1. The Worst of Evils – The Fight Against Pain
This book by Thomas Dormandy is a history of pain relief.
1.1. A Gift of the Gods
In ancient times, physical pain was thought to be inextricably associated with emotional or mental anguish and sleeplessness. The Persian physician Avicenna stated that potions must accomplish three things: they must alleviate pain, calm the mind, and induce restful sleep. Similar views were expressed by Hippocrates in Ancient Greece, and by Hua T’o in
Accounts by Homer, Virgil, and other Ancient Greek dramatists suggest that their civilization was aware of certain pain-killing potions, probably derived from the opium poppy. A papyrus from
1.2. The Grape and the Poppy
Alcohol has been used in tinctures for pain and a variety of ailments since Ancient Egypt and before. Beer brewed from malted barley was prescribed by Egyptian physicians from 2000 BC, and the Egyptians were also responsible for the cultivation of the wild grape around 4000 BC. In
“Wine tempers the spirit while opium lulls the body to rest. It revives our waning joys and is oil to the dying flame of life.” (The Banquet of Xenophon, c. 400 BC).
The word opium is Greek, and means the fresh juice of the poppy. Opium in
Aurelius Cornelius Celsus wrote a book on medicine in 30 AD and expressed a cautionary attitude toward pain relief:
“pills and potions that relieve pain are numerous; but, unless there is an overwhelming necessity, it is improper to use them.” They are “alien and harmful to the stomach.” Of opium, he says “it has been used to calm tempers and to induce pleasant dreams since the Trojan war and is still popular,” but “doctors should use it with circumspection.” He notes that “dreams can be sweet; but the sweeter they are, the rougher tends to be the awakening.”
Nevertheless, the Roman Emperor Claudius’ physician left detailed instructions on how the juice should be extracted and processed, and this method, publicized in the 1st Century, is still in use today in many parts world. Galen, a famous Roman physician from the 2nd Century, noted some of the dangers of opium, particularly digestive upsets, constipation and, occasionally, death – but the dangers of addiction were not mentioned by the Ancient Greeks or Romans, although the poppy was widely cultivated. Diocles, a dentist of the same period, prescribed an opium-based paste for toothache. He wrote:
“There is much that is still unknown about this wondrous flower. The potion prepared from its capsule will soothe some but cast others into melancholy. In some its effect will be immediate. In others, it may be delayed for many hours. In some the medication will be well tolerated. In others it will have unpleasant side-effects. Yet even when it does not abolish pain, the pain no longer preys on the person’s mind.”
1.3. Roots, Barks, Fruit and Leaves
Many different herbal remedies and potions were available in ancient times for the treatment of pain. These included cannabis, mandrake or mandragora, the milk of the mulberry tree, garden lettuces gathered when young and tender, hops, hemlock and ‘deadly nightshade’ (belladonna). Like opium, some of these plants could be deadly, and they were used with caution by physicians. Ancient Greek mythology expresses an association between sleep and death, Hypnos and Thanatos. Hypnotic or anesthetic agents were often used for humane executions, most famously Socrates’ death by hemlock, with his dying words “we owe a cock to Aesculapius” thanking his physician for the painlessness of his parting.
The effects of Cannabis indica were described by Herodotus in the 5th century BC:
“The Scythians are given the seed of this hemp, creep under rugs and then throw the seeds on the red-hot stones. The seeds begin to smolder and send forth so much steam that no Greek vapor bath could surpass it. The wounded Scythians howl with relief and joy.”
Dioscorides was probably the first to use the word anesthesia in the modern, medical sense in the 1st century AD: “One cyathus of the wine of mandragora is given to those who cannot sleep and such as are in grievous pan and those to be cut or cauterized, when it is wished to produce anesthesia.”
While pain-killing agents were available, their use by the healthy and brave was scorned. Plutarch mentions Gaius Marius, a famous dictator from the 2nd Century BC, who was operated on by his army surgeon and endured the treatment for varicose veins “with steadfast countenance” but later refused surgery on the other leg, “judging that the cure was worse than the illness”.
1.4. Pain Denied
“The fakir sleeping peacefully on his bed of nails remains both the tired cartoonist’s standby and a fact.” (Dormandy, 2006). We live in a time and a place that ridicules miracles. We even doubt the evidence of our own senses unless validated by neurophysiological findings. But the empirical validity of ‘hypnosis’ and ‘auto-suggestion’ is undeniable, and has been shown in countless scientific studies, even though we are far from understanding the mechanisms involved. Most likely, they are the same as the stories from antiquity and the sixteenth century, the First and Second ages of Martyrs. According to Dormandy, ‘self-hypnosis’ is “a scientific tag which makes miracles acceptable to those who do not believe in miracles.”
Cosmas and Damian were twins and both practiced as doctors before they were martyred for their Christian faith in
More than a thousand years later, the Second Age of martyrs arrived with the splitting of the church between Protestants and Catholics. Astonishing denials of pain abounded on both sides. Archbishop Cranmer, formerly Henry VIII’s confessor, “burnt to appearance without motion or pain… he seemed to repel the suffering and overlook the torture.” John Foxe wrote of the burning of Bishop Hooper: “In the tyme oof which fire, euen as he first flame, he prayed, saying mildely and not very loud but as one with no paines: ‘O jesus the sonne of David haue mercy vpon me and receaue my soule…”
1.5. Pain Ignored
The Stoic school of philosophy, founded by Zeno in the 3rd Century BC, claimed that passions like anger, fear, grief, and pain are no more than ‘irrational movements of the soul’ and should be suppressed. Zeno’s followers made the distinction between approved emotions, such as joy, watchfulness and caution, and destructive ones, including pain. The pain of physical injury was to be ignored.
Stoicism spread throughout the ancient world, following Alexander’s conquests in Europe and Asia, and became one of the most popular philosophies of the
Unlike the Christian martyrs, stoics did not deny pain, they simply maintained that it was relatively unimportant. A myth concerning the early history of
1.6. The Heresies
Dormandy disputes the view of pain as a ‘useful warning signal’. While pain following injury is of evolutionary significance, warning an animal with a broken leg to stop running, most pain serves no such function. Now we can utilize some pain symptoms to diagnose the patient and identify a cure, although often the pain of diseases such as cancer arrives too late for an effective one. In the past, there was nothing to be done about conditions like acute appendicitis, an ectopic pregnancy, or an ulcer, and the excruciating pain they caused was completely useless. Most people died in agony.
How did the early Christians reconcile this with their faith in an all-powerful, merciful God? According to the Manichean heresy, as well as God there operated in the world of men a power of evil or Satan, and pain was caused by particles of evil. They could be fought by a cult of priests called the electi, and by the slightly less pure auditori.
1.7. Healing and Holiness
The words healing and holiness come from the same root, and early Christians in the ‘Age of Faith’ (according to Dormandy) or the Dark Ages were among the first to found hospitals with the specific aim of caring for the sick. Faith imposed an order on society by the simple belief that souls were to be saved. St. Fabiola, a Christian convert, tended to the sick in
In the Old Testament, the wrath of God was often expressed in the form of pain and sickness, most commonly tzara’at, thought to be leprosy. The prophet Job expressed a masochistic attitude to suffering, saying: “Happy is the man whom God correcteth. Therefore despise not thou the chastening of the Almighty. For he maketh sore, and bindeth up. He woundeth, and his hands make whole.” Although not popular among Jews or Christians through the ages, this approach to pain was later to influence certain strains of protestanism.
The early Christian healers did not rely on miracles alone to cure the sick.
“The nature of our bodies is such, that when imbued with life and in conjunction with a sentient soul, they become more than inert matter. They feel when touched, suffer when pricked, shiver when cold, feel comfort in moderate warmth, waste with hunger and grow fat with eating. Above all, pervaded by the soul, but not when dead, they respond with pain and pleasure to their surroundings. Yet this is not true of the body as a whole or under all circumstances. Most of the sentient body responds with pain to being cut or pierced, but the nails and the hair can be cut without experiencing any discomfort. Also, in certain diseases, even before a limb becomes withered and discolored, it loses all sensation, so that it can be cut and burnt with impunity. Yet it is still part of a living body. Also, when through some grave necessity part of the body has to be cut or removed, the soul can be lulled to temporary sleep either as a whole or in part. Such a body will later return to life and remember no suffering… Some plants can produce death-like forgetfulness. After eating or drinking the extracts of such plants, limbs can be cut off without pain.” In another passage, Hilary refers to putting the limb to sleep by the application of prolonged pressure. Where
1.8. Islam
It was the world of Islam, and not the Christian world of the Dark Ages, that was responsible for the preservation of Ancient Greek and Roman medical knowledge. Harun al Rashid, the Abbasid Caliph of
Famous Arab physicians included Rhazes (born 825) and Avicenna (born 980). Avicenna noted that “it is the body which generates pain but the brain which decides how much of it is tolerable.” He distinguished three approaches to pain. First, removing the cause, for example by splintering a fracture. Second, using measures which “counteract the acrimony of the humors” – for example Cannabis indica. Third, inebriants like poppy juice and mandragora were used to make severe pain bearable. He added recipes for tinctures containing both, to make somebody unconscious quickly and without harm. However, he noted that: “If even double the recommended dose does not work, it should be abandoned. The person should be encouraged to bear his affliction bravely…Most illnesses carry with them the seeds of their own cure and Nature must be given a chance… the patient must be comforted with kind words and the prospect of future happiness… no illness is without hope.” Whereas Christians accepted suffering as a manifestation of God’s inscrutable will, Islamic doctors believed that Allah created no illness without a remedy. If no potion was known, then verses of the Koran were recited in the hope of a miracle.
Jewish scholarship flourished in certain parts of the Islamic world. Most famous among physicians was Maimonides, who lived from 1135-1204. A contemporary writer noted that “Galen’s medicine is only for the body; but that of Maimonides is for both the body and the soul.” Maimonides’ medical writings were filled with practical advice, such as “Above all, a doctor must be understood.” He also believed that “The Lord gave us tears to shed… Do not try to stem their flow. When potions and vapors fail to ease the pain, lamentations often relieve the suffering.” He wrote: “May I never see in any of my patients anything but a fellow creature in pain.” This attitude of fellowship between the doctor and the patient was markedly different from that prevailing in Christian Europe, where the doctor was a giver and the patient a receiver of healing.
Islamic medical writings of this period included instructions on surgery, for which pain-killing potions and inhaled vapors were used as anesthesia. The Koran specifically requires the compassionate treatment of the insane, and physicians recommended various diets and inhalations for calming the mind, many including ‘bhang’ – probably Cannabis indica. “The effect will be soothing and sleep will usually be instantaneous.”
1.9. The Age of the Cathedrals
It was during the Middle Ages that hospitals were established in the major cities of Europe, St Barthelomew’s in
1.10. Pain Exalted
Towards the end of the Middle Ages, the Black Death arrived in Europe, heralding the spread of the flagellant movement which had began in the 11th century and first became popular after the civil war in Perugia in 1235. Flagellants held the belief that God threatened to destroy sinful humanity, and that the Virgin Mary interceded to save those who joined the flagellant processions. Bands of flagellants traveled the land, visiting the cathedrals, worshipping the Mater dolorosa or Virgin of Sorrows as a cult by throwing themselves on the ground with their arms splayed out like a crucifix in front of churches and flogging themselves with metal-tipped leather scourges. History suggests that self-induced fatalities was rare and consisted mostly of children. However, this self torture frequently escalated into violent pogroms, killing Jews in Frankfurt,
1.11. Rebirth, Rediscovery and Reform
The Renaissance was a time of return to the medical texts and potions of Ancient Greece and
Paracelsus, born in
Artists and doctors participated in the study and documentation of anatomy, going beyond the works of Galen to try and understand the workings of the human body. Anatomy as a discipline became the metaphor of the age, in works such as Robert Burton’s Anatomy of Melancholy and John Donne’s Anatomy of the World.
This was an age of emphasis on heroic depictions of pain in art, in place of Ancient and Classical depictions of heroism alone, and Medieval images of torture. In 1506 the Laocoon, a Hellenic sculpture from the 1st century, was rediscovered in
While Columbus and his crew exported chickenpox to the New World, wiping out whole civilizations, they imported syphilis to the
Botanical gardens opened in many of the cities in
A German chemist or apothecary, Valerius Corbus (1515-1545, approx.) was the first person to synthesize ether out of a mixture of alcohol and sulfuric acid. His invention was published posthumously, and used, diluted with wine, by Robert Boyle and Isaac Newton as a remedy for coughs and chest pain. Originally named sweet oil of vitriol, it was renamed ‘spiritus aetherus’ (aka ether) by Frobenius in 1737, but its value as an anesthetic for use in surgery was not appreciated until the mid 19th century, over 300 years later.
1.12. Going to War
During the Renaissance, more new medical schools were established in
1.13. Foundations
William Harvey was a British physician of the 17th Century famous for first describing the circulation of the blood. His discovery was preceded by accumulating evidence concerning the observation that blood flow in veins was controlled by valves, and that these valves somehow played a role in preventing the blood inside living creatures from sinking to the lower regions of the body, although this is what occurs in dead bodies. Michael Servetus was a 16th Century heretic whom Calvin burned at the stake after rescuing him from the Inquisition. He suggested based on his reading of the bible and study of medical anatomy and physiology that the lungs were where God’s breath (in the air) intermingled with the human soul (in the blood). Although most copies of his book were also burnt, it seems likely that some reached the
One way in which
The 17th Century saw the introduction by Descartes of his famous dualistic theory of human existence. Using his explanation of pain as an example, Descartes proposed that a pain inducing stimulus such as a fire has an effect on the skin that pulls on a nerve fiber, which in turn ‘rings a bell’ somewhere in the brain. In essence, this remained the little-questioned metaphor for pain and how it worked over the next 300 or more years. While the underlying neurophysiology and the transmission of neural impulses became elucidated, the basic understanding of the mechanism of pain remained the same. Descartes’ conceptualization of a separation between mind (soul or espirit) and body (or matter) was both intuitively appealing and helpful in disentangling the complexities of earlier conceptual frameworks such as Paracelsus’. The theological underpinning of Descartes’ theory has been increasingly questioned since
In addition to these two major advances, Harvey’s scientific theory of the circulation and Descartes’ conceptual breakthrough regarding the reframing of the spiritual and the corporeal, with the nervous system as an intermediary, Dormandy discusses changes in theological attitudes to pain that began in the 17th Century. He recounts the story of a female saint who founded the movement of the Bleeding Heart of Jesus, following a vision that appeared to her when she was in the throes of pain from her polio and other illnesses. She and her followers propounded the idea common in the Catholic Church to this day that servitude to God can be attained by means of pain and suffering. She was officially made a saint in 1920.
1.14. Heavenly dreams
Thomas Sydenham was a relatively unknown British physician of the 17th Century, but although he ministered to no kings or queens he invented the recipe for laudanum, an opium tincture that became the popular panacea of an era. Opium was readily available in
During this period in history, people started to gather in growing cities leading to epidemics of sickness and poor health. Smallpox spread widely until a vaccine was invented. There was malaria or ague, which could be cured with quinine derived from the bark of the cinchona tree found in
The propensity of opium and laudanum to give rise to pleasure as well as mitigating pain was well described by Thomas de Quincy, who first purchased laudanum for a toothache while he was a student at
The Romantic Age was characterized by a conflation between pain and its relief, at a time when early death from tuberculosis was commonplace and frequently discussed. In a previous age leaders were respected for suffering while they still carried out their duty, like Philippe II of France who worked on paperwork during the months of his final illness and confessed for two days on his deathbed, resisting any mind-clouding administrations from his physicians. During the Romantic Age the poetry and art inspired by laudanum made it not only commonplace and acceptable but also a revered aspect of the practices around death and illness.
1.15. Mesmerism
Anton Mesmer was probably one of the most successful doctors of all time in the treatment of pain. He was born in
Mesmer’s followers, the Puysegur brothers, quietly dispensed with the magnets, bowls of magnetized water, and magnetized trees favored by Mesmer, replacing the term ‘animal magnetism’ with Mesmerism. Instead of the fits and convulsions favored by Mesmer’s patients, they tended to induce sleep or a somnambulist state in their patients, prior to effecting a cure, and Mesmerism gradually became known as hypnosis.
Dormandy contrasts Mesmerism with earlier examples of psychologically generated pain relief, based on either faith or philosophy, because Mesmerism involves a patient and a clinician, and is thus better adapted to the practice of medicine. He also compares the controversy around Mesmerism with the controversy around the placebo effect. The term placebo has been used by physicians since the 17th Century to denote a cure effected by a treatment believed in by the patient, which the physician knows to be inert, such as a bread pill or colored water. Placebos were used in common medical practice, and Thomas Jefferson complained about the distinction between a ‘pious hoax’ played by his physician and an honest false cure believed in by both doctor and patient. The word placebo, in Chaucer’s Canterbury Tales, was the name of a prayer recited in Latin that professional mourners plied to the bereaved. Placebo effects abound in the history of analgesia or pain relief, and are the scourge of drug developers. They have only recently started to be scientifically studied as a genuine method of benign and effective treatment for pain. In the context of modern parallels to Mesmerism, Dormandy describes an experiment in London dental hospital, where ultrasound treatment was used for many years to produce effective pain relief and speed healing following painful surgery and extractions, only to be found to be equally effective when the machine was turned off (but still far better than no treatment at all).
1.16. Pneumatic Medicine
Thomas Beddoes practiced as a physician in
1.17. Laughing Gas
Humphry Davy was appointed superintendent of the new Institute at the young age of 21, and proceeded to experiment enthusiastically on the effects of gases upon animals, his friends, Beddoes’ patients, and last but not least himself. He noted that carbon dioxide made him sleepy, and that too much oxygen gave him a headache and could eventually kill animals forced to inhale the pure gas. Ignoring the advice of his elders, he experimented with inhaling hydrocarbon (carbon monoxide) noting its effects on patients in causing a ‘delightful pinking’ of the skin, and had to be rescued by another researcher who revived him with pure oxygen. Both Mayow and Priestly had isolated nitrous oxide as well as oxygen, but considered it a choking gas. Davy nevertheless experimented with it, and was surprised to find it produced pleasant exhilaration and laughter, like the inhalation of ether. He also noted that inhaling nitrous oxide killed the pain of his wisdom teeth and indigestion, although the pains returned after a while. In a book published in 1801 on the effects of gases, he noted that while not of prolonged benefit in chronic illness, nitrous oxide might be useful in relieving the temporary pain of surgical operations. Unfortunately, this was ignored for half a century. Davy also noticed that he was becoming addicted to the nitrous oxide and using it more and more. He was able to stop for a while, but then returned to his experiments. He moved to
Thomas Beddoes, meanwhile, continued to practice medicine in
1.18. The Terror of the Knife
Pre-anesthetic surgery was often a scene of horror for the patient, the surgeon, and the audience that gathered at the medical schools’ operating theaters. Speed was of the essence in performing a safe operation before the patient went into shock, but patients’ descriptions of the proceedings of nowadays simple surgeries like the removal of bladder stone, or a mastectomy, are horrific. These accounts tell of excruciating pain so terrible that words fail to describe it. Patients most commonly screamed during the surgery, and had to be held down by assistants, as the surgeon dreaded accidentally cutting through an artery and causing the patient to bleed to death. Surgeons practiced their craft on cadavers for hours in the morning before the afternoon’s surgery, like a pianist practicing for a concert. Surgeons were encouraged to talk to and mollify the patients during the entire proceedings, giving them strength to endure their pain and hardship. Many surgeons described having nightmares about their work, and waking up in a cold sweat. For some, this only got worse with time. A famous surgeon, nearing the end of a prestigious career, was observed to suffer from shivers and vomiting after his day in the operating theater. Other surgeons went on operating until they were in their 70’s and 80’s, seemingly addicted to their work. Relatives of the patient would complain many years later that they were still haunted by the cries and screams of the surgery. And yet, in spite of these horrors, advances were made in surgery as more was known about human anatomy, and deaths in the operating theater became a rare occurrence.
1.19. Hospital Disease
Hospital disease made a mockery of these advances in operative techniques. After a successful surgery, the patient left in the hospital bed to recover was likely as not to die of one of the many diseases later found to be caused by bacterial infection. Epidemics of ‘pyemia’ caused patients to die rapidly and painfully when after a spike of fever pus-filled boils appeared on their skin and inside their internal organs. The Hungarian obstetrician Semmelweis noticed in the 1840’s that childbed or puerperal fever rarely occurred in home births assisted by a midwife. When he suggested that it was a manifestation of the same illness, caused by noxious matter picked up by doctors at autopsies, he was ridiculed. ‘Septicemia’ was the cause of slow, painful death usually preceded by loss of consciousness as bacteria multiplied in the patient’s bloodstream. Erysipelas was similar, but accompanied by a rash emanating from the site of the wound or surgical incision. These diseases came and went in epidemics that caused the operating theaters and sometimes whole hospitals to be closed. Doctors and nurses were at risk as well as patients. The British parliament debated closing all the hospitals in London, and Florence Nightingale, famous for originating modern nursing during her service in the Crimean war, suggested building huts Hyde Park to isolate the patients and allow them to recuperate safely. In
1.20. To the Threshold
In his book, Thomas Dormandy hypothesizes that one of the reasons it took so long for well known drugs to be used for the elimination of pain during surgery was that until the middle of the 19th Century society viewed pain as a normal part of life. When Ellioston, Ward and Topham, Braid and Esdaile conducted painless surgery in
1.21. A Gentleman from the South
Crawford Williamson Long, a rural gentleman doctor from
1.22. This Yankee Dodge
The historical origins of ether and nitrous oxide anesthesia are marred in controversy. According to Dormandy, a young
The reason for narrating this history here is its relevance to the pharmaceutical industry today. Ether was a bane to humanity, but its use as a surgical anesthetic could not easily be credited to one person, nor could it be used to make money. What is more surprising is that ether was readily available for hundreds of years, and nitrous oxide for decades, and yet although they were used recreationally as well as therapeutically their usefulness in surgery remained unrecognized for so long. I disagree with Dormandy that this was because of a prevailing acceptance of pain. I think it was a problem of mindset, how these substances were categorized in the minds of physicians and others. Nowadays the drug industry attempts to make profits by re-marketing and re-patenting drugs for previously off-label uses, and unlike the wise judge in Morton’s patent case the legal system allows this. Safe and effective uses of widely available natural substances are shunned and relegated by the medical establishment to the role of alternative quackery because nobody stands to make money from them. I wonder if, in the present pharmaco-economic climate, the use of a common panacea such as sulfuric ether in surgery might have taken much longer to gain hold in the medical establishment, and what this means for future advances in the treatment of pain. It is also worth noting that most of the credit went to Morton, who was the least qualified but shouted loudest, and none to Dr. Long, by far the best scientist and clinician in this story.
1.23. In
In the 19th Century, news of medical discoveries traveled fast. Letters about the
1.24. And Beyond
One of the first uses of anesthesia in continental
1.25. Chloroform
The controversial Scottish obstetrician James Simpson began experimenting with the use of ether to control the pains of childbirth days after hearing of Liston’s successful anesthetic surgery in
1.26. The Shape of Dreams
The use of opium in
I wonder whether we are seeing a parallel to this in the present day expansion of the market for drugs such as anti-depressants and neuroleptics targeted at children as well as adults and dressed in new labels and new indications, including anxiety and pain, promoted directly to the public.
The German chemist Setürner who was the first to isolate morphine, the most potent constituent of opium, was well aware of its potential dangers when he wrote in 1812 ‘I consider it my duty to attract attention to the terrible effects of this new substance’. Experimenting on himself in his spare time, he identified among the anticipated acidic constituents of morphine this alkaline substance and named it ‘morphium’ from the Greek, inspired by the Romantic writers of the time to call it ‘the shape of dreams’ or ‘shapes’. Eventually, in 1817, Setürner’s publication attracted the attention of Louis Gay-Lussac in
1.27. Mr. Anesthetist
John Snow was a dedicated General Practitioner as well as a scientist. He was probably the first anesthetist. By careful research he was able to track the spread of cholera in the epidemic of 1848-49 in
1.28. Conflicting Views
In
1.29. The Rights of Pain
Surprisingly, perhaps, it was in the
1.30. Who Needs an Anesthetic
To bridge the gap between these contrasting views and perhaps also to carve a niche for the practice of medicine among this plethora of technologies and opinions, Oliver Wendell Holmes and others originated what became known as ‘conservative medicine’. When the Declaration of Independence was signed by the physician Dr. Rushmore, all he needed to practice medicine was a general view that diseases were born of too much ‘bad stuff’ and could be cured by letting it out, by means of blood lettings, leeches, cuppings and purges. Any sensible, intelligent person could act as medical advisor to his own family. Suddenly, around the middle of the 19th Century, there was an abundance of available cures promoted by quacks and charlatans of all kinds, and doctors needed to distinguish themselves by means of their education and superior knowledge. The goal of conservative medicine was to replace universal panaceas with individual treatments, and ideally come up with a classification system for all the different kinds of patients.
In regard to pain, it was generally held that against the standard of the white male, women suffered more, and that old, black and indigenous people suffered less. There was controversy as to the suffering of children and animals. Some doctors believed that experience and learning were required to suffer pain, whereas others saw children and infants as closer to women in their general delicacy and tendency to complain. The cause of lesser suffering was variously framed as brutish ‘insensitivity’ (bad) or Christian ‘endurance’ (good). The greater sensitivity of woman was attributed to physiological causes. The rise of Darwinism caused concern over the superior fitness of primitive people who were less sensitive to pain. This was coupled with a misunderstanding of heredity and the notion that although the ‘insensitivity’ of black and indigenous peoples may have been caused by their brutal treatment by whites, this ‘insensitivity’ would be transmitted to future generations. Some American doctors, anticipating the Nazis, conducted cruel experiments on black slaves and Native Americans. Anesthetics and painkillers were most frequently administered to white women, who were led by male doctors to believe in their own delicate sensitivity, a notion that endures to this day.
1.31. The New Physiology
The 19th Century was a period when many new facts were discovered concerning both the human body and the nature of disease, and Dormandy attempts to separate and outline these two areas of advance in this and the next chapter of his book. Dormandy speculates that the invention of anesthesia profoundly changed the conceptual scheme in which pain was viewed. Prior to anesthesia, pain was always associated with a particular part of the body that was injured or diseased and therefore hurt. It was not necessarily obvious that a headache, a stomachache, and a toothache were all the same kind of thing. Some had suggested that pain is simply an exaggeration of other sensations, pointing to the fine line between a nice warm bath and a scalding, which differ only by degree. After the discovery of anesthesia, most doctors came to believe that pain was an experience in its own right, one uniquely susceptible to anesthetics, which must have its own purpose.
Charles Bell was the first in 1811 to distinguish between two kinds of nerve fiber, one carrying signals from the periphery to the brain and the other carrying signals from the brain to the muscles of the body. Francois Magendie, in
Led by Hermann von Helmholtz, Müller’s students took this notion a step further when the published a Physiological Manifesto in 1847 announcing that the aim of the life sciences is to explain all biology in terms of physical and chemical laws, leaving behind Müller’s own notions of vitalism. Müller had suggested that nerve impulses were probably electrical. In the years that followed, Helmholtz not only proved this to be correct but also measured their speed of conduction, which he estimated at 20 meters per second. He invented the ophthalmoscope, an instrument that allowed him to see the human retina, at the back of the eye, and identify the optic disc where the optic nerve exits. Emil du Bois-Reymond, another of Müller’s students, was also fond of inventing instruments and designed the ‘algometer’ a device that generated current with the aim of measuring sensitivity to pain. This was put to use by Havelock Ellis and Cesare Lombroso, who claimed to show that criminals and ‘mental defectives’ were less sensitive to pain than others. According to Dormandy, the instrument is still used in medical schools for the study of pain sensitivity.
Ernst Brücke in
Karl Ludwig, who became the director of the Physiological Institute in
Theodor Schwann identified the cell as the basic unit of all living organisms, including both plants and animals. He characterized the cells of the nervous system and noted that nerves were coated in an electrically insulating sheath, speculating about the possible consequences of damage to this ‘protective coating’. Rudolf Virchow, another of Müller’s students, identified the pus cells as white blood cells and founded modern cellular pathology.
In
Spinal reflexes were discovered in the 18th Century through experiments on decapitated frogs, followed by the work of Marshal Hall in the 19th Century who showed that transection of the spinal cord in frogs resulted in a loss of voluntary movement and an enhancement of reflex actions in the hind legs. Hall suggested that the spinal cord was superior to the brain, since ‘it needed no sleep but was always ready to function’. He was aware that reflexes caused blinking, coughing, and other protective reactions, and was the first to observe that spinal reflexes were responsible for most actions of the newborn, claiming that ‘without spinal reflexes no neonate would survive’. The discovery of reflexes impacted
The pathways nerves follow through the body and to the brain were elucidated by Augustus Waller, who experimented with severing the nerves and showed degeneration of the distal portion, and by Charles Edouard Brown-Séquard who studied the course of nerve tracts and correlated them with the changes observed after strokes. He found that the left side of the brain crossed to the right spinal cord and vice versa, contrary to the Victorian notion that ‘nature is never unnecessarily complicated’. Cerebral localization emerged from the pseudoscience of phrenology, and Franz Joseph Gall’s claim in the late 18th century that the mental functions of different parts of the brain could be detected by palpating bumps and dents on the skull. Flourens discovered that removal of a pigeon’s cerebellum and hindbrain led to loss of balance and muscular coordination, but the bird could still see and hear. He suggested that conscious sensation and pain were in the cerebrum, and the cerebellum served for ‘purposeful movement and hidden feelings’. Legallois localized the respiratory center in the medulla of a patient who suffered damage to the hindbrain in a duel. Dormandy tells the tale of Philip Gage, a Conneticut quarryman, who had a crowbar passed through the front of his skull in an accident and lived for another ten years, the only noticeable change in his demeanor a loss of his violent temper and alcoholism.
This latter story makes me wonder about the quality of some of Dormandy’s facts. The story exists in several different versions. According to the more familiar one, the name of the protagonist was Phineas P. Gage, and he was a railroad worker hit by a tamping iron while blasting rock.
Hitzig and Fritsch continued the exploration of functional localization in the brain, studying soldiers who had parts of their skulls damaged. Using electrical stimulation in these patients and in animals, they identified the motor cortex of the brain, which was named by David Ferrier in
This lengthy review indicates that during the 19th century new treatments were discovered for pain and its prevention, some of which are still not understood. Contrary to the way in which modern medical science portrays itself as proceeding from an understanding of physiology, or the functioning of the healthy body, to an understanding of disease, followed by the creation of a cure, physiology, pathology and treatments were discovered side by side as parts of a massive flowering of empirical science that was based as much on the consistent observation, dissemination and putting together of previously overlooked facts as on the invention of new technologies. It was during this time that physiologists first articulated the goal of basing their science entirely on physics and chemistry. At the same time, doctors began to propound rhetoric basing their treatments on an exhaustive classification of patients.
1.32. The New Pathology
Helmholtz declared that ‘every disease was a physiological experiment, and every physiological experiment was a model of a disease’ (Dormandy, 2006). Some diseases were effectively characterized and understood before the 19th Century. Wepfer showed in the 17th Century that strokes were associated with blood clots in the brain, and suggested that the location of the clot might determine the patterns of pain and paralysis. James Parkinson, in the 18th Century, described the shaking, tremors and stiffness of the disease which is now named after him, hypothesizing that as ‘sensibility’ was not affected it might be the result of damage to parts of the brain where muscle actions are ‘harmonized’.
A major advance in the 19th Century was the description by Romberg of all the specific neurological signs of ‘General Paralysis of the Insane’ which was later found to be caused by syphilis. The symptoms started with searing pains in the feet and calf muscles, which were barely relieved by morphine. There followed tingling and pins and needles in the toes. Eventually, feeling might be lost all over the chest, and over a ‘butterfly area’ surrounding the bridge of the nose, which became known as the ‘masque tabetique’. After months or years, these symptoms were followed by weakness, paralysis and eventually mental illness. Duchenne described these advancing symptoms in terms of the associated spreading damage to the spinal columns caused by syphilis, and in
Dejerine, a contemporary of Duchenne, investigated another pain condition – one that was caused by degeneration of the peripheral nerves. It resulted in symmetrical spreading of tenderness, altered sensations and muscle weakness, starting normally from the feet and hands. Dejerne described the symptoms as following a ‘glove and stocking’ distribution. This condition was commonly the result of alcoholism and vitamin B deficiency but could also be caused by diabetes, and different toxic conditions from poisoning with lead or other metals.
Jean-Martin Charcot, head of the famous Salpêtrière hospital in
Dormandy devotes much space in this chapter to a description of the miracle of
Cruvelhier outlined the symptoms of multiple sclerosis and tried to classify other pain syndromes. Broca examined the damage in aphasias and identified the area in the left hemisphere of the brain which is now named after him as responsible for speech.
Kraepelin devised a new taxonomy of mental illnesses, noting the longitudinal association between mania and depression, and contrasting it with the cognitive decline in dementia praecox (later called schizophrenia). He wrote about the association between pain and mental illness, noting that mental illnesses and particularly depression could sometimes exaggerate and sometimes diminish painful experiences.
Alzheimer, a student and colleague of Kraepelin, described a case of pre-senile dementia, distinguishing it from the ‘melancholy and depression of old age’ by a ‘disinclination to remember facts and retain impressions’.
With Charcot’s example, medical hypnosis became fashionable among his followers, such as the young Sigmund Freud. At least hysterical conditions could sometimes be cured. While a lot was known about neurological diseases by the end of the 19th century, not much could be done about them.
1.33. The Acute Abdomen
The availability of anesthetics made longer surgery than ever before possible. Until 1860 the terrible pain of appendicitis could be said to serve no useful function. That suddenly changed. Appendicitis, which begins with sharp pains in the upper abdomen, fevers and vomiting, due to a swelling of the appendix normally caused by a blockage, progresses untreated to peritonitis, a swelling and irritation of the inner lining of the abdominal cavity as it becomes filled with blood and pus after the appendix bursts. The peritoneum is one of the most densely innervated surfaces inside or outside the body, and is acutely sensitive to pain. An ‘acute abdomen’ was one of the most excruciating ways to die in the days before anesthetic surgery. Ectopic pregnancies where the fetus is embedded in a fallopian tube instead of the uterus were an equally common cause of the ‘acute abdomen’. When the tube burst the abdomen became filled with blood. Operations inside the abdominal cavity which would formerly have been fatal because of the risk of infection were made safe by the antiseptic methods newly invented by Joseph Lister. Lister read Pasteur’s account of germs and not only associated them correctly with hospital disease but also came up with a solution, which was to spray everything in the operating theater during before and after each surgery with carbolic acid. Carbolic acid had a foul odor and inhaling the spray caused rasping coughs in all those present but the adoption of his technique rapidly made hospitals safer and improved the reputations of the surgeons using it. Another method common at the time was washing everything with water and soap. According to Dormandy, this tradition developed independent from any understanding of germs, but like antisepsis it led to more successful surgical outcomes. Both techniques were soon supplanted by asepsis. In the days before anesthesia, when operations had to be timed in seconds before the patient went into shock, antisepsis would never have been possible. Surgery for the acute abdomen and appendicitis was so safe that the death rate approached 1 in 10,000 for a condition that was previously almost always fatal and extremely painful.
There followed a craze for abdominal surgery in a range of different conditions, from ‘chronic remunerative constipation’ as a friend jokingly described the condition that led Sir Arbuthnot Lane of Guy’s hospital to perform a thousand colectomies by his retirement in 1908, to ‘hitching up’ the ‘floating’ kidneys believed to cause lower back pain, and removing kinks in the bowel to ameliorate or even prevent digestive complaints. If visiting
1.34. Old Drugs, New Drugs
The mid to late 19th Century saw an exponential expansion in the range of available analgesics. Besides the many opium-based and morphine-based preparations, cannabis enjoyed a revival following the 1842 publication of a research article by William O’Shaughnessy, who was ‘surgeon to
Thomas Lauder Brunton, a student of Ludwig’s at
Another popular remedy of the 19th Century was bromine and its compounds, bromides. Bromine too was first discovered by Balard. He hoped it might replace the expensive iodine in the treatment of goiter, and found instead that it relieved anxieties, facilitating sleep in those who lay in bed worrying. It had fewer side effects than the available opium derivatives, and was effective as an anticonvulsant in epilepsy, although it sometimes caused an unpleasant rash. Bromides remained in use until the introduction of the more effective but also more toxic barbiturates.
Chloral hydrate was introduced by the German physician Johann Liebreich in 1862 as an alternative to bromine. Its foul taste was thought to add moral uplift to the relief of pain, especially for children. Like opium, it was often addictive, and notable addicts were the artists Dante Gabriel Rosetti and Amadeo Modigliani, and the composer Claude Debussy. Chloral hydrate was marketed under a number of different names, as were some other chemically similar compounds.
Phenacetin was introduced in the 1880’s, in the form of ‘little blue pills’ which neither tasted nor smelled foul, and could relieve fevers as well as reducing the pain of headaches, toothaches and sore joints. It was the first drug made by businessmen rather than quacks, chemists or physicians. The primary goal of Phenacetin for its inventors in
1.35. The Bark of the
Phenacetin was rapidly superseded by another pain relieving remedy, which would become the best selling drug in history. Aspirin had its origins in an ancient remedy for fever, using the bark of the willow tree. In the 18th Century there was an epidemic of ‘ague’ or malaria in
Bayer and Westcott established their chemical factory in the 1860’s, and were soon succeeded by a series of aspiring young chemists. Carl Duisberg headed the pharmaceutical division after the success of his drug phenacetin, which was manufacture from a waste product of the coal tar dye industry. Another such waste product, acetaniline, had been marketed successfully by two Strasburg doctors as ‘Antifebrin’ which gave Duisberg the idea of testing para-nitrophenol (‘phenacetin’) as an anti-pyretic. Felix Hoffman, working with Arthur Eichengrün and Heinrich Dreser at Bayer’s, successfully acetylated salicylic acid in 1897. The name Aspirin, after Spirea for meadowsweet, was coined by Eichengrün, who was later written out of Bayer’s history although he survived a period in a Nazi concentration camp.
In fact, salicylic acid had been acetylated previously by two chemists, Charles Gerhard in
One complication in the marketing of Aspirin was that Duisberg and Dreser, the senior chemists at Bayer’s, were more interested in promoting diacetylmorphine, which had been synthesized in 1874 by a British chemist, C.R. Alder Wright. They rebranded the compound ‘heroin’ after the heroic effects it had on some factory workers who tried it. The plan was to market it as an alternative to codeine in the treatment of coughs because it was more effective and less toxic. They also estimated that as a pain killer it was more potent and less habit forming than morphine. Hoffmann and Eichengrün went ahead with their promotion of Aspirin in clinical trials by the rich and famous, and eventually heroin was dropped after some of the subjects started developing severe cravings for the drug.
1.36. Cocaine
Cocaine was another wonder-drug of the late 1800’s. Coca leaves were widely used in
Freud was among the many young doctors in
James Leonard Corning, a
Coca and cocaine remained popular until the turn of the 20th century. Coca-Cola was marketed in ‘dry’ states as ‘the supreme remedy for all ailments’. Alfred Conan Doyle’s Sherlock Holmes reflects the changing tide of concern about addiction when by the 1890’s he refers to the syringe as ‘an instrument of evil’ and Watson mutters darkly about the ‘drug craze’. In the
1.37. High Victorian Pain
During the nineteenth century, accounts of pain enjoyed a brief period of popularity and this was when, according to Dormandy, the modern construct of illness emerged. Before that, private suffering and anguish clearly existed, but they were of little social or cultural significance. Death among the aristocracy was tragic if it interfered with the continuation of the lineage, and otherwise insignificant. For the masses, what mattered was survival. The horrendous suffering from the plagues that regularly swept across
A large part of the chapter is devoted to the life and illnesses of Mary Ward, a famous Victorian writer and philanthropist, granddaughter of Thomas Arnold (the reformer of
Naming one’s pain was a favorite Victorian and Edwardian pastime. Nietzsche famously called his tabetic crises ‘mein Hund’, Churchill referred to the ‘black dog’ of his depressions, and Austro-Hungarain Queen-Empress Elizabeth called her migraines ‘visits from Torquemada’.
Mary Ward developed a brief infatuation with cocaine, which she took in the form of lozenges that had ‘the most wonderful effect’ when she visited
Dormandy contrasts this heroic tale of personal illness and suffering by a member of the upper-middle class with a case-report in the Lancet about a young working-class girl with hysteria by Edward Kershaw, a general practitioner and doctor to a workhouse hospital in
By around 1890, pain and illness were falling out of fashion. Kershaw’s view of hysteria as a kind of malingering differs notably from Charcot’s sympathetic treatment of hysterics in the 1870’s, and his insistence on the reality of their pain. The new attitude to pain is expressed by Lord Henry in Oscar Wilde’s 1891 novel The Picture of Dorian Gray: ‘there is something terribly morbid in the modern sympathy with pain … The Nineteenth Century has gone bankrupt through an overexpenditure of sympathy’.
1.38. The Power of Pain Control
Now that effective drugs for relieving pain were on the market, there was public concern and debate about how they should best be managed. Regulatory bodies sprang up in
1.39. Seminal Years
The decades immediately before and after the turn of the 20th century were also a time of new discoveries in the emerging field of neurophysiology. Separate from and parallel to the development of new drugs, the structure and function of the nervous system was being unraveled and together with it some understanding of the bodily mechanisms of pain began to emerge.
The Czech physiologist Jan Purkinje was the first to investigate brain cells under the microscope and describe them. He died in 1869. But it was only with the introduction of a silver nitrate stain by Camillo Golgi in the 1870’s that their internal structure and extensive, stellating outgrowth of multiple thin processes were revealed. Golgi thought that the brain was an interconnected lattice or network of such fibers. It was his contemporary and competitor, Santiago Ramón y Cajal, who showed using Golgi’s staining method that in fact the cells were physically disjoint, although the gaps between them were too small to be seen before the invention of the electron microscope. He further investigated the structure of the brain cells and identified and named the incoming dendron (Greek for tree), its branching dendrites, and the outgoing axon.
The brain typically contains about a trillion of these neurons, with the cell bodies located in the grey matter of the cortex and in a few small subcortical nuclei, and the fibers extending into the white matter, coated with electrically insulating myelin sheaths composed of Schwann cells. In between there are even more numerous glial cells (named after the Greek word for glue) that support and nourish the neurons. Axons from the motor neurons descend the spinal cord in bundles or tracts, and axons from gray matter in the spinal cord ascend to the brain. Around the turn of the 20th century, the German physiologist Max Von Frey described in detail microscopic ‘pain receptors’ in the skin thought to connect with the dendrites of these spinal sensory neurons. They featured in the illustrations of medical textbooks until the 1950’s, when they were finally discredited. In fact, open-ended nerve fibers are the receptors for pain.
Charles Scott Sherrington investigated the functions of the nervous system, whose structure had been laid out by Golgi and Cajal. He showed that all voluntary and involuntary movement depends on the synchronous activation of opposing muscle pairs at the joints. Such cooperative movements also govern posture and muscle tone, as well as the peristaltic waves of the gut and sphincters, controlled mostly through spinal reflexes which are ultimately under the influence of subcortical basal nuclei and also the cerebral cortex. Sherrington named the gap between neurons a synapse and coined the adjective synaptic, from the Greek word for clasping, following the suggestion of a friendly Classics scholar. His classic textbook The Integrative Action of the Nervous System was published in 1906.
In
Ernest Starling coined the word ‘hormones’ to describe a class of compounds secreted in different parts of the body, and in 1904 T. R. Elliott suggested that some nerve fibers communicate by means of small amounts of the hormone adrenaline (epinephrine). Henry Dale and Otto Loewi, working in Starling’s Department of Physiology in
Jules Déjérine and Gustave Roussy described in 1906 a syndrome of hypersensitivity to pain caused by lesions in the thalamus. They suggested that the thalamus functions as a primitive brain. Henry Head and Gordon Holmes refined this theory in 1911, noting that not only responses to pain but all emotional reactions were affected by thalamic lesions. They suggested a role for the thalamus in the evocation of pleasure and pain.
Head classified the sensations as ‘visceral’ (from the internal organs), ‘protopathic’ (dominant and crude) and ‘epicritical’ (fine and discriminatory). He demonstrated by cutting and sewing back together his own radial nerve that painful ‘protopathic’ sensations were regained first, followed slowly (if at all) by fine ‘epicritical’ sensations.
Walter Canon in Harvard showed how pain, hunger and fear could trigger ‘drastic alterations in body economy, adapted to the individual’s welfare or even survival’. ‘Alarm’ triggered changes in blood flow and endocrine systems. This response was labeled by MacDougal in 1908 a ‘fight or flight reaction’, and became the basis of the phenomenon known as stress.
1.40. The Gift of Saint Barbara
Johann Adolf von Baeyer first synthesized ‘barbituric acid’ from urea and malonic acid in 1863, naming it after the feast day of Saint Barbara on which it was discovered. There was little interest in the compound until two of his students Emil Fischer and Josef von Mering tested a derivative, ‘barbital’, among a list of potential pain-killing drugs in 1900. The results on rabbits were promising, and they offered it to Merck & Co., with Fischer suggesting the more attractive brand name ‘Veronal’. Over the next half a century, dozens of new barbiturates, all chemically related, were successfully introduced and marketed, varying in their solubility and duration of action. Sodium amytal was the first to be used as an intravenous anesthetic in 1929, and beginning in 1934 thiopentone or pentothal became the most common form of surgical anesthesia, in spite of a disastrous experiment in the aftermath of
Dormandy believes that emotional and physical pain are indistinguishable, and uses the success of drugs such as barbiturates to argue for his viewpoint in this matter. He acknowledges that this is an issue people feel strongly about, with some such as the famous philosopher Karl Popper siding like him with ‘monism’ and others firm ‘dualists’ in regard to the distinction between mental (or emotional) and physical pain. Dormandy’s argument seems frail to me. Antidepressant drugs like Elavil are used against dyspepsia, simply because there are as many or more receptors for serotonin in the gut as there are in the brain. One would not therefore infer that dyspepsia is indistinguishable from depression, or indeed that they even share the same mechanisms. My view is that emotional pain is metaphorically related to physical pain. We use our experiences of physical pain to understand and perhaps even to experience emotional pain, but the two experiences are phenomenally distinct most of the time, like the difference between seeing a real scene and seeing what we know to be a picture or image. This is discussed further in Chapter 2.
Amphetamines were introduced in the 1930’s, originally marketed as over the counter decongestants. Their stimulant properties quickly became evident, and they were lavishly doled out by both sides during the Spanish Civil War and soon after World War II. A headline in the 1941 Evening News read ‘Methedrine wins the Battle of London’. When
Starting in the late 1930’s, synthetic opiates were synthesized. First Meperidine, better known as Pethidine or Dolantin, was sold over the counter in the
Albert Hofman first synthesized diethylamide of lysergic acid, known as LSD, from a common mould fungus in 1943. After the war, Sandoz marketed it as Delsyd, distributing thousands of samples as free gifts to psychiatrists and psychotherapists around the world ‘to provoke liberation of repressed psychic material in the patient, to provide mental relaxation … and to induce short-term experimental psychosis in normal subjects’. The Chemicals Division of the CIA experimented with it from 1956-1960, concluding in the end it had no military potential and only produced ‘a joyous disturbance of the ego function’. Aldous Huxley, a famous proponent of the drug, thought that it would bring world peace and used it as terminal therapy when he was dying of cancer in 1967.
Barbiturates remained the market leaders in mind-altering and pain-relieving substances until the late 1960’s. Suicides and accidental overdose were common risks, but attempts at legal restriction were fiercely opposed by the pharmaceutical industry. In 1971 the US Controlled Substances Act divided barbiturates, narcotics and analgesics according to their potential for abuse and habit-formation, listing the longer-acting drugs as more dangerous. In
1.41. Tic Douloureux
Tic Douloureux is a particularly painful and rare type of neuralgia. The term neuralgia has been used since the early 19th century to refer to a pain which is caused by damage to the sensory system responsible for the sensation of pain. This type of pain is often particularly severe and difficult to treat. Tic Douloureux is caused by damage to the trigeminal nuclei, and specifically the 5th cranial nerve. The nerves serving the head and face pass through these nuclei instead of the spine. The term ‘tic doulourex’ was coined by the French surgeon Nicolas André, who described it in 1757 as ‘an atrocious pain accompanied by hideous grimaces which create an irremovable obstacle to the intake of food, which prevent sleep and which inhibit speech’. The condition was described in detail by a
The pain comes on suddenly and is excruciating. Each pain lasts for a short time, perhaps a quarter or half a minute, but then returns at irregular intervals, the whole attack lasting for quarter or even half an hour. There may be two, three or more repetitions during a day … The attacks are more frequent during the day than in the night, probably from there being fewer triggers of irritation; and they are more frequent during conversation than silence; and still more frequent at times of mastication… Talking or the least motion of the muscles of the face affects others. The gentlest touch of the hand or a handkerchief will sometimes bring it on while strong pressure may have no effect… There is no known way of terminating the attack.
Patients have described the experience as ‘fireworks exploding inside my face’. Some take their own lives. Because of the severity of this condition and its non-responsiveness to pain relieving medications, it became one of the first targets for neurosurgery. Initial attempts, sectioning the nerves as they emerge from the skull, were unsuccessful – even if an attempt was made to divide sensory from motor nerves. James Syme of
1.42. Twilight Sleep
For a brief period, between 1906 and World War I, ‘painless childbirth’ became all the rage. This was achieved by the administration of a cocktail of morphine and scopolamine in small amounts, carefully titrated by the obstetrician to eliminate memory without causing loss of consciousness. Scopolamine is a poison that has been known since ancient times. The method had been tried before, but after the publication in 1906 of a study from two doctors in Freiburg, Carl Gauss and Bernhardt Krönig, on 500 cases, with famous mothers testifying that they woke with a baby lying beside them, society women flocked from the
1.43. Dolorism
Dolorism was a bizarre philosophical movement that emerged between the two World Wars and like the flagellant movement of the middle ages advocated physical suffering instead of the alternative. The term was coined in a 1919 review of Georges Duhamel’s war novel La Possession du Monde, and gained popularity after Julien Teppe published his Apologie pour l’anormal or Manifest du dolorism in 1937. The manifesto claimed that creative power and identity itself were all inspired by physical pain, supporting this idea with quotations from Ecclesiastes to Rimbaud. It heralded the publication of the Revue doloriste, a periodical whose contributors numbered Gide, Valéry, Benda, Colette… all the famous French poets and writers of the age. More on these ideas will be discussed in Chapter 2.
Dormandy rejects outright the ‘dolorist creed’. He claims that three arguments exist in favor of physical pain: 1) Pain is a precondition of life, a ‘warning bell’ that we cannot do without. 2) Pain relieved is intensely gratifying. This he names the ‘lost penny found’ argument. 3) Pain ennobles the sufferer.
Evidence for the first argument comes from the finding that those who suffer from a lack of pain sensation, as in congenital analgesia, secondary syphilis, leprosy or neuropathy, become injured as a result of their insensitivity to pain. However, while an animal with a broken bone will rest the injured limb and let it heal, the pain of a burst appendix was useless until modern anesthetic surgery. Additionally, many pathological conditions that might be treatable, such as certain cancers, go undiagnosed until it is too late because they often cause little or no pain. So pain as a ‘warning bell’ is very ineffective. While it results in some hits, these are probably far outnumbered by misses and false alarms.
Many writers have extolled the ennobling virtues of pain. C. S. Lewis quotes a doctor saying that ‘Pain provides an opportunity for heroism’. Hemingway wrote to Scott Fitzgerald that ‘You have to hurt like hell before you can write seriously’. While Dormandy acknowledges the inspiration many artists have found in the painful coughs and low grade fevers of tuberculosis, for example, he points out that ‘no great poem has been written by a poet in the grips of renal colic’. Dormandy attributes the social advantages of pain more to the opportunities for compassion and love, rather than for heroism. He points out that ‘It is suffering which makes people sufferable’ and it is shared suffering which can establish the closest bond between two unrelated individuals not actually in love’.
My own view is rather more pragmatic. Pain is a given, and rather than fantasize about what life might be like without it, we can examine instead how it functions. In my view, physical pain serves to bind us to our identities in our bodies, in a way that other sensations and feelings do not. This doesn’t mean that it has to be sought out because pain, while unpleasant, is usually unavoidable.
Dormandy goes on to discuss how some people seem to be more prone to pain than others, just as some are accident prone and trip over rugs or burn their hands on kettles. He notes that people prone to physical pain frequently blame their pain on other people around them. In the extreme, some people suffer hypochondria or conversion disorder, the modern term for what used to be known as hysteria. Dormandy draws a clear distinction between these two conditions. Hypochondriacs are, as Thornton Wilder put ‘people who listen to their body as if it were a Stradivarius’. They are easy to diagnose but impossible to treat, stuck in their obsessions. People with conversion disorder, by contrast, convert their emotional pain into real and sometimes serious physical symptoms, such as blindness, backache and paralysis, which they often suffer in silence with the calm resignation called by Charcot la belle indifference. They are hard to diagnose without ruling out many possible real physical illnesses. Dormandy recommends a 1944 article by I. Douglas-Wilson in making this diagnosis, and claims that conversion disorders respond well to care, compassion and psychotherapy.
1.44. Renoir
Dormandy is at his most passionate while writing about the life of the artist Auguste Renoir. Renoir suffered from crippling rheumatoid arthritis from the early years of his success and marriage with Aline Charigot, when he was in his 50’s. He sat in a wheelchair to paint, and brushes were strapped to his hands with gauze so as not to bruise the skin. The Bernheims, his wealthy American patrons, brought the world’s most expensive specialist Rudolf Schade from
While my father is put in position the model takes her place on the flower-spangled grass. Somebody prepares his palette while he adjusts his stricken body to the hard seat. It is painful but it allows him to keep upright and a certain amount of movement. The piece of protective lint is folded into his palm and he points to a brush. ‘That one there… no, the other one’. It is given to him. Flies circle in a shaft of sunlight. ‘Ah, those flies,’ he exclaims in rage, ‘they can smell a corpse.. or not a corpse but a body in pain…’ But then they stop bothering him; and for a moment or two he seems somnolent, hypnotized by a butterfly or the distant sound of cicadas. ‘It is intoxicating.’ He slowly stretches out his arm and dips theh brush into turpentine. But the movement is terribly painful. He waits for a few seconds as if askin g’why not give up?’ ‘Is it worth it?’ But then a glance at the scene in front of him restores his courage. He traces on the canvas a mark of madder red that only he understands. ‘Jean please push that curtain aside a little more’. Then, in a stronger voice: ‘Ahe yes, it is divine.’ He smiles as he calls everybody to witness the conspiracy which has just been arranged between the grass, the olive trees, the sunlight, the model and himself. Another day of happiness has begun for him, a day as wonderful as the one which had preceded it and the one which will surely follow.
Dormandy claims that accounts such as this one demonstrate the effectiveness of life, joy and creativity in overcoming and relieving pain, rather than pain as an inspiration for courage, but to me these seem to be two sides of the same coin. Renoir shunned powerful painkillers such as morphine and opium, contenting himself with small doses of salicylates and his work. Rheumatoid arthritis was first described in the 19th century and over the course of that century replaced gout as the common complaint of middle and old age. Osteoarthritis is an unrelated condition that causes similar symptoms, and was distinguished from rheumatoid arthritis in the 1880’s. The systemic complications of rheumatoid arthritis which are feared today might be the result of vigorous treatment with steroids and other powerful medications rather than the illness itself. In spite of his illness, Renoir fathered a happy family when he was in his 50’s and led an ascetic life well into his 80’s weighing less than 80 lb during his last years.
1.45. Pills and Poisons
Most patients are neither as courageous as Renoir in working to overcome pain, nor as timid about trying new treatments and medications. The infamous drug Vioxx used by millions to treat the pains of arthritis was developed on the basis of an emerging understanding of the actions of all non-steroidal anti-inflammatory drugs. It turns out that drugs such as aspirin typically act by suppressing the a particular enzyme, cycloxigenase 2 (COX-2) which normally promotes inflammation by converting arachidonic acid into a hormone, prostaglandin. The inflammatory reaction is the defense reaction of bodily tissues to injury. Prostaglandins cause vascular changes related to inflammation as well as stimulating neural impulses that are perceived as pain. Unfortunately, the side effect of this class of painkillers known as ‘non-steroidal anti-inflammatory drugs’ (NSAIDs) is to suppress the entire inflammatory reaction, not only the pain caused by this reaction. Thereby they can also impede the body’s ability to defend and repair damaged tissue. Vioxx was a new drug designed specifically to target COX-2. While it was hailed as a wonder in relieving intense arthritic pain, it also led to an increase in strokes and heart attacks, and was taken off the market when the developer Merck was held responsible for punitive damages against the victims.
Most NSAIDs were discovered or developed before their mode of action was understood. One of the first was acetaminophen, developed by Bayer in
The drive to develop an alternative to aspirin came from the finding that the tablets were incompletely broken down during digestion, and fragments were found in some patients clinging to the stomach lining in little pools of blood. This led to anemia in habitual users. Harold Scruton, an industrial chemist in
While there are over 100 NSAIDs, some of them the same drug under different brand names, the third market leader ibuprofen is unrelated to aspirin or acetaminophen. It was developed by Boots the British pharmacy chain from a simple compound propionic acid and launched as Brufen in 1962. Particularly effective against the musculoskeletal aches and pains of rheumatoid arthritis, it was marketed in the
Alongside the development of popular painkillers came advances in surgical anesthesia. The ‘rag and bottle’ method of administering chloroform in John Snow’s day was replaced by gas cylinders and gages to measure and precisely administer the drugs. Edmund Andrews in
1.46. The Surgery of Pain
The surgery of pain was promoted by the French vascular surgeon René Leriche in his book La Chirurgie de la douleur published in 1937, and Dormandy is a fan. It was Leriche who said ‘Let us reject this concept of ‘beneficial pain’ with all our might’, rallying in support of the new medical sciences: ‘Let it be right to cry out when a neuralgia or even the imaginary specters of madness seem unbearable. It is the doctor’s and nurse’s Hippocratic duty to help such people, not to preach heroism and self-control’.
Leriche was a popular surgeon, and he developed a procedure for removing the ganglia of the sympathetic nervous system to prevent the pains of angina and colic as well as resting pains in the lower limbs. It probably worked by blocking vasoconstriction and thereby improving the blood supply to the internal organs and affected limbs. Leriche believed that his procedure might interrupt pain fibers to the brain and also influence chemical activity. He questioned the idea of ‘referred pain’, believing that patients have direct access to sensations in their internal organs. Both these notions were subsequently disproved and yet people traveled from all over
The pain pathways of the body were mapped out through experiments with animals and postmortem analyses of cases where sensation and pain were lost in the lower limbs and abdomen as a result of disseminated tuberculosis. By 1911 the first ‘cordotomy’ was performed on a terminally ill cancer patient who was relieved of his pain, and in 1912 Beer performed a similar operation for ‘intolerable pain due to metastases in the nervous plexus in front of the lower spine’ enabling his patient to walk again some days later. Surgery became possible inside the skull (see 1.41) and in spite of the high mortality rate such operations provided relief from otherwise untreatable pain.
Frontal lobotomies enjoyed a spate of popularity in the treatment of chronic pain and phantom limb syndrome during the 1940’s, although it was unclear whether they cured the pain or simply made the patients impervious to it. The justification was that ‘dissociation between pain perception and reaction to pain can be induced not only by drugs and by strong religious beliefs but also by cerebral damage’ according to Wolff’s
1.47. The Schism
The real break in medicine came not with the invention of anesthetic surgery or the synthesis and promotion of new painkillers but instead with the discovery of antibiotics. Penicillin was discovered (or rediscovered) by Alexander Fleming in 1928, and its antibiotic properties were shown by Howard Florey and others at
The second major advance in medication was the development of cortisone in 1949. Original promotional movies showed crippled and deformed patients barely able to take a step transformed into smiling people climbing stairs and swinging their arms. Steroids proved to have unpleasant and even dangerous complications, but they provided considerable relief from the pains of rheumatoid arthritis.
In 1949 Laborit noticed the calming effects of antihistamine sedatives, and by 1952 a French drug company started to develop chlorpromazine, a drug used to effectively control the emotional pain of schizophrenia. Patients could safely be released from mental institutions. The physical methods used to treat severe mental illness such as electric shock, insulin coma and lobotomy eventually became a thing of the past.
Reconstructive joint surgery for osteoarthritis was introduced with hip replacements in 1961. During the 1960’s and 1970’s kidney transplantation and coronary bypass operations became available, effectively curing previously chronic and painful illnesses such as angina.
These advances came at a cost. Patients who could not be cured became a problem to medical science. Pain was no longer interesting, to the degree that it was barely mentioned in medical textbooks. In all 620 pages of a British 1960’s textbook The Principles and Practice of Medicine for Student Doctors the only mention of pain was that for patients with advanced carcinoma ‘analgesics should be given to control pain but without leading to undue dependence or addiction.’ There was no discussion of how or why dependence and addiction should be avoided in such cases. Helen Neal, a health journalist working at the National Institutes of Health in
At least in part as a result of these advances in medicine, people began to live longer than ever before, and while some of the new treatments targeted the diseases of old age, aging and death remained as painful as they have always been. Within conventional medicine, the gap left by the schism began to be filled with the emergence of specialized multidisciplinary Pain Clinics and by the hospice movement and palliative care. New technologies in neuroscience facilitated the study of the biology of pain, with the hope that this might lead to better treatments.
1.48. Pain Mechanisms
The renewed interest in pain stemmed new definitions. The one adopted by the International Association for the Study of Pain was coined by a group of ‘concerned scientists and doctors’ headed by Harold Mersky at the University of Western Ontario in 1979:
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
Several comments are appended to this definition, including the following:
Many people report pain in the absence of tissue damage of any likely pathological cause. Usually this happens for psychological reasons. There is no way to distinguish their experience from that due to real tissue damage, if we take the subjective report. If they regard their experience as pain caused by tissue damage, it should be accepted as pain.
Activity induced by nociceptors and nociceptive pathways by noxious stimuli is not pain. Pain is always a psychological state, even though we may appreciate that it often has a proximate physical cause.
In other words, pain is a state of mind whose content is bodily damage. It can be stimulated by actual tissue damage or by the activation of particular sensory pathways specific to pain, but each of these three conditions (pain, tissue damage, and activation of neural pathways for pain) can also exist independently.
Sensory nerves in the skin and throughout the body have endings sensitive to changes in pressure, temperature, acidity, and certain chemicals. They are particularly sensitive to ‘free radicals’ a class of chemicals released by damaged tissue. When the nerve fiber is stimulated (either at the ending or by pressure somewhere along its course) a nerve impulse or burst of impulses travels toward the spinal cord. There are at least two kinds of fibers, fast A fibers where the speed of the impulse reaches up to 100 meters per second, and slow C fibers where it is only 0.25 meters per second. Impulses caused by tissue damage are called ‘nociceptive’. Dormandy complains that Descartes might have called these impulses dolorous but since he is out of fashion scientists are prone to ‘long-winded mystification’. A local anesthetic applied anywhere along the course of the nerve fiber prevents the impulse from reaching the spinal cord. The molecular mechanisms for this action of local anesthetics remain unclear.
Sensory impulses traveling toward the central nervous system (the brain and spinal cord) and the fibers carrying them are termed ‘afferent’, whereas the fibers and impulses carrying motor commands from the central nervous system are termed ‘efferent’. The cell bodies of the afferent sensory fibers are bunched in pea-size ganglia that form two vertical chains on either side and in front of the spinal cord. Short fibers from these cell bodies enter the spinal cord via the ‘anterior nerve roots’. The gray matter in the spinal cord is arranged in an X shaped cross section, with two anterior (pointing forward) horns and two posterior (pointing back) horns. In the anterior horns, the anterior nerve roots synapse with a second set of neurons that sends fibers to the subcortical nuclei of the brain and the sensory cortex. The ascending fibers form white matter tracts around the gray matter of the spinal cord.
P. D. Wall and Ronald Melzack showed in the 1960’s that pain messages reaching the spinal cord interact with synchronous impulses from other fibers and also with impulses descending from the brain, so that they do not necessarily travel further. They proposed the ‘Gate Control’ theory of pain.
It had long been known that tissue damage does not necessarily result in the sensation of pain. David Livingston wrote this 1859 description of being mauled by a lion, who before being shot and killed ‘besides crunching the bone into splinters… left eleven teeth wounds on my upper arm.’
The lion caught my shoulder as he sprang and we both came to the ground below together. Growling horribly close to my ear, he shook me as a terrier dog does a rat. The shock produced a stupor similar to that which seems to be felt by a mouse after the first shake of the cat. It was a sort of dreaminess in which there was no sense of pain nor feeling of terror, though quite conscious of all that was happening. It was like what patients partially under the influence of chloroform describe, who see all the operation but see not the knife. This singular condition was not a mental process… The peculiar state is probably induced in all animals killed by carnivore, and, if so, is a merciful provision by our benevolent Creator for lessening the pain of death.
Gate Control also helps explain the pain of phantom limbs and other conditions that cause ‘deafferentiation’, the loss of incoming sensory stimulation at the level of the anterior horn. Besides amputation, this can be caused by injury, for example a motor cycle accident tearing away the plexus of nerves in the armpit, by nerve damage due to a viral infection, for example post-herpetic conditions after infection with the herpes virus, or by metabolic abnormalities such as diabetes. The cell bodies that normally receive their input from the deafferentiated fibers can go into a frenzy of activity due to the lack of a context by which to interpret the residual incoming signals. The picture is like suddenly turning the lights off – every flicker looks like it might be an obstacle. Deafferentiation pains rarely respond to anelgesics, and surgery is usually futile. As Leriche said, ‘the pain always runs ahead of the knife’, because down the line there are always more nerves whose input is being cut. A new technique currently under clinical investigation is the transcutaneous electrical stimulation of peripheral nerves, to try and restore the context of spinal nerve activity. Perhaps this accounts for some of the effects of acupuncture, which might set up calming signals by acting along deafferentiated fibers.
Congenital analgesia, the condition of being born with the absence of pain sensations, is still a mystery. It suggests, perhaps, the existence of a specific enzyme or neurotransmitter concerned with the transmission of pain signals, whose mutation deprives the body of the sensations of pain.
Scientists were surprised to discover in the 1970’s receptor sites in the brain specific to molecules such as morphine and heroin. As one of them remarked, this was ‘like an intrepid explorer entering an unexplored cave in the middle of nowhere and finding a friendly cup of tea waiting for him inside’. In 1973 the first naturally occurring endorphin was identified by Candace Pert. Endorphins (or enkephalins) are chemicals whose action was mimicked by the plant-derived opiates. They are concerned with the modulation of the pain response in different parts of the central nervous system. It has been suggested that they are responsible for the exhilaration experienced by joggers and other athletes, and for the addictiveness of vigorous exercise. Natural endorphins are released in minute doses at specific receptor sites and then rapidly metabolized. Drugs act everywhere and are broken down slowly, causing permanent changes. Nonetheless Dormandy argues that as with joggers, the danger of addiction is greater for those who take opiates for their general well-being as opposed to the specific treatment of pain.
1.49. Pain Clinics
Pain clinics were introduced by John Bonica, a professor of anesthesia who opened the first pain clinic in
1.50. Hospices
The modern hospice movement was started in the 1950’s by Cicely Saunders, a British nurse and later a doctor. After her nursing training at
Our study clearly shows that opiates are not addictive for patients with advanced cancer; that the regular giving of opiates does not cause a major problem of tolerance; that giving oral morphine works and that it does so not by causing indifference to pain but by relieving it. Set alongside the prevailing myths of tolerance and addiction, it is not surprising that a patient arriving at
With the support of some of her patients and by raising money from the British government and the Churches, she founded the St Christopher’s Hospice near
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