By John Quintner and Melanie Galbraith
“I only know one thing, and that is to shout to my children ‘long live Life!’.
But it’s so hard to do, when I am ripped apart by pain.”
From his anecdotal journal entries (translated by Julian Barnes), we can get an idea of how the French novelist, playwright and poet Alphonse Daudet (1840-1897) addressed his extremely painful neurosyphilitic condition i.e., tabes dorsalis. Its manifestations are due to degeneration of the posterior columns and nerve roots of the spinal cord. In today’s parlance, such pain would be described as neuropathic.
Fortunately, syphilis (in all its manifestations) is curable with antibiotics and now rarely seen. But there are many other medical conditions, such as fibromyalgia and complex regional pain syndrome (CRPS), which can be associated with severe pain that is poorly controlled by the currently available medications.
I invited my colleague Melanie Galbraith, physiotherapist, to comment from the point of view of a pain sufferer upon Daudet’s methods for obtaining pain relief. Melanie experiences intractable cervical radicular (neuropathic) pain. She is currently completing a Masters degree in pain management through the University of Sydney and has been a valued contributor to health professional pain education in Western Australia.
With the permission of Professor Abraham Olivier* the following excerpts have been transcribed directly from his book “Being in Pain” (2007):
1. By means of imagination
Daudet: “It’s hilarious, this land of neurotics, filled with shouting, trumpet calls, sirens.”
From such passages, which refer to the people he meets at thermal stations within various health spas, it is apparent that he describes the land of pain in terms of fantasy, of theatre, of tragedy.
I argued (Chapters 4 and 5) that imagination can change a bodily state like pain into an unreal object, even while it remains a bodily state. In this way imagination can make pain vanish behind a mask. We cannot place ourselves into a space of fantasy without any pain, for we remain beings embedded in bodies. But our bodies can change our states of pain by projecting in the place of the land of pain a space of fantasy. Indeed, according to Daudet, this has the effect of a morphine injection (p. 175).
Melanie: “meets at thermal spas” – Heat – it’s a very under-utilised form of treatment for chronic pain. Sometimes when my pain is at a high level I’ll imagine being at the beach on a hot, summer’s day and scrunching the warm, white beach sand between my toes.
Daudet’s use of imagination as a strategy for pain management is supported by recent research, which has found encouraging but inconclusive evidence that guided imagery can alleviate both muscular and non-muscular pain (Posadzki & Ernst, 2011; Posadzki et al, 2012)
Of course, there is a limit to imaginative projection. Theatre is not endless and as the music fades away the pain will return. But the same goes for morphine. Why not try fantasy instead? … But again, it is one thing to use fantasy as an additional tool to physiological therapy, another to integrate it as a primordial means to treat pain. I advocate the latter. Daudet demonstrates the power of this approach: it is like a morphine injection.
Melanie: It would be great – but … when my pain is at a maximum, it’s as if your ‘beach scene’ has been overtaken by a violent storm with booming thunder, torrential rain and blinding lightning. Added to this, vicious waves are crashing against the ‘sea wall’ and threatening to ‘burst the dam’.
2. By means of relocation
Daudet: “One ought to go to different baths each season”
On the one hand, Daudet turns the thermal station into a place of fantasy. On the other hand, he thinks a literal change of space to be as important as positing an imaginative space.
This illustrates once more that space is not, as traditionally thought, some place (a container or extension) belonging to the external environment, but the perspective we adopt toward our environment.
This may be taken as a useful therapeutic insight – we may even label it as space therapy: moving away as a means of removing pain, that is, changing our perspective as a means to change the quality of pain.
But if it would help, then anyone can find a means to travel. If not by plane or car or boat, then our feet, or at the end our fantasy may carry us to places that harbour new perspectives (p. 176)
Melanie: If only Medicare would fund a ‘week away’! Whilst working in the UK I saw many, many patients whose pain improved or disappeared altogether when they were away somewhere that was warm and ‘stress- free’! I’m convinced we could save a mountain of health dollars if doctors could ‘prescribe a holiday’! It’s much cheaper (and likely MUCH more effective!) than a range of ‘interventions’ such as spinal injections, drugs and surgery.
3. By means of compassion
Returning from a sojourn at a thermal station could cast patients into desolation. This could mean extreme loneliness even to someone in a caring family.
Daudet conjures up a dialogue between two ataxic patients to demonstrate this desolation, but also to suggest compassion as a means to counter it. One patient is a bachelor, the other a family father. They discuss whether it is better to be alone while suffering or not.
The family father argues that it is better to be alone: firstly, because it is a terrible weight on a household to have someone around whose pain drags on for years. Furthermore, it adds to your own suffering to see how the pain, which always appears new to you, becomes familiar and wearisome to others. Moreover, the responsibility of taking care of your family while in pain increases your burden. Finally, family life has taught him to keep his pain to himself rather than to show it, but not showing it is a big constraint.
The bachelor counters quite sharply and forcefully: the lack of someone who cares adds to the loneliness the pain brings about, yet it is important to care for others, for your family, instead. Eventually caring for them helps you to get away from yourself, which in turn supports them in caring for you. Compassionately taking another or another’s perspective could thus be an effective means to step out of one’s misery. In this sense compassion entails a liberating perspective (p. 177).
Melanie: This is the classic situation of “the grass is always greener on the other side of the fence.” As I was alone (not in a relationship) when my chronic pain started, I often thought: “how nice it would be to have someone to care for me”. At other times, especially when pain is high, I think: “thank goodness I can shut myself away”. It’s a relief to not feel like a burden on someone else, but I didn’t choose this life situation for myself so surely I have as much “right” as the next person to have a fulfilling relationship with a significant other?
4 .By means of consultation
This does not so much refer to meetings with doctors as to discussions with fellow-patients. Such talks often consisted in the exchange of advice.
To be clear, Daudet knew how to be self-critical about such advice:
“Patients giving one another advice: ‘This is what you have to do.’ ‘But does it work?’ ‘No.’ ‘Are you any better?’ ‘No.” ‘So why are you giving me advice?’ Lunacy.”
But Daudet did give advice … to those who are weak; Daudet recommended that they treat pain as an unwanted guest to whom no special attention should be accorded. Daily life should be continued as normally as possible … this advice has a strong underpinning once we see pain as bodily perception … as a change of perspective changes the quality of pain, it is certainly possible to adopt a perspective to drive out the unwanted guest … Daudet’s advice for those who do not scare too easily is that they should dare to examine their pain carefully … the question is: how can the body remove its pain by means of thinking? Once we rephrase the question, we are much closer to the possibility of realising the power of the bodily axis our perception pivots on (p. 177).
Melanie: If I disclose my own pain problem, my patients appear to appreciate the fact that a health professional “understands what they are going through”. Despite pain being a “unique experience” – personal to the individual, I’ve found patients seem to let go their defenses when they know I’m “one of them”. Sometimes, I’ve found it’s the ONLY thing that will ‘get them on board’ and try some new strategies for managing their pain.
*Abraham Olivier is Professor and Head of the Department of Philosophy at the University of Fort Hare. In addition to this he is Co-founder and Co-chair of the Centre for Phenomenology in South Africa (http://saphenomenology.wordpress.com/). He was Editor of the South African Journal of Philosophy and secretary of the Southern African Philosophical Society (PSSA). Olivier obtained his PhD from the University of Tübingen and has held lecturing and research posts at the Universities of Tübingen, Stellenbosch, Hamburg and Padua. He is the author of Being in Pain as well as numerous international peer-reviewed articles.
References:
Daudet A. In the Land of Pain. Transl. Barnes J. New York: Alfred A Knopf, 2003.
Olivier A. Being in Pain. Frankfurt am Main: Peter Lang, 2007: 161-200.
Posadzski P, Ernst E. Guided imagery for musculoskeletal pain: a systematic review of randomized clinical trials. Clin J Pain 2011; 27: 648-653.
Posadzki P, Lewandowski W, Terry R, et al. Guided imagery for non- musculoskeletal pain. J Pain Symptom Manage 2012; 44: 95-104.
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REFLECTIONS ON DAUDET’S TREATMENT
It may be of interest to the pain community to review the various forms of treatment that Daudet received for his intractable symptoms. This brief review draws parallels with the contemporary treatment on offer to those with chronic widespread pain (aka fibromyalgia).
Then, as now, there were a number of different analgesic medications in the physician’s pharmacological armamentarium. And, as mentioned above, the facilities available at thermal spas were utilised by many pain sufferers. But other forms of physical treatment were also popular.
Daudet’s medications
The list of prescribed medications that Daudet tried included: mercury (by intramuscular injection), laudanum (a tincture of opium), chloral hydrate (“caused thick patches like make-up”), bromide (“the side effects of bromide decrease in terms of depression and memory loss. Unfortunately its curative powers also decrease”), antipyrine (a non-steroidal anti-inflammatory drug), acetanilide (which is metabolized to paracetamol), and morphine.
Only morphine provided him with worthwhile pain relief despite its side effects (“nausea and delirious states”): “Morphine gives you wakeful nights in which you are gently rocked in a heavenly manner.”
In his last weeks of life, Daudet talked to his son Léon about morphine: “I am aware of its inconvenience and hazards, but all in all, it helped me to live and without it I do not know what I would have become” [Daudet 1940].
Medications now available
There are only three medications approved by the NIH for use in the treatment of patients with fibromyalgia – pregabalin, duloxetine and milnacipran – but they appear to be of limited efficacy for most patients [Staud 2011].
Although opioids are now deemed to be inappropriate treatment, there has been a drastic increase in the number of patients being prescribed these medications [Painter & Crofford, 2013]. This increase may simply reflect the analgesic inadequacy of the NIH-approved medications.
Daudet’s physical treatment
For a time Daudet was a patient of the famous French neurologist Jean-Martin Charcot [1825-1893]. The relationship soured when in September 1889 Daudet started coughing up blood after his 13th “suspension”. This treatment was known as Seyres’s suspension and had recently been imported from Russia by Charcot (de la Tourette, Le Progres Médical, Jan 19, 1889).
However, this form of treatment originated in America, having been devised by Lewis Albert Sayre [1820-1900], the first professor of Orthopaedic surgery in the United States, for the treatment of idiopathic scoliosis and spinal tuberculosis (Pott’s disease) [Zampini & Sherk, 2008].
Daudet provides us with his description of this brutal treatment: “The hanging up of poor ataxics, which takes place at Keller’s (a hydrotherapy establishment) in the evening, is a grim business. The Russian they hang up in a seated position. Two brothers; the little dark one writhing away. I am suspended in the air for four minutes, the last two solely by my jaw. Pain in the teeth. Then, as they let me down and unharness me, a terrible pain in my back and the nape of my neck, as if all the marrow was melting: it forces me to crouch down on all fours and then slowly stand up again while – as it seems to me – the stretched marrow finds its rightful place again. No observable benefit.”
The idea behind the use of suspension in cases of tabes dorsalis was to stretch and elongate the spinal cord and its nerve roots [Gowers & Taylor, 1899]. But neurologists at the Queen Square Hospital soon confirmed Daudet’s assessment and showed that “it has no real power of permanently influencing the disease” [Russell & Taylor, 1890].
Incidentally, Gowers and Taylor [1899] remark: “Nerve-stretching was fashionable a few years ago, the operation being usually performed on the sciatic nerve. In the first case in which it was employed (by Langenbuch) the procedure was followed by remarkable and mysterious improvement, not only in the pains but also in the inco-ordination. The patient subsequently died under chloroform, administered in order that the nerves of the arms might be stretched” (p. 489).
Physical treatment methods for those with fibromyalgia
Apart from heat in its various forms, some authorities suggest that patients might try massage, hot mudpacks, sulphur mud baths, trigger point therapy, acupuncture and even whole body cryotherapy [Offenbächer & Stucki, 2009].
Conclusion
None of these “modern” remedies are likely to have been any more helpful to Daudet than those that he was prescribed. Although “suspension” might seem a bizarre form of treatment, perhaps the same could be said of some of the modalities of treatment currently being used by patients with fibromyalgia.
References:
Daudet L. Quand vivail mon père. Paris: Grosset, 1940.
Dieguez S, Bogousslavsky J. The one-man band of pain. Alphonse Daudet and his painful experiences of Tabes dorsalis. In: Bogousslavsky J, Boller F, eds. Neurological Disorders in Famous Artists. Vol 19, Frontiers of Neurology and Neuroscience. Basel: Karger, 2005: 17-45.
Gowers WR, Taylor J. A Manual of Disease of the Nervous System. 3rd ed. London: J & A Churchill, 1899: 444-489.
Offenbächer M, Stucki G. Physical therapy in the treatment of fibromyalgia. Scand J Rheumatol 2009; 29 Suppl 113: 78-85.
Painter JT, Crofford LJ. Chronic opioid use in fibromyalgia syndrome: a clinical review. J Clin Rheumatol 2013; 19(2): 72-77.
Russell JSR, Taylor J. Treatment by suspension. Brain 1890; xiii: 206-223.
Staud R. Sodium oxybate for the treatment of fibromyalgia, Expert Opinion on Pharmacotherapy 2011; 12: 1789-1798. DOI: 10.1517/14656566.2011.589836
Zampini JM, Sherk HH. Lewis Sayre: the first professor of orthopaedic surgery in America. Clin Orthop Relat Res 2008; 466: 2263-2267.