In Memoriam: Peter Nathan
Peter Nathan, MD, FRCP
1914 – 2002
Dr Peter Wilfred Nathan was born in London on 1 February 1914 and died at the age of 88 on 5 December 2002. Amongst his many achievements, his contributions to the understanding of pain, its mechanisms and treatment, have been both profound and enduring, and mark him as a physician of great stature and influence.
Peter was born in London, the second of three children of Alec and Muriel Nathan. In Australia, his father and paternal grandfather, Joseph, had founded Glaxo, the firm which was eventually to become the giant pharmaceutical company of today. Peter, however, had never wanted to go into the family business, and his career took a very different course. After school at Marlborough College, his education continued at a lycée near Geneva in Switzerland. At the age of 18 he went to Paris, studying French literature, architecture and philosophy at the Sorbonne. Changing countries and languages, he then studied in Dresden and Munich, reading psychology and philosophy.
A pivotal event in his life occurred in Munich. The woman in the family where he lodged was working as a social worker in a child guidance clinic, and Peter witnessed the therapeutic benefits of psychological approaches to childhood disorders such as bed-wetting. This prompted Peter to take up medicine, initially at the Middlesex Hospital in London, from where he qualified in 1939, achieving Distinction in his M.D in 1952. He became a Member of the Royal College of Physicians in 1940, and Fellow in 1964.
At the start of his medical career Peter took up psychiatry, but with the outbreak of war he became regimental medical officer, and was posted to a variety of locations in the United Kingdom. In 1941 he was drafted to the Hospital for Head Injuries in Oxford. This posting proved to be of great importance, for at that unit, directed by Sir Hugh Cairns, he met many of the renowned neurologists, including Symonds, Riddoch and McArdle, who were to become his future colleagues at the National Hospital for Nervous Diseases (recently renamed the National Hospital for Neurology and Neurosurgery) at Queen Square. Peter saw well over 2000 cases of head injury at Oxford, but he was also to see many more war-injured in military hospitals he was posted to in Tel Aviv and Naples. When war ended he went to Bangalor in India, and witnessed the effects of malnutrition in soldiers returning from the Far East. After discharged from the army in 1946, he became a registrar at Queen Square.
It was Peter’s experience of head injuries that led him to pursue a career in neurology rather than psychiatry. However, he had not then had a very extensive grounding in routine, everyday neurology, and he decided to devote himself mainly to clinical research, a decision which was to lead to his lifetime’s work.
In 1947 Peter was appointed to the Medical Research Council (MRC) Neurological Research Unit, headed by Arnold Carmichael. Carmichael had seen Foerster’s work on cordotomy, and suggested to Peter that investigation of the spinal cord would be a fruitful area of research. It was then that Peter started the 30 years of collaboration with Marion Smith (‘Mai’), a Glaswegian neuropathologist, who was similarly attached to the MRC unit. Peter remained a member of the External Scientific Staff of the MRC, and Honorary Consultant in Clinical Neurophysiology to the National Hospital, Queen Square, until his retirement in 1979. But his retirement was merely notional, and he not only continued working at Queen Square for many years, but was also appointed Honorary Consultant to the Royal National Orthopaedic Hospital, and to the City Migraine Clinic, both in London.
If these bald facts outline his career, what of his work? Peter considered himself primarily a physician and a neurologist. Roger Gilliatt, Professor of Clinical Neurology at Queen Square at the time, insisted - and many would say rightly - that all neurologists should do a weekly clinic in general neurology to ‘keep their feet on the ground’. Peter undertook such a clinic throughout his career, in addition to his work with pain patients in the clinic and on the ward. He carried out this work single-handedly for over 20 years, before the development of the multidisciplinary pain clinic at Queen Square which Peter welcomed and encouraged.
Peter also had numerous research interests other than those relating to the spinal cord and pain. Foremost amongst these were his studies of various disturbances of micturition. He developed a technique of intermittent tidal drainage and also a cystometrogram, and with the neurosurgeon John Andrew furthered our understanding of the frontal cerebral control of micturition. Other neurological papers included contributions on the pupil, apraxia and amnesia.
What of Peter’s research on pain? As a result of his interest in the spinal cord, he was referred many patients with cancer who suffered intractable pain. At the time, some 50 years ago, open anterolateral cordotomy was a relatively common procedure carried out for relief of such pain, and the opportunity therefore arose for neurologist and neuropathologist to collaborate in studies of these patients. In work which will surely never be repeated, patients with pain from cancer - and who often died of their disease soon after - were examined neurologically before and after cordotomy, and then, their relative’s permission having been previously obtained, a meticulous post-mortem histopathological examination of the spinal cord and often the brain was undertaken. These truly remarkable studies - many of which, together with major review papers, were published over many years in Brain - enabled clinico-pathological correlations to be made which could only be achieved in humans. These papers represent what are acclaimed as classical and definitive accounts of the neural pathways and the functional organization of the spinal cord, and they deal not only with sensation and pain, but also with motility, respiration, micturition, defaecation, and the autonomic nervous system in man. Following Marion Smith’s death in 1988, Peter continued to publish their joint work, always acknowledging (and sometimes including as author) the contribution of Pat Deacon and the other technicians who had assisted them. After his retirement, and up to just a few months before his death, he regularly travelled to the Department of Neuropathology at the Radcliffe Infirmary, Oxford, where he was given laboratory facilities to complete his work.
Although an enthusiastic and knowledgeable follower of basic research, Peter never undertook laboratory work himself, preferring often remarkably simple clinical experiments based on equally simple observations. These investigations led to numerous papers on subjects ranging from cutaneous warm and cold spots to post-ischaemic paraesthesiae, and from relief of pain and paraesthesiae by nerve block distal to a lesion to thermal sensation in the bladder.
A longstanding friend of Pat Wall, Peter was one of the first to try transcutaneous electrical nerve stimulation (TENS) in post-herpetic neuralgia , and a joint paper with Pat on the use of TENS in post-herpetic neuralgia appeared in the BMJ in 1974. This subject, however, had further ramifications. Melzack and Wall’s gate control theory, from which TENS had developed, had appeared in Science and been received with widespread enthusiasm. Peter was sceptical, however, observing that this theory was based on electrophysiological studies in decerebrate and spinal cats, was not based on an investigation of pain, and was supported neither histologically nor, from his own published studies with Peter Rudge, clinically. In 1976, Peter wrote an extensive and critical paper in Brain rebutting, or at least questioning, the theory, concluding with the characteristically thoughtful comment: ‘Ideas need to be fruitful; they do not have to be right’. He had shown the paper to Pat Wall in advance, but Pat did not receive the criticisms warmly. Happily, they nevertheless remained friends and collaborators, and attended Kit Wynn-Parry’s clinic for peripheral nerve injuries at the Royal National Orthopaedic Hospital together.
Peter’s curiosity appeared limitless. For example, he saw acupuncture being performed for dental anaesthesia at a demonstration meeting, learnt the technique from Felix Mann, and then started to use acupuncture in the clinic - being probably the first to do so in the National Health Service in the U.K. He said that he had made acupuncture ‘acceptable’ to the medical fraternity, and wrote a fascinating account of the development of acupuncture analgesia in Trends in Neurosciences in 1978.
Peter’s research on the spinal cord was paralleled by extensive clinical observations on the efficacy, complications and other sequelae of anterolateral cordotomy, and also led to his interest in the neurolytic effects of phenol. Maher had first reported the use of intrathecal phenol around posterior roots to alleviate cancer pain in 1955, and later taught Peter the technique. Peter subsequently used intrathecal phenol to alleviate pain in patients with malignant disease, and to alleviate spasticity in patients with diseases such as end-stage multiple sclerosis. At the same time, with Marion Smith and Tom Sears, he worked on the histological and physiological effects of phenol, establishing that the clinical effects of phenol were non-selective - it was a question of dosage and formulation. With Tom Sears he studied the neural actions of local anaesthetics, and with Dimitrijevic and others, Peter undertook extensive studies over many years on spasticity and clonus, both from the research and clinical perspectives.
The role of the sympathetic nervous system in pain had intrigued Peter ever since the war, when he encountered numerous patients with painful peripheral nerve injuries. Countering Leriche’s vasoconstriction theory, and Lewis’ vascular stasis hypothesis, Peter speculated in a prescient paper on causalgia, published in 1947, that some form of artificial synapse between the sympathetic and afferent nervous systems might be involved. He undertook a variety of studies over many years, and, although the subject remained as much a puzzle to him as to others, he performed therapeutic sympathetic blocks himself, and when regional guanethidine blocks were introduced, he embraced this technique as well - in later years handing over the practical management of patients requiring invasive procedures to his anaesthetic colleague Laurence Loh.
Many of the topics referred to above occupied Peter over many years, even decades. However, Peter’s ever enquiring mind would also seize on any subject he thought interesting and potentially important. For instance, he had read that chlorprothixene was highly effective for post-herpetic neuralgia; doubting this, he decided to do a study himself - finding (as expected) only 30% patients improved. He wrote on gastric sensation, participated in a study comparing acupuncture with medication in migraine, and with Spillane and others he first described the condition of ‘painful legs and moving toes’. He remained intrigued in pain-related phenomena ranging from pain traces in the nervous system to how fakirs and fire-walkers learn not to feel pain, and in 1985 wrote about these phenomena in an unusual paper in the Philosophical Transactions of the Royal Society.
Despite the breadth of his interests, Peter was never a dilettante. Every subject that interested him was subjected to critical assessment and review, and his understanding of general neurology never left him. This is reflected in his book The Nervous System, which was written for laymen. The book is both scholarly and easy to read, and many of the chapters open with a quotation about cats, which he was fond of and which were welcome in his home. The fourth edition appeared in 1997. He contributed to Encyclopaedia Britannica (1989), and his section on the nervous system in Gregory’s Oxford Companion to the Mind (1987) is a masterpiece. Employing a literal ‘cut and paste’ method to edit the text he had written on his self-styled ‘tripewriter’, he published about 130 peer-reviewed papers. He was never in a hurry to publish for its own sake, however, and indeed he never published his war-time observations on phantom pain, saying he had nothing new to contribute to this mysterious subject.
And what of the man? As with his work, Peter was a man of extraordinary breadth and depth. Multilingual, a very good writer, erudite and equally at home with literature and classical music, he was a keen and knowledgeable gardener, interested in birds and conservation, and travelled widely. He was uncompromising in his hatred of aggression, writing on this in The Psychology of Fascism (1943), and he despaired of intellectual life becoming ‘anti-logic and anti-reason’ in Retreat from Reason (1955). He was extremely warm but never sentimental, chatty but never verbose, sociable but yet private, and - a man not of his time - was entirely unconcerned about his status. Apart from a spell as Visiting Professor of Neurology at Denver, Colorado in 1961, he never became a Professor, and never wanted to be. Although uninterested in committee work, he was a founding member both of IASP, albeit not present at the inaugural meeting at Issaquah in 1973, and of the currently named Pain Society in Britain.
Whilst admittedly a man of independent means, and relying on ‘Mai’ to run the department at Queen Square, in Peter the baser qualities of man seemed to be entirely lacking, and he was devoid of aggression, ambition and avarice. Apart from his penchant for chocolate, he was also frugal. At the same time, however, he was neither shy nor prim. He was witty, had an unquenchable ability to pun, and was an endless fount of anecdotes - perhaps helped by the large numbers of friends he made world-wide. His neurologist friends in the past had included Denny-Brown and Geschwind, and in the pain world Bonica, Pat Wall and Noordenbos, but he was equally friendly to his contemporaries and juniors, be they doctors or cleaners and porters at Queen Square. He was exceptionally caring of his patients and their welfare, and greatly admired his friend Dame Cicely Saunders and her pioneering development of the hospice movement and palliative care.
Peter was also very generous. He was generous with his time and his help, as can be seen by the frequency with which his assistance is acknowledged at the end of others’ papers, yet he refused offers of co-authorship. Illustrating his generosity with money is his financing of his life-long friend Martin Starkie’s production of Chaucer’s The Canterbury Tales. This musical proved an enormous success, and Peter, already having given away most of his money to various philanthropic causes, donated the profits to a charitable trust for the arts that he had founded.
Peter was perhaps the last of the British neurological giants who had acquired an over-arching knowledge of the nervous system and psychiatry, yet at the same time he achieved pre-eminence in his chosen fields of interest and research, particularly pain. He remained immensely productive to the very end of his life, and his curiosity and wit remained undimmed. Indeed, he joked he wanted to be informed in heaven after he had died when it was known how the sympathetic system was involved with pain. His last paper, The crossing of the spinothalamic tract, appeared in Brain in 2001 when Peter was aged 87. How few of us would be able to publish a major paper at that age, and would also declare that their life’s work was now complete and that they would write no more.
Peter died peacefully at his home in London. He was pre-deceased by his sister, Pamela, and is survived by his brother Lindsay. It has been a privilege for so many of us, now and in the past, to have known and learnt from this most distinguished, cultured and loveable man.
by G.D. Schott
National Hospital for Neurology and Neurosurgery
Queen Square, London WC1N 3BG, U.K
**Photograph: Courtesy of the Audiovisual Department, National Hospital for Neurology and Neurosurgery