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‘Voyons...ouvrons la bouche’ – Pre-anaesthetic dentistry by Honoré Daumier (1808-79) |
The power of pain to make things better
The thing with pain is that it hurts, but, says Professor Lewis Wolpert, that’s one of the reasons it’s there
THE WORST OF EVILS: THE FIGHT AGAINST PAIN by Thomas Dormandy
Yale, £35 order this book
PAIN is everywhere – just ask your friends – and things get worse with age. Here is a large book that takes one through not the history of the attempts to deal with pain, and also its cultural history.
Mini biographies of those who contributed to the search for pain killers abound.
But the title is, in my view, misleading, as pain is not evil – quite the contrary. Pain has evolved, probably in all vertebrates, as a mechanism of defence against injury. It stops us doing excessive damage to ourselves as we interact with the environment.
If we have a broken leg, pain tells us to stop running. Even toothache tells one that teeth are in a very bad condition. But the pain that comes from a variety of illnesses such as local inflammation, arthritis, and trigeminal neuralgia may be less adaptive, and can be severe and disabling.
It has even been argued, as Dormandy makes clear, that it is only through pain that an individual truly learns who they are.
Expression of pain can evoke sympathy and support. Those born with a genetic defect such that they feel no pain are crippled from birth and usually die young from, for example, painless appendicitis. There has been a continual search for painkillers which were almost always some sort of medication. Alcohol and the juice of the poppy were used from the earliest times, and opium came from the latter.
There has always been a problem of how to balance pain relief with addiction and the effects of mind-bending drugs – Hannibal took his own life with opium some 2,000 years ago, and Socrates took hemlock.
Cannabis was probably there from those early times. Hundreds of medications have been tried.
There were however those, like the early Christian martyrs, who tried to suppress pain by denying it.
There is recent evidence that a kind of self-hypnosis does actually work. This has raised the question as to whether Christ on the cross was in fact in severe pain. And many turned to God for relief of their pain both in ancient times and even more recently
While attention is given to Mesmer and his ideas of animal magnetism, the placebo effect is insufficiently analysed in this book.
With the Renaissance came anatomy and a beginning of understanding of the nervous system. War injuries promoted efforts to stop pain, and the tourniquet helped.
Surgical operations remained a terrible ordeal and the origins of anaesthesia are to be found in the 17th century but it was only in the 18th century that laudanum was widely used and after that nitrous oxide.
These helped but not sufficiently. Painless anaesthesia arrived a century later with ether and it pleases me that doctors at University College Hospital played an important role. Then came chloroform.
The discovery of all these compounds involved both luck and imagination and technical skills. The injection of morphine required the invention of the syringe and the hollow needle. Phenacitin came from the bark of the willow and had been used in ancient times as a herbal remedy.
Advances in chemistry and the rise of the pharmaceutical industry then brought us aspirin and more than 100 agents that unlike cortisone act not on the transmission of the pain stimulus, but on the inflammatory region which causes the pain.
Advances in understanding how nerves functioned and communicated with each other opened up new pathways for research. There were great advances in medicine and painkillers. The list of drugs that affected pain grew longer and longer.
There were also some like LSD that induced hallucinations to which some became addicted. And there was barbiturate intoxication and deaths from Vioxx which I found so helpful.
But Dormandy points out there developed a greater emphasis on curing than caring, and this may be why conditions like non-specific back pain, migraine, and osteoporosis remain very painful.
Just how pain is generated by the body still remains unclear. There can be pain in the absence of any tissue damage and so the cause is not known.
There do not appear to be pain receptors but sensory nerves can respond to changes in chemicals at their ends due to the surrounding cells being damaged.
One theory suggests that when these sensory nerve impulses arrive at the spinal cord they interact with other nerves which act as a gate and determine whether a painful impulse reaches the brain. This is a remarkable history but you will not find here the best way to treat your own pain.
For example Dormandy does not mention how helpful physiotherapy can be, or consider whether acupuncture really works.
There is also only a brief mention of the relationship between physical and mental pain which can also be severe. But for a history of an important aspect of illness and medicine this is an excellent read.
THOMAS Dormandy, MD is a consultant chemical pathologist and retired professor of chemical pathology, at the Whittington Hospital, University of London, and Brunel University.
He is the author of more than 300 scientific papers and three books including The White Death: a history of turberculosis, which was short listed for the prestigious Aventis prize; Old Masters, a work of art history and Moments of Truth: Four creators of modern medicine, which provided an insight into the life of Joseph Lister, inventor of antiseptic surgery, who was Professor of Surgery at King’s College Hospital. |
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