Why It Hurts. Dr. Aneesh Singla

them and use them to better ourselves. Along this journey of trying to better understand pain, I have come to believe that pain is a rich and vital source of learning.

      ***

      Eventually, I was brought to an exam room and asked to sit on a gurney. The familiar sterile environment was accompanied by the smell of alcohol and polished steel. Everything about it said hospital. The physician’s assistant greeted me in a no-nonsense manner.

      “I’m going to numb you up, wash out the wound, and sew you up,” she said. “Okay?” I lay down on my side. As she worked, I prided myself for not complaining about the pain or showing any outward signs of discomfort. It struck me as funny how strongly conditioned we are not to show pain in modern society, despite the fact that this desire to cry out is adaptive, intended to let others know we need help.

      “When was your last tetanus shot?”

      “I can’t remember.” I said, embarrassed. So she gave me another one, just in case. Ouch.

      Chapter 2

       A Blessing in Disguise

      If you want to make peace with your enemy, you have to work with your enemy. Then he becomes your partner.

      —Nelson Mandela

      Before the discovery of surgical anesthesia in the mid-1800s, patients were forced to endure the pain of surgery while awake. This must have been a horrifying experience. In her journals, the 19th-century English novelist and playwright Frances Burney recounted the experience of undergoing breast surgery to remove a mass:

      When the dreadful steel was plunged into the breast—cutting through veins—arteries—flesh—nerves—I needed no injunctions not to restrain my cries. I began a scream that lasted unintermittingly during the whole time of the incision—& I almost marvel that it rings not in my Ears still!

      Before anesthesia, the merit of a surgeon came down to his speed; this was paramount due to the immense pain patients were experiencing. The need to decrease pain so that surgeons could operate more precisely led to the discovery of surgical anesthesia. Anesthesia allowed surgeons to perform longer, more complex surgical procedures while sparing patients the excruciating pain of their work.

      Before the discovery of anesthesia, even the most intense pain was simply accepted as a part of life. Those who suffered turned to religion for solace. It’s no coincidence that Karl Marx called religion “the opiate of the masses.” C.S. Lewis once wrote that “all great religions were first preached, and long practiced, in a world without chloroform.”

      In earlier times, pain and disease were thought to be sent from God as punishment for sins and as an opportunity to seek redemption. Throughout the Middle Ages, pain was thought to provide spiritual purification. In Europe and America as late as the 18th century, physicians were often members of the clergy.

      Early in the 19th century, a shift in thinking occurred. It began a humanitarian ideology that saw pain as something that should be avoided. Some philosophers began to argue that pain and suffering were fundamentally unnecessary.

      In drafting the Declaration of Independence, Thomas Jefferson wrote that we all have a right to “life, liberty, and the pursuit of happiness.” This became a part of the ideological bedrock of the United States of America. If Americans had a right to pursue happiness, presumably this included the right to avoid pain.

      Nineteenth-century scientific advances were paralleled by increasingly secular attitudes toward pain. There was a growing belief that suffering could be avoided and that it was truly unnecessary. As doctors used the scientific method to relieve ailments, people grew more reliant on science and less dependent on religion as the only available salve for pain and suffering. Despite advancing in other ways, the field of medicine was still years away from developing anesthesia.

      Without anesthesia, pain put a major limit on the advancement of medical science. When a surgeon attempted a surgical cure for an illness or affliction, a patient was forced to endure the torture of an operation. There was simply no way around the pain. Some physicians tried using alcohol as a sedative to dull pain. Others asked patients to bite a bullet or use other, similar techniques to distract them from the pain. None of these measures effectively prevented much suffering. At the very least, this new, humanitarian view towards pain and the concomitant belief in the power of science to solve problems drove the search for a safe and effective anesthetic.

      In 1846, William T. G. Morton, an American dentist, tried using ether, a gas, to put a patient under before performing a tooth extraction. When his patient awoke after the bloody procedure, he reported having experienced no pain. Morton went on to give the first successful demonstration of general anesthesia at Massachusetts General Hospital1, putting a patient under with ether while surgeon John Collins Warren removed a tumor.

      Warren wrote about the landmark surgery:

      The patient being prepared for the operation, the apparatus was applied to his mouth by Dr. Morton for about three minutes, at the end of which time he sank into a state of insensibility. I immediately made an incision about three inches long through the skin of the neck and began a dissection among important nerves and blood vessels without any expression of pain on the part of the patient… Being asked immediately afterward whether he had suffered much, he said that he had felt as if his neck had been scratched; but subsequently, when inquired of by me, his statement was, that he did not experience pain at the time….

      Surgical anesthesia led directly to improved medical care. Now surgeons could focus on the complex operation at hand, taking the much-needed time to perform their work correctly.

      Over the years, refinements brought surgical anesthesia to even higher levels. When I began my anesthesiology residency training in 2001, I marveled at the power of surgical anesthesia to quickly and completely shield a patient from the pain of surgery and then to bring them back to full consciousness with no apparent ill effects. The interesting thing is that we still don’t really know how anesthesia works to accomplish this, despite its universal use.

      A surgeon, frustrated that few of his procedures went exactly as he had planned, turned to me in the operating room.

      “Anesthesia is like magic,” he said. “It always works!”

      Anesthesia forever changed society’s attitude on pain and suffering. It also gave surgeons the confidence that they could now tackle many previously inoperable conditions.

      Regional, as opposed to general, anesthesia makes one part of the body numb while the patient is still awake. It gives expectant mothers the option of experiencing little to no pain during childbirth. During my residency, I spent some time on the obstetrics ward. It was immensely gratifying to find a woman in agony from painful contractions and, with the insertion of an epidural, offer her immediate and almost complete relief from that pain. It was like a switch was flipped. Thanks to the invention of regional anesthesia techniques, childbirth pain can be seen as something that may simply be avoided as opposed to something intrinsic to the experience of motherhood.

      Both general and regional anesthesia represent tremendous medical advances. Pain management has been a key function of all physicians but, in retrospect, it seems only natural that anesthesiologists would gravitate toward it. After all, the anesthesiologist’s expertise lies in managing pain before, during, and after surgery. Why not adapt these powerful techniques for patients suffering with pain outside of the operating room?

      That said, when I actually worked at a chronic pain clinic, I became acutely aware of how unsuccessful we were as a specialty field at helping so many sufferers.

      If you’re reading this book, you probably know that chronic pain is an enormous problem, but you may not realize quite how enormous. Once you account for indirect costs like lost workdays, we spend $635 billion a year on chronic