In the 1940s and 50s, before the days of coronary bypass surgery, an operation intended to improve the circulation of blood through the heart was carried out on many thousands of patients with angina. The method was to ligate two arteries below the sternum in the belief that new blood vessels would grow to bypass the block, helping the heart. The rationale for this important operation, which was successful, came to be doubted when the new irrigation of the heart could not be observed. Astonishingly, two groups of surgeons and physicians, one at Harvard and the other at the University of Pennsylvania, obtained ethical permission to carry out a placebo trial. In one group of patients, arteries were exposed and ligated in the approved fashion, while in the other group the arteries were exposed but not blocked. The observing physicians and the volunteer patients did not know who had the true operation and who had the sham. The majority of patients in both groups of patients showed great improvement in the amount of reported pain, in their walking distance, in their consumption of drugs, and in some cases in the shape of their electrocardiogram. This is a rare example of surgery being submitted to a placebo trial, and the improvement of both groups was maintained over six months of observation despite a general belief that placebos have only a brief fading action.*63\219\2*

• The relief of anxiety may greatly lessen pain.     Anxiety is a normal and universal emotion. As with depression, the distinction of abnormal anxiety in patients with physical illness is poorly defined. The clinical features and signs of anxiety are numerous. Patients with cancer may have fears relating to the uncertainty of the future, to bodily dysfunction, unrelieved pain or other symptoms, or it may be the fear of death itself. Panic attacks can occur which consist of sudden, unpredictable attacks of intense fear and physical discomfort, usually lasting 15 to 20 minutes.     Normal anxiety-Anxiety occurs normally in response to the stress and crises associated with cancer and its treatment. These episodes settle with time and general supportive care.     Adjustment disorder-reactive anxiety. Anxiety lasting longer than expected (more than 7 to 14 days) or exceeding the level regarded as normal and adaptive, may be classified as an adjustment disorder. Reactive anxiety follows a defined incident or stress and depressive symptoms frequently coexist.     Organic anxiety syndromes-In patients with cancer, anxiety can occur secondary to other medical problems.     Anxiety disorders-Generalised anxiety, panic disorders and various phobias may be precipitated or aggravated by cancer or its treatment. These patients have more severe and disabling symptoms which appear inappropriate and out of proportion to the medical situation. A generalised anxiety disorder is characterised by chronic unrealistic worries with autonomic hyperactivity, apprehension and hypervigilance.     Treatment-Patients with normal anxiety responses simply require good supportive care. Temporary use of a hypnotic at night and an anxiolytic by day is appropriate if the symptoms are severe. Brief supportive psychotherapy is frequently beneficial. Behavioural techniques including distraction, relaxation therapy and stress management techniques will help some patients. If significant depression is present, an antidepressant should be considered.     Benzodiazepines are the drugs used most frequently to treat anxiety. Drugs with short and intermediate half-lives (alprazolam, lorazepam, oxazepam) are preferred to longer acting drugs such as diazepam. Lorazepam has the advantage that it can be given sublingually. Midazolam can be given subcutaneously and can be included in a subcutaneous infusion with morphine.*80\55\2*