“Farther we look back, further we can see”—Sir Winston Churchill
INTRODUCTION
Pain as a specialty is over half a century old. It is defined as a “discipline of medicine devoted to the diagnosis and treatment of pain related disorders”. Pain is as old as humankind. Hippocrates first mentioned the brain as the center of sensation (over 2000 BC). Descartes (1700s) described nerves as tubes containing threads connecting the skin to the brain. From being a curse in ancient times, it has become the sixth sense.
HISTORICAL ASPECT
The first mention of pain relief in western literature (Thomas Schuman) is of Sushruta (500 BC) for surgical operations; it was achieved by opium, wine or Indian hemp (Fig. 1). In a chronicle “Bhoj Prabandh”, Raja Bhoj (527 AD) mentions use of a concoction “Sammohini” for pain relief. For labor analgesia strong wines, inhalation of burnt mohini flowers, opium and marijuana (bhang) were used (Vagabhatta 400 AD). In Europe cold water, mandrake roots, solanium, and wild lettuce were used (Figs 2A and B). In the 16th–17th centuries hypnotism and mesmerism were practiced, made famous by James Esdaile in Calcutta (1845).
ROLE OF MEDICATION
With the discovery of ether, (1847—Morton) (Fig. 3) chloroform (Fig. 4) and cocaine a local anesthetic (1888—Bier), Esters and amides for local anesthesia revolutionized into nerve blocks and nerve lysis. In the early 20th century analgesics were synthesized. Twilight sleep was used in labor analgesia (1902—Van Steinbuchel) with an injection of morphine and scopolamine abandoned after 30 years! “Gwathmey analgesia” advocated a mixture of morphine, magnesium sulfate and ether in olive oil, alcohol and quinine. This was supposed to be harmless at that time! Inhalation agents like Trilene, Penthrane and Entonox (N2O + O2) had their days.
4
Morphine has a special place in pain relief. First used as an addiction; brought wealth to the British in India and two Sino-British wars (Fig. 5). Banned in India on February 26, 1950 in article 47 of the constitution of India except for medicinal purposes, however oral morphine was banned. Now, new licensing regulation has been enforced since 1998.
Melzack and Wall's “Gate Control Theory” opened up new avenues for pain management. N-methyl-D-aspartate (NMDA) receptor antagonists, opiate receptors in spinal cord and also discovery of endorphins, enkephalins (1970) contributed to the understanding and advances in pain relief.
Neuropathic pain syndrome was first recognized during the American Civil War (1864—Dr Mitchell) as “causalgia”, later reviewed and managed by Dr Bowsher D (1991). Neuropathic pain was defined as “pain arising as a direct consequence of a lesion or5 disease affecting the somatosensory system”, referred to by some as “deafferentation pain”. Regional pain syndrome was conceptualized in 1994.
Electricity and pain relief—natural sources like electric fish and static electricity from amber were used in ancient times! Man-made electricity as electrostatic generators (1672); electro-acupuncture (1823) and peripheral nerve stimulators were in use and later banned in the US because of misuse and again revived with spinal cord stimulation by Sheeley (1967), and stereotaxic surgery for central pain syndrome (1970s).
An array of new drugs have been synthesized—opiates, opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), NMDA receptor antagonists, gabapentine; pregabalin, adjuvants like tricyclic antidepressants, steroids, and antiepileptics. These have helped in supportive treatment. Neurolytic drugs like alcohol, phenol, etc. were introduced as a last resort in cancer pain (1970s).
Regional blocks (spinal and epidural) and peripheral as well as sympathetic nerve blocks have revolutionized pain management. A series of procedures and gadgets have revolutionized pain relief like fluoroscopy, radiofrequency ablation (1970s), a quarter century of percutaneous interventions have been introduced. Spinal endoscopy and myelos-copy (1931—Burmann). Endoscopy with rigid arthroscope and recognition of bands in the epidural space (1985—Bloomberg). Koki Simoji introduced the flexible fiberscope for subarachnoid and epidural visualization (1991).
Cancer pain needs a special mention, these patients need pain relief, palliative care, perhaps “end-of-life” care. This program has been adopted by some states in India (Kerala and Maharashtra). The World Health Organization introduced the “three-step analgesia ladder” in the treatment of cancer pain. Recent advances in drug delivery systems, e.g. percutaneous patches of opioids, etc. have alleviated the suffering of cancer patients.
Recent advances in drug delivery systems like percutaneous patches, analgesics, psychotherapy, radiation, chemotherapy or hormonal therapy and in extreme cases neurosurgery. However, there are many issues to be tackled, such as addiction, tolerance, depression and toxicity. Newer procedures and medications have made it possible for precise diagnosis, location and ablation of pain sources and created the modern pain physician.
CONCLUSION
It is highly important to know historical aspects to understand pain better and it definitely helps in clinical practice.
BIBLIOGRAPHY
- Bowsher D. Neuropathogenic pain syndromes and their management. Br Med Bull. 1991;47(3):644–66.
- Bennett I. Spinal cord stimulation. In: Bennett MI (Ed). Neuropathic Pain, 2nd edition. London: Oxford University Press; 2010. p. 161.
- Keys TE. The History of Surgical Anaesthesia. New York: Schuman; 1945. pp. 84, 110, 111.
- Melzack R, Wall PD. Pain Mechanisms: a new theory. Science. 1965;50(3699):971–9.
- Simpson BA. Electrical stimulation and relief of pain. In: Simpson BA (Ed). Pain Research and Clinical Management. Amsterdam: Elsevier; 2003.
- Souvenir—Centenary of the Afzal Gunj Hospital and Diamond Jubilee Osmania Hospital, Hyderabad; 1988.
- Souvenir—III Joint Indo-US Anaesthesiology—update cum workshop. New Delhi; 1994. p. 15.
- Sushruta Samhita. Ayurveda. 500 BC.
- World Health Organization. Analgesic Ladder for Pain Management. Geneva: WHO; 1986.