- Email: [email protected]
UNDERSTANDING PAIN
43
According to a tentative minimal occurrence curve a daily dose under 0-44 g. might not induce S.M.O.N. despite long administration. In animal experiments, clioquinol was confirmed as neurotoxic. Pathological changes in the peripheral nerves of rabbits given clioquinol orally or intravenously resembled those of S.M.O.N. Since last September, when clioquinol was banned by the Ministry of Health and Welfare in Japan, the steady occurrence of S.M.O.N. in many hospitals in Tokyo has abruptly ceased-a cessation confirmed by statistics from many parts of Japan. This fact could not be explained by various factors other than clioquinol, including mycoplasma, agricultural chemicals, or virus, reported by Professor Inoue and his colleagues.2The question why so many cases of clioquinol intoxication occurred in Japan, although this drug has been widely used in the world without any serious side-effects, must be elucidated by comparative S.M.O.N.
studies with other countries. Department of Neurology, Institute of Brain Research, Tokyo University.
AKIHIRO IGATA.
SIR,-Workers in Japan3 reported lately a striking inin a neurological syndrome designated as subacute
" ’
is another point that has to be conThe word itself is ambiguous, for both the person who feels little pain and the one who feels it more, but bears it philosophically, may be called insensitive. As a rule it may be accepted that sensitivity refers to the mental aspect of pain ... difference in attitude will influence pain experience ... observations exist of British and French soldiers wounded in battle in the 1914-18 war, who were treated at the same advanced hospital. Some soldiers of the French units, whose courage and bravery was proverbial, screamed, yelled and winced even before the surgeon began to examine them. Their British comrades preferred to bite their lips, or drive their fingernails into their palms, and to groan occasionally. On questioning, it was found that they did this because: (1) they believed that it would reduce the pain if they remained as quiet as possible; (2) they had (correctly) noted from previous experience that the existence of one pain (biting lips) raises the threshold for perception of another (wound); (3) upbringing, family and community influence induced them to do so. " The attitude of the French soldiers was dictated by: (1) getting some relief of tension by screaming and fatigue, and also increasing thereby the threshold for the perception of the wound pain; (2) expecting gentler treatment by the surgeons and the nursing personnel; (3) upbringing, &c. as mentioned in the case of the British soldiers."
Sensitivity’ specially.
to pam
sidered
...
V. C. MEDVEI.
London S.W. l.
crease
myelo-optico-neuropathy (S.M.O.N.). On the basis of epidemiological surveys, they believe that this syndrome is caused by halogenated oxyquinolines, especially clioquinol (chinoform, ’Enterovioform ’). Clioquinol and the related diiodohydroxyquinoline (known in Israel as ’Enterosept ’) are taken, as in other parts of the world, in very large amounts. Diiodohydroxyquinoline is in especially heavy use as a symptomatic anti-amoebic drug: it is easy to take, absorption is thought to be slight, and no contraindication seems to exist, apart from thyrotoxicosis. Side-effects are rare. Both drugs are prescribed in large amounts over long and repeated periods (but apparently not in the very large amounts which have been associated with optic atrophy in a few patients 4,5). Patients with the common chronic recurrent intestinal amoebiasis take the drugs, especially diiodohydroxyquinoline, very often, even without prescription, in repeated courses, because they learn that their symptoms are improved, at least temporarily. In 37 years of a mostly gastroenterological practice, including 18 years in charge of a gastroenterological clinic of the Workers’ Sick Fund, I prescribed both drugs in thousands of tablets, but I do not remember one patient presenting with neurological complications. Inquiries in large neurological hospital departments showed that S.M.O.N. or a similar neurological syndrome has very rarely been observed in Israel. Taking into account these clinical experiences, it seems to us very improbable that there is a causal relationship between S.M.O.N. and these drugs and that one has to look for another explanation for this common
syndrome
in
SIR,-The present system for the care of surgical patients in many hospitals inevitably leads to the inadequate relief of pain. There is evidence that, at least in patients having upper abdominal incisions, pain is more or less continuous throughout the 48 hours after operation.1 Studies at present being carried out in this department also indicate that this is so. Resident surgical staff and anxsthetists are usually necessarily confined to the operating-theatre for long periods of time. Therefore, they are not always available for the individual assessment of a patient’s pain. Because of the present shortage of nursing staff nurses are unlikely to be able to do this either. We try to solve the problem by writing up a patient for a slug of a drug to be given should he complain. No is made to titrate the attempt patient’s response against drug dose. Even if this was done, the evidence from your columns suggests that the patient would not get the drug when he actually needed it. Although methods for adequate postoperative pain relief are available, such as continuous extradural analgesia, their use on a general ward runs into the same problems as the use of parenteral analgesics. It seems, therefore, that postoperative pain will continue to be inadequately treated until these patients are looked after in a recovery or high-dependency area, where medical and nursing staff, adequate in both numbers and training, are in constant attendance. Department of Anæsthetics, Guy’s Hospital,
Japan.s
Gastroenterologic Clinic, Central Clinic’ Zamenhof’, Workers’ Sick Fund, Tel-Aviv, Israel.
J. F. SEARLE.
London S.E.1.
H. STEINITZ.
UNDERSTANDING PAIN SIR,-Your interesting annotation (June 19, p. 1284) reminds me sadly how short human memory is. In an essaypublished in 1949, I devoted a whole chapter to the discussion of the mental effects of pain. I said: 2. 3.
Inoue, Y. K., Nishibi, Y., Nakamura, Y. ibid. p. 853. Tsubaki, T., Honrra, Y., Hoshi, M., ibid. 696. 4. Berggren, L., Hannson, O. ibid. 1966, i, 52. 5. Etheridge, J. E., Jr., Stewart, G. J. ibid. p. 261. 6. ibid. 1971, i, 690. 7. The Mental and Physical Effects of Pain. Buckston Browne Prize Essay, Harveian Society of London, 1948. Edinburgh, 1949.
ETHACRYNIC ACID WITH PACKED RED CELLS
SIR,-Continuing the discussion about the addition of ethacrynic acid to a transfusion of packed cells, I would reiterate the first part of the letter by Dr. Lieberman and Dr. Kanashiro (May 1, p. 911) that nothing be added to red cells-or for that matter to whole blood. If one wishes to study the effect of ethacrynic acid or any other drug on blood cells, this is perfectly acceptable, but for the purpose of proper and safe transfusion no medication should ever be added to the bottle of blood itself. This negation is in concert with the Standards for Blood Banks and Trans1.
Spence, A. A., Smith, G.
Br.
J.
Anœsth. 1971, 43, 144.
According to a tentative minimal occurrence curve a daily dose under 0-44 g. might not induce S.M.O.N. despite long administration. In animal experiments, clioquinol was confirmed as neurotoxic. Pathological changes in the peripheral nerves of rabbits given clioquinol orally or intravenously resembled those of S.M.O.N. Since last September, when clioquinol was banned by the Ministry of Health and Welfare in Japan, the steady occurrence of S.M.O.N. in many hospitals in Tokyo has abruptly ceased-a cessation confirmed by statistics from many parts of Japan. This fact could not be explained by various factors other than clioquinol, including mycoplasma, agricultural chemicals, or virus, reported by Professor Inoue and his colleagues.2The question why so many cases of clioquinol intoxication occurred in Japan, although this drug has been widely used in the world without any serious side-effects, must be elucidated by comparative S.M.O.N.
studies with other countries. Department of Neurology, Institute of Brain Research, Tokyo University.
AKIHIRO IGATA.
SIR,-Workers in Japan3 reported lately a striking inin a neurological syndrome designated as subacute
" ’
is another point that has to be conThe word itself is ambiguous, for both the person who feels little pain and the one who feels it more, but bears it philosophically, may be called insensitive. As a rule it may be accepted that sensitivity refers to the mental aspect of pain ... difference in attitude will influence pain experience ... observations exist of British and French soldiers wounded in battle in the 1914-18 war, who were treated at the same advanced hospital. Some soldiers of the French units, whose courage and bravery was proverbial, screamed, yelled and winced even before the surgeon began to examine them. Their British comrades preferred to bite their lips, or drive their fingernails into their palms, and to groan occasionally. On questioning, it was found that they did this because: (1) they believed that it would reduce the pain if they remained as quiet as possible; (2) they had (correctly) noted from previous experience that the existence of one pain (biting lips) raises the threshold for perception of another (wound); (3) upbringing, family and community influence induced them to do so. " The attitude of the French soldiers was dictated by: (1) getting some relief of tension by screaming and fatigue, and also increasing thereby the threshold for the perception of the wound pain; (2) expecting gentler treatment by the surgeons and the nursing personnel; (3) upbringing, &c. as mentioned in the case of the British soldiers."
Sensitivity’ specially.
to pam
sidered
...
V. C. MEDVEI.
London S.W. l.
crease
myelo-optico-neuropathy (S.M.O.N.). On the basis of epidemiological surveys, they believe that this syndrome is caused by halogenated oxyquinolines, especially clioquinol (chinoform, ’Enterovioform ’). Clioquinol and the related diiodohydroxyquinoline (known in Israel as ’Enterosept ’) are taken, as in other parts of the world, in very large amounts. Diiodohydroxyquinoline is in especially heavy use as a symptomatic anti-amoebic drug: it is easy to take, absorption is thought to be slight, and no contraindication seems to exist, apart from thyrotoxicosis. Side-effects are rare. Both drugs are prescribed in large amounts over long and repeated periods (but apparently not in the very large amounts which have been associated with optic atrophy in a few patients 4,5). Patients with the common chronic recurrent intestinal amoebiasis take the drugs, especially diiodohydroxyquinoline, very often, even without prescription, in repeated courses, because they learn that their symptoms are improved, at least temporarily. In 37 years of a mostly gastroenterological practice, including 18 years in charge of a gastroenterological clinic of the Workers’ Sick Fund, I prescribed both drugs in thousands of tablets, but I do not remember one patient presenting with neurological complications. Inquiries in large neurological hospital departments showed that S.M.O.N. or a similar neurological syndrome has very rarely been observed in Israel. Taking into account these clinical experiences, it seems to us very improbable that there is a causal relationship between S.M.O.N. and these drugs and that one has to look for another explanation for this common
syndrome
in
SIR,-The present system for the care of surgical patients in many hospitals inevitably leads to the inadequate relief of pain. There is evidence that, at least in patients having upper abdominal incisions, pain is more or less continuous throughout the 48 hours after operation.1 Studies at present being carried out in this department also indicate that this is so. Resident surgical staff and anxsthetists are usually necessarily confined to the operating-theatre for long periods of time. Therefore, they are not always available for the individual assessment of a patient’s pain. Because of the present shortage of nursing staff nurses are unlikely to be able to do this either. We try to solve the problem by writing up a patient for a slug of a drug to be given should he complain. No is made to titrate the attempt patient’s response against drug dose. Even if this was done, the evidence from your columns suggests that the patient would not get the drug when he actually needed it. Although methods for adequate postoperative pain relief are available, such as continuous extradural analgesia, their use on a general ward runs into the same problems as the use of parenteral analgesics. It seems, therefore, that postoperative pain will continue to be inadequately treated until these patients are looked after in a recovery or high-dependency area, where medical and nursing staff, adequate in both numbers and training, are in constant attendance. Department of Anæsthetics, Guy’s Hospital,
Japan.s
Gastroenterologic Clinic, Central Clinic’ Zamenhof’, Workers’ Sick Fund, Tel-Aviv, Israel.
J. F. SEARLE.
London S.E.1.
H. STEINITZ.
UNDERSTANDING PAIN SIR,-Your interesting annotation (June 19, p. 1284) reminds me sadly how short human memory is. In an essaypublished in 1949, I devoted a whole chapter to the discussion of the mental effects of pain. I said: 2. 3.
Inoue, Y. K., Nishibi, Y., Nakamura, Y. ibid. p. 853. Tsubaki, T., Honrra, Y., Hoshi, M., ibid. 696. 4. Berggren, L., Hannson, O. ibid. 1966, i, 52. 5. Etheridge, J. E., Jr., Stewart, G. J. ibid. p. 261. 6. ibid. 1971, i, 690. 7. The Mental and Physical Effects of Pain. Buckston Browne Prize Essay, Harveian Society of London, 1948. Edinburgh, 1949.
ETHACRYNIC ACID WITH PACKED RED CELLS
SIR,-Continuing the discussion about the addition of ethacrynic acid to a transfusion of packed cells, I would reiterate the first part of the letter by Dr. Lieberman and Dr. Kanashiro (May 1, p. 911) that nothing be added to red cells-or for that matter to whole blood. If one wishes to study the effect of ethacrynic acid or any other drug on blood cells, this is perfectly acceptable, but for the purpose of proper and safe transfusion no medication should ever be added to the bottle of blood itself. This negation is in concert with the Standards for Blood Banks and Trans1.
Spence, A. A., Smith, G.
Br.
J.
Anœsth. 1971, 43, 144.