Anaesthesia, 1978, Volume 33, pages 225-226
Editorial ‘Pain is perfect misery, the worst of all evils and, if cjxcessioe, overtirrns id1 patience‘
JOHNMILTON (1 608-74)
Paradise Lost
Failure to relieve acute pain may distress the patient and shame the physician (Anaesthesia, 1975, 30, 305) but, at least a cure is effected by the removal of the cause aided, perhaps, by distraction and natural amnesia-‘A woman when she is in travail has sorrow . . .; but as soon as she is delivered of the child, she remembereth no more the anguish for joy that a man is born into the world’ (St John, 16, xxi). Failure to relieve chronic pain condemns the unfortunate patient to a life of untold misery. Eradication of the cause of the agony is often impossible either because of its malignant and relentless nature or because it is obscure and undiagnosable. The physician must, therefore, either attack the lines of transmission of the painful impulse or seek to interfere with its reception and interpretation in the higher levels of the central nervous system. The results of such therapy are often disappointing because the pathways of pain are multiple and devious, and the mechanisms of evaluation of peripheral stimuli by the brain are complex and often unpredictable. Deliberate malingerers are rare in the pain therapy clinic but patients to whom pain is a crutch on which to lean, or a defence against environmental factors, whether real or imagined, are frequent attenders. Sometimes the only compromise which can be achieved is to reach a point at which there is an unspoken acknowledgement by the patient that he knows, that the doctor knows, that the patient’s pain is an essential protection against some unacceptable external threat rather than the result of a physical condition. Miraculous cures do occur but they are rare and often inexplicable. How does a single injection of a short acting local analgesic succeed in permanently relieving a chronic pain of obscure origin, which has made the life of the patient a misery for weeks or months? The conventional explanation that it has ‘broken the vicious circle’ is surely intellectually unsatisfactory. This issue of Anaesthesia contains the first two articles of a new series under the general title of ‘Current views o n the therapy of chronic pain’ in which we shall seek to explore and evaluate the multiplicity of treatments now available for controlling chronic pain. The first paper, by three expert workers in the field, is a broad consideration of the philosophical, organisational and technological problems involved. All the authors are anaesthetists but they emphasise, on the one hand, the need for a multi-disciplinary consultative approach to chronic pain and, on the other, the necessity for the treatment of the patient as a whole by a single physician. These two requirements are not contradictory. The role of the co-ordinating doctor, like that of the conscientious general practitioner, is essential. The physician anaesthetist is as well fitted by temperament and training to fill the coordinating role in the pain clinic as he does both in the operating theatre and in the intensive care unit. Members of the specialty of anaesthesia must beware, however. They are accustomed to an immediate and practically one hundred per cent response--oblivion at the depression of the plunger
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of a syringe. They must not expect the same kind of result in pain therapy-unless of course, they wish to limit their practice in the pain field to that of a technician who carries out nerve blocks at the behest of specialists of other disciplines. Those who wish to treat chronic pain effectively must train themselves to adopt many roles in relation to the patient. They may have to relate to him in the guise of psychotherapist, priest, confessor, counsellor, friend or witch doctor and they must know when the time is ripe to call in experts in each particular field. It is therefore salutary that Dr Mark Mehta, the author of the second article in the new series should direct our attention to alternative, non-invasive methods of relieving pain which can supplement or replace the use of drugs or nerve blocks. The support of everyone involved in the care of the patient in pain is essential. Nursing staff experienced in the field are an invaluable asset. They will have learned to understand that perfect results are rare, that analgesic drugs must often be continued in combination with other treatments and that the patients must be encouraged to appreciate small improvements. Hippocrates wrote, ‘Divine is the task to relieve pain’. Did he mean that success depended on the intervention of the gods of that the physician who attempts to relieve pain will have his reward in Heaven?-perhaps both interpretations are correct! T.B. BOULTON
Editorial notices Anaesthesia-Ten
issues in 1978
Annesthesia will appear every month with the exception of August and December in 1978
News and Notices sections The.first issue of each quarter will contain full News and Notices sections. Copy dates for these issues will be: 3 April for July; 3 July for October and 3 October for January 1979. Stop Press sections will be published in other issues but they will contain only material which requires urgent publication before the next full News and Notices section.
The use of Systeme International (SI) units Authors will still be permitted to use either the SI system or the old metric notation throughout 1978 but they will be expected to be consistent in each manuscript. Blood pressure will continue to be expressed as nimHg. Imperial measurements will not be used even in parentheses except in exceptional circum$tances (e.g. historical articles). Conversion fables were published in the January 1978 number but will not be published again this year. Blnding Anaesthesia Kemp Hall Bindery will undertake to bind all volumes from 1973 onward. Details will be found in Association News in News and Notices sections. The Index and rifle Page for 1977 (Volume 32) appeared as an integral part of the November 1977 issue as all indices and title pages have done since 1973.
Editorial ‘Pain is perfect misery, the worst of all evils and, if cjxcessioe, overtirrns id1 patience‘
JOHNMILTON (1 608-74)
Paradise Lost
Failure to relieve acute pain may distress the patient and shame the physician (Anaesthesia, 1975, 30, 305) but, at least a cure is effected by the removal of the cause aided, perhaps, by distraction and natural amnesia-‘A woman when she is in travail has sorrow . . .; but as soon as she is delivered of the child, she remembereth no more the anguish for joy that a man is born into the world’ (St John, 16, xxi). Failure to relieve chronic pain condemns the unfortunate patient to a life of untold misery. Eradication of the cause of the agony is often impossible either because of its malignant and relentless nature or because it is obscure and undiagnosable. The physician must, therefore, either attack the lines of transmission of the painful impulse or seek to interfere with its reception and interpretation in the higher levels of the central nervous system. The results of such therapy are often disappointing because the pathways of pain are multiple and devious, and the mechanisms of evaluation of peripheral stimuli by the brain are complex and often unpredictable. Deliberate malingerers are rare in the pain therapy clinic but patients to whom pain is a crutch on which to lean, or a defence against environmental factors, whether real or imagined, are frequent attenders. Sometimes the only compromise which can be achieved is to reach a point at which there is an unspoken acknowledgement by the patient that he knows, that the doctor knows, that the patient’s pain is an essential protection against some unacceptable external threat rather than the result of a physical condition. Miraculous cures do occur but they are rare and often inexplicable. How does a single injection of a short acting local analgesic succeed in permanently relieving a chronic pain of obscure origin, which has made the life of the patient a misery for weeks or months? The conventional explanation that it has ‘broken the vicious circle’ is surely intellectually unsatisfactory. This issue of Anaesthesia contains the first two articles of a new series under the general title of ‘Current views o n the therapy of chronic pain’ in which we shall seek to explore and evaluate the multiplicity of treatments now available for controlling chronic pain. The first paper, by three expert workers in the field, is a broad consideration of the philosophical, organisational and technological problems involved. All the authors are anaesthetists but they emphasise, on the one hand, the need for a multi-disciplinary consultative approach to chronic pain and, on the other, the necessity for the treatment of the patient as a whole by a single physician. These two requirements are not contradictory. The role of the co-ordinating doctor, like that of the conscientious general practitioner, is essential. The physician anaesthetist is as well fitted by temperament and training to fill the coordinating role in the pain clinic as he does both in the operating theatre and in the intensive care unit. Members of the specialty of anaesthesia must beware, however. They are accustomed to an immediate and practically one hundred per cent response--oblivion at the depression of the plunger
225 0003-2409/78/0300-0225 $02.00 fi 1978 Blnckwcll
Srientifir Pnhlirltinn.
226
Editorial
of a syringe. They must not expect the same kind of result in pain therapy-unless of course, they wish to limit their practice in the pain field to that of a technician who carries out nerve blocks at the behest of specialists of other disciplines. Those who wish to treat chronic pain effectively must train themselves to adopt many roles in relation to the patient. They may have to relate to him in the guise of psychotherapist, priest, confessor, counsellor, friend or witch doctor and they must know when the time is ripe to call in experts in each particular field. It is therefore salutary that Dr Mark Mehta, the author of the second article in the new series should direct our attention to alternative, non-invasive methods of relieving pain which can supplement or replace the use of drugs or nerve blocks. The support of everyone involved in the care of the patient in pain is essential. Nursing staff experienced in the field are an invaluable asset. They will have learned to understand that perfect results are rare, that analgesic drugs must often be continued in combination with other treatments and that the patients must be encouraged to appreciate small improvements. Hippocrates wrote, ‘Divine is the task to relieve pain’. Did he mean that success depended on the intervention of the gods of that the physician who attempts to relieve pain will have his reward in Heaven?-perhaps both interpretations are correct! T.B. BOULTON
Editorial notices Anaesthesia-Ten
issues in 1978
Annesthesia will appear every month with the exception of August and December in 1978
News and Notices sections The.first issue of each quarter will contain full News and Notices sections. Copy dates for these issues will be: 3 April for July; 3 July for October and 3 October for January 1979. Stop Press sections will be published in other issues but they will contain only material which requires urgent publication before the next full News and Notices section.
The use of Systeme International (SI) units Authors will still be permitted to use either the SI system or the old metric notation throughout 1978 but they will be expected to be consistent in each manuscript. Blood pressure will continue to be expressed as nimHg. Imperial measurements will not be used even in parentheses except in exceptional circum$tances (e.g. historical articles). Conversion fables were published in the January 1978 number but will not be published again this year. Blnding Anaesthesia Kemp Hall Bindery will undertake to bind all volumes from 1973 onward. Details will be found in Association News in News and Notices sections. The Index and rifle Page for 1977 (Volume 32) appeared as an integral part of the November 1977 issue as all indices and title pages have done since 1973.
