The Under-treatment of Pain - Part I, some history

A growing number of health professionals and patient advocacy groups are pressuring doctors to change their attitude about what is appropriate medication for chronic pain. The debate about proper pain management was recently brought to the fore by a commission which accredits health care organizations and which has adopted new standards for evaluating and managing pain - in effect loosening the controls and increasing medication. In a subsequent DoctorInternet column, the details of those new standards will be covered; but here the focus will be on some historical background about pain and suffering. It is an interesting tale and will give a better understanding about some of the subliminal attitudes that may be operative in this issue.

The use of artificial methods for pain relief in drastic medical procedures, such as surgery, seems to have never received any moral opposition throughout history. Wine and beer in large amounts could anesthetize; and various plants such as henbane, mandrake, hemp, and opium were used in various concoctions in virtually every culture. Even knock-out blows to the head may have been used in surgical operations. In 1536, Paracelsus described "laudanum", an alcoholic tincture of opium, for pain, and soon thereafter, Valerius Cordus described "sweet oil of vitriol" or ether, which, some 300 years later, was demonstrated by William Morton (1846) to be a scientifically effective anesthesia for surgery - thus, initiating the modern science of anesthesiology. However, the artificial relief of pain to mitigate suffering has been another issue, and the aspect of its morality has played a powerful role in governing the medical use of analgesics even into the current discussion.

The word "pain" is derived from the Greek word for payment, penalty, and punishment; and "suffering" is the generic term for everything that produces the feeling of pain. Thus, one can see, embedded in the concept, the notion that a person's suffering and pain are due to some wrong for which one is being punished; and in Judeo-Christian theology, suffering is integral to salvation. Of course, one of the mandates of medicine is to eliminate suffering; thus, a confrontation between religion and science is inevitable.

The landmark case in this confrontation involved the Scottish physician, James Young Simpson, who was the first to used chloroform to alleviate pain in child birth (1847). Of all the various types of pain, child birth occupies a unique place in Western theology. Recall that in the Biblical story called The Fall of Man (Genesis III), Eve and Adam violate God's prohibition against eating the fruit from the Tree of Knowledge; and because of that, God fears that they will proceed to the second tree, the Tree of Life, and become immortal like himself. As a preemptive strike, He expels the two from paradise giving punitive sanctions on them both. For Eve, "I will intensify the pangs of your childbearing; in pain shall you bring forth children." This divine curse was taken so literally by religious fanatics that in 1591 King James VI of Scotland had burned at the stake a gentlewoman named Euphanie Macalyane who secretly used a remedy to relieve her pangs of childbirth. Although biblical interpretation had change by the 19th Century, Dr. Simpson still was to encounter vehement opposition on religious grounds for his use of chloroform in childbirth. Simpson's discovery of the use of chloroform is an interesting tale and warrants recitation here. The excerpt is from "Triumph Over Pain" by Rene Fulop-Miller, 1938; pages 331-333.

Dr. Simpson determined to make immediate trial of this fluid, and asked Duncan and Keith to supper on November 4, 1847. There were also present on this occasion Mrs. Simpson, her niece Miss Petrie, and a naval officer who was a friend of the family. At table, of course, there was talk of the proposed experiment with chloroform, the three nonprofessional members of the party - the two ladies and the naval officer - being equally keen on inhaling the vapor. "I have always wanted to join in one of these experiments," said Mrs. Simpson to her husband. Miss Petrie and the young naval man chimed in, and the professor agreed that they should all try it. Thus, when the meal was over, the dinner party was transformed into a chloroform party.

Each of the participants was handed a tumbler containing a modicum of chloroform in the bottom. "Are you ready?" asked Simpson. "One, two, three." He clapped his hands, and at the same instant they all began to draw long, deep breaths of chloroform vapor.

The effect was first noticed by Miss Petrie. Usually a retiring young woman, she displayed ecstasy and excitement: "I'm beginning to fly!" she shouted. "I'm an angel, oh, I'm an angle!" Hardly had she spoken these words when her head dropped forward and she was fast asleep.

At the same moment Dr. Keith burst out laughing. Was it Miss Petrie's ecstasic words which had amused him? No one could tell, but his laughter proved infectious. Dr. Duncan, Mrs. Simpson, the professor himself, all began to laugh. They felt very happy, became extremely loquacious, shouted loudly and roared with laughter. Only the navl officer sat looking on, puzzled and aloof. He stared at the other's strange antics. "What are you all so excited about?" he was on the point of saying, but hardly had he begun to speak, in a deep bass, when his voice broke into falsetto. Then he began to crow like a cock, which made the others more hilarious than ever.

Next, as the joyful mood reached a climax, Dr. Simpson leaped up from his chair and stood on his head in the middle of the room, waving his feet in the air. Mrs. Simpson tried to get him out of the undignified posture, but before she could reach him he fell with a crash onto the floor, where he began to snore loudly. Mrs. Simpson, too, was soon overpowered with sleep.

On awaking, Simpson first perception was mental. "This is far stronger and better than ether," said he to himself. His second was to note that he was prostrate on the floor. Hearing a noise, he turned round and saw Dr. Duncan beneath a chair - his jaw dropped, his eyes staring, his head bent under him; quite unconscious, and snoring in the most determined manner. Dr. Keith was waving feet and legs in an attempt to overturn the supper table. The naval officer, Miss Petrie and Mrs. Simpson were lying about on the floor in the strangest attitudes, and a chorus of snores filled the air.

They came to themselves one after another. When they were soberly seated round the table once more, they began to relate the dreams and visions they had had during the intoxication with chloroform. When at length Dr. Simpson's turn came, he blinked and said with profound gratification: "This, my dear friends, will give my poor women at the hospital the alleviation they need. A rather larger dose will produce profound narcotic slumber."

With the success of his "chloroform party", Simpson immediately initiated its use in obstetrics. But, he soon met an onslaught of religious criticism, calling his work "a Satanic invention" and him a "shameless heretic". His fellow physicians turned on him, labeling him an "irresponsible charlatan". Fortunately, he was an obstinate man; and highly religious, himself. He quickly became a biblical scholar and met each condemnation with skilled theological refutation. During 4 years of vigorous debate, his reputation grew; and gradually the wives of the clergy and his fellow physicians began seeking his obstetric services. Finally, when Queen Victoria commanded her physician to give her chloroform during the birth of her 8th child, opposition evaporated; and Simpson was eventually given great honors and fame. On one occasion, after receiving a commemorative from the city of Edinburgh (which only 10 years before was prepared to condemn him) he made the following remark: "I came to settle down and fight among you a hard and uphill battle of life for bread and name and fame, and the fact that I stand before you this day testifies that in the arduous struggle I have - won."

Anesthesia and Pain History - Resources on the Internet.

Images of Dr. Simpson from the National Library of Medicine.