Therapy: Relief of Pain

The operation for breast cancer appeared to have been successful, but the patient developed unbearable pain in her right arm. Some of the many doctors she consulted were convinced that her cancer must have recurred—but they could not find it. Others blamed her pain on an emotional (“hysterical”) reaction—but they could not help her either. Still, the woman was more fortunate than most people who have severe, unyielding pain: she was able to go to the University of Washington’s pain clinic in Seattle. There, a team of experts found that her arm nerves had been scarred by “cobalt-bomb” radiation after surgery. The pain was relieved by alcohol injections that killed the affected nerves. The case was one more reminder that finding an effective treatment for pain can become one of the most difficult problems of medicine. Even after doctors have done their best in dealing with an injury or a disease, the patient may still suffer pain so severe and persistent that it dominates his life and distorts his personality. Sometimes the pain persists because the disease itself is incurable. Often there is no disease at all, and the pain is in the mind. But either way, even the wisest of physicians cannot handle many cases of intractable pain by himself. Diagnosis is too tricky, and some of the medical and surgical techniques for treatment are beyond him. Little Bit, Big Stride. At the Seattle clinic, Dr. John J. Bonica and Dr. Lowell White have collected all available data on the causes of pain and the treatments for it. And to make sure that the patient who needs an unusual treatment can get it, a team of specialists in anesthesiology, neurosurgery, radiation treatment, physiatry (physical medicine), orthopedics and psychiatry has been assembled. Sometimes, only two or three of these physicians have to be called in to diagnose a case of stubbornly resistant pain and to lay out a course of treatment. But for the toughest cases, the whole group meets to thresh them out. “The management of pain is time-consuming and frustrating,” says Dr. Bonica. “It may take a week or ten days just to get a diagnosis. Treatment is likely to be slow, especially if it is psychotherapy. And not all the patients can be cured. But if we can help half of them, and relieve the pain of the others even a little bit, it is a great stride forward.” Most obvious candidates for the pain clinic’s exhaustive care are victims of cancer. Anesthesiologist Bonica points out that many of the 200,000 Americans a year who die of cancer spend their last few days, weeks or months in agony. But they are by no means the only ones who suffer. Back injuries, fractures, some kinds of sprains, bursitis and a variety of other arthritic disorders, muscular rheumatism, kidney stones and diseases of the pancreas and gall bladder can all cause disabling pain. Body & Mind. Treatments are as varied as causes, says Dr. Bonica. Barbiturates have their place; so have the narcotics, though these are so easy to use that they are often misused. For some pains, the prescription is heat. For others, cold. For some, exercise. For others, X rays. And for many of the most severe cases, the only treatment is an operation on a nerve to cut the pathways by which sensations are transmitted to the brain. Some treat ments are only temporary “nerve blocks.” In others, nerves have to be completely severed by the neurosurgeon’s knife. With every patient, the pain-clinic team has to answer two basic questions. How much of the unbearable pain is really the physical sensation, the pain itself? How much of it is reaction to the pain, a far more complex and elusive psychophysiological process? These are questions, says Dr. Bonica. that many more medical men should be asking themselves. But in all the U.S., there are only two or three clinics like Seattle’s. There should be many more, says Dr. Bonica—at least one in every major medical center—because pain is the common denominator in virtually all human ills.