A Brief History of Pain Management Shelagh Wright, PhD

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A Brief History of Pain ManagementShelagh
Wright, PhD

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References

• Clark, D (2002) Cicely Saunders. Oxford
  University PressIASP http//www.iasp-pain.org/term
  s-p.html
• Dormandy, T.(2006) The Worst of Evils The fight
  against pain. New Haven,Yale University Press
• McCaffery, M. Pasero C. Pain Clinical Manual
  2nd Ed Mosby
• Meldrum ML A Capsule History of Pain Management
  JAMA 290, 2471-2475
• Melzack, R Wall, P (1982, 1988) The Challenge
  of Pain. London, Penguin
• The John C. Liebeskind History of Pain
  Collection UCLA History of Pain Project Relief
  of Pain and suffering http//unitproj.library.ucl
  a.edu/biomed/his/painexhibit/panel1.htm
• Power, K.(2006) The end of suffering. Philosophy
  Now http//www.hedweb.com/hedethic/end-suffering.h
  tml

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Milton, Paradise Lost, BK vi, 1, 462

• Pain is perfect misery, the worst
• Of evils, and, excessive, overturns all patience

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Pain management through the centuries

• The fight against pain does not fit into a neat
  chronological framework
• Rendering unconcious with knock out blow was one
  of the earliest methods of anaesthesia
• When nitrous oxide, ether and choloroform emerged
  in the 19th century considered new beginning
  however, the effects of certain gases to make
  people sleep had been known since biblical times
  (Dormandy,2006)

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Pain relieving substances Opium

• Plant pain relievers were often powerful and when
  taken in overdose, deadly.
• Opium derived from the poppy flower, Papaver
  somniferum was commonly used.The word opiumis
  Greek for the fresh juice of the poppy Papaver
  somniferum and Papaver rhoeas were grown in
  Ancient Egypt and Mesopotamia. (Dormandy,2006)

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Roman attitudes to opium

• All poets of the Augustan age praised opium in
  contrast medical doctors tended to disapprove
• Celsus (1st century AD) coined terms dolor
  (pain ) rubor (redness) tumor (swelling) and
  calor (heat) for acute inflammation and
  emphasised it is the cause of pain rather than
  pain itself which doctors should treat.
• Celsus stated that opium has been used to calm
  tempers and to induce pleasant dreams since
  the Trojan War and is still popular but
  doctors should treat it with circumspection.
  (Dormandy,2006)

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Fears around opium use

• Galen (2nd century AD) more than anything else
  I deplore carotic drugs
• Recommended pain relief in older patients
• Specifically warned against constipation and that
  too big a dose can kill patients.
  (Dormandy,2006)

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Long term influence

• Celsus was a landed gentleman cultivated
  medicine as hobby 6 volume De Medicina
  completed about 30 AD
• Printed in 1478 , at least 50 editions and widely
  used until mid eighteenth century
• Galen no doctor in the history of medicine has
  exercised such a profound influence on
  professional practice...for so long.
  (Dormandy,2006)

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Morphine

• Ist century AD Scribonius Largus, personal
  physician to Emperor Claudius, described how the
  pod of the poppy should be split and how the
  escaping juice should first be dried and then
  scraped off
• In 1803 Friedrich Wilhelm Sertürner (1783-1841)
  isolated crystals of a powerful analgesic agent
  from crude opium. Sertürner named the chemical
  morphine, after Morpheus, the Greek God of
  dreams. It could be introduced on the point of a
  lancet or a solution could be washed into a
  wound. (Dormandy,2006)

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Necessity.the syringe

• In the 1850's Charles Gabriel Pravaz (1791-1853),
  a French surgeon, and Alexander Wood (1817-1884)
  of Edinburgh independently invented the syringe.
  Injections of morphine were generally used for
  local pain.

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Other pain relieving substances

• Alcohol or wine, mandragora or mandrake from the
  plant Atropa mandragora, belladonna from the
  deadly nightshade, and marijuana or Cannabis
  indica.
• Hellebore, henbane, datura, and hemlock were used
  carefully, their strength being recognized.

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Recipe for the soporific sponge from Theodoric
of Cervia from the work, Cyrurgia (Venice, 1498)

• take opium, and the juice of unripe mulberry
  (probably a textural mistake for black
  nightshade), hyoscyamus (henbane), the juice of
  hemlock, the juice of leaves of mandragora, juice
  of climbing ivy, of lettuce seed, and of the seed
  of the lapathum (dock) which has hard, round
  berries, and of the water hemlock, one ounce of
  each. Mix all these together in a brazen vessel,
  and then put into it a new sponge. Boil all
  together out under the sun during the dog days,
  until all is consumed and cooked down into the
  sponge. As often as there is need, you may put
  this sponge into hot water for an hour, and apply
  it to the nostrils until the subject for the
  operation falls asleep (he who must go under the
  knife,--llit. be cut into). Then the surgery may
  be performed and when it is completed, in order
  to wake him up, soak another sponge in vinegar
  and pass it frequently under his nostrils. For
  the same purpose, place the juice of fennel root
  in his nostrils soon he will awaken."

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Aspirin

• The real wonder drug proved to be a compound
  found naturally in willow tree bark or meadow
  grasses. In 1897 Bayer chemist Felix Hoffmann
  developed a stable form of this natural compound
  which could be safely used by most people,
  without side effects. Acetylsalicylic acid (ASA),
  sold by Bayer under the trade name "Aspirin," was
  the first reliable and effective such pain killer
  or analgesic.

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Five vintage Bayer bottles and tins,
1930-1955Used with permission of Bayer
Corporation
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Surgery

• Its hard to imagine that anyone could have been
  anything but pleased when painless surgery was
  introduced in the mid-19th century. And yet,
  although many welcomed anaesthesia, some did
  object. In Zurich, anaesthesia was even outlawed.
  Pain is a natural and intended curse of the
  primal sin. Any attempt to do away with it must
  be wrong, claimed the Zurich City Fathers.
  Painless delivery in childbirth was a
  particularly contentious issue. Some insisted
  that in sorrow thou shalt bring forth children
  (Genesis 316). Others, like Doctor Charles
  Delucena Meigs (1792-1869), Professor of
  Obstetrics and Diseases of Women at Jefferson
  Medical College, believed that labour pains were
  a most desirable, salutary and conservative
  manifestation of the life force. There was even
  a belief, expressed in 1847 in The New York
  Journal of Medicine, that pain was vital to
  surgical procedure.

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Pain A burden to be borne

• In the 1800s, most people expected to experience
  pain in their lives and relied on religion or
  personal fortitude to help them endure it. Pain
  was one of God's punishments for the wicked and
  purifying trials for the good for the woman in
  labor, pain was the spiritual experience that
  would transform her into a self-sacrificing
  mother.

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Nitrous Oxide

• Humphrey Davy (1778-1829) suggested that the pain
  and shock of surgical operations might be
  relieved if patients inhaled nitrous oxide, a
  gaseous compound discovered by Joseph Priestley
  (who was also the first to isolate oxygen).

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Morton and ether

• In 1846, Morton made his famous demonstration of
  surgical anaesthesia at the Massachusetts General
  Hospital, using a hastily rigged apparatus to
  deliver ether to the patient. The new technique
  was to revolutionize practice, enabling surgeons
  to develop finer skills and life-saving invasive
  procedures. But the use of anaesthesia became
  common only gradually many physicians were
  accustomed to relying on "the healing power of
  pain" and were wary of the ethics of operating on
  an insensate patient.

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James Young Simpson (1811-1870)

• James Young Simpson (1811-1870), a Professor of
  Midwifery at Edinburgh, wanted to find an
  alternative to ether " . . . in order to avoid,
  if possible, some of the inconveniences and
  objections pertained to sulphuric ether, -
  (particularly its disagreeable and very
  persistent smell. . . and the large quantity of
  it occasionally required to be used, more
  especially in protracted cases of labour.)"

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James Young Simpson (1811-1870)

• Simpson experimented with various compounds and
  found chloroform to be efficacious and reasonably
  safe. He began using it to relieve the pains of
  childbirth and incurred the wrath of those
  holding to the Biblical view that "In sorrow thou
  shalt bring forth children." After Queen Victoria
  chose to be anaesthetized in 1853 for the birth
  of Prince Leopold and again in 1857 for the birth
  of Princess Beatrice, however, the practice
  became common among the upper and middle classes.
  

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1880s

• By the 1880s anaesthesia, with aseptic technique,
  was standard practice in American and European
  surgical theaters. Hospitals were transformed
  from charitable asylums for the poor into
  consumer-oriented service institutions. While the
  surgeon's prestige and power soared, the
  anaesthetist was a mere assistant--a nurse,
  intern or medical student. The development of the
  independent medical specialty of anaesthesiology
  would not occur until the early 20th century.

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20th Century successful persuaders
ProfessorJohn Bonica

• Professor John Bonica born 1917 1927 Emigrated
  with his family from Aeolian islands off coast of
  Sicily
• 1960 1st Professor of Anaesthesia at Washington
  Medical School in Seattle, USA
• Opened first Pain Clinic championed
  multidisciplinary pain team ground breaking book
  1953 The Management of Pain
• Two beliefs pain deserved to be treated even
  when its cause was unknown such treatment could
  be effective only through MDT (Dormandy,2006)

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Dame Cicely Saunders (1918-2005)

• Accepted in the St. Thomas Nightingale School of
  Nursing, 1940
• Endured chronic disability due to back pain
• Changed career to lady almoner (MSW)
• Within a year worked as volunteer at St Lukes
  Hospital, originally home for the Dying Poor
• Then read medicine in order to start a home for
  the dying and frail elderly
• Qualified in 1957 aged 39 years (Clark, 2002)

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1950s

• NHS in place for more than a decade
• Welfare state pledged to provide care from the
  cradle to the grave
• Nothing done to promote care of the dying
• Globally no more that a dozen homes for the
  dying founded late 19 century
• Concerns were religious, philantropic and moral
  and gave special concerns to poor and
  disadvantaged (Clark, 2002)

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Throughout 1960s

• Development of Saunders work
• Distinguished between different grades
• -mild, moderate severe pain
• Thorough understanding of available pain
  relieving drugs
• aspirin, codeine (tablet)
• Brompton Mixture (liquid)
• Morphine, diamorphine (injection)
• Hard headed approach constant pain needs
  constant control
• Linking of physical pain and mental suffering

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Concept of Total pain

• Physical and mental suffering each capable of
  influencing and shaping the other
• If physical symptoms are alleviated then mental
  pain is lifted also letter to BMJ 1963
• Approach required attention to the meaning of
  pain
• Required response breadth of vision for
  understanding and huge versatility in its
  alleviaiion
• Emerging field of terminal care furnished with
  most important concept (Clark, 2002)

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Psychosocial aspects of pain

• The phrase total pain (1964-1967) was coined by
  Dame Cicely Saunders to emphasize the
  multidimensional ramifications of pain in
  advanced cancer
• physical
• psychological
• social
• spiritual

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Gate Control Theory

• In 1965, a collaboration between two
  self-described iconoclasts, Canadian psychologist
  Ronald Melzack and British physiologist Patrick
  Wall, produced the gate control theory. Their
  paper, "Pain Mechanisms A New Theory," (Science
  150, 171-179, 1965) has been described as "the
  most influential ever written in the field of
  pain." Melzack and Wall suggested a gating
  mechanism within the spinal cord that closed in
  response to normal stimulation of the fast
  conducting "touch" nerve fibers but opened when
  the slow conducting "pain" fibers transmitted a
  high volume and intensity of sensory signals. The
  gate could be closed again if these signals were
  countered by renewed stimulation of the large
  fibers.

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GATE CONTROL THEORY
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The biopsychosocial model of pain

• first applied to low back pain by Waddell (1987)
• the vast majority of backache starts with a
  physical source of pain. However,
• distress (the emotional reaction to pain and
  disability) and
• illness behaviour (the presentation of distress
  to the carer) may come to dominate the picture,
  which in turn both affects and is affected by the
  patients social interactions

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• Pain
• Inter-relationships

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Definition of pain for clinical practice
(McCaffrey, 1968)

• pain is whatever the experiencing person says it
  is, existing whenever the experiencing person
  says it does
• specifically, this definition means that when the
  patient indicates he or she has pain the health
  care team responds positively. The patients
  report of pain is either believed or given the
  benefit of the doubt.
• the subjectivity of pain affects all who care for
  patients with pain

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Implications

• For listening
• Patient empowerment
• Coping and problem solving skills acquisition
• Patient education
• Cognitive behavioural therapy
• CAM

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Link between mental and physical pain

• Taken for granted in all ancient civilisations
• Now recognised by advanced researchers that the
  two are inseparable
• No Victory of Pain can be celebrated until the
  treatment of mental hurt has advanced at least as
  far as the treatment of physical suffering
  (Dormandy,2006)
• Hope-but not triumph.