Page 16 Guide to Pain Management in Low-Resource Settings

4 Wilfried Witte and Christoph Stein

Th e isolation of the opium alkaloid morphine was fi rst Th e fi rst decades of morphine use may be seen
accomplished in 1803 by the German pharmacist Fried- as a period of high expectations and optimism regard-
rich Wilhelm Sertürner (1783–1806). Th e industrial ing the ability to control pain. Th e fi rst drawback to
production of morphine began in Germany during the this optimism was the discovery made in the Ameri-
1820s, and in the United States in the 1830s. During the can Civil War (1861–1865), when cases of morphine
late 18th to the mid-19th century, the natural sciences dependence and abuse appeared. As a consequence,
took over the lead in Western medicine. Th is period restrictions on the distribution of opiates were begun.
marked the beginning of the age of pathophysiological Th e negative view of morphine use was enhanced by
pain theories, and scientifi c knowledge about pain in- experiences in Asia, where an extensive trade in opium
creased step by step. and morphine for nonmedical purposes was already
Th e discovery of drugs and medical gases was established during the 19th century. Th erefore, at the
a cornerstone of modern medicine because it allowed beginning of the 20th century, societal anxiety regard-
improvements in medical treatment. It was modern an- ing the use of morphine became strong and developed
esthesia in particular that promoted the development of into opiophobia (i.e., the fear of using opioids), which
surgery. General anesthesia using ether was introduced was a major step backwards for pain management in
successfully in Boston on October 16, 1846, by the phy- the following decades.
sician William Th omas Morton (1819–1868). Th e im- Wars stimulated pain research because soldiers
portance of this discovery, not only for surgery but for returned home with complex pain syndromes, which
the scientifi c understanding of pain in general, is under- posed insurmountable problems for the available ther-
scored by the inscription on his tombstone: “Inventor apeutic repertoire. Following his experience after 1915
and Revealer of Inhalation Anesthesia: Before Whom, in during the First World War, the French surgeon René
All Time, Surgery was Agony; By Whom, Pain in Sur- Leriche (1879–1955) began to concentrate on “pain
gery was Averted and Annulled; Since Whom, Science surgery,” mainly addressing the autonomic nervous
has Control of Pain.” Th is statement suggested that pain system. Leriche applied methods of regional anesthe-
would vanish from mankind just by applying anesthe- sia (infi ltration with procaine, sympathetic ganglionic
sia. Surgery itself changed to procedures that were not blockade) as well as surgery, particularly periarterial
necessarily connected with a high level of pain. Th us, sympathectomy. He not only rejected the idea of pain
the role of surgery changed. Surgeons had more time to as a necessary evil but also criticized the reductionist
perform operations, and patients were no longer forced scientifi c approach to experimental pain as a purely
to suff er pain at the hands of their surgeons. neuroscientifi c phenomenon. He viewed chronic pain
Further innovations followed. One year later, as a disease in its own right (“douleur-maladie”), not
in 1847, chloroform was used for the fi rst time for an- just as a symptom of disease.
esthesia in gynecology by the Scottish physician James Regional anesthesia was the mainstay of pain
Young Simpson (1811–1879). In Vienna, the physi- therapy applied by the French surgeon Victor Pauchet
cian Carl Koller (1857–1944) discovered the anesthetic (1869–1936). Already, before his experiences in the
properties of cocaine in 1884. At about the same time, war, he had authored the fi rst edition of his textbook
during the last two decades of the 19th century, the U.S. L’Anesthésie Régionale in 1912. Th rough Louis Gas-
neurologist James Leonard Corning (1855–1923) and ton Labat (1876–1934), a physician from Paris who
the German surgeon August Bier (1861–1949) carried later practiced in the United States, his wisdom be-
out trials of spinal anesthesia with cocaine solutions. came known in the New World and was an important
Modern anesthesia enabled longer and more complex stimulus for the dissemination of regional anesthesia in
surgical procedures with more successful long-term the United States between the two World Wars. In the
outcomes. Th is advance promoted the general consen- 1920s, the notion that regional anesthesia could be used
sus that the relief of somatic pain was good, but it was not only for surgery but also for chronic pain spread
secondary to curative therapy: no pain treatment was throughout the United States.
possible without surgery! Th us, within the scope of an- After the Second World War these ideas
esthetic practice, pain management as a therapeutic were taken up by John Joseph Bonica (1914–1994),
goal did not exist at that time. Chronic pain was not a who had emigrated with his parents from Sicily to
topic at all. the United States at the age of 11 years. As an army