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from the " onset of disease " rather than from the timeof diagnosis, the diagnosis of milder cases, and a greaterawareness of the dangers of treatment with adrenalcorticosteroids. Nevertheless, 9 out of 53 deaths wereattributed primarily to side-effects of treatment, andtreatment contributed to 3 other deaths. 8 patientsdied from causes unrelated to systemic lupus and 36died from the disease itself, 19 of them from renalfailure. Patients with focal glomerulonephritis sur-vived longer than those with diffuse proliferativenephritis or with membranous glomerulopathy. Treat-ment with corticosteroids did not seem to benefit

any of the patients with renal disease in this series.In contrast to these findings, Pollak et aL found thatthe renal function and histological changes in patientswith lupus membranous glomerulopathy deterioratedvery slowly, regardless of treatment, and that treat-ment with a large dose of prednisone for at least sixmonths improved the survival of patients with diffuseproliferative lupus glomerulonephritis.

It is good to find that the prognosis of systemiclupus may be better than it was thought to be. Thetreatment remains hazardous and we still need to knowmuch more about the natural history of the untreateddisease-or syndrome. For example, will patientswho have isolated manifestations such as a mild

haemolytic anxmia or a recurrent pleural effusion withpositive L.E.-cell phenomenon eventually have othermanifestations of systemic lupus ? Will treatment withadrenal corticosteroids delay or prevent the onset ofsystemic disease ?

UNDERSTANDING PAIN

BOTH patients and doctors have lately expressed con-cern in our columns about inadequate treatment ofpain in hospital. The situation does not apparentlyarise from any lack of humanitarian feelings in nursesor doctors, but perhaps from a combination of cultur-ally determined attitudes and an incomplete under-standing of the many factors which influence the

experience of pain. Considering the ubiquity of thissymptom, it is remarkable that medical students,postgraduates, and nurses in training are rarely in-structed on its psychological aspects, although theyoften receive lectures on the anatomy and physiologyof " pain pathways " and the pharmacology of anal-gesics.A clue to the further understanding of pain lies in the

common observation that its intensity at any givenstage in physical illness varies between individuals.Thus, some have pain and others do not, and, of thosewho do, not all complain or ask for relief. Moreover,each sufferer is aware of variations in pain with

changes in emotion and environment. Investigationsof environmental factors chiefly reveal variations in

complaint behaviour secondary to culturally deter-mined attitudes of different ethnic groups and of the

family, especially in childhood.’ 7 Again, the effect ofthe attitudes of hospital staff on patients’ pain andcomplaint behaviour is striking. 8 Moreover, in this

6. Pollak, V. E., Pirani, C. L., Schwartz, F. D. J. Lab. clin. Med.1964, 63, 537.

7. Merskey, H., Spear, F. G. Pain, Psychological and PsychiatricAspects. London, 1967.

8. Bond, M. R., Pilowsky, I. J. psychosom. Res. 1966, 10, 203.

situation the potential risk to life, health, and socialor economic status also influences pain because of thesignificance of the illness to the patient. The severityof pain tends to increase in the presence of moderateand severe anxiety, but in states of extreme excite-ment, as in the heat of battle or other physical combat,substantial wounds may be inflicted without knowledgeof the participants.

Experiments on pain thresholds yielded the first

quantitative measures of induced pain, and two thresh-olds have been identified: the point at which a noxiousstimulus induces pain; and the point at which thepain becomes unbearable. Thresholds tend to belower in women than men, in those from lower socio-economic groups, and in people engaged in sedentaryoccupations, compared with those doing hard physicalwork. Keele 9 divided patients according to theirthresholds into hypersensitives, hyposensitives, andnormosensitives. In illness, the proportion of the firstincreases at the expense of the other groups. Keelecommented that hyposensitive people may be at risk,because they do not seem to experience pain early inillness.

By means of the extraversion/introversion neuroti-cism/stability dimensions developed by Eysenck," ithas been shown that introverts have lower thresholdsfor pain than extraverts, but the former complain lessreadily than the latter, who are thought to " exaggerate"their experiences. Both forms of behaviour have

advantages, for introverts, being " non-complainers ",are regarded with favour for their stoicism, whereasextraverts, although " complainers ", usually gainaccess most readily to analgesics. The idea of " exag-geration

" of complaints arises from the observationsof Petrie and others 11 that some individuals processstimuli by reducing them (reducers), some by increasingthem (augmenters), whereas others do neither (moder-ates). Reducers are more than usually tolerant ofpain and less of all-round reduction in environmentalstimulation, whereas augmenters are less tolerant ofpain and more of sensory deprivation. Thus, reducersare similar to extraverts and augmenters to introverts.Clearly, there is a difference between tolerance of painand complaint behaviour.More detailed information about personality struc-

ture and pain has been provided. 12 In a group of womenwith advanced cancer, stable extraverts were pain-free,and introverts with raised emotionality experiencedpain but tended not to complain. Extravertedpatients with increased emotionality experienced painand complained, and, together with introverts withincreased emotionality, had had more painful or psy-chologically determined illness in the past than thestable extraverts.

Information providing a basis for improving ourknowledge of pain is thus emerging. The plea 13 forindividual assessments of patients’ pain, rather than theacceptance of traditional views that disorders of asimilar type are equally painful or painless, deservessupport.9. Keele, K. D. Lancet, 1954, i, 636.

10. Eysenck, H. The Biological Basis of Personality. Springfield,Illinois, 1968.

11. Petrie, A., Collinc, W., Soloman, P. Am. J. Psychol. 1960, 73, 80.12. Bond, M. R., Pearson, I. J. psychosom. Res. 1969, 13, 13.13. Parkhurst, J. Lancet, April 24, 1971, p. 865.