The Worst of Evils: The Fight Against Pain
by Thomas Dormandy
Yale University Press, 560 pages, $35
In 1983, my father, who was dying of colon cancer, underwent surgery. When I visited him after the procedure, I was aghast to find him lying in bed, clearly in agony, pressing an ice pack against his abdomen. “Didn't the doctors offer you any pain pills?” I asked. They had, Dad admitted, but he had refused the medicine. “Why would you do that?” I demanded. Dad's sad answer: “I don't want to get addicted.”
I quickly devised a plan to change his mind. A highly decorated World War II combat veteran, he had always taken quiet pride in being strong, so I said: “You're a tough guy, Dad. I know you won't get addicted, and even if you do, you'll beat it.” “OK,” he blurted out, grateful for being given permission not to be in pain. He was soon resting comfortably. A month later, he entered a hospice, and, even though the cancer eventually spread, he never experienced serious pain again.
Years later, my mother needed a hip replacement. We met with her surgeon a few days before the procedure and spoke about the anesthesia she would receive and agreed that pain control would be an important part of her postoperative care. Mom received morphine in the hospital and was soon weaned to less potent forms of palliation. Within a few weeks, she was off pain medication and on her way to recovery.
I recount these stories not because they are exceptional but because they are unremarkable. Palliating pains large and small is such an integral part of modern life that we often take it for granted. We shouldn't. It took thousands of years of cumulative effort to reach the point that most pain can be alleviated. Indeed, the quest to overcome suffering has profoundly impacted the direction of the human story, a history recounted thoroughly and expertly by physician-author Thomas Dormandy in The Worst of Evils: The Fight Against Pain.
Dormandy's narrative proceeds from the earliest methods to the sophisticated multidisciplinary approach of the modern hospice movement. By the time the earliest civilizations emerged, medical practitioners and shamans already understood the medicinal qualities of flora: The palliative properties of wine were recognized four thousand years ago, and opium poppies were grown in ancient Egypt and Mesopotamia. The earliest known medical document, an Egyptian papyrus from 1500 b.c., Dormandy reports, “suggests the existence of specialists whose expertise seems to have been in easing aches and pains of various kinds.”
In an unexpected turn, the author does not restrict himself to explicitly medical approaches to overcoming pain. Indeed, he spends much time on the power of the human mind to deny pain, using as his prime illustration the early Christian martyrs who willingly embraced the most brutal tortures with joy and thanksgiving. Dormandy recounts the gory details of many of these deaths, and it is difficult reading. Indeed, it is hard to imagine the agony of being torn apart by animals or burned alive—and yet, as Tacitus wrote, these martyrs not only rejoiced at the opportunity to suffer for Christ but appeared to feel no pain. The author writes: “The martyrs kissed, laughed and embraced on the scaffold or in the circuses. When Bishop Polycarp was tied to the stake and the fire was lit he proclaimed in strong tones: ‘I bless Thee that Thou hast deemed me worthy of this happy day and hour, that I should share in the fate of Thy martyrs. I rejoice.' When the flames did not appear to touch him, a centurion had to be sent in to kill him with a dagger. The executioner succumbed to his burns.”
Was this capacity to undergo the worst tortures seemingly without suffering a miraculous gift of the Spirit or something that has a natural explanation? Dormandy shrugs: “By definition, such acts are not only unexplained but also inexplicable in purely medical terms. . . . It in no way detracts from the loftiness of their sacrifice that their actions can be also approached at another level,” meaning self-hypnosis, “a scientific tag which makes miracles acceptable to those who do not believe in miracles.”
Dormandy is a scholar, which is both his most irritating weakness and his greatest strength as an author. There is seemingly no historical detail or biographical note too trivial to be excluded from his narrative, which makes for sometimes ponderous reading. But just as one's eyes threaten to glaze over, the narrative suddenly bursts into life as the author recounts fascinating details and amazing historical coincidences that led to major breakthroughs in the struggle against pain.
The chapters on the development of general anesthesia in the nineteenth century are among Dormandy's strongest. The story begins on an entirely unexpected note, with Sam Colt—who would gain world fame as a gun manufacturer—touring country fairs in the 1830s touting himself as “The Professor of New York, London, and Calcutta.” Colt had learned how to mix nitrous oxide (laughing gas), and he earned his living charging locals for hits of the intoxicating concoction. Colt eventually brought these “gas frolics” to Georgia, where they became wildly popular as a “relatively innocent form of entertainment.”
At some point, these frolics came to the attention of a small-town physician and pharmacist named Crawford Williamson Long. In 1842, Long was asked by his young friends, who wanted to have a lark, to administer laughing gas to them. But Long didn't have any. He had been experimenting, however, with ether as a means of providing a similar high and found it “exhilarating.” Long was soon hosting ether-breathing parties at his home and soon noticed an interesting side effect of the gas: People who were on the gas could receive injuries and not realize they had been hurt.
This phenomenon intrigued the physician in Long, and he began to wonder whether ether could be used to allow surgery to be performed without pain. When he subsequently was asked by one of his frolic friends to remove two neck tumors, Long suggested that the operation be performed with the patient under the effects of ether. On March 30, 1842, Long soaked a towel in ether, placed it over his patient's face, and performed the first surgery on a patient rendered unconscious by general anesthesia.
Pain-free surgery swept the medical world four years later, after a doctor named William Thomas Green Morton, who had invented an ether-delivery system more reliable than a soaked towel, convinced nationally famous medical surgeon John Collins Warren to remove a vascular tumor with the patient under general ether anesthesia. On October 16, 1846, Morton, Warren, and the patient, Gilbert Abbott, took their places in an auditorium packed with medical students and hospital staffers.
Dormandy's account of the historic surgery is riveting and demonstrates vividly the excruciatingly brutal reality of surgery before the availability of general anesthesia: “Morton turned to Warren and uttered the words that would echo down the centuries in uncounted operating theaters the world over: ‘Sir, your patient is ready.'”
Warren seized the engorged veins of the tumour with his left hand and with his right made the first incision. Years of hearing the anguished outcry in response to the first impact of the knife had made him steel himself for the inevitable scream. There was always a barely perceptible pause before the next step. Patients occasionally lapsed into a state of shock. Some had been known literally to die of fright. This time no sound came. With the controlled swift movement for which he was famous, Warren completed the excision. Because of the proximity of important nerves, the dissection took fourteen and a half minutes. Then the bleeding points were tied, the skin sutured, the face washed of blood. With the [ether] tube removed from his mouth, Abbot gradually regained consciousness. Morton was the first to break the silence.
“Did you feel anything, Mr. Abbot?”
“It was good,” Abbot mumbled with a sigh.
Warren turned to the students, and . . . remarked: “Gentlemen, this is no humbug.” It was the high point of Morton's life and career.
Many of the other great advances in pain management—and their societal consequences—are similarly recounted. Readers of The Worst of Evils learn, for instance, about the placebo effect and its capacity to ameliorate the most intense pain. The book recounts the inadvertent part Sigmund Freud's experiments with cocaine played in the development of local anesthesia and how an English pastor chewing on the bark of a willow tree led to the development of aspirin.
Dormandy documents the intense clash between secularism and religion generated by the documented medical miracles at Lourdes, and the part emotional and mental health plays in the experience of pain. One of the most fascinating stories in the book is his account of how the friendship between a dying Jewish survivor of the Warsaw Ghetto and a devout Christian nurse and social worker inspired the creation of the modern hospice movement.
The Worst of Evils is devoid of controversy. Indeed, Dormandy is so intent on playing it down the middle that he avoids volatile subjects that, given the depth and breadth of the book, would seem to cry out for coverage. For example, Dormandy does not mention euthanasia despite the (false) claim by proponents that mercy killing is a method of ameliorating pain. And while the author does discuss the palliative properties of cannabis, he takes no position on the current controversies over “medical marijuana.”
Still, Dr. Dormandy has performed brilliantly in his exhaustively researched, thoroughly credible, and frequently fascinating book. And while I wish that the author's editor had red-penciled about fifty pages of historical minutiae, The Worst of Evils belongs in the library of anyone interested in the history of medicine.
Wesley J. Smith is a senior fellow at the Discovery Institute, an attorney for the International Task Force on Euthanasia and Assisted Suicide, and a special consultant to the Center for Bioethics and Culture.