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Four people with radically different outlooks on the world meet on a train and start talking about what they believe. Their conversation varies from cool logical reasoning to heated personal confrontation. Each starts off convinced that he or she is right, but then doubts creep in. During February, we will be posting a series of extracts that cover the viewpoints of all four characters in Tetralogue. What follows is an extract exploring Sarah's perspective.

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Many students, when asked by a teacher or professor to volunteer in front of the class, shy away, avoid eye contact, and try to seem as plain and unremarkable as possible. The same is true in dental school – unless it comes to laughing gas.

As a fourth year dental student, I’ve had times where I’ve tried to avoid professors’ questions about anatomical variants of nerves, or the correct way to drill a cavity, or what type of tooth infection has symptoms of hot and cold sensitivity. There are other times where you cannot escape having to volunteer. These include being the first “patient” to receive an injection from one of your classmate’s unsteady and tentative hands. Or having an impression taken with too much alginate so that all of your teeth (along with your uvula and tonsils) are poured up in a stone model.

But volunteering in the nitrous oxide lab … that’s a different story. The lab day is about putting ourselves in our patients’ shoes, to be able to empathize with them when they need to be sedated. For me, the nitrous oxide lab might have been the most enjoyable 5 minutes of my entire dental education.

In today’s dental practice, nitrous oxide is a readily available, well-researched, incredibly safe method of reducing patient anxiety with little to no undesired side effects. But this was not always the case.

The Oxford Textbook of Anaesthesia for Oral and Maxillofacial Surgery argues that “with increasingly refined diets [in the mid-nineteenth century] and the use of copious amounts of sugar, tooth decay, and so dentistry, were on the increase.” Prior to the modern day local anesthesia armamentarium, extractions and dental procedures were completed with no anesthesia. Patients self-medicated with alcohol or other drugs, but there was no predictable or controllable way to prevent patients from experiencing excruciating pain.

That is until Horace Wells, a dentist from Hartford, Connecticut started taking an interest in nitrous oxide as a method of numbing patients to pain.

Wells became convinced of the analgesic properties of nitrous oxide on December 11, 1844 after observing a public display in Hartford of a man inhaling the gas and subsequently hitting his shin on a bench. After the gas wore off, the man miraculously felt no pain. With inspiration from this demonstration and a strong belief in the analgesic (and possibly the amnestic) qualities of nitrous oxide, on December 12, Wells proceeded to inhale a bag of the nitrous oxide and have his associate John Riggs extract one of his own teeth. It was risky—and a huge success. With this realization that dental work could be pain free, Wells proceeded to test his new anesthesia method on over a dozen patients in the following weeks. He was proud of his achievement, but he chose not to patent his method because he felt pain relief should be “as free as the air.”

This discovery brought Wells to the Ether Dome at the Massachusetts General Hospital in Boston. Before an audience of Harvard Medical School faculty and students, Wells convinced a volunteer from the audience to have their tooth extracted after inhaling nitrous oxide. Wells’ success came to an abrupt halt when this volunteer screamed out in pain during the extraction. Looking back on this event, it is very likely that the volunteer did not inhale enough of the gas to achieve the appropriate anesthetic effect. But the reason didn’t matter—Wells was horrified by his volunteer’s reaction, his own apparent failure, and was laughed out of the Ether Dome as a fraud.

The following year, William Morton successfully demonstrated the use of ether as an anesthetic for dental and medical surgery. He patented the discovery of ether as a dental anesthetic and sold the rights to it. To this day, most credit the success of dental anesthesia to Morton, not Wells.

After giving up dentistry, Horace Wells worked unsuccessfully as a salesman and traveled to Paris to see a presentation on updated anesthesia techniques. But his ego had been broken. After returning the U.S, he developed a dangerous addiction to chloroform (perhaps another risky experiment for patient sedation, gone awry) that left him mentally unstable. In 1848, he assaulted a streetwalker under the influence. He was sent to prison and in the end, took his own life.

This is the sad story of a man whose discovery revolutionized dentists’ ability to effectively care for patients while keeping them calm and out of pain. As a student at the University of Connecticut School of Dental Medicine, it is a point of pride knowing that Dr. Wells made this discovery just a few miles from where I have learned about the incredible effects of nitrous oxide. My education has taught me to use it effectively for patients who are nervous about a procedure and to improve the safety of care for patients with high blood pressure. This is a day we can remember a brave man who risked his own livelihood in the name of patient care.

Featured image credit: Laughing gas, by Rumford Davy. Public domain via Wikimedia Commons.

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September is Pain Awareness Month. In order to raise awareness of the issues surrounding pain and pain management in the world today, we’ve taken a look back at pain throughout history and compiled a list of the eight most interesting things we learned about pain from The Story of Pain: From Prayer to Painkillers by Joanna Bourke.

1. In the past, pain was most often described as an independent entity. In this way, pain was described as something separate from the physical body that might be able to be fought off while keeping the self intact.
2. In India and Asia some descriptions of varying degrees of pain involved animals. Some examples include “bear headaches,” that resemble the heavy steps of a bear, “musk deer headaches” like the galloping of a running dear, and “woodpecker headaches” as if pounding into the bark of a tree.
3. In the late twentieth century, children’s sensitivity to pain was debated. There were major differences in the beliefs of how children experienced pain. 91 % of pediatricians believing that by the age of two a child experienced pain similarly to adults, compared with 77% of family practitioners, and only 59% of surgeons.
4. It had long been observed that, in the heat of battle, even severe wounds may not be felt. In the words of the principal surgeon to the Royal Naval Hospital at Deal, writing in 1816, seamen and soldiers whose limbs he had to amputate because of gunshot wounds “uniformly acknowledged at the time of their being wounded, they were scarcely sensible of the circumstance, till informed of the extent of their misfortune by the inability of moving their limb.”
5. Prior to 1846, surgeons conducted their work without the help of effective anesthetics such as ether or chloroform. They were required to be “men of iron … and indomitable nerve” who would not be “disturbed by the cries and contortions of the sufferer.”
6. Concerns about medical cruelty reached almost hysterical levels in the latter decades of the nineteenth century, largely as a consequence of public concern about the practice of vivisection (which was, in itself, a response to shifts in the discourse of pain more widely). It seemed self-evident to many critics of the medical profession that scientists trained in vivisection would develop a callous attitude towards other vulnerable life forms.
7. In the 19th century it was believed that pain was a necessary process in curing an ailment. In the case of teething infants, lancing their gums or bleeding them with leeches were painful treatments used to reduce inflammation and purge the infant-body of its toxins.
8. John Bonica, an anesthetist and chronic pain suffer himself established the first international symposium on pain research and therapy in 1973, which resulted in the founding of the International Association for the Study of Pain (IASP).

Featured image credit: The Physiognamy of Pain, from Angelo Mosso, Fear (1896), trans. E. Lough and F. Kiesow (New York: Longmans, Green, and Co., 1896), 202, in the Wellcome Collection, L0072188. Used with permission.

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Some are going through a horrible time right now.
Some are feeling lost.
Hopeless.
Abandoned.
Worthless.
Helpless.
Alone.
Depression.

Feeling as if nobody hears them, sees them, knows they are alive.
God sees you, my darling.
He hears you.
He feels you.
Catches every tear that falls from your precious eyes.
I promise.

Focus on something for just a moment.
Something outside of your pain.
Focus on the Glory of God.
Take a deep breath.
Breathe.

If you can't muster the strength to say it aloud-
then say it inside.
You can do this.
I have faith in you.
I believe in you.

"Take me Lord.
Take my junk.
Take my mess.
I am Yours.
Help me.
Lead me beside the still waters.
Restore my soul.
My mess, is Yours.
Use it to be glorified.
Give me peace.
Give me hope.
I find my strength in You, oh Lord.
Bring me to the place of joy.
And bring me into You.
In Jesus' name."

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It’s easy to assume that we know what pain is. We’ve all experienced pain, from scraped knees and toothaches to migraines and heart attacks. When people suffer around us, or we witness a loved one in pain, we can also begin to ‘feel’ with them. But is this the end of the story?

In the three videos below Joanna Bourke, author of The Story of Pain: From Prayer to Painkillers, talks about her fascination with pain from a historical perspective. She argues that the ways in which people respond to what they describe as ‘painful’ have changed drastically since the eighteenth century, moving from a belief that it served a specific (and positive) function to seeing pain as an unremitting evil to be ‘fought’. She also looks at the interesting attitudes towards women and pain relief, and how they still exist today.

On the history of pain

Click here to view the embedded video.

How have our attitudes to pain changed?

Click here to view the embedded video.

On women and pain relief

Click here to view the embedded video.

Joanna Bourke is Professor of History at Birkbeck College, University of London. She is the prize-winning author of nine books, including histories of modern warfare, military medicine, psychology and psychiatry, the emotions, and rape. Her book An Intimate History of Killing (1999) won the Wolfson Prize and the Fraenkel Prize, and ‘Eyewitness’. She is also a frequent contributor to TV and radio shows, and a regular newspaper correspondent. Her latest book is The Story of Pain: From Prayer to Painkillers.

The post Does pain have a history? appeared first on OUPblog.

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By Mark Johnson

The prevalence of chronic pain in the general adult population worldwide may be as high as 30%. Yet pain is not seen as a major health care problem by politicians, probably because people do not die of pain, although many people die in pain. Chronic pain challenges our traditional beliefs about the process of diagnosis, treatment, and cure, with over 40% of individuals reporting inadequate management of chronic pain. Chronic pain is an enigma.

We have all experienced pain and we know with certainty when we have it. Yet, we may doubt others who tell us that they are in pain especially if their pain has a vague or uncertain diagnosis and is not responding to conventional treatment. The medical management of pain evolved from the view that pain is a symptom of pathology and diagnosis, and treatment of pathology will relieve pain. This approach usually works well for pains associated with recent tissue damage (acute pain) but starts to fall apart when pain becomes chronic. This is because the link between pain and tissue damage (pathology) is not quite as strong as we are led to believe. For example, soldiers seriously injured in battle often report no pain for some time after the injury occurred. The link between pathology and chronic pain is particularly variable. In fact chronic pain may uncouple from the pathology that caused the pain in the first place. In essence, pain can become a disease entity in its own right.

Life experiences teach us that pain warns of tissue damage and we adapt our behaviours to avoid pain accordingly. Body parts often become “sensitive” in the presence of tissue damage so that non-painful activities become painful. Pain makes us avoid things that may hinder tissue healing so we learn to “fear” walking on a twisted ankle for example, because it provokes pain. Sensitivity associated with pathology results from the nervous system amplifying input from the site of tissue damage increasing the input to the pain producing brain — no brain, no pain. Pain resulting from sensitivity within the nervous system fades over time as tissue heals, although occasionally the nervous system remains in a persistent sensitive state despite tissue having healed. The consequence is chronic pain that has uncoupled from the original tissue damage. Pain of this nature has limited usefulness and is detrimental to well-being and reflects a dysfunctional pain system.

In such circumstances medical tests may fail to detect appreciable pathology, diagnosis may become vague, and treatment uncertain and unsuccessful. Practitioners may start to doubt the legitimacy of the person’s pain and believe that the pain is “psychogenic” (fake). This is entirely irrational because it is impossible to prove or disprove that a person is in pain, because pain is a subjective phenomenon with no objective way of measuring. The only way to gain insight into a person’s personal pain experience is through their self-report — pain is whatever the patients says it is. If a person reports that they are experiencing pain, they should be believed.

Knowledge that pain may persist without appreciable tissue damage has shifted the focus of management strategies for chronic pain that advocate progressive return to and continuation of normal activities despite the presence of pain. The challenge for the practitioner is balancing advice about under-activity, leading to disability, with over-activity leading to further pain and harm. The challenge for the patient is being able to accept and commit to a pain management plan that encourages undertaking activities in the presence of pain, because this is counterintuitive to life experiences that have taught us to avoid pain because it warns of harm. Accepting that total resolution of pain may be unlikely and committing to integrating a painful body into normal life has been shown to have a positive impact on suffering and long-term disability. In fact inactivity is a risk factor for the development of long-term pain, suffering and disability. Easy explanations of the factors contributing to chronic pain to promote a benign view of chronic pain can help individuals to change the way they think and behave about their pain. Pain management plans offering advice about the risk of harm of daily activities and self-management techniques to find solutions for pain flare ups, medication use, sleep disturbances, depression, anger, and relationship problems are becoming available.

Exercise regimes aim to get individuals to return to normal activities through stretching, strengthening, and cardiovascular fitness with the focus on progressive return to activities. Manual therapies such as massage of soft tissue and mobilization and manipulation of joints, and electrophysical agents such as transcutaneous electrical nerve stimulation (TENS), acupuncture, low level laser therapy, and ultrasound, are all part of the multidisciplinary pain management team’s toolkit. Clinical experience suggests that these non-pharmacological interventions are beneficial and popular with patients, although the findings of clinical research have been inconsistent. This is due to the complex nature of administering some of the interventions where optimal technique (dose) is not known.

So the puzzle of chronic pain is being unravelled with the realization that a reliance on diagnosis and treatment of pathology causing pain may not be the most effective way to help patients. We need a multidisciplinary model of care that is flexible enough to shift in emphasis from a biopsychosocial model in the acute phase to a “sociopsychobio” model in the chronic phase.

Mark Johnson is Professor of Pain and Analgesia at Leeds Metropolitan University in the UK. He is author of Transcutaneous Electrical Nerve Stimulation (TENS): Research to support clinical practice.

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Image: Doctor talking with a patient by National Cancer Institute. Public domain via Wikimedia Commons.

The post Unravelling the enigma of chronic pain and its treatment appeared first on OUPblog.

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Imagine this nut is your head. And this vice . . . is a migraine.

According to Migraine.com, “In the U.S., more than 37 million people suffer from migraines. Some migraine studies estimate that 13 percent of adults in the U.S. population have migraines, and 2-3 million migraine suffers are chronic. Almost 5 million in the U.S. experience at least one migraine attack per month, while more than 11 million people blame migraines for causing moderate to severe disability.”

I have been battling migraines since my early twenties. Unfortunately, as I get older, my migraines have gotten more frequent and more debilitating. In fact, today, I had one while on vacation with my family and had to be left behind in a darkened hotel room with ear plugs in place and a sign on the door, no housekeeping please. It’s not the first time I’ve missed out on something with the kids because, “Mommy has a headache today,” and I’m sure it won’t be the last.

“Take some Excedrin and get back to business.” If only it were that simple. If you get migraines or know someone who does, you understand that over-the-counter pain relievers do not even make a dent in the pain. Sometimes Hydrocodone can knock me out long enough for the migraine to pass, and a couple times a shot of morphine at the ER has done the trick.

Preventive medicine has had mixed results. For a while I was taking Topimax (normally prescribed for folks who suffer from seizures) . It worked at keeping the migraines at bay, but the side effects were miserable: kidney stones and liver cysts, hallucinations, tingling hands and feet, and horrific brain fog. They don’t call it “Dopimax” for nothing. When I first started taking it, I snapped out of one stupor to find I’d been brushing my teeth for twenty minutes. Despite my uber-white smile, I decided to trade out the Topimax for rational thought.

These days I’ve been managing with daily high doses of magnesium and Vitamin D and Imitrex shots and pills. It works. But only if those shots and pills are timed just right. If I don’t catch the migraine when it first starts, I just end up with the dizzy, racing-heart side effects of the medication on top of the migraine pain.

A strategy that has been semi-successful is the headache diary. It’s been helpful to keep a log of the things that I’ve eaten and the things I’ve done on the days preceding and during a migraine. The result? A crazy-long list of headache triggers, which I share with you now in no particular order:

Dehydration, Aspartame, Sucralose, Alcohol (especially wine and beer), Flashing lights, Wearing 3D glasses, Monosodium Glutamate, More than 26 mg of caffeine in 24 hours, Grape juice, Monthly hormone fluctuations, the Summer Solstice, the Winter Solstice, Cigarette smoke, Staying out in the hot sun for 5+ hours at temps greater than 90 degrees Fahrenheit, Sinus infections, Mold, Not eating for 10+ hours, Stress lasting multiple consecutive days, Vigorous workouts, Pinching neck nerves, Lima beans.

OK, lima beans don’t trigger my migraines. I just hate their nastiness and avoid them at all costs.

So, some of these triggers are completely within my control and I successfully avoid them. And others, not so much. As an Earthling, it’s a bit difficult to avoid the solstices.

If you have a migraine sufferer in your life you can help by listening and avoiding insensitive comments such as, “It’s just a headache” or “Get some sunshine and fresh air” or “Reduce the stress in your life” or “have you tried XYZ? It worked for a friend of mine”.  Because a migraine is not just a headache, and going outside can often be a trigger or exacerbate the pain, and even a stress-free, meditation-filled, yoga lover will still suffer from migraines, and chances are, the person has been afflicted with migraines for decades and has tried everything. Every. Thing.

Hypnosis. Been there. Acupuncture. Done that. Biofeedback. Yep. Drugs. Tends to be the first recommendation from the medical professionals, so, yes. And too many other “remedies” to mention.

The best thing I’ve done recently for myself is find a doctor who specializes in migraine treatment. It’s nice to have a physician who speaks the language of migraines. It’s nice to have a physician who doesn’t look at me like I’m a nut when I tell him I can’t drive underneath the canopy of a tree-line road while the sun is shining. “Perfectly understandable,” he says. “I bet you can’t watch the new Transformers movie in IMAX 3D either.”

Photo © Robert Faric

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What do anaesthetists do? How does anaesthesia work? What are the risks? Anaesthesia is a mysterious and sometimes threatening process. We spoke to anaesthetist and author Aidan O’Donnell, who addresses some of the common myths and thoughts surrounding anaesthesia.

On the science of anaesthesia:

Click here to view the embedded video.

The pros and cons of pain relief in childbirth:

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Are anaesthetists heroes?

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Aidan O’Donnell is a consultant anaesthetist and medical writer with a special interest in anaesthesia for childbirth. He graduated from Edinburgh in 1996 and trained in Scotland and New Zealand. He now lives and works in New Zealand. He was admitted as a Fellow of the Royal College of Anaesthetists in 2002 and a Fellow of the Australian and New Zealand College of Anaesthetists in 2011. Anaesthesia: A Very Short Introduction is his first book. You can also read his blog post Propofol and the Death of Michael Jackson.

The Very Short Introductions (VSI) series combines a small format with authoritative analysis and big ideas for hundreds of topic areas. Written by our expert authors, these books can change the way you think about the things that interest you and are the perfect introduction to subjects you previously knew nothing about. Grow your knowledge with OUPblog and the VSI series every Friday!

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It's three months until we move, but in the spirit of making hay while the sun shines, I've begun casually, nostalgically sorting and packing a few things.  In a pile of books in the parlor I came across a collection of Anne Sexton's poems.  Opening randomly, I read--and burst into tears.

Daisy doesn't care for horses, but she is 13, and I see this moment coming.



Pain for a Daughter // Anne Sexton


Blind with love, my daughter
has cried nightly for horses,
those long necked marchers and churners
that she has mastered, any and all,
reining them in like a circus hand -
the excitable muscles and the ripe neck -
tending, this summer, a pony and a foal.

She who is squeamish to pull
a thorn from the dog’s paw
watched the pony blossom with distemper,
the underside of the jaw swelling
like an enormous grape,
Gritting her teeth with love,
she drained the boil and scoured it
with hydrogen peroxide until pus
ran like milk on the barn floor.

Blind with loss all winter,
in dungarees, a ski jacket, and a hard hat,
she visits the neighbors’ stables,
our acreage not zoned for barns,
they who own the flaming horses
and the swan-necked thoroughbred
that she tugs at and cajoles,
thinking it will burn like a furnace
under her small-hipped English seat.

Blind with pain, she limps home;
The thoroughbred has stood on her foot.
He rested there like a building;
He grew into her foot until they were one.
The marks of the horseshoe printed
into her flesh, the tips of her toes
ripped off like pieces of leather,
three toenails swirled like shells
and left to float in blood in her riding boot.

Blind with fear, she sits on the toilet,
her foot balanced over the washbasin,
her father, hydrogen peroxide in hand,
performing the rites of the cleansing.
She bites on a towel, sucked in breath,
sucked in and arched against the pain,
her eyes glancing off me where
I stand at the door, eyes locked
on the ceiling, eyes of a stranger,
And then she cries…
Oh! My god, Help me!

Where a child would have cried “Mama!”
Where a child would have believed “Mama!”
She bit the towel and called on God,
And I saw her life, stretch out…
I saw her torn in childbirth,
And I saw her, at that moment,
in her own death,
And I knew that she knew.

******************************
Poetry Friday is hosted today by Tabatha at The Opposite of Indifference, where she's sharing some of the poems exchanged through the Summer Poem Swap she has organized.  I'm participating and will have at least three to share next Friday--thanks, Tabatha!

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