Abdul-Ghaaliq Lalkhen - An Anatomy of Pain: How the Body and the Mind Experience and Endure Physical Suffering

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Copyright 2021 by Abdul-Ghaaliq Lalkhen

With the exception of Louise and Alan, all patients described and quoted are composites created by the author based on his years of clinical experience.

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First Scribner hardcover edition February 2021

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Interior design by Erika R. Genova

Jacket design by Jaya Miceli

Jacket artwork: Dying Abel, 1850 (Marble) Miglioretti, Pasquale (182281), Photograph Veneranda Biblioteca Ambrosiana/Paolo Manusardi/Mondadori Portfolio/Bridgeman Images

Library of Congress Cataloging-in-Publication Data has been applied for.

ISBN 978-1-9821-6098-2

ISBN 978-1-9821-6099-9 (ebook)

To my wife, Nichola, whose patience and kindness has no equal, and to my parents and siblings, who have always been both the anchors of my life and the wind in my sails.

But pain is perfect misery, the worst of evils, and, excessive, overturns all patience.

John Milton, Paradise Lost

T here is a special quality to the sound of the telephone when it rings at two in the morning. When you are working as the anesthesiologist on a labor and delivery ward, that call causes your heart to race and your stomach to do a little flip, adding another layer of fatty damage to your overstressed coronary arteries. You have usually just fallen into an uneasy sleep on a lumpy bed in a damp but overheated on-call room, where many doctors have tossed and turned before you. The voice on the other end of the line is typically that of a harassed and overworked midwife. Epiduralroom 4 might be all you hear before the deafening click of the slammed handset. There is the urban legend of an anesthesiologist who, on receiving such a message, walked up to the room he had been sent to and stuck an epidural needle directly into the door before turning around and going back to his bed.

On entering a birthing room at 2:00 a.m., when the human spirit is at its lowest ebb, the scene is often predictable. There is a partner who looks scared out of his wits, a midwife who is fretting and trying her best to reassure everyone, and a pregnant woman who is screaming in pain. You are greeted by an individual who would normally present a reasonable and calm image to the world but who is now reduced to a feral and illogical specter as she is consumed with pain. The pain experienced during labor does not spare social class, color, or creed. Pain reduces us all to our basest elements; it is a great equalizer and unifier and one thing we all experience.

As an anesthesiologist I am confronted by a woman who is demanding pain relief and is now screaming at me and everybody who comes into her line of vision. Administering an epidural in these circumstances is challenging, to say the least. When I return later, however, after the epidural has taken effect, I am greeted by somebody completely different: a calm, personable individual. The ability to transform someones demeanor completely by abolishing a barrage of unpleasant sensations that are coming from distended and damaged tissues has made a lasting impression on me, and I continue to be amazed at the transformation that takes place when pain is removed.

While we now accept pain relief in labor as being an absolute rightand in first-world countries epidurals are provided on demandthis was not always the case. We have vacillated over the centuries between advocating that pain should be aggressively treated and believing that pain is necessary and important to the curing of the condition or an integral part of the treatment being given. Inflicting suffering was thought to sometimes be inevitable, for example in the case of amputations before the invention of anesthesia or when releasing evil humors by bloodletting with leeches. Pain was sometimes thought to be intrinsic to the success of the therapy, a sign of the patients vigor and helpful to their personal growth. Pain is weakness leaving the body was a phrase often shouted by my rugby coach. Pain is good for you. It tells you that you are still alive was a lesson sometimes uttered by stressed doctors in the emergency department where I worked, when the umpteenth stab victim of the evening complained about the chest drain inserted to inflate a collapsed lung.

At one time priests believed that the pain of childbirth strengthened the bond between mother and child, reinforcing the idea that self-sacrifice is inherent in motherhood, and that interfering with the pain would disrupt this maternal bond. Even in the early days of medical procedures, pain was not always seen as something that needed to be treated, largely because it was a sign of whether the patient was well and whether the treatment was working. It was only after 1800 that doctors became increasingly preoccupied with managing pain from injury or surgery, treating patients who had painful cancer as well as those with arthritis and migraines. When surgical anesthesia was first introduced in the mid-nineteenth century, however, there was uncertainty about the ethics of operating on an unconscious person and a concern that pain relief might retard the healing process. Priests, and some physicians, feared that anesthesia would corrupt the individuals soul, bringing into play a moral calculator to assess whether or not pain should be relieved. The development of medicine and surgery as endeavors that can be accomplished only by relieving pain, and a philosophical shift toward the value of the individual, changed the narrative from one claiming pain was necessary and a part of human life to viewing pain as an experience that needed to be actively managed.