Brian Dwyer and the St. Vincent's Pain Clinic 1962 to 1989.
Brian Dwyer was the Director of the Department of Anaesthetics at St. Vincent's Hospital in Sydney from 1955 to 1985. He developed a major interest in the management of intractable pain and was most impressed by the multidisciplinary pain clinic which was commissioned at the University of Washington in Seattle by John Bonica in 1960. In August 1962, Dr Dwyer established the first pain clinic in Australia, based on the Seattle model. Initially the St. Vincent's Pain Clinic specialized in the management of pain of malignant origin but in the 1970s and 1980s the work expanded to include the treatment of pain arising from a variety of benign conditions. The great strengths of the Pain Clinic were its multidisciplinary approach to pain problems and the realisation of the importance of psychological factors in the persistence of pain. As a result of his work, Brian Dwyer received international recognition as a pioneer in the field of chronic pain management and the St. Vincent's Pain Clinic served as a model for the establishment of similar units, both in Australia and overseas. Brian Dwyer was the first chairman of the Clinic and remained in that position until his retirement in 1989.
Key Words: pain clinic, history, St. Vincent's Hospital, Brian Dwyer
The Origin of Pain Clinics
During the first half of the twentieth century, considerable interest developed in the concept of relieving chronic pain by the use of neural blockade. In 1930 Alexander and Livingstone established a nerve block clinic, which produced encouraging results in this field (1). Because of their particular skills, anaesthetists became involved in this area and in 1941 Rovenstine and Wertheim published a classical paper on the use of procaine and alcohol blocks in the management of chronic pain. This type of nerve block practice had become well established by the time Brian Dwyer commenced his training at Oxford in 1951. During the subsequent four years he received extensive instruction in regional anaesthesia from Bryce-Smith and his colleagues, and studied the use of neurolytic blockade for the treatment of lower limb ischaemia and pancreatic disease (2). On returning to St. Vincent's Hospital in 1955, he further extended his interests to the relief of cancer pain by the use of intrathecal neurolytic blockade (3). This work was encouraged by the Director of Radiotherapy, Lester Atkinson, who felt that procedures of this type were more appropriate for debilitated terminal patients than the more widely accepted neurosurgical treatments. Neurosurgical colleagues objected to this practice, however, because they regarded nerve destruction techniques as part of their clinical province. There was no satisfactory resolution of this problem until the multidisciplinary Pain Clinic was established some years later.
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By the 1950s, the inadequacies of the "nerve block clinic" approach had become apparent to many. Papper recognised that chronic pain was a disease entity rather than just a symptom, and that psychological and social factors may perpetuate pain despite the apparently effective denervation of a painful area (1). Anaesthetists received little training in the aetiology, pathophysiology or general therapeutic aspects of pain and were therefore not equipped to undertake the management of these patients. Worse still, anaesthetists frequently acted simply as technicians, taking little interest in the patient's history or disabilities and being unaware of any beneficial results or adverse effects of their procedures. The scene was therefore set for a more professional approach to this problem.
Establishment of the St. Vincent's Pain Clinic
During the Second World War, John Bonica became interested in the management of pain due to injuries caused by high velocity projectiles. He subsequently extended this interest to other types of chronic intractable pain and established the first multidisciplinary pain management clinic at Tacoma General Hospital in Washington State, U.S.A. in 1946. This work was greatly expanded in 1960 by his commissioning of the Multidisciplinary Pain Clinic at the University of Washington in Seattle (1,4-6). In addition to anaesthesiologists, the clinic incorporated psychologists, surgeons, physicians and other specialist clinicians.
Brian Dwyer was most impressed by Bonica's achievements and followed his publications with great interest. This interest led to the establishment of Australia's first multidisciplinary pain clinic at St. Vincent's Hospital in Sydney in August 1962. The Clinic in Sydney was, however, primarily concerned with pain of malignant origin. Founding members included the radiotherapists Brian McEwen and Franz de Wilde, neurosurgeons Kevin Bleasel and Tom Connelley, neurologist Dudley O'Sullivan and the newly appointed Director of Psychiatry John Woodforde.
In 1964, Brian Dwyer travelled to the United States to study recent advances in the field of chronic pain management (2). He visited John Bonica in Seattle, Daniel Moore at the Mason Clinic, Rita Jacobs at the Memorial Sloane-Kettering Cancer Center in New York and the M.D. Anderson Cancer Center in Houston. He was most impressed with the organizational and entrepreneurial aspects of these hospitals and with the meticulous psychological assessments undertaken, although the type of patients attending these clinics and the results of treatment appeared to him to be very similar to those in Sydney. In 1965 a report from the St. Vincent's Pain Clinic was published in the Medical Journal of Australia, detailing the results of therapy in 107 patients over a two-year period (Table 1). This was one of the first publications concerning a Pain Clinic to appear in the world literature (7).
By the mid 1960s, the pattern of the St. Vincent's Clinic was well established with 150 to 250 patients being treated each year. Formal meetings of the panel were held in the Outpatients Department on Friday afternoons, although inpatients were seen in the wards at other times. Where necessary, patients from the Clinic were admitted to the Hospital for more extensive observation, investigation and treatment. By this time many patients with chronic pain of benign origin were being referred to the Clinic. Conditions such as low back pain, painful scars, autonomic dystrophies and post-herpetic neuralgia were commonly encountered. Because the resources of the Clinic were limited, a conscious effort was made to restrict attendances to those most likely to benefit from the expertise available. Pain is a commonly encountered symptom in all medical disciplines and the panel did not welcome the referral of patients in whom standard and well-established methods of pain control had not first been tried. Similarly the panel did not wish to be swamped by patients complaining of headache, facial neuralgia and similar conditions, which were rightly the province of the neurologist. There was also the risk that the Clinic would become a dumping ground for difficult or incurable patients, or be viewed by solicitors as a convenient source of cheap medicolegal opinions.
The Pain Clinic was never intended to have a diagnostic function, but rather to be a Panel of Review. With this in mind it was expected that all patients attending the Clinic would be accompanied by comprehensive notes, investigations and details of previous treatment from their referring physicians. Once an assessment and therapeutic recommendations had been made, patients would be referred back to their local doctor or attending specialist for implementation of the recommended management.
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The Pain Clinic in the 1970s
In the 1970s a number of new techniques for the management of intractable pain were investigated (8). Brian Dwyer reviewed, in particular, the use of neurolytic blockade in the treatment of pain arising from pancreatic disease and from cancer of the head and neck (Table 2 and 3) (3,9,10).
Although this approach produced excellent results in some patients, accumulated experience led to a reduced use of these interventional procedures in favour of improved drug therapy and greater attention to the psychological, behavioural and social needs of the patient. Kevin Bleasel studied the use of spinothalamic cordotomy, particularly for the management of unilateral lower limb pain of malignant origin. Results with this procedure were, however, variable and it was therefore abandoned. Subsequently there was a waning of interest in the Pain Clinic by the neurosurgeons, although they continued to offer consultative services. Following the visit of President Nixon to China in 1972 considerable interest in the analgesic effects of acupuncture was expressed in the West. A brief trial of acupuncture was carried out at the Clinic in 1974, but the practitioners employed were not scientifically trained and proved uncritical and unreliable. A grant by the Ramaciotti Foundation was awarded to the Clinic to study acupuncture, but it was considered too difficult to design an appropriate controlled trial. The grant was returned, and shortly after the use of acupuncture as a therapeutic modality in the Clinic was abandoned. As an alternative to acupuncture, transcutaneous electrical nerve stimulation (TENS) was introduced by David Gibb in 1974. Useful therapeutic results were achieved with TENS in a number of cases of low back pain, peripheral nerve injuries and painful scars (Table 4).
The most important advances in the 1970s, however, were those introduced by John Woodforde. In pioneering work with Harold Merskey on the relationship between chronic pain and depression, he demonstrated the highly beneficial effects of the tricyclic antidepressants in a wide variety of painful conditions. He also established the important role of patient education, psychological and socio-economic support, behaviour modification and rehabilitation in the healing process (11-14).
The Pain Clinic in the 1980s
During the 1980s the Pain Clinic was conducted principally by Drs Dwyer, Woodforde and Gibb (15) with ready backup by Drs O'Sullivan, Connelley and Bleasel where indicated.
With the establishment of the St. Vincent's Palliative Care Unit by Brian Dwyer in 1982, there was a reduction in referral of patients with malignant pain so that by 1989 they represented only 5% of those attending the Clinic. Although some procedures such as stellate ganglion blockade were further investigated (Table 5) there was a general shift away from interventional therapy and the use of strong analgesics at this time. Instead, more emphasis was placed on treatments requiring the active participation of the patient such as self-education, weight loss programs and exercise.
Only two of the members of the Panel, John Woodforde and Brian Dwyer, served continuously throughout the 27 years of the Pain Clinic's existence. Dr Woodforde's contribution was invaluable, not only in terms of his perceptive and innovative approach to patient management, but also in educating his medical colleagues to appreciate the importance of psychological factors in the aetiology and persistence of chronic pain. It is widely acknowledged, however, that the Clinic owed its continued success to the enthusiasm and drive of its Chairman, Brian Dwyer. Dealing with patients complaining of intractable benign pain is difficult work, frequently frustrating and financially unrewarding. It took a leader of exceptional abilities to guarantee the viability and continuity of such a service. Through his persistence, thoroughness, warmth and wise counsel, he proved an inspiration to patient and clinician alike.
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The Legacy of the St. Vincent's Pain Clinic
The Pain Clinic established at St. Vincent's Hospital by Brian Dwyer in 1962 was the first multidisciplinary pain management unit commissioned in Australia and one of the first in the world. Brian Dwyer became recognised both nationally and internationally for his work in this field and the St. Vincent's Pain Clinic served as a model for similar units subsequently established in Australia and overseas. The guiding principles of the Clinic were a multidisciplinary approach to chronic pain problems, a realisation of the great importance of psychological factors in the persistence of pain and a willingness to explore innovative approaches to the management of intractable pain. Largely due to the work of Brian Dwyer as Chairman over a 27-year period, the Pain Clinic gained a substantial reputation for clinical excellence, academic research and advanced training programs. These achievements were formally recognised by his appointment as Honorary Fellow in Pain Medicine in 2000.
Subsequent History of the Pain Clinic
Following Brian Dwyer's resignation as Chairman of the St. Vincent's Pain Clinic in 1989, supervision of the Clinic, for an interim period, was undertaken by Dr Marie McKell of the Department of Anaesthetics.
Subsequently the chairmanship of the Clinic has been shared between Dr Milton Cohen, rheumatologist, and Dr Robert Fisher, psychiatrist, who have continued in this position from 1989 up until the present time.
Dr Cohen was appointed Associate Professor in Medicine at the University of New South Wales in 1999 and Dean of the Faculty of Pain Medicine of the Australian and New Zealand College of Anaesthetists in 2004. At the College meeting in May 2000 Professor Cohen read a citation to Dr Dwyer and presented him with an Honorary Fellowship of the Faculty of Pain Medicine16.
I wish to thank Dr Douglas Rigg for his contribution to the preparation of this manuscript and Mrs Samira Haddad for her expert secretarial assistance.
(1.) Carron H. History of pain clinics and pain centers. Proceedings of the Second International Symposium on Regional Anesthesia (Combined American and European Societies of Regional Anesthesia) 1988; 38-40.
(2.) Dwyer B. A Career in Anaesthesia--A Memoir. St. Vincent's Hospital Publication 2003; 36-39, 52-54.
(3.) Dwyer B, Gibb D. Chronic pain and neurolytic neural blockade. In: Cousins M J, Bridenbaugh PO, eds. Neural Blockade. J. B. Lippincott Company 1980; 637-650.
(4.) Bonica JJ. Evolution of pain concepts and pain clinics. Clin Anaesthesiol 1985; 3:1-16.
(5.) Bonica JJ, Black RG. The management of a pain clinic. In Swerdlow M, ed. Relief of Intractable Pain. Excerpta Medica, Amsterdam, London, New York, 1974; 116-129.
(6.) Bonica JJ, Benedetti C, Murphy TM. Functions of pain clinics and pain centres. In: Swerdlow M, ed. Relief of Intractable Pain. Elsevier Science Publishers BV 1983; 65-73.
(7.) McEwen BW, de Wilde FW, Dwyer B, Woodforde JM, Bleasel K, Connelley TJ. The pain clinic: A clinic for the management of intractable pain. Med J Australia 1965; 1:676-682.
(8.) Gibb D, O'Sullivan DJ, Bleasel K et al. Modern concepts in the treatment of chronic pain. Curr Therapeutics March 1976; 33-43.
(9.) Black A, Dwyer B. Coeliac plexus block. Anaesth Intensive Care 1973; 1:315-318.
(10.) Dwyer B. Treatment of pain of carcinoma of the tongue and floor of the mouth. Anaesth Intensive Care 1972; 1:59-61.
(11.) Woodforde JM, Dwyer B, McEwen BW et al. Treatment of post-herpetic neuralgia. Med J Australia 1965; 869-872.
(12.) Woodforde JM, Fielding JR. Pain and cancer. J Psychosomatic Res 1970; 14:365-370.
(13.) Woodforde JM, Merskey H. Personality traits of patients with chronic pain. J Psychosomatic Res 1972; 16:167-172.
(14.) Woodforde JM, Merskey H. Some relationships between subjective measures of pain. J Psychosomatic Res 1972; 16:173178.
(15.) Dwyer BE. Recent trends in pain clinics. Anaesth Intensive Care 1983; 1:54-55.
(16.) Cohen ML. Citation to Brian Eric Dwyer. Australian and New Zealand College of Anaesthetists Meeting, Melbourne, May 6, 2000.
D. B. GIBB * Anaesthesia, Emergency Medicine and Intensive Care, University of New South Wales, Department of Anaesthetics, The St. George Hospital and Department of Anaesthetics, St. Vincent's Hospital, Sydney, New South Wales, Australia
Presented at the Annual Scientific Meeting of the Australian and New Zealand College of Anaesthetists, Adelaide, May 2006.
* Professor, Discipline of Anaesthesia, UNSW. Emeritus Consultant, St. Vincent's Hospital. Former Director of Anaesthetics, St. George Hospital.
Address for reprints: Professor D. B. Gibb, 76 Woolwich Road, Woolwich, N.S.W. 2110.
Table 1 First report of patients treated at the St. Vincent's Pain Clinic, May 19657 Cause of Pain Males Females Total Malignant disease 49 24 73 Neuralgia 3 13 16 Peripheral vascular disease 1 2 3 Painful scars 4 1 5 Other conditions 4 6 19 Total 61 46 107 Table 2 The results of neurolytic coeliac plexus block, May 1973 (9) Indication No Improvement Successful (%) (%) Peripheral vascular disease 33 36 Chronic pancreatitis 32 64 Carcinoma of the pancreas 0 70 Other intra-abdominal malignancy 13 70 Miscellaneous, extra-abdominal 54 15 Table 3 A list of the neurolytic blocks performed for pain due to carcinoma of the tongue and floor of mouth, August 1972 (10) Neurolytic Block Patients Blocks Mandibular nerve block 27 35 Intrathecal cervical 15 25 plexus block Mandibular and cervical 5 5 plexus block Mandibular, glossopharyngeal 5 5 and vagus nerve block Total 52 70 Table 4 Assessment of the effectiveness of transcutaneous electrical nerve stimulation (TENS) in patients with intractable pain of benign origin (1975) Indication Patients Good Results (%) Back pain and sciatica 83 33 Upper limb injuries 23 31 Painful scars 17 54 Causalgia, phantom limb, 12 9 post-herpetic neuralgia Other conditions 28 43 Table 5 Assessment of the effectiveness of stellate ganglion blockade with local anaesthetic in the management of benign intractable pain. Results of 79 blocks carried out in 36 patients in the period 1980-1985. Horner's syndrome was clearly elicited in 92% of patients Indication Patients Satisfactory improvement (%) Reflex sympathetic dystrophy 15 80 "Repetitive strain injuries" 5 20 Raynaud's disease 2 50 Atypical migraine 1 100 Brachial plexus injury 4 0 Other arm injuries 4 0 Head and chest pain 5 0