Pain in 19th & 21st Centuries
A Window into Different Medical Worlds
A research study compares surgical and non-surgical interventions on patients with back pain. This article contrasts the views of pain in 19th & 21st century medicine.
Writing in 1847, Sir James Young Simpson recounted how his recent use of chloroform anesthesia had enabled him to reduce the pain of childbirth for a woman in labor. Simpson observed that “I most conscientiously believe that the proud mission of the physician is distinctly twofold—namely, to alleviate human suffering, as well as preserve life.”
This view—that the physician had a duty to reduce pain as well as save life—constituted a sea change in professional attitude. In earlier times, surgeons had to develop a very thick skin professionally and be willing, when medically necessary, to inflict pain in order to save life. As the medieval author Henri de Mondeville declared, the surgeon had to be able “to cut like an executioner.” This view of surgery and pain was vividly portrayed by the English novelist Frances Burney in her account of the breast surgery she underwent in Paris in 1811. She recounted how 7 men entered her room, she was placed on a bed, and a veil was placed over her face. She observed that “when the dreaded steel was plunged into the breast . . . I needed no injunctions not to restrain my cries. I began a scream that lasted unintermittingly during the whole time of the incision--& I almost marvel that it rings not in my Ears still! So excruciating was the agony.”
Earlier this week, the Journal of the American Medical Association reported on the results of a clinical trial, which was designed to determine whether patients who suffered from sciatica, a form of back pain from herniated disks, should receive surgery, or be treated without surgery through a combination of physical therapy and medication; in the study, about 500 patients were randomized—that is, they were assigned either to the surgery group or the non-surgery treatment group. In other words, the debate now in the 21st century is the mirror image of the one in the 19th century: should surgery be done to relieve rather than inflict pain? Furthermore, as the New York Times reported, some physicians were so convinced of the efficacy of surgery in relieving pain that they thought it would be unethical for their patients to participate because they might be assigned to the non-surgery treatment group.
The researchers found that there was no difference in outcomes in the two groups—at follow-up, both groups showed reductions in levels of pain. As health correspondent Susan Dentzer pointed out, “The lead investigators hope that what comes out of this is an agreement that the best choice, the right rate of surgery or of non-operative care, is what informed patients decide to do once they're presented with all of the evidence.” By empowering the patient to make an informed decision (rather than providing unambiguous guidance to the physician), this outcome is also emblematic of the greater focus on informed consent as an ethical requirement that has come to guide the contemporary physician-patient interaction.
