o m p t intervention may abort severe neu-
rotic depression or even prevent p s y c h o t i c episodes. A g a i n it is
necessary to recognize that death is i m m i n e n t to a loved one and
General Systems Approach 13

that such a loss may o f t e n act as a precipitant to psychiatric

decompensation.

Free Will and Calvinism

In an effort to help the clinician deal with the effect of family

and staff value s y s t e m s o n the pharmacologic treatment of the
dying patient, a few w o r d s s h o u l d be said about d o m i n a n t West-
ern tradition in the matter.
In dealing w i t h the issue of death as p u n i s h m e n t for sin, it is
essential to recall that this was a pervasive t h e m e of the Middle
Ages, is f o u n d m e n t i o n e d in H a m l e t , w h e n the ghost tells the
prince to leave his m o t h e r to Heaven; and is not u n c o m m o n l y
f o u n d in the religious b a c k g r o u n d s of people in our own day.
An awareness of this belief, especially in terms of sin's being a
product of free will, may be very helpful clinically in dealing
with seemingly punitive staff and family. Similarly, classical
Calvinism holds that w e all m u s t carry out God's will and that
suffering has been p r e o r d a i n e d , especially for those w h o are not
m e m b e r s of the Elect. In such cases, staff or family will appear
resistant to the use of medication for relief of suffering, fearing a
violation of w h a t has been preordained. Again, awareness of the
possibility of this belief may m a k e it a good deal easier to dis-
cuss the matter and have the patient treated appropriately. These
beliefs are often u n c o n s c i o u s and may be as deeply rooted as any
infantile conflictual material. A n o n j u d g m e n t a l question c o n -
cerning t h e m may o f t e n allow treatment to progress.

Summary and Conclusion

This discussion has presented a General Systems T h e o r y ap-

proach to the p h a r m a c o l o g i c treatment of the dying patient, the
family, and other bereaved people. It has assumed that such
pharmacologic t r e a t m e n t , especially for pain, is often appropri -
ate and necessary. It has f u r t h e r examined the nature of belief
systems of family and staff, within a systems f r a m e w o r k , e m -
14 Irwin M. Greenberg

phasizing the effect that value systems and other intrapsychic

and social beliefs have on the patient's treatment. It is suggested
that discussion of such beliefs with staff and family may allow
the clinician more freedom in treating the patient pharma-
cologically and may ensure greater cooperation from those con-
cerned.

References

B e c k e r , E . 1973, The Denial of Death. N e w Y o r k : T h e F r e e Press.

Eissler, K . R . 1955. The Psychiatrist and the Dying Patient. N e w Y o r k : I n t e r n a -
t i o n a l U n i v e r s i t i e s Press.
E r i k s o n , Ε. H . 1950. Childhood and Society. N e w Y o r k : N o r t o n .
Feifel, H , e d . 1959. The Meaning of Death. N e w Y o r k : M c G r a w - H i l l .
G r e e n b e r g , I. M . , n . d . In J o h n A . T a l b o t , ed. Social Calvinism, Free Will,
Ideology and Treatment in Stare Hospitals: Problems and Potentials. N e w Y o r k :
H u m a n S c i e n c e s Press.
1978. " G e n e r a l S y s t e m s T h e o r y : Social a n d B i o l o g i c a l I n t e r a c t i o n s . "
Psychiatry.
G r e e n b e r g , I. M . a n d I. E. A l e x a n d e r . 1962. " S o m e C o r r e l a t e s o f T h o u g h t s
a n d Feelings C o n c e r n i n g D e a t h . " Hillside Hospital Journal 2 : 1 2 0 - 2 6 .
G r o t j a h n , M . 1960. " E g o I d e n t i t y a n d t h e Fear o f D e a t h a n d D y i n g . " Hillside
Hospital Journal 9 : 1 4 7 - 5 5 .
G r o u p for the A d v a n c e m e n t of Psychiatry (GAP) C o m m i t t e e o n Research.
1975. Pharmacotherapy and Psychotherapy: Paradoxes, Problems and Progress.
N e w Y o r k : G r o u p f o r t h e A d v a n c e m e n t o f P s y c h i a t r y 9, R e p o r t 9 3
(March).
H i n t o n J . 1967. Dying. H a r m o n d s w o r t h , M i d d l e s e x : P e n g u i n B o o k s .
K ü b l e r - R o s s . E. 1969. On Death and Dying. N e w York.: M a c m i l l a n .
K i i b l e r - R o s s , E., ed. 1975. Death, the Final Stage of Growth. E n g l e w o o d C l i f f s ,
N.J.: Prenticc-Hall.
L u r i a , A. R. 1973. The Working Brain. N e w Y o r k : B a s i c B o o k s .
S h n e i d m a n , E. S. 2nd N . L. F a r b e r o w . 1957. Clues to Suicide. N e w Y o r k :
McGraw-Hill.
Von B e r t a l a n f f y , L. 1975. Perspectives on General System Theory. New York:
Brazilier.
Z i l b o o r g , G . 1943. " F e a r o f D e a t h . " Psychoanalytic Quarterly 12:465-75.
 T H E NEEDS OF D Y I N G PATIENTS

STEWART G. WOLF

D e a l i n g w i t h d y i n g patients i n v o l v e s m o r e than relieving their

pain; c o m f o r t and serenity, in a d y i n g patient experiencing pain,
depend on m o r e than blunting the pain. So, w h i l e management
o f pain is v e r y i m p o r t a n t , there are other objectives. T h e s e fall
into several categories: the need to blunt depression and obses-
sive ruminative t h i n k i n g ; the need to reduce tension; the need t o
w e a k e n b a r r i e r s — b e t w e e n patient and doctor, and patient and
f a m i l y — t h e need f o r interhuman communications, especially
w h e n the precious t i m e f o r this c o m m u n i c a t i o n is running out;
the need t o induce serenity and detachment. N o drug sub-
stitutes f o r the w a r m , understanding support o f the physician,
and time has a p h y s i o l o g i c a l c o m p o n e n t and is not s i m p l y a w a y
o f repressing feelings.
T h e p o w e r o f the relationship b e t w e e n patient and physician
can be illustrated w h e n measurable aspects o f the b o d y p h y s i o l -
o g y are m o d i f i e d . In this instance, I have selected nausea be-
cause it is easier t o d o c u m e n t than pain. In nausea, w e have an
associated p h y s i o l o g i c change that can be measured by a relaxa-
tion o f the stomach (so that it hangs l o o s e l y like a b a g ) and b y
an increase o f the contractual state o f the d u o d e n u m , which
makes a reverse gradient and pushes whatever is in the small
intestine back t o w a r d the stomach. In an experimental setup f o r
one patient, a three-lumen tube was put d o w n the patient's
throat. Gastric contractions w e r e recorded. A t first, not much
was happening in the stomach, and there w e r e duodenal c o n -
16 Stewart G. Wolf

tractions measurable through the second lumen. The third

lumen was open so that whatever we wanted could be intro-
duced into the stomach or gastric juice withdrawn from it. The
tip of the tube was in the first portion of the duodenum. Then,
nausea was induced by a commonly reliable mechanism—run-
ning warm water into one ear and cold water into another. The
nausea was associated with a sensation of whatever motor ac-
tivity was going on in the stomach, a decrease in the tone of the
stomach as it hung loose; in the d u o d e n u m it was associated
with an increase in the contractual state and a regurgitation of
an inserted balloon that carried the tube back toward the stom-
ach. N o matter how nausea is induced, this is the physiological
effect.
With a particular subject, after the lumen tube was in place,
we undertook a discussion about pregnancy. Actually, this
woman was not pregnant, but we simply discussed the pos-
sibility. In association with this, her gastric activity ceased, her
duodenum activity increased, and the tube was regurgitated
back toward the stomach. This is a clear illustration of what can
happen in a relationship with respect to measurable physiologic
change.
We became very interested in studying the nausea and vomit-
ing of pregnancy. The gastric motor activity in an individual
who was subject to the nausea and vomiting of pregnancy but
who did not happen to be nauseated at the time was recorded.
Gastric contractions were taking place. When we introduced a
10-cc solution of syrup of ipecac through the open lumen, gas-
tric activity ceased within five minutes and the individual said
that she was nauseated. After a time the effects of the ipecac
wore off, the stomach was contracting again, and the nausea
was gone.
This patient was asked to return to the laboratory on a day
when she was nauseous. We could perceive no vigorous motor
activity in the stomach at all. At this point, I told the patient
that we had just received a shipment of a new medicine that
eliminated nausea. I injected the same 10-cc of ipecac down the
open lumen of her tube. Instead of becoming more nauseous,
the woman reported that her nausea had gone, and we recorded
a return of gastric contractions.
The Needs of Dying Patients 17

This particular e x p e r i m e n t illustrates a n u m b e r of things,

a m o n g t h e m the e n o r m o u s p o w e r of the doctor-patient situa-
tion and the fact that this p o w e r exceeds that of ordinarily
p o w e r f u l p h a r m a c o d y n a m i c agents. In a parallel experiment
with patients w h o were experiencing pain of several weeks' d u -
ration f o l l o w i n g a b d o m i n a l surgery, we i n t r o d u c e d a "new
m e d i c i n e , " "a special s h i p m e n t f r o m G e r m a n y , " w h i c h was "far
more p o w e r f u l as a pain killer than m o r p h i n e b u t did not have
any toxicity, did n o t cause constipation, did n o t have any of the
side effects p r o d u c e d by m o r p h i n e . " T h e bottles were carefully
m a r k e d and the nurses were cautioned about n o t getting t h e m
mixed up. For those individuals w h o were given the usual
postoperative medication—15 m m of m o r p h i n e , q4h p r n — w e
substituted this "special m e d i c i n e . " These individuals were able
to call for injections w h e n e v e r they wanted. T h e result, per-
haps, could have been anticipated. T h e special medicine was j u s t
saline solution, and the patients w h o received it did m u c h better
and had less pain than those patients w h o were receiving m o r -
phine. When w e talked w i t h t h e m and revealed w h a t had been
done, the general reply was that the thing that had helped m o s t
was to be able to ring the buzzer and get the medicine right
away. T h e f r u s t r a t i n g thing was to be in pain, call the nurse, and
have the nurse say, "I'm sorry, but you have a n o t h e r h o u r and
fifteen m i n u t e s to wait before another shot is d u e . "
N e w d e v e l o p m e n t s in pain research offer the possibility of
i m p o r t a n t d r u g and n o n d r u g solutions for dealing w i t h patients
in pain. T h e issue is not j u s t one of interfering w i t h incoming
pain " t r a f f i c " but also of recruiting a central n e r v o u s system
mechanism that actually m o d u l a t e s , damps, and restricts that
i n c o m i n g pain traffic. Indirect evidence on the existence of such
a system goes back quite a long time, but only in the past eight
to ten years has the evidence evolved to the point that we are
quite sure it is there. We k n o w s o m e t h i n g about h o w it works,
especially a b o u t the lower levels of the nervous system; we still
have a great deal to learn a b o u t the higher levels.
For a long t i m e there was a dispute about w h e t h e r pain was
carried in its o w n system of n e u r o n s or w h e t h e r any neuron can
carry pain. As so often occurs in medical controversy, everyone
was right. T h e r e are some effluent neurons capable of carrying
18 Stewart G. Wolf

various kinds of sensations f r o m the periphery, presumably be-

cause of different kinds of coating, but there are also central
nervous system neurons in the dorsal horn that are specialists
and carry only pain.
However, in addition to k n o w l e d g e about the physiology of
pain, we m u s t recognize the i m p o r t a n c e of social m a n a g e m e n t
of the patient in pain. T h e effect of the social setting has been
d e m o n s t r a t e d in experiments w i t h alcohol. Laboratory w o r k e r s
given e n o r m o u s a m o u n t s of alcohol in the laboratory really
could not get very d r u n k . T h e social circumstances p r o b a b l y
were not conducive to that. Even m o r e i m p o r t a n t , n o m a t t e r
what was mixed together and c o n s u m e d , we could not p r o d u c e
hangovers. So social circumstanccs arc useful in the m a n a g e -
ment of the patient. T h e r e is n o c o o k b o o k approach, f o r every
patient is an individual.
What is to be done for a patient w h o has had pain for a long
time? T h e r e is not a n y t h i n g definitive. It depends on a lot of
things that have to do w i t h the patient's identity, goals, vul-
nerabilities, and so f o r t h . Behavioral modification in g r o u p s
takes advantage of special peculiarities of people. This approach
is not appropriate for s o m e people. T h e y do not like to get into
that togetherness, sharing situation. O t h e r s , on the o t h e r hand,
derive e n o r m o u s s u p p o r t f r o m the sharing experience. It is
i m p o r t a n t not to prescribe s o m e t h i n g w i t h o u t u n d e r s t a n d i n g
the patient and the patient's needs.
T h e physician's j o b is to relieve and to share the b u r d e n . It is
not the mission of medicine to defeat death. Similarly, the o b -
jective of medicine is n o t to create a heaven on earth, to keep
everybody free of feeling, free of suffering. The Christian and
other m a r t y r s have proved that there can be s o m e t h i n g e n n o -
bling about s u f f e r i n g — a l t h o u g h we do not r e c o m m e n d e m u -
lating this. However, with a sense of worthwhileness and the
s u p p o r t — t h e unique s u p p o r t — t h a t physicians, nurses, and so-
cial workers can give, the ability to tolerate a situation, the
ability to face a difficult circumstance in life, and the positive
aspect of being able to m a n a g e oneself in a suffering and u n -
c o m f o r t a b l e position can be an invigorating experience.
 3.
PRACTICAL A N D PHILOSOPHICAL
CONCEPTS
OF PAIN CONTROL

WILLIAM REGELSON

There are facts about pain that represent more than its physiol-
ogy or pathophysiology. In coronary insufficiency, people say
that the pain serves as a warning to stop activity, and that makes
it g o o d pain. Obviously, pain fulfills a good role f r o m the point
of view of mobilization, and it is easy to speak about pain as
being beneficial. Yet these are our feelings when we do not
suffer the pain.
We also have to think about the fact that patients' pain is
readily transmitted to the medical staff. In terms of medical
m a n a g e m e n t , obviously patients suffering f r o m pain and anx-
iety in relation to their needs can quickly inflict psychic pain on
the people administering to these needs. T h e n we face an inter-
action between the medical staff—nurses, doctors, and so
forth—and there arises a pattern of interaction between w h a t
the patients are asking for or what the patients are signaling
with their complaints.
T h e fact that concerns me most is that for reasons related to
our o w n reactions to the patient, we frequently produce p r e m a -
ture death pharmacologically by so heavily sedating patients
that they are unable to enjoy or participate in the level of life still
remaining. In this regard, w e have to be aware of the fact that
we are m a n a g i n g t w o kinds of pain: acute pain—associated with
20 William Regelson

side e f f e c t s s u c h as c h a n g e s in pulse, p r o f u s e s w e a t i n g , h y p e r -
t e n s i o n and p h y s i o l o g i c a l r e a c t i o n s — a n d c h r o n i c pain. In c o n -
f r o n t i n g c h r o n i c pain in the p a t i e n t w h o is c h r o n i c a l l y ill, w e are
d e a l i n g w i t h w h a t c h r o n i c pain does to the p e r s o n a l i t y o f t h e
i n d i v i d u a l , t h e w h o l e p r o b l e m o f d e p r e s s i o n , d e s p o n d e n c y , and
despair. I f o n e m e a s u r e s p e o p l e o n p s y c h i a t r i c scales, using the
P F 16 o r t h e M M P I o r any s i m i l a r p s y c h o m e t r i c tests, these
i n d i v i d u a l s are a s s e s s e d as d e s p o n d e n t and d e p r e s s e d . W i t h a n y -
o n e w h o is c o m p l a i n i n g o f c h r o n i c pain, there is u n d e r l y i n g
d e p r e s s i o n and a n x i e t y present c o n s t a n t l y . In relieving the a n x -
iety and t h e d e p r e s s i o n , o f c o u r s e , p h y s i c i a n s play a t h e r a p e u t i c
role.
M a n y p h y s i c i a n s b e c o m e i n v o l v e d in u s i n g p s y c h i c e n c r -
gizers, w i t h p a r t i c u l a r e m p h a s i s o n the t r i c y c l i c s o r the m o n o -
a m i n e o x i d a s e i n h i b i t o r s used t o treat the e n d o g e n o u s d e p r e s -
sions seen in m a n i c d e p r e s s i v e s . S o m e are useful as sedatives f o r
i n d u c i n g sleep, a use a p p r o v e d b y the F D A . H o w e v e r , in dealing
w i t h t h e p a t i e n t in pain w e c o n f r o n t a d e s p o n d e n c y that is i n d e -
p e n d e n t o f an e n d o g e n o u s d e p r e s s i o n , that is n o t a b i o c h e m i c a l
m a n i c d e p r e s s i v e p h e n o m e n o n but s o m e t h i n g related t o the r e -
alistic p r o b l e m o f pain o r c a n c e r and related to the q u a l i t y o f life
as it reflects f e e l i n g s o f s u r v i v a l : " A m I g o i n g t o see the n e x t
s p r i n g ? A m I g o i n g t o s u r v i v e until n e x t m o n t h ? " W h e n v i s i t o r s
c o m e , the p a t t e r n o f i n t e r r e a c t i o n p r o d u c e s a m i x e d r e s p o n s e ,
and t h e r e is real d e s p o n d e n c y b e c a u s e the p e r s o n w h o is d y i n g is
g i v i n g up s o m e t h i n g .
T h i s p e r s o n is n o t s u f f e r i n g f r o m the d e p e r s o n a l i z a t i o n and
p s y c h o s i s o f a t r u e e n d o g e n o u s d e p r e s s i o n . In m y o w n e x p e r i -
e n c e , t h e n , t h e use o f p s y c h i c e n e r g i z e r s is c o u n t e r p r o d u c t i v e .
A l t h o u g h t h e r e are c a n c e r patients w i t h p r e e x i s t i n g e n d o g e n o u s
d e p r e s s i o n s w h o c a n b e helped b y these agents, a p p l y i n g t h e m
w i t h o u t r e a l i z i n g w h e n there is a realistic reason for d e s p o n -
d e n c y is u s i n g t h e m i n a p p r o p r i a t e l y .
A g e n t s w e t e n d t o f o r g e t a b o u t are the a m p h e t a m i n e s . M a n y
patients in t h e t e r m i n a l phases o f life suffer f r o m a n o r e x i a , and
w e i g h t l o s s is a real p r o b l e m . We are always t r y i n g t o e n c o u r a g e
a p p e t i t e , so w e f o r g e t that a m p h e t a m i n e s have a n a l g e s i c p r o p e r -
ties that are useful in the r e l i e f o f pain. T h e y arc b i p h a s i c in t h e i r
Pain Control 21

effects and w o r k on several levels. A l t h o u g h they can enhance

sensitivity to pain, after a while a reverse phase occurs and
patients have a true analgesic response. D e x e d r i n e , for example,
is a psychic energizer that can restore a patient's alertness and
interest in w h a t is going on.
T h e person w h o gives the medicine is a critical force in a
pattern of reinforcement as it relates to the m e a n i n g of giving
the d r u g . In other w o r d s , a person should never give a d r u g he
does not believe in. For all caregivers there m u s t be a very
s t r o n g belief system. As a medical oncologist, I never give
c h e m o t h e r a p y that I do n o t believe in. I transmit a belief and I
am part of a system. T h e physicians' w h i t e coats or the nurses'
u n i f o r m s and our belief in the medication that w e are giving are
absolutely critical. When we give a d r u g , w e are conveying the
fact that it is useful. This is very clear and very i m p o r t a n t , but,
unfortunately, because we are living in an age of i n f o r m e d con-
sent, we are forced in effect to defeat o u r o w n p u r p o s e . We go
into the side effects, we g o into the negatives, w e go into the
o d d s . N o w a person like m e learns h o w to play the g a m e ac-
c o r d i n g to the law—versus w h a t 1 consider to be humanistically
i m p o r t a n t and curative for patients. I accentuate the positive in
a way that I think is m e a n i n g f u l to the patient in a therapeutic
sense. I transmit m y belief, and I think this can affect a patient's
response because belief is a part of a placebo reaction. T h e effec-
tiveness of the medicine is increased by d o i n g this.
T h e r e are also reinforcing techniques that can be used. For
example, w h e n I visit a patient w h o is suffering f r o m pain de-
spite having received a narcotic shortly before, I often tell the
nurse to give the patient an extra dose of narcotic. In this way, I
reinforce m y role as s o m e b o d y w h o can relieve pain and play a
d o m i n a n t role as s o m e o n e w h o can help. I use d r u g s that are
pleasant and that reinforce m y role as a h u m a n being.
O f course, s o m e o n e m i g h t say to me, " W h a t are you doing?
You're playing fast and loose; you are playing G o d . " In a sense,
the role being played is that of a shaman in society; u n f o r t u n a -
tely, it is being undercut by our o w n activities, as well as by the
F D A . T h e American public is being protected f r o m noxious
agents by the Food and D r u g Administration rules and regula-
22 William Regelsoti

tions, w h i c h are n o t d r a w n to establish priorities. For e x a m p l e ,

if t h e p r o g n o s i s o f the patient f r o m the p o i n t o f view o f survival
is u n d e r t w o years, the p r i o r i t y relevant to d r u g s and t o x i c o l o g y
and a preclinical w o r k u p s h o u l d certainly be l o w e r than that f o r
an illness in w h i c h the p r o g n o s i s is m e a s u r e d as a n o r m a l life
expectancy. S u p p o r t i v e agents m u s t be separated f r o m curative
agents. Certainly, p r i o r i t y is relevant to t h o s e agents that relieve
t h e m i n o r aches and irritations displayed o n television c o m m e r -
cials f o r p r o p r i e t a r y agents. T h e p r i o r i t y there has to be d i f f e r -
ent f r o m that f o r an agent that m a y c o n c e i v a b l y cure, p e r h a p s
c a u s i n g d e a t h in 50 p e r c e n t but c u r e in 50 p e r c e n t . In o t h e r
w o r d s , in p h a r m a c o l o g y and clinical p h a r m a c o l o g y , we have to
be given the o p p o r t u n i t y relative t o t h o s e o d d s f r o m the point
o f view o f triage in life-versus-death situations.
T h e review c o m m i t t e e s that interact in a d v i s o r y fashion w i t h
the F D A s h o u l d be clearly d e f i n e d in r e g a r d to their c o m p o s i -
tion. M e m b e r s h i p on these c o m m i t t e e s s h o u l d include clini-
cians w h o practice m e d i c i n e — f o r instance, cardiologists w h o
practice cardiology, n o t a c a d e m i c p e o p l e c o n c e r n e d only w i t h
preclinical p h a r m a c o l o g y . Clinicians k n o w the quality of life
a n d survival and w h a t is essential t o their patients.
C o n s u m e r s s h o u l d be on the c o m m i t t e e s . For e x a m p l e , the
v o l u n t a r y societies c o n c e r n e d w i t h cancer or w i t h heart or res-
p i r a t o r y disease have a vested interest because they themselves
or their f a m i l y m e m b e r s are s u f f e r i n g f r o m disease, and these
laypeople are needed o n the c o m m i t t e e to interact.
An a r b i t r a t i o n s y s t e m is n e e d e d — p e r h a p s o n e w i t h a federal
j u d g e s h i p , so that the F D A is n o t b o t h the reviewer and the
j u d g e . A n alternative i n d i v i d u a l s h o u l d be available so that the
p h a r m a c e u t i c a l i n d u s t r y and t h o s e in the special interest
g r o u p s — l i k e the A m e r i c a n Society o f Clinical O n c o l o g y — c a n
have s o m e o n e to deal w i t h o t h e r t h a n t h e officials of the F D A .
T h e r e is always the fear, valid or n o t , that we could be treated
p u n i t i v e l y if w e c o n f r o n t bureaucracy.
In m y o w n experience, there a p p e a r s to be a sort o f never-
never land in a d m i n i s t r a t i v e j u r i s d i c t i o n . T h i s is particularly
evident in the d e s i g n a t i o n of narcotics as b e i n g o n schedule o n e
or schedule t w o . For e x a m p l e , I did a s t u d y w i t h dclta-9-
Pain Control 23

tetrahydrocannabinol (THC). It took seven different commit-

tees one whole year to approve the study. We had joint commit-
tees in the FDA, and then the National Institute of Mental
Health came into the act. There was also a state committee
dealing with narcotics. Finally, it was relayed to the Department
of Justice and the narcotics agents. Often they would come by
with sidearms and inspect me to make sure that I was not ped-
dling the drugs on the street.
When our program had been cleared, we did an inpatient
study, and we were ready to go to our outpatient program when
we were told by the FDA that under no circumstances could we
give the drug to outpatients, despite the fact that all the pro-
tocols had been cleared through numerous committees. Higher
officials of the FDA were called to find out why an approved
protocol, with $70,000 worth of graduate support—and six
psychology graduate students working for me, drawing salary
and doing nothing—was not going through. They said, "Dr.
Regelson, we know that you can conduct a good study and
control your drug, but if we give you permission to go outpa-
tient with this drug, we will have another methadone-type
problem on our hands. Every doctor's mother's uncle's cousin
will want to do a study, and we won't be able to control it.
Therefore, we are not going to allow you to go ahead." The
issue had become a social one, not a medical one. However, if
one wants to find out if a drug has medicinal value, one does not
stop using it because someone may steal a couple of capsules.
This will destroy society.
The drug we wanted to work with, T H C , is a good prescrip-
tion drug. We have shown that it has good antianxiety and
antidepressive activity for cancer patients. One out of three pa-
tients benefited from it. It apparently has a good antiemetic
activity. It stimulates appetite and, in cancer patients, it seems
to stabilize weight for a period of time.
We have to learn to deal with these social aspects realistically.
Wc have to recognize that all drugs have side effects and that
doctors who have prescriptions and narcotics numbers are not
peddling pills on the street. So certain drugs should be put into
schedule two. 1 think that heroin is such a drug. In England,
24 William Regelson

heroin has a place in the care of the dying patient. Its addiction
p r o b l e m as related to pain or its effect as a "psychic energizer"
indicates that there may be a place for it. T h e r e f o r e , as a con-
trolled d r u g it s h o u l d be available to commissions, because we
need as m a n y d r u g s available to us as we can possibly have. G r o f
and o t h e r s (1973) have s h o w n LSD to have value for the dying
patient; certainly in the h a n d s of trained therapists it may have a
place. Again, as l o n g as it is in schedule one, it is going to be
very difficult for us to use a d r u g of this kind. Society has to say
that w e cannot be penalized for "abuse" if w e have people w h o
are sick. Within the f r a m e w o r k of controlled medical e n v i r o n -
ments w h e r e people have to be helped, there is no reason w h y
w e cannot use t h e m .
In regard to narcotics, I am not a withholder; I am a giver,
particularly w i t h cancer patients w h o suffer pain. We c o m b i n e
t h e m w i t h phenothiazines or haloperidol. We exercise care in
using phenothiazines so that we d o not wind up with Parkinson
patients w h o are rigid and lose the ability to express themselves
because of frozen muscles. Certain drugs clearly can synergize
w i t h narcotics to decrease pain.
O n e of the biggest p r o b l e m s in acute pain is the pain of nerve
root d i s c o m f o r t or multiple spinal fractures seen in patients
with osteolytic cancer. T h e r e is a need for maintenance, so that
patients are given a q 4 H and narcotics on d e m a n d under certain
circumstances because it takes so long for t h e m to w o r k . There
are a b u i l d u p in muscle spasm and an increase in pain beyond the
threshold for the d r u g to produce an effect. Nurses and doctors
should n o t be w i t h h o l d i n g but should consider a r o u n d - t h e -
clock use of narcotics.
Inhalation anesthesia o f f e r s another option. O n e such agent
comes in a h a n d y little sniffer that can be given to the patient.
N o t every patient can use it. T h e thing about it is this: patients
can learn w h e n the pain is starting to build; they can breathe the
d r u g in; and they can learn to control oblivion if it sets in.
Instantly, they are out. S o m e patients like this and can handle it,
yet others are f r i g h t e n e d by the sudden loss of consciousness
that can a c c o m p a n y it. But patients can learn h o w to use it. It is
relatively safe because the hand drops down w h e n the anesthesia
develops. Too f r e q u e n t use can produce renal tubular injury, but
Pain Control 25

relative to the gain, this m a y n o t be c o n s i d e r e d to be of i m p o r -

tance.
In r e g a r d t o t h e w o r d placebo, I m e n t i o n a s t u d y w i t h n o r m a l
v o l u n t e e r s in w h i c h w e a t t e m p t e d t o e v a l u a t e T H C as a p o t e n -
tial a n a l g e s i c . We f o u n d t h a t it l o w e r s t h e p a i n t h r e s h o l d , s o t h a t
p a i n s e n s i t i v i t y is g r e a t e r . T h e v a l u e o f t h i s a g e n t as a n a n a l g e s i c
f o r p a i n r e l i e f is t h a t it relieves a n x i e t y , m a k i n g it h e l p f u l f o r t h e
d e s p o n d e n t patient. To develop this further, w e studied 40 o u t
o f 40 p o s t o p e r a t i v e c a n c e r p a t i e n t s w h o w e r e o n n a r c o t i c s .
T h e y w e r e five to seven days p o s t o p e r a t i v e and o f f parenteral
i n t r a m u s c u l a r n a r c o t i c . All t u b e s w e r e o u t , a n d t h e y w e r e ali-
m e n t i n g . We d i s c o v e r e d t h a t e v e r y o n e o f t h e s e p a t i e n t s w a s a
placebo responder w h o did not need a narcotic. T h e placebo
e f f e c t is a v e r y real o n e , a n d w e s h o u l d l e a r n h o w t o u s e it.
T h e r e are n u m e r o u s i n t r i g u i n g e x p e r i m e n t a l u s e s o f d r u g s :
t h e r o l e o f t r y p t o p h a n e t a k e n o r a l l y in e n h a n c i n g n a r c o t i c a c -
tivity, t h e p l a c e o f a m i n o a c i d s in t h e c e n t r a l n e r v o u s s y s t e m ,
the use of the p h e n o t h i a z i n e tranquilizers, a n d the use of p e n -
tazocine derivatives (except for c h r o n i c narcotic users w h e r e
acute w i t h d r a w a l s y m p t o m s can be a hazard). S o m e n o n n a r c o t i c
d r u g s are a c t u a l l y s u p e r i o r t o m o r p h i n e a n d , at c e r t a i n d o s e
levels, arc c l e a r l y c o m p e t i t i v e w i t h D e m e r o l a n d a n o n a d d i c t i n g
agent.
In c a r i n g f o r p a t i e n t s , I c l e a r l y i n d i c a t e o n c h a r t s w i t h o r d e r s
m y f e e l i n g s a b o u t life s u p p o r t . I i n d i c a t e in w r i t i n g t h a t I w i l l
n o t u s e h e r o i c m e a s u r e a n d t h a t I w i l l w i t h d r a w life s u p p o r t
f r o m patients. I so advise the nurses and the h o u s e staff. I d o n o t
think there s h o u l d be a living will; I f o u g h t legalization of this
t o t h e e n d a n d s t o p p e d it f r o m b e i n g p a s s e d in V i r g i n i a . I a m f o r
t h e i n d i v i d u a l d e c i s i o n o f t h e p h y s i c i a n o p e r a t i n g in c o n c e r t
w i t h t h e f a m i l y a n d / o r t h e p a t i e n t t o play a r o l e in t h i s r e g a r d ,
o n o c c a s i o n . H o w e v e r , I d o n o t t h i n k t h e r e s h o u l d b e legal
p r o t e c t i o n f o r t h e w i t h d r a w a l o f life s u p p o r t , b e c a u s e o f w h a t
h a p p e n e d in G e r m a n y . In S e p t e m b e r 1939, H i t l e r p a s s e d an
o r d e r l e g a l i z i n g e u t h a n a s i a f o r A r y a n s . B y A u g u s t 1941, a b o u t a
quarter of a million G e r m a n s had been killed.
T h e bureaucratization of decision m a k i n g takes away the in-
d i v i d u a l r e s p o n s i b i l i t y o f t h e p h y s i c i a n . It m a k e s it e a s y t o kill.
W h e n w e r e p r e s e n t a n i n d i v i d u a l in m a k i n g t h e f i n a l d e c i s i o n , it
26 William Regelsoti

b e c o m e s a m o r a l decision between us and those w i t h w h o m we

interreact. We have to m a k e these decisions openly, but we have
to be legally vulnerable, because if we are not, as a physician
w h o k n o w s his colleagues, I k n o w that we can m a k e very seri-
ous mistakes. We always have to feel that w e are c o m m i t t i n g
murder. It is critical that w e have controls on us, and in o u r
society these c o n t r o l s have to be legal ones, m a k i n g us v u l n e r a -
ble. D o not take vulnerability away f r o m the doctor.
I have s t r o n g feelings a b o u t autopsy. I used to be as persistent
a b o u t autopsies as the next person, until I realized after long
experience that I learned very little f r o m autopsies unless I was
present myself and unless I really wanted the autopsy. I got 100
pcrccnt a g r e e m e n t to autopsies by asking for limited autopsies
f r o m w h i c h o n l y the i n f o r m a t i o n I wanted could be gained. For
instance, after a patient dies, the family is told the patient had a
p r o b l e m in the chest (which, of course, they know), and it is
i m p o r t a n t to see w h a t happened to that lung cancer as a result of
chemotherapy. I ask, " M a y we go in and look? We will not
r e m o v e organs; w e will j u s t d o biopsies as they relate to w h a t is
present that w e can see. We will be very respectful, and I will be
p r e s e n t . " If a relationship w i t h the family is developed and indi-
cation given that the physician will be there at the autopsy,
permission to proceed will be given. O n the a u t o p s y consent
f o r m , it should be indicated that the d o c t o r is g o i n g to be pres-
ent to find an answer. O t h e r w i s e , it cannot be done. T h e p h y s i -
cian's presence hallows the autopsy; o t h e r w i s e it has n o
significance.
I believe that w e have to have advocates for patients. N u r s e s
and medical personnel all have to play this role. We need holistic
approaches. If one is d y i n g or if one's life expectancy is limited,
survival m u s t be p r o g r a m m e d . Even w h e n d y i n g , one must
have s o m e t h i n g to look f o r w a r d to the next day, the next week,
the next m o n t h , because o n e is not going to die right away. If
life is not p r o g r a m m e d , if there are n o events to look f o r w a r d
to, w h a t is life? A c o o r d i n a t i n g individual m u s t be available to
interact w i t h the family and the patient in a contractual relation-
ship that includes love, attention, and concern. We do not need
technicians: w e need h u m a n beings w h o care for our patients
even t h r o u g h the final m o m e n t s .
Paitt Control 27

Reference

Grof, S., W. Ν . P a h n k e , L. E. G o o d m a n , and A. A. K u r l a n d . 1973. " P s y c h e -

dclic D r u g Assisted P s y c h o t h e r a p y in Patients w i t h T e r m i n a l Cancer. Part
T w o . " In I. K. G o l d b e r g , et al. eds. Psychopharmacologic Agents for the
Terminally ¡II and Bereaved, pp. 91-133. N e w York: C o l u m b i a U n i v e r s i t y
Press.
 4.
SOME LIMITATIONS OF
PSYCHOTROPIC DRUGS
IN S U P P O R T I V E T R E A T M E N T OF
ONCOLOGY PATIENTS

PATRICIA M U R R A Y

T h e philosophy underlying o u r modern pharmacologic and an-

algesic approach to the management of pain in the cancer
patient is probably best s u m m e d up by the subtitle of this paper.
With this statement, we confront two beliefs of our present
health system:

1. It is pills or p o t e n t s (surgery, radiation, and so forth) that relieve

pain and disease.
2. If you have a disease for w h i c h w e have no pills or p o t e n t s or in
w h i c h our pills and p o t e n t s are ineffective there is n o t h i n g more that
can be done.

These two beliefs reflect a level of personal awareness and social

consciousness that is inadequate and even destructive to the
awesome and challenging task of curing and comforting the
person with cancer (Cousins 1979).
T h e major emphasis in management of cancer and treatment
and control of its pain is external and institutional. We have
invested billions in dollars and more billions in hours of energy
and research to alleviate pain and disease through mechanical,
technological, and chemical alteration, manipulation, and even
disfiguration of the h u m a n body. Despite our efforts, cancer
and pain persist.
Limitations of Psychotropic Drugs 29

By concentrating our efforts on external approaches to the

treatment of disease and pain, we have fostered the belief that
healing and health are primarily and almost totally d e p e n d e n t
on people and things outside one's personal control. People
fully expect that a pill, injection, surgeon's knife, radiation ther-
apy, chemotherapy, and o t h e r n o s t r u m s will dispense w i t h their
disease and pain with little or no effort on their part. Feeling
inadequate about their personal recovery powers, people have
disassociated f r o m their disease and pain as if these w e r e the
province of "official healers" w h o by a stroke of m a g i c (of
whatever f o r m ) w o u l d m a k e t h e m disappear. As a result, m o s t
of us no longer see ourselves as active participants in the healing
process.
This expectancy of " o t h e r " as p o w e r f u l and self as i m p o t e n t
is, I suspect, the basis for the ineffectiveness of m a n y of the
present protocols used to alleviate pain and disease for cancer
patients. O u t of i m p o t e n c e grows a resistance, expressed in the
body, to protocols meant to relieve pain and disease. I m p o t e n c e
and powerlessness are strong negative emotional sets. O u r past
response to these p o w e r f u l negative, internal, emotional experi-
ences of patients has been to m a n u f a c t u r e m o r e external and
ritualistic approaches to treatment. We build bigger institutions,
create larger machines, m a n u f a c t u r e m o r e complex and toxic
drugs, p e r f o r m m o r e extensive and disfiguring surgery. We
have responded in the way we have learned to handle o u r o w n
impotence. We have reached out f u r t h e r and higher and placed
our potency in external giants that cannot be questioned be-
cause they are our main source of power and identity.
Pain and disease hold a meaning, purpose, and experience for
each person w h o is not relieved by our therapeutic modalities.
When a person with cancer suffers pain, a question is being
raised that does not confine itself to any physiological state. We
are geared not to recognize the question marks that pain raises
in people. We are not trained to listen to "What is w r o n g ? "
" H o w much longer?" " W h y me?" We have been prepared in-
stead to organize the person's pain into a list of complaints that
arc treatable or untreatable.
In addition, the personal invitation for compassion, u n d e r -
standing, sympathy, honesty, trust, and self-actualization that
30 Patricia Murray

m a n y o f us k n o w h o w to ask f o r o n l y t h r o u g h t h e q u e s t i o n
m a r k of pain is b y p a s s e d , and the o p p o r t u n i t y f o r t h e i n d i v i d u a l
t o face w i t h s u p p o r t w h a t c a n n o t b e faced a l o n e is lost. So also
is t h e o p p o r t u n i t y f o r t h e p e r s o n t o e x p e r i e n c e integrity, m a s -
tery, and belief in o n e s e l f and o n e ' s ability t o c o p e w i t h the
q u e s t i o n s t h a t the pain is raising.
F o r m a n y p a t i e n t s w i t h cancer a n d t h e i r families the q u e s t i o n
m a r k of pain is t h e reality o f d e a t h : "Will I d i e ? " " C a n I die?" A
h e a l i n g r e s p o n s e t o pain is a creative r e s p o n s e . A creative re-
s p o n s e to d e a t h , to cancer, will i n v o l v e d i s r u p t i o n and recovery.
Traditionally, w e have c o n c e n t r a t e d o u r t r e a t m e n t o n the area o f
p h y s i c a l d i s r u p t i o n a n d recovery. T h e p s y c h i c , social, and spir-
itual d i s r u p t i o n o f the p e r s o n w i t h c a n c c r is o f t e n m o r e intense
a n d m o r e p a i n f u l . A n d even w h e n t h e r e is an a t t e m p t to r e s p o n d
to this part o f the h u m a n p e r s o n , it is o f t e n d o n e in a m e c h a n i c a l
a n d n o n c r e a t i v e way.
O u r society values anesthesia r a t h e r t h a n sensitivity and d i s -
cipline. Sensitivity is l e a r n e d t h r o u g h s u f f e r i n g . Sensitivity al-
ways implies disruption and recovery or f u s i o n and
a c c o m m o d a t i o n . T h e idea of s u f f e r i n g as a c h o s e n m e a n s t o t h e
m a s t e r y o f pain and the c o n t r o l of life a n d d e s t i n y is in-
c o m p r e h e n s i b l e and s h o c k i n g t o m o d e r n m e d i c i n e and is la-
b e l e d m a s o c h i s t i c . In his b o o k Medical Nemesis (in a c h a p t e r
called " T h e Killing o f Pain"), Ivan Illich states:

In t h e c a p a c i t y f o r s u f f e r i n g is a p o s s i b l e s y m p t o m o f h e a l t h . S u f f e r i n g is a
responsible activity By equating personal participation m toeing unavoid-
a b l e p a i n w i t h m a s o c h i s m w e j u s t i f y p a s s i v e life s t y l e s . . . a n d seek m e a n -
ing for our passive lives, and power over others by inducing
u n d i a g n o s a b l e p a i n a n d u n r e l i a b l e a n x i e t y s u c h as t h e h e c t i c life o f b u s i -
ness executives, the s e l f - p u n i s h m e n t o f the rat race and intense e x p o s u r e
t o v i o l e n c e a n d s a d i s m o n T V a n d 111 m o v i e s In s u c h a s o c i e t y a d v o c a t i n g
n e w ( c r e a t i v e ) t e c h n i q u e s w i l l i n e v i t a b l y b e i n t e r p r e t e d as a s i c k d e s i r e f o r
p a i n (Illich 1976:142).

T h e p o s i t i o n o f this p a p e r is t h a t a p p r o a c h e s to cancer and

pain achieve full e f f e c t i v e n e s s o n l y w h e n equal a t t e n t i o n is
g i v e n to the m e a n i n g a n d d i r e c t i o n p a i n has f o r a p a r t i c u l a r
i n d i v i d u a l . D r u g s that alleviate pain will be e n h a n c e d w h e n
Limitations of Psychotropic Drugs 31

given in c o n j u n c t i o n w i t h a therapy that assists the person to

face i m p e n d i n g d i s r u p t i o n and to mobilize energies for active,
conscious participation in healing. Disruption—physical, psy-
chological, spiritual—is a n o r m a l response to the stress of can-
cer. A balance is needed that allows patients w i t h cancer to face
the disruption and gather together an integrity of self that will
mobilize their energies in the direction of healing and health. To
assist another person to mobilize energies in the direction of
health requires correcting the imbalance in the patient and in
our o w n belief that p o w e r lies solely in the potency of the d r u g
or treatment and is n o t dependent on the patient's inner re-
sources, attitudes, and expectancies (Pelletier 1979).
T h e w o r k that needs to be d o n e to m a k e our medical m a n a g e -
ment of patients w i t h cancer m o r e effective lies, therefore, as
m u c h within ourselves as within o u r technology. T h e attitudes
and beliefs of the healer will very readily c o m m u n i c a t e t h e m -
selves to the patient. Facing one's attitudes and beliefs regarding
cancer and pain causes the same disruption in the healer as the
experience of serious disease does in the patient. O u r attitudes
and beliefs are the source of our life energies. If the attitudes and
beliefs of healers are characterized by impotence beyond the use
of technology, then the healer is limited to technology and n o t
only fails to tap his or her o w n potency but will also be unable
to mobilize or activate the healing powers within patients.
Given this situation, the healer is b o u n d to face very limited
success, and the constant frustration that such limits p r o d u c e
must be faced ( M u r r a y 1981).
To begin to e x a m i n e our attitudes and beliefs regarding can-
cer and pain b e y o n d the limits of technology and chemistry
involves the possibility of bringing us face to face with our o w n
pessimism, cynicism, and impotence. T h e pain of this c o n f r o n -
tation can never be alleviated by reaching for more p o w e r f u l
technology and m o r e c o m p l e x chemistry although the t e m p t a -
tion to do so will be very strong. For like the patient, w e t o o
have been educated in m o s t cases to rely solely and entirely on
external p o w e r s and protocols. T h e healer w h o is willing to
bear the d i s c o m f o r t of questioning previous limits and to resist
the temptation to find answers in external, mechanical re-
32 Patricie Murray

sponses opens the self to a broader understanding of the reality

of pain and disease. This knowledge and awareness of the total
dimensions of pain and disease create the possibility for a more
holistic response. In the treatment of cancer, as in no other
disease, is this response more challenged. In this disease, both
healer and patient experience victimhood when treatment and
belief are limited to technology and chemistry. The feelings of
impotence and pessismism in both the healer and patient will
resist the most powerful treatment protocols (Flach 1974).
An attitude of responsibility for one's own health and a belief
that one is a full participant in that process reestablishes the
balance of healing power for the patient. The same attitude in
the healer not only relieves the healer of the burden of an all-
powerful position but also frees the healer to seek more creative
alternatives to what has formally been considered incurable dis-
ease and intractable pain (Flynn 1980).
What are needed are not only new and better technologies but
also a penetrating look into the attitudes and beliefs systems
upon which our technologies are founded. If our attitude and
belief systems are rooted in impotency, then our technology and
chemistry will maintain us all as victims of disease and pain. If
our attitude and belief systems are rooted in potency, then we
will be masters of our technology, accommodators of our
chemistry, and active participants in our own healing.
In summary, the challenge of managing the cancer patient's
and the family's pain is as much personal and social as it is
medical and psychopharmacological. Modern research in the
treatment of pain for cancer for the most part does not reflect
the creativity that is born of disruption and recovery. The dis-
ruption that needs to take place is a change in the direction of
present belief systems that fail to emphasize the ability of the
individual to face, with support and understanding, the pos-
sibility of death and to find in that confrontation the power to
become a participant in the healing of self and a consciously
creative h u m a n being.
Limitations of Psychotropic Drugs 33

References

Cousins, N . 1979. The Anatomy of an Illness: Reflections on Healing and Regenera-

tion. N e w York: N o r t o n .
Flach, H 1974. The Secret Strength of Depression. N e w York: L i p p i n c o t t .
Flynn, R 1980. Holistic Health: The Art and Science of Care. B o w i e , M d . : R o b e r t
J. B r o d y C o .
Mich, I. 1976. Medical Nemesis. N e w York: B a n t a m B o o k s .
Murray, Ρ 1981. " N u r s i n g M a n a g e m e n t o f the E m o t i o n a l C o m p o n e n t s o f
P a i n . " In L. B. M a r i n o , e d . , Cancer Nursing. St. Louis: M o s b y .
Pelletier, Κ. 1979. Holistic Medicine from Stress to Optimum Health. N e w York:
D e l a c o r t e Press.
 5.
PSYCHOLOGICAL HAZARDS OF
DRUG THERAPY

RICHARD S. BLACHER

M a n y u n d o u b t e d l y would agree on the i m p o r t a n c e o f treating

the " w h o l e p e r s o n " in the m a n a g e m e n t o f the dying and b e -
reaved. I should nevertheless like to offer a n u m b e r o f caveats
c o n c e r n i n g the use o f drugs in such cases.
It is difficult to i m a g i n e a responsible physician treating a
patient in pain w i t h o u t s o m e recourse to analgesic agents, but
the very availability o f an increased battery o f chemical agents
poses a d a n g e r f o r the patient. T h e situations we arc discussing
are a m o n g t h o s e that have traditionally demanded o f the c o n -
cerned the greatest sensitivity to the h u m a n needs o f the patient;
they have also caused the d o c t o r a great deal o f suffering. Aware
o f his or her o w n helplessness in the face o f reality, the physician
struggles to keep an equilibrium between opposing forces. I f
o n e really a l l o w s o n e s e l f to experience the pain o f a dying pa-
tient, then o n e fears being swept up in the e m o t i o n a l t u r m o i l . I f
o n e m u s t d o this with a n u m b e r o f patients, one may feel a b s o -
lutely o v e r w h e l m e d . O n the o t h e r hand, d o c t o r s are c o n c e r n e d
lest, in the interest o f s e l f - p r o t e c t i o n , they b e c o m e insensitive to
patients' feelings and present themselves as cold and indifferent.
T h e task b e c o m e s o n e o f appreciating the patient's reactions
while m a i n t a i n i n g one's o w n balance. In such a situation, the
prescription o f a tranquilizer may be seductively easy, not as a
m e a n s o f c a l m i n g the patient but as a substitute for the p h y s i -
cian's i n v o l v e m e n t — a s a means o f solving one's o w n d i l e m m a
Psychological Hazards of Drug Therapy 35

Obviously the ideal situation is one in which the drug is given

along with the physician's continuing interest and concern.
Another danger is commonly seen when the stark reality of
the patient's condition is dealt with by denial on the part of
medical attendants and an attempt to minimize reality. It is not
at all unusual to find dying patients, in severe pain, undermedi-
cated in many hospitals—probably in most hospitals—and the
staff expressing concerns about the patient's becoming addicted
to narcotics. This is not a problem of the staff s moral concerns
over drug abuse, I believe; colleagues are not so naive as to
believe that a patient a few days or weeks from death is a poten-
tial addiction problem. Rather, it is an attempt on the part of
nurses and doctors to treat the dying patient as curable and thus
avoid facing the difficult reality. That patients can be helped to
die comfortably and without pain has been amply demonstrated
in the hospice program (Saunders 1973). Here an attempt is
made to prevent the onset of pain by the frequent administra-
tion of analgesic agents in an atmosphere of concern and accep-
tance of the patient's real situation.
The importance of the presence and impact of the physician
on pain and suffering is generally accepted and well docu-
mented. Many centuries ago, Hippocrates noted: "Some pa-
tients, though conscious that their condition is perilous, recover
their health simply through their contentment with the good-
ness of the physician." The history of medicine since then has
been in good measure the history of the placebo, since only in
recent years have physicians had many useful drugs available for
treating specific conditions (Shapiro 1971). Most treatments in
the past have ranged from innocuous to disgusting to d o w n -
right dangerous. O p i u m has been used for relief of pain for
thousands of years. This, along with cinchona bark for malaria,
lime juice for scurvy, and digitalis for heart failure, was the only
specific drug available until recently. Nevertheless, physicians
have usually been respected members of society and their heal-
ing powers have been valued.
Beecher (1955) reviewed the powerful effect of placebo medi-
cation on a wide variety of conditions, ranging from headache
to angina pectoris to severe postoperative pain. While morphine
36 Richard S. Blacher

relieved 75 percent of those w i t h severe postoperative pain, a

placebo alone was effective in 35 percent of the cases. T h i s also
holds true for cancer patients. T h e role of the physician is f u r -
ther emphasized in a study by Beecher's anesthesiology g r o u p
(Egbert et al. 1963). In a carefully m o n i t o r e d evaluation, it was
shown that a preoperative visit and discussion of the procedure
by the anesthesiologist resulted in a measurable calming effect.
This was c o m p a r e d w i t h the use of a preoperative barbiturate,
which resulted in patient's c o m i n g to the surgical amphitheater
drowsy but still anxious.
These studies underline the needs of the patient w h o is facing
death. Medication is, of course, a blessing, but the concerncd
presence of an u n d e r s t a n d i n g physician may fill the real need.
Needless to say, medication cannot ease the oft-felt anger of the
dying patient. Patients may be angry at themselves for the
failure of the b o d y to w o r k right; often the patient is angry at
the doctors w h o have not effected a cure. T h e anger makes the
patient fear a b a n d o n m e n t o n the part of the physician, and then
the patient may b e c o m e even m o r e angry at this anticipated
desertion. T h e presence of the d o c t o r tends to alleviate the an-
ger. But there is a great t e m p t a t i o n for those w h o tend the
patient to slip in and out of the r o o m and write an order for
medication instead. While this is understandable on the part of
the staff, they cannot expect the patients themselves to be u n -
derstanding.
For those w h o are bereaved, there is strong evidence that they,
especially spouses are at considerable risk for increased m o r -
bidity and mortality (Rees and Lutkins 1967). This is again a
situation o f t e n calling for the services of an understanding p h y -
sician. Certainly there may be a need at times for sedation w h e n
a survivor is o v e r c o m e or cannot sleep. Here the danger is t w o -
fold. First, a need for m u c h sedation may cover a need t o talk
about the situation, and d r u g s may b e c o m e a substitute f o r a
receptive ear. Second, the w o r k i n g t h r o u g h of grief is a painful
but necessary process if the m o u r n e r is to be able to continue a
productive life. By gratuitously alleviating the painful affects
with medication, the physician may contribute to the preven-
tion of the satisfactory resolution of the m o u r n i n g .
Psychological Hazards of Drug Therapy 37

T h e upwelling o f painful and tumultuous feelings in the face

o f death and bereavement may be especially difficult for m e m -
bers o f the medical professions to deal with. First, their main
goal is to cure and alleviate suffering and prevent death. Thus,
these times are extremely frustrating. Second, the members o f
the healing professions are chosen on the basis o f an ability to be
precise. Indeed, only those able to deal with large masses o f
specific data with exactness are able to get into o r pass courses
in medical p r o g r a m s . In practice, however, those in the healing
arts are faced with e n o r m o u s areas o f ambiguity and impreci-
sion and thus are bound to be in a position o f great stress.
In summary, the availability o f the physician may be at least as
important as the prescription pad in the treatment o f the dying
and bereaved. T h e temptation to substitute medication for pres-
ence is one we should all struggle against.

It is the hard lot o f the d o c t o r to k n o w that in the end he is always

defeated; his victories at best are temporary. Death he can never finally
conquer. B u t death's ally is fear, and this ally the doctor can defeat. Let
him help the patient to conquer fear, and he will win many a skirmish; and
i f he can never hope to win the last g r i m battle, he can at least do much to
rob that ultimate defeat, for his patient and for the patient's family, o f the
terror that is its most grievous pain [Williams 1975],

References

Beecher, H. K . 1955. " T h e Powerful P l a c e b o . "Journal of I he American Medical

Association ( D e c e m b e r 24) 1 5 9 : 1 6 0 2 - 6 .
Egbert, L. D . ; A. E. Battit. H . Turndorf, and H. Κ . Beecher. 1963. " T h e Value
o f the Preoperative Visit by an A n e s t h e t i s t . " Journal of the American Medical
Association (August 17) 1 8 5 : 5 5 3 - 5 5 .
Rees, W. D. and S. G. Lutkins. 1967. " M o r t a l i t y o f B e r e a v e m e n t . " British
Medical Journal ( O c t o b e r 7) 4:13-16.
Saunders, C. 1973. " A Death in the F a m i l y : A Professional View." British
Medical Journal (January 6) 1:30-31.
Shapiro, A. K . 1971. " P l a c e b o Effect in M e d i c i n e , Psychotherapy, and P s y c h o -
analysis." In A. E. B e r g i n and S. L. Garfield, eds. Handbook of Psycho-
therapy and Behavior Change: Empirical Analysis. N e w York: J o h n Wiley
and Sons.
Williams, B. A. 1975. " T h e Greeks Had a Word for I t . " New England Journal of
Medicine ( O c t o b e r 11) 233.
 6.

DRUGS, PHYSICIANS, A N D PATIENTS

IRVING S. WRIGHT

Physicians and patients have direct concerns in c o m m o n w h e n

dealing with drugs employed in treating multiple diseases—
rather than a single disease—in an individual patient particularly
in the geriatric patient. T h e patient may have cancer, and the
cancer may be the ultimate and predictable cause of death, but
frequently these patients also have heart disease or diabetes or
e m p h y s e m a or any of the many other diseases whose descrip-
tions fill textbooks. As a result, we are confronted also with
multiple drug problems. It is not just a matter of prescribing
e n o u g h sedation or enough analgesia to relieve the patient's pain
(although this is of great importance). We are now confronted
with the fact that some of these patients are taking so m a n y
interacting drugs that the interactions of the drugs may obscure
the problems of the disease itself.
A patient of mine returned f r o m Florida with 30 bottles of
drugs, all of which had been prescribed for her and all of which
she was taking. This patient was extremely ill. She had drifted
f r o m one doctor to another, f r o m one specialist to another. We
set up the whole army of bottles on m y desk. I found that she
was taking t w o kinds of digitalis every day without k n o w i n g
this, of course, because the names were different and because
different doctors had prescribed them. These were enough to
produce toxicity and many varieties of symptoms—even death
in some patients. She was taking three kinds of diuretics, also
without k n o w i n g what they were. Sometimes we do prescribe
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 surface. Yet they had multiplied and differentiated until this little pool
contained millions of them, varying in length from 6 inches to 10 feet and
curiously diversified in their forms, their scales, and spines, and in the
ornamentation of their enamel-covered heads" (498).
"To the paleontologist there are few places in the world more interesting
than the Diamond mine, at Linton, since here we get such a view of the life
of the Carboniferous age as is afforded almost nowhere else, and of the
great numbers of species found there, not more than three or four have
been met with elsewhere" (497).

On page 18 is a list of the Amphibia which are thus far described

from the Linton deposits. They all belong, so far as known, to the
Microsauria, the reference of any of the species to other orders
being doubtful. The larger Amphibia seem to be indicated by a large
rib which resembles very much that described by Huxley in 1863 for
Anthracosaurus.
Amphibia from the Linton Beds (51 SPECIES).
Brachydectes newberryi Cope. Fragment of a skull.
Cercariomorphus parvisquamis Cope. Impression of body.
Cocytinus gyrinoides Cope. A skull and anterior dorsal vertebræ.
Ctenerpeton alveolatum Cope. Large portion of skeleton, no skull.
Diceratosaurus lævis Moodie. Complete skull.
Diceratosaurus punctolineatus Cope. Anterior vertebræ, part of skull,
with ribs and portion
of ventral armature.
Diceratosaurus robustus Moodie. Incomplete cranium.
Eoserpeton (Ceraterpeton) tenuicorne Cope. Incomplete skull.
Erpetosaurus acutirostris Moodie. Complete skull.
Erpetosaurus obtusus Cope. Incomplete skull.
Erpetosaurus radiatus Cope. Incomplete skull.
Erpetosaurus tabulatus Cope. Incomplete skull, with clavicles.
Erpetosaurus tuberculatus Moodie. Incomplete skull.
Eurythorax sublævis Cope. A single interclavicle. (Operculum of lung
fish, Sagenodus.)
Hyphasma lævis Cope. Incomplete skull and anterior vertebræ.
Ichthycanthus ohiensis Cope. Portion of dorsal region.
Ichthycanthus platypus Cope. Posterior portion of body.
Leptophractus dentatus Moodie. Mandible.
Leptophractus lineolatus Cope. Incomplete skull.
Leptophractus obsoletus Cope. Portions of skull.
Macrerpeton deani Moodie. Mandible and part of skull.
Macrerpeton huxleyi Cope. Part of cranium.
Molgophis brevicostatus Cope. Part of vertebral column with ribs.
Molgophis macrurus Cope. Vertebral column.
Molgophis wheatleyi Cope. Part of skull with 25 vertebræ.
Odonterpeton triangularis Moodie. Skull and anterior part of body.
Œstocephalus rectidens Cope. Part of mandible.
Œstocephalus remex Cope. Skull and anterior part of body.
Pelion lyelli Wyman. Cranium, fore part of body, hind limb.
Phlegethontia linearis Cope. Skull and anterior part of body.
Phlegethontia serpens Cope. Series of 22 dorsal vertebræ.
Pleuroptyx clavatus Cope. Part of vertebral column and limbs.
Ptyonius marshii Cope. Part of skull and anterior vertebræ.
Ptyonius nummifer Cope. Skull and greater part of vertebral column.
Ptyonius pectinatus Cope. Many specimens, some nearly perfect.
Ptyonius serrula Cope. Nearly complete skeleton.
Ptyonius vinchellianus Cope. Skull and anterior vertebræ.
Saurerpeton latithorax Cope. Skull and fore part of body.
Sauropleura digitata Cope. Greater part of body minus skull.
Sauropleura (Anisodexis) enchodus Cope. Part of jaw.
Sauropleura foveata Cope. A single interclavicle with impression.
Sauropleura longidentata Moodie. Incomplete skull with mandible.
Sauropleura newberryi Cope. Two incomplete skulls with vertebræ.
Sauropleura pauciradiata Cope. Elements of a pectoral arch.
Sauropleura scutellata Newberry. Imperfect skeleton.
Stegops divaricata Cope. Nearly complete skull.
Thyrsidium fasciculare Cope. Dorsal vertebræ.
Tuditanus brevirostris Cope. Skull and anterior vertebræ.
Tuditanus longipes Cope. Part of vertebral column with limbs.
Tuditanus punctulatus Cope. Skull and anterior part of body.
Tuditanus walcotti Moodie. Skull and portions of body.
 Besides the above-listed species there are others indicated by
fragments too poorly preserved to be worthy of specific designation.
The Linton Amphibia are all apparently confined exclusively to that
locality. Species from the Cannelton slates have been assigned,
however, to genera which occur at Linton, i.e., Erpetosaurus and
Tuditanus. This reference may be due to lack of knowledge, as the
forms are insufficiently known. A single Linton species has been
assigned to Ichthyerpeton, a genus known otherwise only from the
Coal Measures of Kilkenny, Ireland. Cope referred species from
Linton to the genus Ceraterpeton of Huxley, from Kilkenny, Ireland,
but Jaekel (347) and the writer (462) have shown that the species
were incorrectly assigned to the genus Ceraterpeton, and that in fact
they represent widely distinct genera. A single species has been
identified by Eastman from the Des Moines limestone of Iowa as
identical with one from Linton, Pleuroptyx clavatus Cope. The Linton
fauna is distinct from that of the Mazon Creek beds, and also from
that of South Joggins, Nova Scotia.
(o) The deposits in Nova Scotia have been correlated with the
Coal Measures strata of the United States (Bell, Summ. Rpt. Geol.
Surv. Canada, 1912, 1914, 360-371). They are very near the same
age as the Linton beds and come in near the base of the Allegheny
River series. The exposures are at the South Joggins, along the sea-
coast. Here in strata of clay interstratified with coal are found the
erect stumps of the Sigillariæ, and it was in the rock within these
stumps that Lyell and Dawson, in 1853, discovered the remains of
the amphibians which they termed "reptiles."
"The bones of Dendrerpeton hitherto found, as well as those of the
smaller species, have been obtained from the interior of erect Sigillariæ, and
all of those in one of the many beds which, at the Joggins, contain such
remains. The thick cellular inner bark of the Sigillaria was very perishable;
the slender woody axis was somewhat more durable; but near the surface of
the stem, there was a layer of elongated cells, or bast tissue of considerable
durability, and the outer bark was exceedingly dense and indestructible.
Hence an erect tree, partly imbedded in sediment, and subjected to the
influence of the weather, became a hollow shell of bark. When they remained
open for a considerable time, they would constitute pitfalls into which
 animals walking on the surface might be precipitated. When the surface was
inundated all such remains would be covered and imbedded in the sediment.
These seem to have been the precise conditions of the bed which afforded
these remains." (Dawson, 223, 1894.)

Fifteen species have been described from the Joggins deposits.

Two are known from the Albion mines, south Nova Scotia, where
were obtained the remains of Baphetes planiceps Owen and B.
minor Dawson.
The following 17 species of Amphibia are known from the
Carboniferous of Canada:
Amblyodon problematicum Dawson. Teeth and fragments.
Baphetes minor Dawson. An incomplete mandible.
Baphetes planiceps Owen. An incomplete cranium from Albion.
Dendrerpeton acadianum Owen. A jaw, limb bones, and fragments.
Dendrerpeton oweni Dawson. Phalangeal bone and fragments.
Eosaurus acadianus Marsh. Two dorsal vertebræ.
Fritschia curtidentata Dawson. A mandible, vertebræ, ribs.
Hylerpeton dawsoni Owen. Mandible, teeth and incomplete maxilla.
Hylerpeton intermedium Dawson. Mandible and portions of skull.
Hylerpeton longidentatum Dawson. Fragments of mandible and
skull.
Hylonomus latidens Dawson. Mandible and teeth.
Hylonomus lyelli Dawson. Incomplete skeleton and part of skull.
Hylonomus multidens Dawson. Fragments of skull.
Hylonomus wymani Dawson. Mandible and vertebræ.
Platystegos loricatum Dawson. Incomplete skull, vertebræ.
Smilerpeton aciedentatum Dawson. Teeth, ribs, fragments.
Sparodus sp. indet. Teeth, scales.
(p) All the remains representing the above species were collected
by Sir J. William Dawson at the South Joggins and at the mines of
Albion, with the exception of Eosaurus, which was collected by O. C.
Marsh. The collections of Dawson are now in the Peter Redpath
Museum of McGill University in Montreal and in the British Museum
of Natural History at South Kensington, London. The history of the
discovery of the deposits and their amphibian fossils at the South
Joggins is so interesting that it was thought worth while to
reproduce in large part Dawson's paper "On the Mode of Occurrence
of Remains of Land Animals in Erect Trees at the South Joggins,
Nova Scotia," published in 1891 in the Transactions of the Royal
Society of Canada, section IV, p. 127:
"The remarkable section of coal-formation rocks at the South Joggins, in
Cumberland County, has long been known as one of the most instructive in
the world; exhibiting as it does a thickness of 5,000 feet of strata of coal-
formation in a cliff of considerable height, kept clean by the tides and waves,
and in the reefs extending from this to the shore, which at low tide expose
the beds very perfectly. It was first described in detail by the late Sir W. E.
Logan (Report Geol. Surv. Canada, 1844), and afterwards the middle portion
of it was still more detailed by the author (Dawson), more especially in
connection with the fossil remains characteristic of the several beds and the
vegetable constituents and accompaniments of the numerous seams of coal
(Jour. Geol. Soc. Lond., X, p. 1, 1853). It was on occasion of a visit of the
author in company with Sir Charles Lyell, and in the pursuit of these
investigations, that one of the most remarkable features of the section was
disclosed in 1851. This is the occurrence, in the trunks of certain trees
imbedded in an erect position in the sandstones of Coal-mine Point, of
remains of small reptiles, which with one exception, a specimen from the
Pictou coal-fields, were the first ever discovered in the Carboniferous rocks of
the American continent, and are still (1891) the most perfect examples
known of a most interesting family of coal-formation animals, intermediate in
some respects between reptiles proper and batrachians, and known as
Microsauria. With these were found the first-known Carboniferous land snails
and millipedes. Very complete collections of these remains have been placed
by the author with his other specimens in the Peter Redpath Museum and in
the British Museum.
"A forest or grove of the large ribbed trees known as Sigillariæ was either
submerged by subsidence or, growing on low ground, was invaded with the
muddy waters of an inundation, or successive inundations, so that the trunks
were buried to the depth of several feet. The projecting tops having been
removed by subaerial decay, the buried stumps became hollow, while their
hard outer bark remained intact. They thus became hollow cylinders in a
vertical position and open at the top. The surface having then become dry
land, covered with vegetation, was haunted by small quadrupeds and other
land animals, which from time to time fell into the open holes, in some cases
nine feet deep, and could not extricate themselves. On their death, and the
 decomposition of their soft parts, their bones and other hard portions
remained in the bottom of the tree intermixed with any vegetable debris or
soil washed in by rain, and which formed thin layers separating successive
animal deposits from each other. Finally, the area was again submerged or
overflowed by water, bearing sand and mud. The hollow trees were filled to
the top and their animal contents thus sealed up. At length the material
filling the trees was by pressure and the access of cementing matter
hardened to stone, not infrequently harder than that of the contained beds,
and the whole being tilted to an angle of 20°, and elevated into land exposed
to the action of the tide and waves, these singular coffins present themselves
as stony cylinders projecting from the cliff or reef, and can be extracted and
their contents studied. The singular combination of accidents above detailed
was, of course, of very rare occurrence, and, in point of fact, we know only
one set of beds at the South Joggins in which such remains so preserved
occur; nor is there, so far as I am aware, any other known instance
elsewhere. Even in the beds in question, only a portion of the trees, about 15
out of 30, have afforded animal remains. We have, however, thus been
enabled to obtain specimens of a number of species which would probably
otherwise have been unknown, being less likely than others to be preserved
in properly aqueous deposits. Such discoveries on the one hand impress us
with the imperfection of the geological record; on the other, they show us
the singular provisions which have been made in the course of geological
time for preserving the relics of the ancient world, and which await the
industry and skill of collectors to disclose their hidden treasures.
"There is evidence in coprolitic matter on one of the surfaces within the
trunks, and also in certain trails on these surfaces, that some of the
imprisoned animals lived for a time in their subterranean prisons; that they
crept around their walls in search of a way of escape, and that the larger
animals fed on smaller species entrapped along with them."

After the discovery of these entombed amphibians Sir William

Dawson was given a grant of £50 from the Government Fund by the
council of the Royal Society of London, to aid in the extraction of
these trees and the collection of their contents. The trees were
carefully taken out and their contents examined; the portions
containing the animal remains were carefully boxed to be taken to
Montreal for final cleaning and study. Erosion goes on rapidly at the
South Joggins, but no one has paid any attention to the occurrence
of Amphibia along the coast of Nova Scotia within recent years.
 (q) A deposit which will be of
undoubted interest in connection with
the occurrence of Amphibia in the Coal
Measures is that which outcrops along
the banks of Rock Creek in the South
western part of Douglas County,
Kansas, in Marion Township (Township
14 south, Range 18 east, SW. and SE.
quarters of section 7), about 2 miles
from the now-abandoned post-office of
Twin Mounds, so called from the two
flat-topped, elongated mounds of
Oread limestone to the west of the
town. Fig. 5. Dawson's tree No. 13 at
the South Joggins, Nova Scotia.
The interest in these beds is not Upper part, in situ, in the reef
after it had been exposed by
due to the discovery of Amphibia in blasting. (After Dawson, based
them, but the possibilities of such on a photograph.)
discoveries. This is indicated by the
occurrence of fossils, in nodules similar
to those obtained from Mazon Creek, which are identical generically,
nd in most cases specifically, with the Mazon Creek animals and
plants.
The fossils so far collected from this interesting locality are:
Insecta (Identified by Dr. E. H. Sellards).
Spiloblattina maledicta (Scudder). The basal half of a front
wing.
Etoblattina sp. The hind wing of a cockroach.
Arachnida.
Anthrocomartus. Impression of the body.
Prestwichia danæ M. & W. Nearly complete specimen.
Crustacea.
Acanthotelson stimpsoni M. & W. Three nearly complete
individuals.
Plants (Identified by Mr. J. C. Carr, of Morris, Ill.).
 Pecopteris sp.
Sagittaria reticulata Lesquereux.
Annularia longifolia Lesquereux.
Annularia inflata Lesquereux.
Pecopteris villosa Brongniart.
Neuropteris decipiens Lesquereux.
Pecopteris serpulifolia Lesquereux. By far the most abundant
plant is Pecopteris.
The fossils occur in definite strata of nodules immediately above
a 10-inch coal seam which is worked for local consumption. The coal
lies near the base of the exposure in the more western portion of
the outcrop, but it is raised by an anticlinal fold to near the top of
the creek-banks by the bridge across Rock Creek, along the banks of
which the shales are exposed. Nodules containing fossils are found
most abundantly at the western exposure on the McKinzie place,
only a few having been found near the bridge.
Below the coal-seam, nodules of various shapes and sizes occur,
but they seldom contain fossils and never good ones. Occasionally,
as at Mazon Creek, fragments of plants adhere to the outside of the
incrusting shale. A single nodule may have adhering to it fragments
of 4 genera of plants. The fossiliferous nodules all occur above the
coal and are most prolific and abundant immediately above the
seam, within the first 10 inches. In the same stratum of shale with
the nodules are found abundant impressions of plants in the shale,
often perfect fronds being uncovered. (See, in this connection,
Twenhofel and Dunbar, 1914, "Nodules with Fishes from the Coal
Measures of Kansas," Amer. Journ. Sci., XXXVIII, pp. 157-163.)
G. F. Matthew (408-413) has described numerous genera and
species of footprints, presumably amphibian, from the Carboniferous
of Canada. The impressions indicate small creatures for the most
part. Other imprints have been described by Logan, Dawson, Lyell,
Marsh, Mudge, and Lea. Since the present work is intended largely
for a morphological review, only passing notice can be given to the
ichnites. The literature on the "Ichnites" has been brought together
in Hay's "Bibliography and Catalogue of Fossil Vertebrata of North
America," pp. 538-553. References since the publication of Hay's
catalogue (317) will be found in the bibliography at the end of this
work. Footprints are of interest in that they are the only evidence we
have of the occurrence of land vertebrates in the Devonian and
Mississippian of North America.
 CHAPTER IV.

THE MORPHOLOGY OF THE COAL

MEASURES AMPHIBIA.
The anatomy of the Coal Measures Amphibia presents many
primitive types of structure. Their organization represents a stage
passed through in the ontogeny of higher vertebrates. The animals
are similar in a general way, yet so diverse are the modifications
which they have suffered under different environmental conditions,
that close scrutiny is needed to discern the exact relationship of the
forms. Our knowledge of this relationship is based on the structures
preserved, which are largely skeletal, since little is known of the soft
anatomy (471) of the air-breathing vertebrates of the Coal
Measures. The pubis is ossified in the Paleozoic Amphibia later than
the ischium and ilium; the carpus and tarsus are cartilaginous; the
vertebræ consist of a pleurocentrum and two neurocentra, thus
paralleling conditions in modern mammalian embryos.
Fig. 6.—Generalized figure of dorsum of an
early amphibian skull to show position
of elements and terminology adopted in
this work. The outline is based on that
of Eryops, but is in no way intended to
indicate that form.
a. com, anterior commissure of lateral-line
canals; com, commissural
communication between infra- and
supra-orbital lateral-line canals; fr,
frontal; inf, interfrontal; inn, internasal;
info, infraorbital lateral-line canal; it,
intertemporal; jl, jugal lateral-line canal;
j, jugal; lar, lacrimal; mx, maxilla; n,
nasal; oc, occiput; occ, occipital cross-
commissure of the lateral-line system;
or, orbit; par, parietal; pof, postfrontal;
pmx, premaxilla; pf, prefrontal; po,
postorbital; pp, postparietal; g,
quadrate; qj, quadratojugal; spo,
supraorbital lateral-line canal; sq,
squamosal; spt, supratemporal; t,
temporal lateral-line canal; tab,
tabulare.

(a) The skull of the Coal Measures Amphibia has (fig. 6)

essentially the same structure in the different groups. It is largely
formed of bones of intramembranous origin, representing the face
bones of the mammalian skull. The skull in life was doubtless a
chondrocranium with the membrane bones laid down upon the
cartilaginous box containing the sense-organs, as in the sturgeon
(Acipenser), where the surface bones of the face were probably
originally scales, which later became consolidated into large bony
scutes. The membrane bones of the early Amphibia may have been
originally derived from scales, but at present nothing is known of
this origin; doubtless the elements had an intramembranous origin in
the ancestors of the group. Judging from Credner's studies on the
series of specimens of Branchiosaurus amblystomus Credner (187),
the skull bones do not ossify completely until relatively late in the life
of the individual. The skull in the youngest individual figured by
Credner (op. cit., Taf. XVI, fig. 1) seems to be largely cartilaginous,
with beginnings of separation into the skeletal elements. The
manner and time of development and ossification of the skull seems
to proceed much as it does in modern amphibians. The condition
found in the skull of Cryptobranchus allegheniensis or Necturus
maculosus will represent pretty accurately the condition of most of
the Coal Measures Amphibia. The face bones in certain forms were
sculptured and cut by lateral-line canals.
A median suture divides the skull into two equal regions dorsally.
On the sides of this median suture lie pairs of elements which are
common to all higher vertebrates. These elements are: the
premaxillæ, nasals, frontals, parietals, and post-parietals. All of these
elements vary somewhat in shape and slightly in arrangement, but
always occupy the same relative positions. To the side of these
elements lie the prefrontal, the postfrontal, the supratemporal, the
squamosal, and tabulare, and occupying the margin of the skull are
the maxilla, the jugal, the quadratojugal, and possibly the quadrate
in a few forms. The parietal foramen occurs usually within the
parietal bone, but its position is subject to slight variations and it
may occur on the suture between the frontal and the parietal, or
even far posterior near the postparietal. The nostrils often lie well
forward and are included by the premaxillæ, nasals, and prefrontals.
The orbit is usually well posterior, but it may occur far forward. It is
bounded by the prefrontal, the frontal, the postfrontal, the post-
orbital, and the jugal. Sometimes the lacrimal is present and has
been clearly identified on the anterior margin of the orbit in a few
cases.
(b) Sclerotic plates often occur within the orbits, and are not
confined to any particular group, though they are quite constant
among the Branchiosauria. They are usually delicate, thin, broad
plates which evidently overlap and operate as in modern animals.
The number varies, as many as 30 occurring within the orbit of one
branchiosaur. Between the margin of the orbit and the sclerotic
plates there often occur, in the Branchiosauria (186) particularly,
small scale-like particles which were doubtless embedded in the
heavy skin above the orbit during life.
(c) The palate of the skull is very incompletely known, being
indicated in a very few cases. These specimens, however, show that
the characters of the palate were quite similar, if not identical, in
essential respects with the palate among the European species of
the same or slightly later time.
A large cultriform parasphenoid occupies the posterior portion of
the palate, on either side of which in some species lies the posterior
palatine foramen. On the sides of the anterior prolongation of the
parasphenoid lie the vomers (186), membranous bones often
bearing minute tubercular teeth, apparently adapted for crushing.
The vomers and the maxillæ, with sometimes the palatine, surround
the anterior palatine foramen, which is almost always present;
sometimes, however, quite small. The transverse or ectopterygoid
unites the pterygoid, a broad plate of thin bone, with the maxilla and
jugal.
(d) The teeth of the Coal Measures Amphibia (194) are
remarkably similar in the various forms. They are always slender,
pleurodont denticles arranged in a single row on the jaws or as
tubercular eruptions on the palate bones, with a large pulp-cavity
and the enamel often striated. The food of the creatures must have
been small Crustacea, worms, insects, and succulent vegetation,
such as is the food of the modern Amphibia.
(e) The occiput is formed of partially ossified (465) ex- and basi-
occipitals, though these elements are never firmly united by ossific
union. Often a pair of condyles occur, one on either exoccipital. The
occiput was usually, however, cartilaginous and no trace of its
structure is preserved.
(f) The mandible is usually as long as the skull and is slender. It
is composed of 6 elements so far as known (465); these are the
articular, the surangular, the angular, the coronoid, the dentary, and
the splenial. Other elements may be present, but the anatomy of
this portion of the animals is not very completely known. The bones
are sculptured and cut by lateral-line canals (458) in a few forms.
Whether the articular operated on an osseous or cartilaginous
quadrate is unknown, though certain specimens seem to indicate an
osseous condition for that element. The anterior symphysis was
doubtless ligamentous, the halves always separating before
fossilization. The dentary always bears a single row of pleurodont
teeth, which may vary greatly in size and number.
(g) The hyoid apparatus is well preserved in a few forms (123).
Doubtless it was present in all of them, though it has seldom been
preserved. The condition of the hyobranchial apparatus in Cocytinus
gyrinoides (text-fig. 16) from the Coal Measures of Linton, Ohio,
seems to indicate that the species was a perennibranchiate
salamander (123). It is well known from the studies of Credner that
the European Branchiosauria, in the young, possessed external
branchiæ (187) supported by lateral basibranchials. The gill-arches
seem to have been slightly calcified or ossified in a few cases, and
they supported denticle-like projections which bore the gill-filaments.
When the Branchiosauria had attained a length of 100 mm. or more
they lost their gills (187). This change was accompanied by the
reduction of the tail, expansion of the pelvis, and increase in
ossification of the skull and skeletal elements. Gills have not yet
been detected among the American Branchiosauria.
(h) The eye in a few species had a large amount of black
pigment, as indicated by the blackening of the stone in the Mazon
Creek nodules. Professor Cope (107) thought that this would
indicate a nocturnal and crepuscular habit for these vertebrates,
since the pigmentum nigrum of the choroid is largely developed.
Other than this suggestion nothing is known of the soft parts of the
head.
(i) The alimentary canal (text-fig. 7) is beautifully preserved as a
cast in three specimens of the American branchiosaur species
Eumicrerpeton parvum Moodie (471) from the Mazon Creek beds.
The nodules which contain these interesting little fossils measure
less than 3 inches in long diameter. The fossil salamanders, about 30
mm. in length, are preserved on their backs and occur as nearly as
is possible in the center of the nodule.
If it were not for the fact that the œsophagus became loosened
and dropped from its place shortly after death, the alimentary canal
would be in place and would immediately recall a freshly dissected
specimen of a recent salamander. The anterior end of the
œsophagus lies obliquely across the chest region with its tip pointing
slightly downward. The length of the œsophagus proper, in one
specimen, is only about 3 mm. As it is preserved, the œsophagus
lies in a semi-sigmoid curve with the convexity anterior, and enters
the cardiac portion of the stomach by a gradual constriction. The
stomach is clearly preserved as a distinct sac-like organ with two
lobes which correspond to the cardiac and pyloric limbs. It measures
about 7 mm. in length by 2 mm. in its greatest diameter. The
muscular constriction which divides the organ into pyloric and
cardiac divisions occurs at a distance of 4 mm. from the upper end.
The pylorus is designated by a rather pronounced constriction which
may be partly accidental, although it recalls the pylorus of modern
frogs. From this constriction, which lies on the left side of the fossil,
as it is preserved, the duodenal portion of the intestine makes a
straight course posteriorly to near the anal region, where it takes a
sharp bend and curves back to run parallel with itself for the
distance of 4 mm. In its upward course the intestine enlarges, and
practically the same enlargement continues throughout the
remainder of the course to the anus. At a distance of 1 mm. from
the anal end, the rectum dilates probably 0.125 mm. to form the
cloaca. After the intestine has continued its parallel course for the 4
mm., as above stated, it turns abruptly to the right for a distance of
2 mm. It then runs posteriorly for a short distance, then bends back
and under itself to again make a double sigmoid curve, when at a
distance of 6 mm. from the anus it assumes a straight course, which
it continues to the end.
 The anus lies at a level which is approximately
that of the lower end of the femur, which is
preserved as an impression on the left side of the
fossil, thus agreeing in its position with that found
in modern Caudata. Lying inside the curve of the
stomach and partly inclosed by the œsophagus is a
smooth area which may possibly represent the
impression of some of the accessory digestive
glands, such as the liver. Occurring in this smooth
area are numerous fine lines which possibly
represent the impressions of blood-vessels; but
they are so imperfectly preserved that one can not
be sure. Fig. 7.—
Alimentary canal
Representatives of several genera of the of Coal Measures
modern Caudata have been dissected in order to salamander as
make a direct comparison of the fossil alimentary illustrated by the
canal with that of the recent forms. The alimentary smaller specimen
tract of Desmognathus fuscus Raf. from the vicinity of Eumicrerpeton
parvum Moodie,
of Ithaca, New York, resembles in a marked degree from the Mazon
that of the fossil form. The nearest approach to the Creek shales. ×
condition there represented is found, however, in 3. Original in Yale
an immature branchiate individual, some 47 mm. in University
length, of Diemyctylits torosus Esch., from a fresh- Museum. a, anus;
dd, duodenum;
water pond on Orcas Island in Puget Sound. The in, intestine; l,
presence of this species on the island is very impression of
suggestive. It is of extreme interest, too, that the liver(?); oes,
condition represented in the alimentary tract of the œsophagus; st,
fossil branchiosaurs should resemble so closely that stomach.
of an immature rather than a mature form.
(j) The vertebral column is clearly and readily separable into
cervical, dorsal, sacral, and caudal regions. The neck is always short,
with from 5 to 10 vertebræ, cervical ribs often present. The dorsal
region is not long, but varies from 20 to 30 in the constituent
vertebræ. There is a single sacral vertebra not always to be readily
distinguished from those of the dorsal and anterior caudal series.
The tail may be very short or extremely long, with neural and hæmal
spines elongate and flattened into an oar-like appendage. The distal
caudals are in some species cartilaginous, apparently always so in
the Branchiosauria.
(k) The atlas and axis are unknown among the American
specimens, but we are able to infer from the structure of the other
vertebræ what this must have been; and our inferences are partly
confirmed by the conditions existing in the European forms (187).
The atlas, apparently, consisted of a pair of neurocentral plates
which are partly ossified, partly embedded in cartilage, judging from
the edges of the plates which have been preserved. The centrum
seems not to have been present in the atlas, or if present it was only
very slightly developed and quite free from the neural pieces and
largely embedded in cartilage. A fairly accurate picture of the
condition of the atlas and axis may be seen on examining a cow, pig,
or chick embryo (378) in the early stages of vertebral development,
which has been cleared by the Schultze method (Amer. Journ. Anat.,
VII, No. 4, 1908).
(l) The dorsal vertebræ, as well as those of the other series,
present a primitive character (fig. 8) in the persistence of the
notochord (540). Among the Branchiosauria the notochord was not
at all or but slightly constricted intravertebrally, but among the
Microsauria it was constricted so far that the notochordal remnants
in each centrum resemble an hour-glass.
The structure of the vertebræ among American forms agrees
fully with that outlined by Credner, Fritsch, and others for the
European species. The details of structure are so fully given by Zittel
(642, pp. 346-353) and by Schwarz (540, 541) that it will not be
necessary to state more here as to their structure, since there is
nothing new to add concerning the American species.
The temnospondylous vertebra of the same nature and type as
exhibited by the Permian forms has its representatives (94, 478) in
the Coal Measures. Spondylerpeton spinatum Moodie (478) (plate 4,
figs. 1, 2) and Eryops sp. (plate 18, fig. 2) indicate the
embolomerous and rachitomous types of vertebral structure. The
occurrence of these widely different types of vertebral structure
indicates a long history for the group prior to the Coal Measures.
This history is further indicated by footprints in the Mississippian and
Devonian of this continent.

Fig. 8.—Vertebræ and ribs of Amphibia from the

Coal Measures of Linton, Ohio. Originals in Geol.
Inst. Berlin. (All after Schwarz.)
A. Caudal vertebra of Œstocephalus remex
Cope. Lateral view. × 4.
B. Caudal vertebra of Ptyonius vinchellianus
(?) Cope. Lateral view. × 6.
C. Dorsal vertebra of Ptyonius pectinatus
Cope. Lateral view. × 9.
D. Notochordal cones and spinal canal of
Thyrsidium fasciculare Cope. × 3.
E. Rib of Molgophis sp. Cope. × 1.75.
c=capitulum; t=tuberculum.
F. Vertebra of Molgophis sp. Cope, from
ventral side. × 2.
G. Dorsal vertebra of Ptyonius pectinatus
Cope. From above. × 8.
 H. Dorsal vertebra of Thyrsidium fasciculare
Cope, from below. × 2.5.
I. Vertebra of Phlegethontia linearis Cope,
from above. × 5.5
J. Rib of Œstocephalus remex Cope, from
posterior dorsal region. × 5.
K. Dorsal vertebra of Thyrsidium fasciculare
Cope, from above. × 1.5
L. Anterior dorsal vertebra (cervical?) of
Thyrsidium fasciculare Cope. Lateral
view. × 1.5.
M. Vertebra of Phlegethontia linearis Cope,
from side. × 5.

(m) The ribs (fig. 8) are very diverse in structure and in their
mode of articulation (541) with the vertebral column. The characters
of the ribs and vertebræ constitute the best means of classification
of these animals so far discovered. In the Branchiosauria the ribs are
always straight, heavy, and short, and articulate intravertebrally
upon a large and strong transverse process. They occur throughout
the vertebral column. There is a single pair of sacral ribs which are
not to be clearly distinguished from the pre-sacral and post-sacral
series. The cervical and caudal ribs are shorter than the dorsal
series. The branchiosaurian rib is composed almost entirely of
perichondral ossification. It presents the same condition as does the
humerus of the cow embryo of 2 to 3 inches in length. The ribs of
the branchiosaurs are identical in every way with the ribs of modern
salamanders and form one of the strong arguments in favor of the
relationship of the Branchiosauria to the Caudata. Among the
Microsauria the ribs are always long, slender, curved, and
intercentral. They may be either single or double headed, but usually
the former. They resemble in their characters the ribs of some of the
early reptiles and an attempt has been made to relate the
Microsauria (469) to the primitive reptiles on this basis. The ribs of
the other groups are still unknown. Indeed, representatives of the
Temnospondylia and the Stereospondylia are very scanty in the
American Coal Measures. One large rib (plate 22, fig. 4) may
represent a labyrinthodont, but nothing is known of the species to
which the rib belonged.
(n) The pectoral girdle (187) is a very simple and uniform
structure, although the details of the association of the elements still
remain to be determined. A single, median, usually large and
elongate interclavicle occupies the ventral line of the chest. This is
morphologically the same element which occurs in the middle line of
the chest of the lizards. It is a dermal bone and is usually, especially
among the Microsauria (462), highly sculptured. It varies
considerably in size and shape, but is remarkably uniform
throughout the various groups. Lying anterior to the interclavicle and
overlapping its antero-lateral margins lie the two clavicles, which are
usually diamond-shaped and are sculptured, dermal bones. The
position of the coracoid is still uncertain, and in fact its clear
association in the pectoral girdle of these species is still a question.
It seems to be constant in the European (186, 251) species and is
usually represented by a small rounded plate of bone, which in life
no doubt had a large amount of cartilage to form its borders. A
cleithrum (285) has been ascribed to one of the Linton, Ohio,
species (plate 15, fig. 3) by Jaekel (347), but this needs
confirmation. An osseous scapula is usually present, resembling the
scapula of modern salamanders, in that it was largely embedded in
cartilage. The position of the pectoral girdle is largely a matter of
doubt, especially for the American species. After death and before
fossilization the girdle was always moved by post-mortem shifting,
so that its exact relation to the ribs and vertebral column is still in
doubt. Credner (186) has restored the pectoral girdle close behind
the head, which would cause an amount of rigidity in the body which
probably did not exist.
(o) The arm consists of the humerus, radius, ulna, and 4 digits.
The characters of the arm-bones are such as is constant among
primitive animals and developing mammals. The osseous portion is
perichondral. Epiphyses are totally lacking and it is doubtful if the
endochondrium was at all ossified. The digits are often terminated
by ungual phalanges, although usually the terminal phalanx was
merely embedded in the web of the foot; and among the terrestrial
forms a claw was well developed. An osseous carpus is not known in
the species from the Coal Measures. Its impression indicates a broad
hand, well adapted for swimming.
(p) The pelvic girdle consists uniformly (462) of the ilium and
ischium. A small rounded pubis is present in some of the later forms
of Amphibia; it is, however, totally absent from the Coal Measures
species. The condition of the pelvis is paralleled by the partially
grown pelvis of mammalian embryos in which the elements ossify in
the order of ilium, ischium, and pubis. The ilium is always the larger
of the elements. It supported or was attached to the sacral rib by
means of a ligamentous union. The ischium did not ossify completely
until the animal was nearly mature. The union between the elements
of the pelvis was probably of a loose, membranous sort or else the
whole mass was embedded in cartilage; of the two hypotheses the
former is the more probable.
The pubis is indicated as a calcified quadrangular plate in a
specimen of Amphibamus grandiceps Cope (478) from the Mazon
Creek shales, and it is present as a rounded osseous element among
some of the Permian forms.
(q) The leg (fig. 21, B) is composed of the femur, tibia, fibula,
and 5 digits. The tarsus is usually cartilaginous, a single osseous
tarsus (483, 484) being known (plate 23, fig. 1) from America. The
distal phalanges may or may not be clawed, depending on the habits
of life of the animal. The elements of the leg are ossified in a similar
manner to those of the arm.
(r) The ventral scutellation (fig. 9), so commonly present among
all groups of Amphibia in the Coal Measures, consists of a series of
ossifications or calcifications in the myocommata. Among modern
amphibians they occur as thin perpendicular planes of connective-
tissue which are sometimes cartilaginous, especially in Necturus,
regarded by Wilder (Memoirs of the Boston Society of Natural
History, vol. V, No. 9, p. 400, fig. 6, 1903) and by Wiedersheim (605,
p. 58) as a homologue or predecessor of the sternum, although
Wiedersheim says:
"The sternum appears for the first time in Amphibians in the form of a
small variously shaped plate of cartilage situated in the middle line of the
chest. It arises as a paired cartilaginous plate in the inscriptiones tendineæ
of the rectus abdominis muscle, and therefore may be looked upon as
corresponding to a pair of 'abdominal ribs.' Such cartilaginous abdominal ribs
must have been present in greater numbers in the ancestors of existing
Urodeles."

This supposition is fully sustained by the anatomy of the

Branchiosauria (459), which must be looked upon as the actual
ancestors of the Caudata. Wilder says of these structures in
Necturus (op. cit., p. 400):
"The several cartilaginous rudiments which represent this part (i.e.,
sternum) in Necturus are somewhat difficult of detection and thus entirely
escaped the attention of the earlier investigators. They consist of a number
of thin cartilages found in several successive myocommata of the pectoral
region and confined mainly to the area covered by the overlapping
epicoracoids."

The homologue of the ventral scutellæ is found

in plesiosaurs, crocodiles, Sphenodon, and other
reptiles in the "abdominal ribs," and the same
myocommatous ossifications undoubtedly go to the
formation of the chelonian plastron. What the
causes were which produced the development of
the ventral scutellæ to such a high degree among
the primitive land vertebrates is uncertain, but they
are certainly more highly developed among the Fig. 9.—Ventral
primitive reptiles and amphibians than among the scutellæ of
Micrerpeton
later members of those classes. Among the caudatum, a Coal
Amphibia of the Coal Measures they attained, in Measures
some forms, a high degree of development and salamander from
differentiation. They are present in all families so Mazon Creek. × 5.
far known, except the Tuditanidæ, in which the f, femur; h,
humerus; ls, lines
myocommata may have been cartilaginous. The of scutes; v,
Sauropleuridæ present the highest development of vertebral column.
these structures among the American forms, in
which the scutes are large and osseous. Among
the Branchiosauria they are calcified or partially ossified and are
always arranged en chevron on the belly, chest, arms, and throat,
their arrangement and direction of the chevron being modified
according to the myomeres of the various regions. The ventral
scutellæ of the European Branchiosauria are figured and described
fully by Credner (192, p. 21, figs. 4 to 11).
(s) Scales (fig. 10 and plate 24, figs. 2 and 3) are present on the
body of (462, 485) several species. It is a matter of regret that their
preservation is so imperfect that nothing can be found out as to their
structure. The Linton species, which possess scales, are, of course,
carbonized and hence impracticable for microscopic study, and in the
Mazon Creek species of Amphibamus and Micrerpeton the scales
have been replaced by kaolin. The bodies of two species
(Cercariomorphus parvisquamis and Ichthyerpeton squamosum) of
the Linton Coal Measures Amphibia were completely scaled. The
scales in the Branchiosauria (462), so far as they have been
observed, are slightly imbricated; rounded, with concentric markings
after the manner of the modern cyprinoid fish-scale. They are
extremely minute, and whether or not they covered the entire body
of the animal is unknown. On the body of Cercariomorphus the
scales have the appearance of being tubercular without imbrication,
and they apparently covered the entire bodily surface of the animal.
 Fig. 10.—Horny armor of back of Hylonomus. a,
imbricated scales; b, horny plates; c, horny
spines or tubercles; d, small imbricated scales.
(After Dawson, based on a photograph.)

Among the Paleozoic Amphibia from Nova Scotia as described by

Dawson and Owen (193, 201, 485) scales are well developed and
frequent, although the details as to their occurrence on the bodies of
the animals are still unknown, since the Nova Scotian species are all
based on very fragmentary remains. Dawson (208, p. 34) has given
a detailed discussion of the discovery and anatomy of the various
types of scales possessed by the species from the Coal Measures of
Nova Scotia. Suffice it to say here that none of the scales appear to
be bony, but have a cuticular appearance with concentric markings.
Some of them are tubercular, and Dawson thought that a few
specimens indicated that some of the species possessed scaly
lappets and a dorsal nuchal fringe of scaly skin along the back. He
has indicated these facts in his restorations of the forms. The scales
were all carbonized and burned readily with a strong flame. A
section of the scale shows a thick upper corium with a vascular body
(208, pl. IV, fig. 29) much like a fish-scale. Fragments of the skin
were also preserved with the scales. Dawson says of the skin:
"One of my specimens is a flattened portion of cuticle two and a quarter
inches in length. The greater part of the surface is smooth and shining to the
naked eye, and under the microscope shows only a minute granulation. A
limited portion of the upper and, I suppose, anterior part is covered with
imbricated scales, which must have been membranous or horny, and
generally have a small spot or pore near the outer margin, some having in
addition smaller scales or points on their surfaces" (208, pl. IV, figs. 22 and
25).

(t) Muscle tissue (fig. 21) is preserved in a single specimen,

previously described by the writer (464, p. 17, pl. 7, fig. 1). The
carbonized muscles show a myomeric arrangement and the portions
preserved probably represent one of the recti muscles of the
abdominal wall.
(u) The lateral-line system in the Coal Measures Amphibia will be
best understood from a comparative review of the occurrence of
these organs among all extinct Amphibia. Since all the orders of
Amphibia are represented in the Coal Measures, such a review will
not be out of place here.
The preservation of the lateral-line system among ancient
Amphibia is due to the fact that the skull of many forms (especially
the later and larger) are grooved and marked by a regular series of
furrows and pits, in which the sense-organs of the lateral-line system
were contained (see fig. 6), as well as by the preservation of a series
of clearly marked scales on the sides of the tails and bodies of
others. The grooves are never arched over as in the
Macropetalichthyidæ, where "in favorable specimens each is shown
to be covered by a delicate roof perforated by two lines of minute
openings" (Dean, N. Y. Acad. Sci. Mem., vol. II, pl. III, p. 115). They
are always widely opened canals, either with perfectly smooth
bottoms and sides or roughened with large pits, or even becoming a
series of well-marked pits. An attempt has been made (458) to
homologize the organs with those of fishes.
The nomenclature adopted here for the canals does not depart
from that used by Allis for Amia (Journ. of Morphology, vol. II,
1889). The supraorbital and infraorbital canals are readily correlated
with those of the same name in fishes, where they are very clearly
marked. The anterior commissure is also homologous with that of
the fishes, as is also the canal here called the "antorbital
commissure." The others are not so readily homologized. The upper
canal (see fig. 6) in the posterior part of the cranium is here
designated the temporal canal. It is, however, clearly a part of the
infraorbital of the fishes. Its relations in the Stegocephala are such
that a new name is deemed necessary. The jugal canal is, I believe,
a new formation in Amphibia. The transverse canal of the amphibian
skull is homologous with the "occipital cross-commissure."
The figure (see fig. 6) is a composite picture of the lateral-line
system of the higher or truly stegocephalous Amphibia. The outline
of the skull is based on that of Eryops. All of the canals do not exist
on any one skull or in any one order, but all are found somewhere in
the group.

Fig. 11.
A. Skull of Eoserpeton tenuicorne Cope,
showing arrangement of cranial elements.
× 2. fr, frontal; j, jugal; mx, maxilla; n,
 nasal; or, orbit; par, parietal; pof,
postfrontal; pmx, premaxilla; po,
postorbital; pp, postparietal; qj,
quadratojugal; sq, squamosal; spt,
supratemporal; tab, tabulare.
B. Outline of skull of Ceraterpeton galvani
Huxley from the Carboniferous of England.
Heavy broken lines show the distribution of
lateral-line canals. × 1. (After Andrews.) fr,
frontal; par, parietal; or, orbit; po,
postorbital; pp, postparietal; spt,
supratemporal; tab, tabulare.

The canals have been described in all known orders of fossil

Amphibia and the system is found likewise in all the living orders,
including the Gymnophiona, which have "a strong line of lateral
sense-organs" (Gadow). In the Branchiosauria, the earliest of the
true Amphibia (Euamphibia) and ancestral to the modern Caudata,
the lateral-line system is known on the tails of two genera (462,
478) from the Mazon Creek, Illinois, shales—Micrerpeton and
Eumicrerpeton. The system as there defined has been fully
discussed in the description of the anatomical details of the species,
to which reference may be made for further data (pp. 52-60). Suffice
it to say here that the system of sense-organs there preserved is
identical with that of the larval Necturus; the lines arising as a
median from the tip of the tail and a dorsal springing from the
median at a distance of a few millimeters from the tip of the tail. The
lines are more evident on account of the fact that the lateral-line
sense-organs were located under specialized pigmented scales. The
significance of the close similarity between the arrangement of the
lateral-line systems on the tail of Necturus, Micrerpeton, and
Eumicrerpeton is doubtless of genetic (459) importance, indicating
the origin of the caudate Amphibia from the Branchiosauria by a
degenerative or recessive evolution in other structural characters.
This system of sense-organs has been described in no other
branchiosaurian.
 The Microsauria (458) are exceedingly interesting in possessing a
very peculiar type of lateral-line system. It is known in a few forms
and in one specimen especially well (Erpetosaurus tabulatus) (fig.
22, G). In this species, which is represented by a single imperfect
skull, there are evidences of a nearly complete lateral-line system of
canals and pits. The occipital cross-commissure is represented on
the posterior border of the skull by a row of elongate pits such as
Andrews described for Ceraterpeton (8). I fail to find in American
species the pores described by Andrews. The temporal canal forms
with the jugal canal a complete ring, much as it is in Trematosaurus,
only in Erpetosaurus tabulatus the temporal canal does not touch
the tabulare. I think there are indications of a connection of the
temporal canal with the supraorbital. The temporal canal cuts the
supratemporal, the squamosal, and jugal. The jugal canal lies for the
most part on the supratemporal and quadratojugal, and joins the
infraorbital on the jugal. A portion only of the infraorbital canal is
preserved. There is also a portion of the supraorbital canal. It seems
not to be connected with the temporal canal, although there is a
possible indication of this connection. The supraorbital crosses the
frontal, prefrontal, and a part of the nasal. The squamosal element
is peculiar in Erpetosaurus tabulatus in that it is excluded from the
parietal by the extension of the tabulare and postorbital. This
condition is found in several other species of the Microsauria. It will
be noticed that with the changed condition of the squamosal the
temporal canal has changed also, and this is further proof of the
close connection between the cranial elements and the lateral-line
canals, as Allis has maintained for Amia. (See in this connection C. J.
Herrick, Journ. Comp. Neurol., vol. II, p. 224, 1901.)
The Diplocaulia, an amphibian order allied to the Branchiosauria
(477) and through them to the Caudata, have the lateral-line system
apparently well-developed. The skulls are always crushed flat, so
that the canals are nearly obliterated. On the mandible, however, the
canals are clearly distinct and apparently run the entire course
around the mandibular rami. On a well-preserved skull of
Diplocaulus magnicornis Cope there are indications of three lateral-
line canals (477, pl. 1). The infraorbital is clearly marked as a well-
defined groove just below the orbit. The supraorbital is indicated
only for a short distance, and there are indications of the temporal
canal. The operculo-mandibular canal has its course, for the most
part, near the middle of the rami, but as it approaches the posterior
angle of the mandible it suddenly changes its course and drops
down to the lower edge, only to rise again and to come out strongly
marked near the median plane on the posterior angle of the
mandible.
The Temnospondylia, as represented by Eryops, Cricotus, and
Archegosaurus, possess well-developed lateral-line canals (458). H.
von Meyer (428) many years ago made out the course of the canals
in Archegosaurus. The greater part of the following description is
based on Eryops megacephalus Cope from the Texas Permian. The
entire surface of the cranial elements in Eryops, as in other of the
Stegocephala (458), is covered with coarse pits. The fossæ are
present even in the bottoms of the grooves which represent the
lateral-line system, and are more marked in the members of the
Temnospondylia than in the Stereospondylia.
The occipital cross-commissure occurs in a well-developed form
in Eryops. It is short and ends abruptly within the limits of the
tabulare. Its ends are occupied by large pits. The commissure, as in
Amia, grooves the postparietal and the tabulare elements. There is
no evidence of an anterior commissure. I think there is evidence of a
temporal canal on the left side of the skull, but am not sure. The
jugal and infraorbital canals are well developed and strongly
connected. The jugal canal starts far back on the supratemporal, and
after curving around over the quadratojugal joins the infraorbital, or
rather becomes a part of that canal, somewhere on the jugal. There
is nothing unusual in the infraorbital. The antorbital commissure is
well developed. It is longer and better developed than in any other
known form. The supraorbital canal starts in the region of the orbit,
and after curving downwards to meet the antorbital commissure,
ends abruptly anterior to the nostril. There are faint traces of a
lateral-line canal, the operculo-mandibular, on a poorly preserved
mandible of Eryops. It does not differ greatly from that described
below for Anaschisma.
Although Archegosaurus has been known for more than a
century, we have had no adequate discussion of the manner of
occurrence of the lateral-line canals. Burmeister (80) gave a figure of
the canals as he thought they occurred on the cranium, but H. von
Meyer (428) states that the representation is inaccurate, and they
seem to be based largely on Trematosaurus.
The lateral-line canals occur in well-developed form on the skulls
of the Stereospondylia. The sutures between the elements of the
skull are usually clearly marked by smooth, narrow grooves. The
lateral-line canals can always be distinguished from the sutural
grooves by the shape of the bottom, being U-shaped in the former
and V-shaped in the latter. The lateral-line canals also at times have
their bottoms roughened by pits occurring in them; the sutural
grooves always have smooth bottoms. The lateral-line canals are
usually rather shallow and sometimes broad, with the edges of the
grooves more or less perpendicular, but in Metoposaurus the canals
are deep and the borders are sharply incised.
The temporal canals in Anaschisma from the Triassic (49) of
Wyoming are represented by broken furrows. The portions preserved
exhibit the usual downward tendency to unite with the infraorbital
on the postorbital element. In its course forward from the epiotic the
temporal canal cuts the squamosal. The supraorbital canal has an
unusually deviating course in Anaschisma, but aside from the minor
twists and curves it does not differ essentially from the same canal
in other forms. It ends abruptly on the anterior end of the muzzle. In
its course it gives off the vestige of an antorbital commissure which
tends to join a vestige from the infraorbital canal. The jugal canal
begins broadly at the very posterior edge of the skull as though it
were continued, as it undoubtedly was, to the body of the animal. In
its course forward it joins the infraorbital canal on the jugal. The
course of the infraorbital is not unusual in any respect. There is no
anterior commissure on the skull, nor is the occipital cross-
commissure developed on either skull of the genus at hand.
There are distinct evidences of an operculo-mandibular lateral-
line canal on the mandibles. The canal enters the mandible on the
surangular and passes forward around the mandible as described for
Diplocaulus (477).
Other members of the Stereospondylia, such as Mastodonsaurus,
Metoposaurus, and Trematosaurus possess well-developed lateral-
line canals, but the above description fits, in a general way, the
condition in all genera; and for our present purposes that will suffice.
 CHAPTER V.

THE AMPHIBIA OF THE DEVONIAN

AND MISSISSIPPIAN OF NORTH
AMERICA.
Evidences of the earliest land vertebrates are exceedingly scanty
in the strata between the close of the Silurian and the opening of
the Coal Measures, being represented solely by footprints. In the
Devonian our knowledge of the group is confined to a single
footprint, and in the Mississippian to series of footprints from several
localities. These have been described by Lea (371), Rogers (Geology
of Pennsylvania, pt. II, 1856, p. 831), Barrell (21), Dawson (223),
and Branson (50). The last-named author has described a new
species from the Mississippian of Giles County, Virginia. His
description of the footprints, with a photograph of one of the series,
are published herewith (plate 18, fig. 3). Branson (50) has given a
résumé of the knowledge of Mississippian Amphibia in North
America.

Thinopus antiquus Marsh, 1896.

Marsh, Am. Jour. Science, II, p. 374, Nov. 1896, with figure.

Type: Specimen No. 784, Yale University Museum.

Horizon: Near top of Chemung, in the upper Devonian.
[The] "specimen shows one vertebrate footprint in fair preservation, and
with it part of another of the same series. These impressions are of much
interest, both on account of their geological age and the size and character
of the footprints themselves. The one best preserved [fig. 12] is nearly 4
 inches in length, 2.25 inches in width, and was apparently made by the left
hind foot. On the inner side in front of the heel, a portion of the margin is
split off, and this may have contained the imprint of another toe. The other
footprint was a short distance in front, but only the posterior portion is now
preserved in the present specimen. It is probably the imprint of the forefoot.
"The specimen [plate 18, fig. 4] ... was ... found in the town of Pleasant,
one mile south of the Allegheny River, Warren County, Pennsylvania, by Dr
Charles E. Beecher, who presented it to Yale Museum, where it still remains.
"The geological horizon is near the top of the Chemung in the upper
Devonian. In the same beds are ripple marks, mud cracks, and impressions
of rain drops, indicating shallow water and shore deposits. Land plants are
found in the same general horizon. Marine molluscs also occur, and one
characteristic form (Nuculana) is preserved in the footprint slab" (Marsh).

This still remains after nearly 20 years the

only evidence of air-breathing vertebrates in
the Devonian of the world.

Dromopus aduncus Branson.

Fig. 12. Copy of Marsh's
Branson, Jour. Geol., XVIII, No. 4, pp. 356- drawing of footprint of
358, fig. 1, 1910. Thinopus antiquus, from
the Devonian of
Type and other specimens in Oberlin Pennsylvania. × 1/3.
College Museum.
Horizon and type locality: Near the
bottom of the Hinton formation in Giles County, Virginia. (Plate 18,
fig. 3.)
The following description of the shales and footprints are from
Dr. Branson's paper cited above:
"The Hinton shales, like the Mauch Chunk, seem to have been subaerial
in origin and are made up for the most part of variegated shales interbedded
with thin layers of argillaceous, fine-grained sandstone. The footprints occur
in fine-grained sandstone, and remains of land plants are not uncommon in
the same beds.
"Twenty-two footprints made by one animal walking in a straight course
were collected in a slab. They give the impression of having been made by a
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