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Transcript of 1 1 Neuropathic Pain - Diagnosis Mechanism and Management Dr Amit Verma M.D, D.N.B, P.D.C.C, F.I.P.P...
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Neuropathic Pain - Neuropathic Pain - Diagnosis Mechanism Diagnosis Mechanism and Managementand Management
Neuropathic Pain - Neuropathic Pain - Diagnosis Mechanism Diagnosis Mechanism and Managementand Management
Dr Amit VermaDr Amit VermaM.D, D.N.B, P.D.C.C, F.I.P.PM.D, D.N.B, P.D.C.C, F.I.P.P
CONSULTANT ANAESTHESIOLOGISTCONSULTANT ANAESTHESIOLOGISTDR BALWANT SINGH’S HOSPITALDR BALWANT SINGH’S HOSPITAL
Dr Amit VermaDr Amit VermaM.D, D.N.B, P.D.C.C, F.I.P.PM.D, D.N.B, P.D.C.C, F.I.P.P
CONSULTANT ANAESTHESIOLOGISTCONSULTANT ANAESTHESIOLOGISTDR BALWANT SINGH’S HOSPITALDR BALWANT SINGH’S HOSPITAL
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CASE 1CASE 1CASE 1CASE 1
• 55 yr. , Female
• Presented with pain in back of chest for 5 yrs
• No h/o HZ, DM, Trauma, Loss of weight
• Quality - burning
• Intensity 5 - 6 / 10
• Tried NSAIDs multiple times
• 55 yr. , Female
• Presented with pain in back of chest for 5 yrs
• No h/o HZ, DM, Trauma, Loss of weight
• Quality - burning
• Intensity 5 - 6 / 10
• Tried NSAIDs multiple times
44
CASE 2CASE 2CASE 2CASE 2• 75 yrs, Female
• Feels Depressed due to Pain in chest
• Severe lancinating pain with increased sensitivity
• H/O very painful rash in the same distribution 5 months back
• Rash subsided but pain didnt
• 75 yrs, Female
• Feels Depressed due to Pain in chest
• Severe lancinating pain with increased sensitivity
• H/O very painful rash in the same distribution 5 months back
• Rash subsided but pain didnt
55
CASE 3CASE 3CASE 3CASE 3
• 35 yr., female patient with severe headache.
• Diagnosed as a case of migraine
• Wincing in pain , ℅ jolts of pain while combing her hair
• On Migraine prophylaxis
• 35 yr., female patient with severe headache.
• Diagnosed as a case of migraine
• Wincing in pain , ℅ jolts of pain while combing her hair
• On Migraine prophylaxis
66
CASE 4CASE 4CASE 4CASE 4• 45 yr. Old Male on a hot summer day with a
wool shawl draped around his shoulder and right arm
• ℅ Pain in the right hand following closed reduction of wrist fracture
• Right arm was cold and sometimes sweaty
• Severe pain on cutting nail
• Visited three physician who referred her to a psychiatrist with the diagnosis of Conversion disorder
• 45 yr. Old Male on a hot summer day with a wool shawl draped around his shoulder and right arm
• ℅ Pain in the right hand following closed reduction of wrist fracture
• Right arm was cold and sometimes sweaty
• Severe pain on cutting nail
• Visited three physician who referred her to a psychiatrist with the diagnosis of Conversion disorder
22
Pain Pain Pain Pain
Poena - penalty / punishment
Start of Pain Clinics
Insight into the Etiopathogenesis
Fifth vital Sign
Poena - penalty / punishment
Start of Pain Clinics
Insight into the Etiopathogenesis
Fifth vital Sign
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Classification ( IASP)Classification ( IASP)Classification ( IASP)Classification ( IASP)
Region
System
Acute Vs Chronic
Mild / Moderate / Severe
Nociceptive / Inflammatory/ Neuropathic ( Clifford J Woolf )
Region
System
Acute Vs Chronic
Mild / Moderate / Severe
Nociceptive / Inflammatory/ Neuropathic ( Clifford J Woolf )
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DefinitionDefinitionDefinitionDefinitionIASP defines Pain as
an unpleasant sensory or emotional experience which we primarily associate with tissue damage or describe in terms of such damage , or both
Neuropathic Pain as -
Pain initiated or caused by a primary lesion or dysfunction of the peripheral or central nervous system
IASP defines Pain as
an unpleasant sensory or emotional experience which we primarily associate with tissue damage or describe in terms of such damage , or both
Neuropathic Pain as -
Pain initiated or caused by a primary lesion or dysfunction of the peripheral or central nervous system
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Neuropathic Pain - Neuropathic Pain - DifficultiesDifficulties
Neuropathic Pain - Neuropathic Pain - DifficultiesDifficulties
No Consensus on Definition
Pain Perception is subjective
Rarely One Diagnostic Test
Lack Of Specificity in Diagnosis
Signs & Symptoms Change Over Time
Patients not believed
No Consensus on Definition
Pain Perception is subjective
Rarely One Diagnostic Test
Lack Of Specificity in Diagnosis
Signs & Symptoms Change Over Time
Patients not believed
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Components of Components of Neuropathic PainNeuropathic PainComponents of Components of
Neuropathic PainNeuropathic Pain
Pain
Lancinating/burning/pricking/stabbing
No ongoing tissue damage
Delay in onset after nerve injury
Spontaneous paroxysmal electric shock sensation
Pain
Lancinating/burning/pricking/stabbing
No ongoing tissue damage
Delay in onset after nerve injury
Spontaneous paroxysmal electric shock sensation
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Abnormal SensationsAbnormal Sensations
PAIN INCREASED PAIN
Low Intensity Stimulation
Innocuous sensation
ALLODYNIA
PAINFUL STIMULUS
HYPERALGESIA
1414
Negative sensory signs
Pain with numbness
Presence of neurologic deficit
Negative sensory signs
Pain with numbness
Presence of neurologic deficit
1515
Descriptions of Neuropathic Descriptions of Neuropathic PainPain
Descriptions of Neuropathic Descriptions of Neuropathic PainPain
“I feel as though someone has pulled the skin off my left arm and is then constantly rubbing salt into the wound.”
“I feel as though my leg is on fire. My skin feels burnt, and it is as though someone is taking a claw and tearing into my skin 24 hours a day.”
“I feel as though someone has taken a hot poker knife and is jabbing it deep into my right eye. If I could pull my eye out, only to remove the sensation, I would gladly do so.”
“I feel as though someone has pulled the skin off my left arm and is then constantly rubbing salt into the wound.”
“I feel as though my leg is on fire. My skin feels burnt, and it is as though someone is taking a claw and tearing into my skin 24 hours a day.”
“I feel as though someone has taken a hot poker knife and is jabbing it deep into my right eye. If I could pull my eye out, only to remove the sensation, I would gladly do so.”
1515
Neuropathic Pain Syndromes
Neuropathic Pain Syndromes
1.Peripheral Nervous System ( focal and multifocal lesions )
2.Peripheral Nervous System ( Generalized polyneuropathies )
3.Central Nervous System Lesions
4.Complex Neuropathic Disorders
1.Peripheral Nervous System ( focal and multifocal lesions )
2.Peripheral Nervous System ( Generalized polyneuropathies )
3.Central Nervous System Lesions
4.Complex Neuropathic Disorders
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Peripheral Nervous System (focal and multifocal lesions)
Peripheral Nervous System (focal and multifocal lesions)
Trigeminal neuralgia
Post herpetic neuralgia
Diabetic Mono neuropathy
Entrapment Syndrome
Ischemic Neuropathy
Phantom Limb
Post Traumatic Neuralgia
Trigeminal neuralgia
Post herpetic neuralgia
Diabetic Mono neuropathy
Entrapment Syndrome
Ischemic Neuropathy
Phantom Limb
Post Traumatic Neuralgia
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Peripheral Nervous System Peripheral Nervous System Generalized Polyneuropathies Generalized Polyneuropathies
Peripheral Nervous System Peripheral Nervous System Generalized Polyneuropathies Generalized Polyneuropathies
Metabolic - DM, Amyloid
Toxic - Alcohol, taxanes
Infective - HIV
Autoimmune - GBS
Hereditary - Fabry’s Disease
Malignancy
Metabolic - DM, Amyloid
Toxic - Alcohol, taxanes
Infective - HIV
Autoimmune - GBS
Hereditary - Fabry’s Disease
Malignancy
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Central Nervous System Central Nervous System LesionsLesions
Central Nervous System Central Nervous System LesionsLesions
Spinal Cord Injury
Prolapsed Disc
Stroke
Multiple Sclerosis
Parkinson’s Disease
Surgical Lesions
Spinal Cord Injury
Prolapsed Disc
Stroke
Multiple Sclerosis
Parkinson’s Disease
Surgical Lesions
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Complex Neuropathic DisordersComplex Neuropathic DisordersComplex Neuropathic DisordersComplex Neuropathic Disorders
Complex Regional Pain Syndrome I
Complex Regional Pain Syndrome II
Complex Regional Pain Syndrome I
Complex Regional Pain Syndrome II
1616
MECHANISM OF MECHANISM OF NEUROPATHIC PAINNEUROPATHIC PAIN
MECHANISM OF MECHANISM OF NEUROPATHIC PAINNEUROPATHIC PAIN
1919
Brain
Spinal Cord
Peripheral nerve fibers
Sympathetic Fibers
Cerebral ReorganizationMolecular Changes
Spinal Cord anatomical reorganizationDorsal Horn Denervation SensitivityMolecular Changes
Ephaptic Crosstalk
•Ectopic Discharge•Collateral Sprouting
•Nociceptive sensitization
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Ectopic DischargesEctopic DischargesEctopic DischargesEctopic Discharges
• Increase in the level of spontaneous firing in the injured neurons as well as their uninjured neighbor neuron
• Result of alteration in the expression of Sodium channels
• Increase in the level of spontaneous firing in the injured neurons as well as their uninjured neighbor neuron
• Result of alteration in the expression of Sodium channels
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Ephaptic ConductionEphaptic ConductionEphaptic ConductionEphaptic Conduction
• Cross excitation among the neurons having spontaneous firing capacity leading to amplification of depolarization
• Important in association of Sympathetic system
• Cross excitation among the neurons having spontaneous firing capacity leading to amplification of depolarization
• Important in association of Sympathetic system
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Collateral SproutingCollateral SproutingCollateral SproutingCollateral Sprouting
• Primary afferent neuron injury leads to sprouting of collateral fibers from sensory axon in their attempt to regenerate
• These sprouts are sensitive to low threshold stimulus
• Primary afferent neuron injury leads to sprouting of collateral fibers from sensory axon in their attempt to regenerate
• These sprouts are sensitive to low threshold stimulus
2929
SNS AND PNS COUPLINGSNS AND PNS COUPLINGSNS AND PNS COUPLINGSNS AND PNS COUPLING
• DUE TO ENHANCED SENSITIVITY TO CATECHOLAMINES LEADING TO PAIN PERCEPTION
• DUE TO ENHANCED SENSITIVITY TO CATECHOLAMINES LEADING TO PAIN PERCEPTION
3030
Nociceptive SensitizationNociceptive SensitizationNociceptive SensitizationNociceptive Sensitization
• Increase in Bradykinin binding sites within DRG following axotomy leading hyperalgesia
• Increase in Bradykinin binding sites within DRG following axotomy leading hyperalgesia
3232
CENTRAL MECHANIMSCENTRAL MECHANIMSCENTRAL MECHANIMSCENTRAL MECHANIMS
• Spinal Cord reorganization
• Spinal Cord hyper excitability ( central sensitization )
• Cerebral Reorganization
• Spinal Cord reorganization
• Spinal Cord hyper excitability ( central sensitization )
• Cerebral Reorganization
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DIAGNOSIS OF DIAGNOSIS OF NEUROPATHIC PAINNEUROPATHIC PAIN
DIAGNOSIS OF DIAGNOSIS OF NEUROPATHIC PAINNEUROPATHIC PAIN
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Healing begins with the History
Clinical description and history taking are the best mechanism to diagnose Neuropathic Pain
Identify
Painful symptom
Altered sensation
History
Healing begins with the History
Clinical description and history taking are the best mechanism to diagnose Neuropathic Pain
Identify
Painful symptom
Altered sensation
History
} All matching neuroanatomical or dermatomal pattern
2323
Leeds Assessment of Neuropathic Symptoms and Signs ( LANSS ) scale
Sens / Spec - 83 / 87 %
Pain DETECT questionnaire
Neuropathic Pain Questionaire
Neuropathic Pain Scale
Leeds Assessment of Neuropathic Symptoms and Signs ( LANSS ) scale
Sens / Spec - 83 / 87 %
Pain DETECT questionnaire
Neuropathic Pain Questionaire
Neuropathic Pain Scale
Screening MethodsScreening MethodsScreening MethodsScreening Methods
2525
Bedside ExaminationBedside ExaminationBedside ExaminationBedside Examination
Identify the altered sensation in painful area ( compare with non painful area )
Dysesthesia (Allodynia, Hypoalgesia, Hyperalgesia )
Inability to distinguish warm and cold objects
Identify the altered sensation in painful area ( compare with non painful area )
Dysesthesia (Allodynia, Hypoalgesia, Hyperalgesia )
Inability to distinguish warm and cold objects
2626
Pain & Functional Brain Pain & Functional Brain ImagingImaging( F.B.I )( F.B.I )
Pain & Functional Brain Pain & Functional Brain ImagingImaging( F.B.I )( F.B.I )
Positron Emission Tomography
Functional MRI
Both Measure energy consumption in activated brain regions
FBI has mapped the brain neuromatrix ( area of brain that processes pain response )
Positron Emission Tomography
Functional MRI
Both Measure energy consumption in activated brain regions
FBI has mapped the brain neuromatrix ( area of brain that processes pain response )
4040
Functional Brain ImagingFunctional Brain ImagingFunctional Brain ImagingFunctional Brain Imaging• Neuromatrix -
• 1o & 20 somatosensory cortex ( mediate sensory discriminative features of pain )
• Anterior cingulate gyrus cortex and insula ( mediate affective motivational component of pain
• Pre frontal cortex - mediate cognitive aspects of pain
• Thalamus - gateway between cortex and brainstem
• Increased regional blood flow of neuromatrix in Neuropathic Pain
• Neuromatrix -
• 1o & 20 somatosensory cortex ( mediate sensory discriminative features of pain )
• Anterior cingulate gyrus cortex and insula ( mediate affective motivational component of pain
• Pre frontal cortex - mediate cognitive aspects of pain
• Thalamus - gateway between cortex and brainstem
• Increased regional blood flow of neuromatrix in Neuropathic Pain
4242
Approach To TreatmentApproach To Treatment
TREAT UNDERLYING CONDITION
DIAGNOSIS
REDUCEPSYCHOLOGICAL DISTRESS
IMPROVE QUALITY OF LIFE
PREVENTION
IMPROVE PHYSICAL FUNCTION
REDUCE PAIN
3333
ManagementManagementManagementManagement
Mx of ectopic activity / Ephaptic Conduction
Na+ Channel Blockers -
Phenytoin
Lignocaine
Oxcarbazepine
Gabapentin
Mx of ectopic activity / Ephaptic Conduction
Na+ Channel Blockers -
Phenytoin
Lignocaine
Oxcarbazepine
Gabapentin
3434
Reducing Central Sensitization
NMDA receptor antagonistKetamine
Amitryptyline
Methadone
Gabapentin, Pregabalin
Reducing Central Sensitization
NMDA receptor antagonistKetamine
Amitryptyline
Methadone
Gabapentin, Pregabalin
3535
Improving Descending Control
Local Inhibitory controlsGABA - B agonist - Baclofen
Opioids - Oxycodone, tramadol
Descending inhibition form brain Clonidine
TCA
Improving Descending Control
Local Inhibitory controlsGABA - B agonist - Baclofen
Opioids - Oxycodone, tramadol
Descending inhibition form brain Clonidine
TCA
3636
Sympathetically Mediated Sympathetically Mediated PainPain
Sympathetically Mediated Sympathetically Mediated PainPain
Sympathetic Plexus Block
Stellate ganglion
Lumbar Sympathetic chain block
Central Neuraxial Block
Epidural infusions of adjuvants and local anesthetics
Intrathecal infusions - opioids / baclofen
Sympathetic Plexus Block
Stellate ganglion
Lumbar Sympathetic chain block
Central Neuraxial Block
Epidural infusions of adjuvants and local anesthetics
Intrathecal infusions - opioids / baclofen
3737
Somatic / Sensory Nerve Block
Brachial Plexus Block
Para - vertebral Block
Lateral Cutaneous Nerve of Thigh Block
Intercostal Nerve Block
Somatic / Sensory Nerve Block
Brachial Plexus Block
Para - vertebral Block
Lateral Cutaneous Nerve of Thigh Block
Intercostal Nerve Block
3838
Interventional StrategiesInterventional StrategiesInterventional StrategiesInterventional Strategies
Diagnostic
Break in cycle of Pain
Should be Imm. Followed by active physiotherapy
Epidural, Trans Foraminal , Facet Blocks
Spinal Cord Stimulation
Diagnostic
Break in cycle of Pain
Should be Imm. Followed by active physiotherapy
Epidural, Trans Foraminal , Facet Blocks
Spinal Cord Stimulation
3939
Complementary TherapiesComplementary TherapiesComplementary TherapiesComplementary Therapies
Acupuncture
Nutritional Counseling
Massage Therapy
Mirror Therapy
Acupuncture
Nutritional Counseling
Massage Therapy
Mirror Therapy
PharmacotherapyPharmacotherapyPharmacotherapyPharmacotherapy
• Carbamazepine
• Dose – 100 mg BD - 1000 mg / day
• S/I – Dizziness, Ataxia, N/V, S.J Syndrome, TCP
• C/I – Liver Dysfunction, B.M suppresion
• Carbamazepine
• Dose – 100 mg BD - 1000 mg / day
• S/I – Dizziness, Ataxia, N/V, S.J Syndrome, TCP
• C/I – Liver Dysfunction, B.M suppresion
4040
GabapentinGabapentinGabapentinGabapentin
• Multi modal action - Reduces ectopic activity, dampens central sensitization and decreases glutamate activity
• Dose – 300 – 3000 mg / day
• S/I – dizziness, sedation, weight gain
• C/I - Hypersensitivity
• Multi modal action - Reduces ectopic activity, dampens central sensitization and decreases glutamate activity
• Dose – 300 – 3000 mg / day
• S/I – dizziness, sedation, weight gain
• C/I - Hypersensitivity
4141
PregabalinPregabalinPregabalinPregabalin
• Dose – 75 – 600 mg / day in divided doses
• S/E – Dizziness, sedation, confusion, peripheral edema
• C/I - Hypersensitivity
• Dose – 75 – 600 mg / day in divided doses
• S/E – Dizziness, sedation, confusion, peripheral edema
• C/I - Hypersensitivity
4242
TCA - AmitriptylineTCA - AmitriptylineTCA - AmitriptylineTCA - Amitriptyline
• Dose – 10 – 75 mg / day in EDD
• S/E – anticholinergic, constipation, confusion
• C/I – narrow angle glaucoma, urinary retention, 2nd or 3rd degree heart block
• Dose – 10 – 75 mg / day in EDD
• S/E – anticholinergic, constipation, confusion
• C/I – narrow angle glaucoma, urinary retention, 2nd or 3rd degree heart block
4343
KetamineKetamineKetamineKetamine
• Dose – 0.25 mg / kg – 1000mg/day
• S/I - delirium, hallucinations, confusion, night mares
• C/I – hypersensitivity, psychiatiric disorders
• Dose – 0.25 mg / kg – 1000mg/day
• S/I - delirium, hallucinations, confusion, night mares
• C/I – hypersensitivity, psychiatiric disorders
4444
Lignocaine Lignocaine Lignocaine Lignocaine
• Dose – 5 mg/kg over 1 hour
• S/E- hypotension, Neurotoxicity, sedation
• Effective diagnostic tool to identify responsiveness to Na channel blockers
• Dose – 5 mg/kg over 1 hour
• S/E- hypotension, Neurotoxicity, sedation
• Effective diagnostic tool to identify responsiveness to Na channel blockers
4545
Tramadol Tramadol Tramadol Tramadol
• Dose – 50mg bd – 400 mg /day
• S/I – sedation , Nausea
• C/I- hypersensitivity, drowsy , elderly
• Dose – 50mg bd – 400 mg /day
• S/I – sedation , Nausea
• C/I- hypersensitivity, drowsy , elderly
4646
5959
CASE 1CASE 1CASE 1CASE 1
• 55 yr. , Female
• Presented with pain in back of chest for 5 yrs
• No h/o HZ, DM, Trauma, Loss of weight
• Quality - burning
• Intensity 5 - 6 / 10
• Tried NSAIDs multiple times
• 55 yr. , Female
• Presented with pain in back of chest for 5 yrs
• No h/o HZ, DM, Trauma, Loss of weight
• Quality - burning
• Intensity 5 - 6 / 10
• Tried NSAIDs multiple times
6060
CASE 2CASE 2CASE 2CASE 2
• 75 yrs, Female
• Feels Depressed due to Pain in chest
• H/O very painful rash in the same distribution 5 months back
• Rash subsided but pain didnt
• 75 yrs, Female
• Feels Depressed due to Pain in chest
• H/O very painful rash in the same distribution 5 months back
• Rash subsided but pain didnt
6161
CASE 3CASE 3CASE 3CASE 3
• 35 yr., female patient with severe headache.
• Diagnosed as a case of migraine
• Wincing in pain , ℅ jolts of pain while talking, combing her hair
• On Migraine prophylaxis
• 35 yr., female patient with severe headache.
• Diagnosed as a case of migraine
• Wincing in pain , ℅ jolts of pain while talking, combing her hair
• On Migraine prophylaxis
6262
CASE 4CASE 4CASE 4CASE 4• 45 yr. Old Male on a hot summer day with a
wool shawl draped around his shoulder and right arm
• ℅ Pain in the right hand following closed reduction of wrist fracture
• Right arm was cold and sometimes sweaty
• Severe pain on cutting nail
• Visited three physician who referred her to a psychiatrist with the diagnosis of Conversion disorder
• 45 yr. Old Male on a hot summer day with a wool shawl draped around his shoulder and right arm
• ℅ Pain in the right hand following closed reduction of wrist fracture
• Right arm was cold and sometimes sweaty
• Severe pain on cutting nail
• Visited three physician who referred her to a psychiatrist with the diagnosis of Conversion disorder
4949
ConclusionConclusionConclusionConclusion
Neuropathic pain is a neuropsychiatric condition in which pain is initiated or caused by a primary lesion or dysfunction in the nervous system. Understanding the complexity of neuropathic pain becomes the cornerstone for appropriate diagnosis and management. Successful management depends on realistic patient-physician expectations and an individualized, multidisciplinary approach that takes advantage of the ever-evolving armamentarium of evidenced- based treatments.
Neuropathic pain is a neuropsychiatric condition in which pain is initiated or caused by a primary lesion or dysfunction in the nervous system. Understanding the complexity of neuropathic pain becomes the cornerstone for appropriate diagnosis and management. Successful management depends on realistic patient-physician expectations and an individualized, multidisciplinary approach that takes advantage of the ever-evolving armamentarium of evidenced- based treatments.
Thank YouThank YouThank YouThank You
• We must all die. But that I can save him from days of torture, that is what I feel as my great and ever new privilege. Pain is a more terrible lord of mankind than even death itself
• Albert Schweitzer
• We must all die. But that I can save him from days of torture, that is what I feel as my great and ever new privilege. Pain is a more terrible lord of mankind than even death itself
• Albert Schweitzer
5050