8/30/09
Dr. Ronald B. Rice
PAIN, THE GIFT NOBODY WANTS
2 Corinthians 1:3-7; 12:7-10
Three months ago, on a Wednesday afternoon, May 27th, I suddenly developed an excruciating pain behind my right eye socket. Was it a stroke? But there is no pain in a stroke. A broken blood vessel? I had no idea what it was. I was able to get in to see my doctor the next afternoon. He looked closely at a sensitive little spot above my eyebrow. “You’ve got herpes zoster,” he explained, “commonly known as shingles.” It seems that for those of us who had chicken pox when we were kids, the virus stays dormant for the rest of our life and can break out at any time, especially as we get older. The pain and the sores usually last a month or so, but for some percentage, the nerve damage is severe enough that it can last for months or the rest of your life. As the weeks of pain go by, I guess I’m in that lucky group. I won’t bore you with all the details, except to say that I’m on a medication which seems to be lessening the pain, both the severity and the frequency. And I appreciate all your prayers.
As I have been thinking about pain, I suddenly remembered what one reviewer called the greatest book about pain of the 20th century, by our own Dr. Paul Brand, Pain, The Gift Nobody Wants. I had never actually sat down and read the entire book, but now that I have, I’ll never complain about pain again! Phillip Yancey, whom I regard as perhaps the greatest Christian writer of the second half of the 20th century collaborated with Dr. Brand to produce this amazing book. It is long, but very readable, full of stories, an autobiographical account of Dr. Brand’s life and medical career studying pain and those who have no pain. It was first published in 1993. Evidently it didn’t sell well, because most people want to read feel-good books and they don’t want to read a book about pain, so Zondervan republished it in 1995 as The Gift Nobody Wants. They republished it again in 1997 as The Gift of Pain. You can get it on Amazon, both the 1997 edition brand new or very inexpensive used ones of the older editions. Christianbook.com also has the new one at a discount. I highly recommend this book to anyone experiencing pain.
I hope you won’t mind if I use Dr. Brand’s first name, Paul, this morning, because that’s how we all knew him. One of Paul’s early lessons about pain came when he was doing rotations at London suburban hospitals during the Second World War. Penicillin had just come out and distillers had not yet perfected the purification process and the thick yellowish miracle drug was highly irritable to living tissue. One of his patients, Jake, had had his legs shattered in the no-man’s-land between trenches. Dragging himself into a foxhole he looked down and saw his legs were a mess. A few minutes later, one of his buddies was hit in the open field, unconscious and exposed to enemy fire. Jake crawled out of the foxhole and somehow dragged his friend to safety. Yet back in a London hospital, Jake cried like a baby when the nurse came around in the middle of the night for his penicillin injections.
It fell to Paul as the house surgeon to reason with him. “Jake, all the guys tell me you’re a hero. Not even the pain of two broken legs could keep you from saving your buddy in no-man’s-land. Now tell me, why are you giving us so much trouble over a needle prick in your backside?”
“It’s not just a needle prick, Doc. That penicillin may be good stuff, but it burns and it stings! There isn’t a place on my backside that’s not sore.”
“Yes, I know it stings, Jake, but you’re a hero. You’ve proved you know how to handle pain.”
“Oh, on the battlefield, yes. There’s a lot more going on there—the noise, the flashes, my buddies around me. But in the ward, I have only one thing to think about all night in bed: that needle. It’s huge, and when the nurse comes down the row with her tray of syringes, it gets bigger and bigger. I just can’t take it, Dr. Brand.!”
“Having heard his story from other soldiers,” Paul writes, “I had a vivid mental picture of the battlefield hero defying all protective instincts, including pain, for the sake of his friend. But the night nurse gave me an equally vivid picture of Jake the coward, his face contorted in fear, awaiting the nighttime needle. Those two images underscored an important fact about pain: pain takes place in the mind, nowhere else.”
The treatment of pain became a national priority because of the war and some of the best minds at Paul’s medical school, University College, took up the subject. He was fascinated by the pioneering research some of them were conducting, and he began formally researching the subject in libraries. The dazzling complexity of the pain network astounded him. He began studying pain out of simple curiosity, having no idea he was accumulating a foundation for his life’s work. He came away with an enduring sense of awe and gratitude for the very sensation most people view with resentment.
For example, the eye is a thousand times more sensitive to pain that the sole of the foot because it faces peculiar hazards. Vision requires that the eye be transparent, thus limiting the number of opaque blood vessels immediately available. Any intruder, even a speck of dirt, poses a threat, because with its limited blood supply the eye cannot easily repair itself. For protection the eye has such a hair-trigger response that virtually anything touching it causes pain and trips the blink reflex.
On the other hand, the foot is designed to bear the body’s weight: it has tougher supporting structures, a plentiful blood supply, and a thousand times less sensitivity to pain. Fingertips can likewise withstand much duress: carpenters would be rare indeed if the gripping fingers fired off pain signals to the brain at every stroke of the hammer. In each case, a body part’s function determines its surrounding structure, and the pain network loyally adapts.
One of the student’s favorite instructors was Graham Weddell who went on to travel the globe, researching pain. Once he was having trouble explaining to some Nigerian tribesmen why he wanted them to undergo certain tests. His translator interjected, “He’s like a chicken scratching around until he finds something.” Weddell loved telling that story. He said it was the finest definition of scientific research he had ever heard.
I don’t think many of us who knew Paul Brand as a member and elder here at West Side, had any appreciation for what a pioneering scientist he was. He was so humble and unassuming. If leprosy had been a more widespread disease in the West, I wouldn’t have been surprised if he had won the Nobel Prize for Medicine. Two Australian doctors, Robin Warren and Barry Marshall won the prize in 2005 for shooting down the long-held belief that stomach ulcers are caused by stress or diet. In 1982 they proved instead that stomach ulcers are caused by bacteria. That research was rejected by the medical establishment for years, and 27 years later the stress and diet myth is still widely held by the general public. Paul likewise had his pioneering research into leprosy rejected for years. Eventually however he was honored by just about every relevant prize there is in the world except the Nobel Prize for Medicine.
After finishing his surgical residency in 1946 Paul was recruited to serve at the famous Vellore Hospital in India in lieu of his mandatory army stint. Margaret was pregnant with their second child and Paul could not bear the thought of leaving at such a time. Margaret quashed that objection: “The army would likely send you to the Far East anyway. And I’ll have the baby all the same whether you’re in Europe, the Far East, or India.” She promised to join him in a few months, after the delivery and a little time for recuperation.
At Vellore as a general surgeon, Paul set up a foot clinic and was overwhelmed with patients, especially those with club feet, a genetic deformity that causes the foot to rotate and turn inward. He pioneered a way to gradually manipulate the foot until there was a twinge of pain, then make a cast for the foot in that position. Removing the cast a week later, he manipulated the foot a little further. Week by week he pressed the foot a little more, with progressive splinting, until the young person could walk, using the soles of their feet. I’ll let you read the book how he figured out how to tell just how far he could manipulate a baby’s foot each time just before the point of pain. That method of treating club feet without surgery, evidently pioneered by Paul Brand in Vellore in the late 1940s, was also developed by Dr. Ignacio Ponseti of the University of Iowa in the 1950s and repopularized in the year 2000 and is now widely endorsed as the Ponseti method by the WHO and most medical organizations around the world. I don’t know if there was any connection between the two pioneers, but I suspect the University of Iowa had a far wider influence than a hospital in India.
In 1947 Paul visited a leprosy sanatorium run by the Church of Scotland. He was astonished to see hundreds of patients whose hands were only stumps, or whose fingers and thumb were curled into a claw which they could not release. He quizzed the director, Dr. Robert Cochrane, about the hands. “Bob, these patients will need their hands for any kind of livelihood. Something’s destroying the tissue. You can’t just let those hands waste away.”
“And who is the orthopedist around here, Paul! I’m a dermatologist, and I’ve studied this disease for 25 years. I know most of what there is to know about how leprosy affects the skin. But you go back to that medical library at Vellore and look up research on leprosy and bones. I can tell you what you’ll find—nothing. No orthopedist has ever paid attention to this disease, even though it has crippled more people than polio or any other disease.”
Paul found it incredulous that not one of the thousands of orthopedic surgeons in the world had taken an interest in a disease that produced such terrible deformities. “You’re thinking of leprosy like other diseases, Paul,” Cochrane added. “But doctors, like most people, put it in a separate category altogether. They view leprosy as a curse of the gods. It still has the aura of supernatural judgment about it. You’ll find priests, missionaries, and a few crackpots working in leprosy settlements, but rarely a good physician and never a specialist in orthopedics.”
Paul examined one man’s hand who had his useless fingers and thumb curved in, in the classic “leprosy claw hand.” To his surprise the fingers were soft and supple. He pried them apart and slipped in his own hand. “Squeeze,” he said. “As hard as you can.”
“Stop!” Paul cried, for the man had the grip of a bodybuilder. “I felt more than pain in that moment,” Paul writes. “I felt a sudden awakening, a tiny electric prod signaling the beginning of a long, boundless search. I had the intuitive sense of stumbling across a path that would send my life in a new direction. I had just spent a very depressing morning, seeing hundreds of hands that cried out for treatment. As a surgeon who loved hands, I had shaken my head in sadness at the waste, for until this moment I had thought them permanently ruined. Now, in this one man’s grip I had first hand proof that a “useless” hand concealed live, powerful muscles. Paralysis? My own hand still ached from his grip. The man’s puzzled look only added to the mystery. Until I cried out, he had no idea he had hurt me. He had lost sensory contact with his own hand.”
Checking the scant literature, Paul learned that 10 to 15 million people worldwide suffered from the disease, and since a third of them suffered significant damage to hands and feet, leprosy probably represented the single greatest cause of orthopedic crippling. One source suggested leprosy caused more hand paralysis than all other diseases combined. But the only surgical procedure recommended was amputation. The good news was that 99 percent of the population is completely immune to leprosy. It is the least communicable of all communicable diseases. The further good news was that a new drug, sulfone, introduced several years before, was proving effective at killing any active bacteria. Leprosy was virtually disappearing from their bodies. The bad news was that the damaged hands and feet and disfigured faces remained and there was no way these social outcasts could return to their villages or lead a normal life.
The mystery was that some muscles remained strong and others were paralyzed. Ever the scientist, Paul organized an assembly-line of technicians to examine the hands and feet of all the thousand patients at the sanatorium and a thousand more at other leprosy centers, mapping the sensitivity to touch and pain, measuring the range of movement, recording the precise length of fingers and toes, and X-raying the most interesting cases. Early on Paul noticed a peculiar pattern. Muscles controlled by certain nerves were paralyzed, while other muscles were unaffected.
The next step was an autopsy, near impossible in India where Muslims forbade any bodily mutilation after death and Hindus required that as soon as possible the entire body be burned to ashes in a purifying fire. Finally one evening Paul was notified of the death of a patient at the sanatorium, and he would be allowed access to the body until dawn. Because of car trouble Paul, another doctor and his pathology technician didn’t arrive until 2:30 am. The night guard loaned them a dim kerosene lantern and they got right to work on the body which had been in the little stifling death hut all day in the broiling sun. Just as dawn was breaking Paul discovered a surprising pattern. Where the nerves lay close to the skin surface, they were swelled to many times normal size, caused by an infestation of leprosy germs. Where nerves were deep in the tissue they were normal. It would be years before they unraveled the full mystery, but the answer was a simple one. Leprosy bacteria prefer the cooler temperatures that prevail close to the surface. It was there that the body’s immune system swarmed in, swelling the nerve’s insulating sheath and choking off vital nourishment, killing the nerve.
Paul went on to develop a hand surgery where he moved the tendons of good muscles to the back of the fingers and thumb, so that with retraining of the brain, the patients could open their hands as well as close them, and regain the use of their hands. Next Paul tackled the problem of fingers that seemed to shrink and foot ulcers that would never heal. For centuries the medical profession and those who treated leprosy patients had attributed this to “bad flesh,” that there was something about the disease that made flesh rot away and die.
For months Paul had treated the angry red ulcers on the balls of the feet of one bright young man. His toeless feet were already shortened by half. Before he came to Vellore several doctors had recommended amputation below the knee. Paul’s frustrating cycle of treatment went on for months with no success at healing. Finally one day he watched as the young man walked down the steps and down the road, after Paul had just spent half an hour cleaning out the grossly abscessed wound on the ball of his foot. He had no limp! He was putting his full weight on the exact spot that had been so carefully treated. No wonder the wound never healed! There was no such thing as bad flesh. It was painlessness. With no pain, the young man didn’t realize the damage he was doing. A couple of months in a hard plaster cast to protect the foot, and the ulcer healed beautifully. Research with a group of 25 teenage boys showed the same thing with their hands. It wasn’t leprosy that was causing the deep infections in their fingers and hands, it was insensitivity to pain. Without pain, they weren’t taking care of their wounds and injuries.
Paul’s discovery that leprosy was a disease of the nerves, that it merely silenced pain, and that all further damage was the result of painlessness, and was thus preventable, flew in the face of centuries of tradition. As he subsequently published papers and traveled the world to leprosy centers, his notion was met with great skepticism. The director of the US Public Health Service Hospital in Carville, Louisiana said, “I’ve been in this business a long time, and I can assure you that Hansen’s disease causes these fingers to shorten.” Finally in 1957 an Italian filmmaker helped provide the breakthrough. His documentary on Paul’s work, Lifted Hands, made a vivid impression at a Tokyo conference of leprosy experts from 43 countries. Only one dissenter, a strict scientist, demanded scientific proof before any resolution would be issued. An investigating team of hand surgeons, medical scientists, and leprologists descended on Vellore, examining the meticulous records and photographs of each patient. The result was explosive. With great enthusiasm they issued a report endorsing Paul’s approach to rehabilitation and vindicating his pioneering work. Soon Paul was hired by the WHO as a consultant and Vellore became the critical stopping place for leprosy experts from around the world.
There is so much more I wish I had time to share from this book, but let me add just one more amazing discovery. Paul and his family moved to the US, as the medical director of the US Public Health Service Hospital in Carville, Louisiana. Quite by accident one day looking through a medical journal, he noticed that X-rays of diabetics with foot problems were identical to the X-rays of some of his leprosy patients. He began to realize that it was the identical problem. Diabetics who had lost feeling in their feet because of nerve damage now had ulcers that wouldn’t heal, and were having their legs amputated. In fact 100,000 diabetics a year were having their legs amputated, because of ulcers that wouldn’t heal. Again, Paul’s view was met with much skepticism. But a renowned expert on diabetes in Atlanta agreed to test the theory. By detecting foot problems early, and keeping wounds in plaster casts, the idea of non-healing wounds proved to be a myth. Again, Paul’s pioneering work was vindicated and amputations plummeted. If you go to any website about diabetes today, you’ll see that somewhere close to the top of the list is foot care, the importance of examining the bottom of the feet every day with a mirror, and immediately caring for every little wound or blister. Thank you, Paul Brand!
The Bible has a great deal to say about pain and suffering. I’ve read two of the important passages from 2 Corinthians this morning. For one thing, the Bible shoots down any feel-good ideas that Christians will be spared from pain and suffering. If God refused to remove the thorn in the flesh from the Apostle Paul, of all people, then I guess the rest of us shouldn’t complain when we have our thorn in the flesh. There has been a lot of speculation about what that thorn was, but I think it is great that Paul didn’t specify exactly what it was, and we can all identify with that wonderful metaphor when we have our thorn in the flesh. I certainly do, and I’ve had the advantage of all this medical science that the Apostle Paul never knew. He said the thorn was there to keep him from being too conceited. I guess there’s probably a few of us who can use a little humility. I’m sure I can, and these thorns in the flesh are pretty effective at doing that. Further God told Paul, “My grace is sufficient for you, for my power is made perfect in weakness.” “That is why,” said Paul, “for Christ’s sake I delight in weaknesses, in insults, in hardships, in persecutions, in difficulties. For when I am weak, then am I strong.”
In 1 Corinthians 12, Paul wrote about the Body of Christ, comparing the church to the body and how each part of the body, each member of the church, has to fulfill its unique part in order for the body to function. Paul ends that classic passage with these famous words, “When one member suffers, all suffer together, when one member is honored, all rejoice together. That principle is one of the most important in dealing with pain. The community, beginning with the family and then broadening to the church can be most effective in helping us with our pain. That begins when we are children and run to our mother when we skin our knee. We saw that yesterday at Senator Kennedy’s funeral, when his oldest son Ted Jr. told so poignantly how he fell on the ice and just gave up trying to climb an icy driveway not long after he had his leg amputated from cancer at age 12. “I’ll never do it,” he cried. “I know you can do it, there’s nothing you can’t do,” his dad said as he grabbed him around the waist. “We’ll make it to the top if it takes all day!” Ted Jr. could hardly finish as the emotion of that memory of his father’s support welled up within him. Then his younger brother, Congressman Patrick Kennedy, told of his childhood struggle with asthma, and how the medication gave him severe headaches. He remembered fondly how his father seemed to always be there, holding a cold cloth to his head until he went to sleep.
It is not only family, but the body of Christ that can be a great help in easing pain and suffering. Our prayer chain, our deacon’s ministry, the support of a small group, the acts of kindness in bringing meals or sitting at a bedside can be of enormous help. There is nothing worse than enduring pain and suffering alone. Just to know that others are concerned, are praying for you, are there to divert your attention from your pain, is wonderful.
Twenty years ago Sharon and I attended worship at the largest church in the world, in Seoul, Korea. The whole church was built on small groups that met weekly to pray for each other. Christian taxi drivers would form a group and then invite their non-believing fellow drivers if they would like to come to a group where they prayed for your problems. If someone in the group, for example, was having surgery, the whole group would take off work and go to a prayer room at the church and pray during the entire duration of the surgery. As groups got too large they would divide and keep dividing, until the church had grown to 650,000 members. It was all because people were drawn to those caring small groups, where when one member suffered, they all suffered, when one member rejoiced, they all rejoiced.
In his introduction to 2 Corinthians, Paul wrote that God is the Father of compassion and the God of all comfort who comforts us in all our troubles. But he didn’t stop there. The reason God comforts us is so that we can comfort others who are in any kind of trouble with the same comfort we have received from God. In other words, suffering has a purpose. We suffer so that we can experience God’s comfort, and then we can share that comfort with others.
My colleague in Nigeria, Dr. Danny McCain, has written, “God often chooses to advance a person to a leadership position through suffering. There is something about suffering and trouble and pain that causes one to think more clearly. Suffering has a way of removing from us the distractions of life and showing us what is really important.” In his widely acclaimed book for African church leaders, Tough Tests for Top Leaders, Professor McCain recounts the story of Joseph, and all the suffering and injustice and pain that Joseph endured, the very things God used to prepare Joseph for his incredible leadership position in Egypt. Dr. McCain lists these benefits of suffering:
Suffering helps remove pride. God hates pride and will go to great lengths to destroy it.
1. Suffering helps to make us obedient to God’s word. Psalm 119:67 contains this amazing confession: “Before I was afflicted I went astray, but now I obey your word.”
2. Suffering gives us an opportunity to forgive those who offend us. Jesus said if we do not forgive others, God will not forgive us. Therefore, God arranges opportunities for us to forgive others.
3. Suffering helps us to be compassionate to others who are suffering. No matter what you thought of Senator Kennedy’s politics, you would have to agree that he was a man who had suffered, and he was a man of compassion for the poor, in spite of his great wealth.
4. Suffering helps us become a model for others who suffer. That is the point of verse 6: “If we are comforted, it is for your comfort, which produces in you patient endurance of the same sufferings we suffer.” The point Paul is making is that his suffering has provided a model for others to follow.
5. Suffering forces us to depend on God, not on ourselves.
6. Suffering helps us to identify more closely with Christ. Paul wrote, “I want to know Christ and the power of his resurrection and the fellowship of his sufferings, becoming like him in his death.” (Phil 3:10)
7. Suffering helps to restore us to a condition of strength, firmness and steadfastness. Peter wrote, “And the God of all grace, who called you to his eternal glory in Christ, after you have suffered a little while, will himself restore you and make you strong, firm and steadfast.” (1 Peter 5:10)
I’d like to close with a dramatic story from the opening pages of Paul Brand’s book. In 1953 he had been traveling around the US studying and researching sponsored by the Rockefeller Foundation. In New York he spent 6 days in bed by himself in a cheap student hostel suffering from a severe case of influenza. Finally with help he was able to make it to his ship sailing for England. When they docked in Southampton 7 days later he could barely cope with his luggage. He boarded the train to London and hunkered down by the window in a cramped compartment. He arrived at his aunt’s house physically and emotionally drained. He wrote:
Thus began the darkest night of my life. I pulled off my shoes, and a terrible awareness hit me with the force of a wrecking ball. I had no feeling in half my foot. I sank into my chair, my mind whirling. I closed my eyes and pressed against my heel with the tip of a ballpoint. Nothing. No sensation of touch whatsoever.
A dread fear worse than any nausea seized my stomach. Had it finally happened? Every leprosy worker recognizes insensitivity to pain as one of the disease’s first symptoms. Had I just made a wretched leap from leprosy doctor to leprosy patient? I rummaged in my suitcase for a sewing needle. I pricked a small patch of skin below my ankle. No pain. I jabbed the needle deeper, probing for a reflex, but there was none. A dark speck of blood eased out of the hole I just made. I put my face between my hands and shuddered, longing for pain that would not come.
Rest did not come that night. I lay on the bed fully clothed except for shoes and socks, perspiring and breathing heavily. From that night on, my world would change. I had crusaded to combat prejudice against leprosy patients. I had scoffed at the possibility of contagion, assuring my staff they were in little danger. Now the story of my infection would spread through the ranks of leprosy workers. What would this do to our work?
What would this do to my life? I had gone to India in the belief that I would serve God by helping to relieve suffering. Should I now stay in England and go underground, so as not to create a stir? I would need to separate myself from my family, of course, since children were unusually susceptible to infection. How glibly I had coaxed patients to defy the stigma and forge a new life for themselves. Welcome to the society of the accursed.
I knew all too well what to expect. My office files were filled with diagrams charting the body’s gradual march to numbness. Ordinary pleasures in life would slip away. Petting a dog, running a hand across fine silk, holding a child—soon all sensation would feel alike: dead.
The rational part of my mind kept cutting in to calm my fears, reminding me that sulfone drugs would likely arrest the disease. But already I had lost the nerve supplying portions of my foot. Perhaps the nerves to my hand would go next. Hands were my stock in trade. I could not possibly use a scalpel if I suffered any loss of the refined sensations from fingertips. My career as a surgeon would soon end. Already I was accepting leprosy as a fact of life, my life.
At last dawn came and I arose, unrested and full of despair. I stared in the mirror at my unshaven face, checking my nose and earlobes for any sign of the disease. Since I knew more about the disease than the average doctor in London, it was up to me to determine a course of treatment. First, I must map out the affected area of insensitivity to get some sense of how far the disease had progressed. I sat down, took a deep breath, jabbed the point of the sewing needle into my heel—and yelped.
Never have I felt a sensation as delicious as that live, electric jolt of pain. I laughed aloud at my foolishness. Of course! It all made perfect sense now. As I sat hunched on the train, my body too weak for the usual restless motion that redistributes weight and pressure, I had cut off the blood supply to the main branch of the sciatic nerve in my leg, causing a temporary numbness. Temporary! Overnight the nerve had renewed itself and was now faithfully spitting out messages of pain and touch and cold and heat. There was no leprosy, only a weary traveler made neurotic by illness and fatigue.
That single sleepless night became for me a defining moment. I had caught only a fleeting glimpse of life without touch and pain, yet that glimpse was enough to make me feel frightened and alone. My numbed foot seemed like a foreign appendage grafted onto my body. I will never forget the desolation of that sensation like death.
The opposite happened the next morning when I learned with a start that my foot had come back to life. I breathed a prayer, Thank God for pain!
Yes, thank God for pain!