The Body in Pain

2. The Body in Pain

Elaine Scarry writes about and explains the history of culture through the lens of pain and the human attempt to express and modulate bodily pain by creating artifacts such as clothing, furniture, language and God. She outlines the structure of two kinds of human interaction, torture and war, in which pain is a major currency. Her argument is that both torture and war, through their use and objectification of pain, severing it from its experiential origins in a single human consciousness, act to unmake or destroy language and culture. On the other hand, according to Scarry, human imagination is crucial in the process of making or creating artifacts, and serves as a complement to pain. Scarry goes on to outline the stories of the Judeo-Christian bible and Marx’s Das Capital as histories of three kinds of objects, the ‘weapon’, the ‘tool’ and the ‘artifact’. The artifact is created by the imagination of a single human consciousness and enables sentience to be shared, unlike pain which is a fundamentally private and unsharable experience.

Virginia Woolf complained that “English, which can express the thoughts of Hamlet and the tragedy of Lear has no words for the shiver or the headache… The merest schoolgirl when she falls in love has Shakespeare or Keats to speak her mind for her, but let a sufferer try to describe a pain in his head to a doctor and language at once runs dry.” According to Scarry, pain not only resists language but destroys it, resulting in a reversion to a stage before language, to the cries and grimaces of an infant.

Pain entails this shattering of language because, in contradistinction with our other internal states of consciousness, it has no object. Scarry observes that we do not simply ‘have feelings’, instead we ‘have feelings for X’ when X is the object of love, or hatred. Similarly, our senses are accompanied by objects – we see Y, hear Z. Even our drives have an object – we are hungry for a particular food, we thirst for water. Physical pain alone has no referential content.

Pain is by its nature divisive, because it signals at once certainty in the person experiencing it subjectively, and at the same time doubt or uncertainty in the objective witness, because there is no way of getting around the fact that the pain is located inside the sufferer’s sentient body and sensorium or subjective soul. The lack of speech, language or verbal expression for pain amplifies this dichotomy.

Nevertheless, pain as a symptom is crucial to medical science, and therefore there have been attempts to objectify it. One example is the Melzack McGill Pain Questionnaire, which allows for the evaluation not only of the severity of the pain, but also its other sensory qualities, such as ‘throbbing’, ‘burning’, ‘sharp’, ‘dull’ etc. Melzack was inspired by his patients’ verbal descriptions of their pain to formulate his neurological ‘Gate Control Theory of Pain’.

Amnesty International relies on descriptions of the pains of torture to try and bring about an end to this cruel and unnecessary practice. The first part of Scarry’s book is an analysis of the pain, structure, and political implications of torture, compiled with the help of research by Amnesty International. The legal system is another arena in which the physical reality of pain must be translated into words in order to achieve justice.

Art is another arena in which pain enters the language of human objectification. Scarry quotes Nietzsche’s description of his pain as a ‘dog’: “It is just as faithful, just as obtrusive and shameless, just as entertaining, just as clever as any other dog – and I can scold it and vent my bad mood on it, as others do with their dogs, servants and wives.” Bergman’s movie Cries and Whispers opens with a woman’s diary entry, “It is Monday morning and I am in pain,” which becomes a repeated theme as hinted at by the title. However, Scarry notes that psychological suffering dwarfs physical pain as far as its representation in art, calling our attention to the question whether expressing pain and eliminating pain are related. It also makes me wonder whether physical pain is somehow taboo as an object for art and conversation, given the plenitude of representations both of physical violence and of emotional pain.

The inexpressibility of physical pain makes it a difficult subject politically, and yet it is of mounting concern in view of the global effort to make civilization more human, by eliminating torture, and (in my view) the increasing objectification of medicine as a science rather than an art. While the latter has its underpinnings in technological progress, the resultant silencing of the patient’s subjective experiences of pain has much in common with the dialog concerning torture and war.

The word pain has its roots in the Latin for punishment, ‘poena’. Scarry notes that perhaps because of the aforementioned difficulty in representing pain itself, it is often represented with the sign of the weapon. We use words such as ‘sharp’, or ‘like a knife’ to describe pain. Conversely, the experience of pain is associated with weapons, as when the 14^th Century mystic Margery Kempe speaks of the ‘boisterous nail’ emulating the cries produced by the person in pain, and Wittgenstein conceives of a stone that causes hurt as having ‘pain patches’ on it. Primitive healing rituals can involve pulling the pain out of the body with a weapon, and the language used to describe the physiological mechanisms of pain includes terms such as ‘trigger points’. Odysseus, initially blind to Philoctetes’ pain, notices it when he is required to attend to his bow. As Michael Waltzer astutely observed, “I cannot conceptualize infinite pain without thinking of whips and scorpions, hot irons and other people.”

Writing that emphasizes the language of agency negates pain, illustrated by the litany of weapons in De Sade’s writings. The language of agency confuses pain and the causing of hurt with power. One can see how the absence of an object makes it tempting to use weapons, which have an object, as a metaphor for pain, but that such an analogy is vastly misleading because the weapon has a wielder as well as a victim.

Scarry proposes that the complement of pain is the imagination, which has objects but no associated ‘objectless’ internal process. In other words, one can think of seeing still going on when there is nothing to look at, but imagination only happens in the act of imagining something. The pain of torture, according to Scarry, deconstructs rather than destroys the prisoner’s voice, shattering their world and making it meaningless. In contrast, the human imagination creates real (and meaningful) objects in the world, whether these are concrete like the products of technology or abstract like God, political and legal systems. This process of construction, by means of created objects of the imagination, is necessary for other persons and their sentience to become visible to us, in order to counteract the depersonalization that happens during torture and war.

2.1. The Structure of Torture

Torture is an act that converts the ‘incontestable reality’ of physical pain into an enactment of power, through the “obsessive, self-conscious display of agency.” Scarry notes how the torturers’ slang frequently refers to the torture chamber as a stage, such as the ‘production room’ in the Philippines, the ‘cinema room’ in South Vietnam, and the ‘blue lit stage’ in Chile. The ‘moral stupidity’ of torture has an unconscious structure whereby the pain is amplified within the person’s body, made visible to those on the outside, and denied as pain only to be read instead as power.

In torture, pain and interrogation always occur together, and Scarry emphasizes that the interrogation is a part of the process and cannot be separated from the pain by claiming it as the motive or justification for the torture, because the torturer’s questions make it clear that they are being asked as if the content of the answer matters when really it does not. The torturer pretends that the answer matters, politically, in order to become blind to the prisoner’s pain. In turn, the prisoner’s world is shattered by world-destroying, intense pain, in order to elicit a ‘betrayal’ in the confession of a family member’s name, a fact, or other information, obliterating meaning in an internal psychic world that has already been rendered meaningless by the pain.

Scarry gives as an example the experiences of Pablo Ibbieta in Sartre’s short story “The Wall”. Ibbieta, threatened with execution by the fascist regime, gives false information about his friend’s hiding place. Ironically, his friend is found at the place he named, and Ibbieta survives. During the night, as he waits to die, Ibbieta vacillates between acute attention to his body’s sensations and a sense of alienation from his body. Ibbieta notes that it is the living tissue of the body, the sentience of pain, that allows it one day to be dead. He experiences the moment in which, as described by George Eliot, the person’s knowledge that “All men must die” is replaced by the intimate awareness that “I must die – and soon.” Ibbieta imagines the body as an “enormous vermin” to which he is tied, for which he has no affection. Nor does the political situation in Spain mean much to him any longer. There is a shrinking of the world around the body, as experienced by very old or sick people, where the sensations of the body breaking down become the all-encompassing objects of attention. Oedipus and Lear, in their dying moments, cling to the world with an outpouring of impressive verbosity, knowing that in silence “the edges of the self become coterminous with the edges of the body it will die with” (Scarry).

As Karl Marx observed, “There is only one antidote to mental suffering, and that is physical pain,” or, on the flipside, Oscar Wilde humorously implored, “God spare me physical pain and I’ll take care of the moral pain myself.” George Eliot’s Arthur Donnithorne introspects morosely that physical pain might lift his obsessive boredom and prevent him from damaging himself, a very young woman, and their societal norms. Emil Zola’s Monsieur Hennebeau wishes that like the coal miners, his “empty belly wre twisted with pains that made his brain reel,” to distract him from his obsessive sorrow over his unfulfilled marriage. Scarry suggests that this power of physical pain to eliminate emotional suffering, by obliterating all psychological content, is what gives it value as a religious experience. Many primitive religious forms of worship climax in pain ceremonies, and the crucifixion of Christ is at the center of Christianity, which historically encompassed self-flagellation and still incorporates forms of asceticism. Surgery, often viewed as a climactic achievement of modern medicine, has historically often achieved healing from pain without what would now be considered a proper scientific explanation (see Chapter 1). Bronte’s Wuthering Heights centers on Lockwood’s dream that the pilgrim’s staff is also a cudgel, and Huysman’s dandy recognizes his susceptibility to religious conversion in moments of great physical pain.

The experience of the prisoner who is tortured is very different from that of pain in a religious context, because the prisoner does not choose this experience. Instead, the prisoner’s pain diminishes his world, and enlarges the world of the torturer. The sentience of the prisoner, and his susceptibility to pain, is what gives the torturer power. According to Scarry, one can rephrase the statement “the torturer inflicts pain in order to produce a confession” with the statement “the torturer uses the prisoner’s sentience to obliterate the objects of the prisoner’s sentience” or, in plainer words, “the torturer uses the prisoner’s aliveness to crush the things that he lives for.” The confession is one of several manifestations of the prisoner’s absent world.

Words for the houses of torture illustrate the metaphor of the room as a hospitable anchor of civilization, such as “guest rooms” in Greece and “safe houses” in the Philippines. A room is also a metaphor of the human body, or of the hug. In torture, the room, like the body is inverted, turned inside out. The room itself like its furnishings becomes a torture weapon. In Greece, prisoners were taken to the window and threatened that they would be “de-fenestrated”, or the door left open so they could overhear threatening conversations about their families. The prisoner’s physical world is constricted to the room and its contents, which all become manifestations of the prisoner’s absent world.

Scarry quotes a detailed account of torture with water that exemplifies the subjugation of the ordinary meanings of the objects of civilization such as pipes and tubs to their Machiavellian enlistment as instruments of bodily agony. The nomenclature used for such apparatus is typically technological, such as “the telephone” in Brazil, “the plane ride” in Vietnam, or “the Motorola” in Greece. Alternatively, it refers to ceremonies such as “the dance” in Argentina, “the birthday party” in the Philippines, and “hors d’oeuvres” or “tea party” in Greece. A third source of names, less frequently used than the first two, is nature tamed, such as “tiger cages” in Vietnam, “the little hare” in Greece, “the parrot’s perch” in Brazil and Uruguay, and “the dragon’s chair” in Brazil.

The context of torture, and the torture room, unmakes two benevolent institutions of society, the trial (representing the state) and the practice of medicine (representing the body). The trial examines evidence that may lead to punishment. In torture punishment is used that may lead to evidence. South Vietnamese torturers openly announce, “If they are not guilty, beat them until they are,” and “If you are not a Vietcong, we will beat you until you admit you are; and if you admit you are, we will beat you until you no longer dare to be one.” Reports of torture from the Philippines include references to “unwanted dental treatment”. Doctors in Portugal studied maimed prisoners in order to better design the torture weapons. Forms of torture in Brazil were called “the mad dentist” and “the operating table.” Syrian prisoners in Israel claim their limbs were unnecessarily amputated, wounds cleaned with petrol, and excessive amounts of blood drawn. In Nazi Germany, the “body” was subverted through the scientific laboratory, torturing prisoners of the concentration camps under the pretense of research rather than as an inversion of medical treatment, and the “state” was subverted through the process of production, in factories, rather than as the inversion of a trial.

Scarry underlines this process of inversion by noting the similarity between words meaning healing and hope, as in ‘host’, ‘hostel’, and ‘hospital’, derived from the root word ‘hos’ meaning house, and their proximity to words such as ‘hostage’ and ‘hostility’. Kafka’s story “In the Penal Colony” illustrates this subversion of civilization’s artifacts to the end of torture and world unmaking in his description of the lethal apparatus as a giant sewing machine. Poe’s “The Pit and the Pendulum” aptly closes with the walls, vestiges of civilization and hospitality, collapsing on the human center and crushing it alive.

The enactment of power in torture emerges from the opposition of body and voice. Both the torturer and the prisoner experience their body and voice as opposites, and their experiences are an inversion of each other. The prisoner loses himself and his voice in the engulfing bodily pain, whereas the torturer amplifies himself and his political world in the question. The question part of the interrogation is an act of wounding, with the words as weapons, and the answer is a scream, a letting go of the capacity to express oneself in words. These metaphorical relations are embedded in the language of the torturers, dramatizing the connection between open wounds and confession: “Here, you’re going to tell all. You will open out like a rose.” Or “You’ll vomit blood and tell us yourself.” (Both witnessed by prisoners under the Colonels’ Regime in Greece).

The body itself is used as an instrument of torture, and its pain is experienced by the prisoner as a form of self-betrayal. In Vietnam, prisoners were forced into a cramped position for months or years, in Spain they were forced to walk on bended knees, in the Philippines to carry a heavy stone while being beaten, in Argentina to stand upright for eleven hours each day, and in Greece, in a torture called “making knots,” to throw the head back and swallow their own saliva repeatedly. These distortions of the human body itself can cause as much pain as any other weapon. In The First Circle, Solzhenitsyn describes how prisoners were forced to keep their hands outside the blanket in the searing cold as they slept at night. “It was a diabolical rule. It is a natural, deep-rooted, unnoticed human habit to hide one’s hands while asleep, to hold them against one’s body.” The body’s small gestures of friendship towards itself have been made by the torturer into the enemy.

Torture emphasizes the ever present distinction between the “body” and the “self” which is otherwise latent except in the extremity of sickness or death. The prisoner’s attempt to let out the pain in screams or cries is subverted by the torturers goal of ‘getting it out’ of him. The words of the confession are tape-recorded and taken away, to become the property of the political regime. Even screams are sometimes recorded, to be played to other prisoners later as part of their torture, rendering them in a state of confusion over who was emitting the cries – themselves, somebody else being tortured concurrently, their family member, or an actor.

Scarry recounts how the smallest communication from a fellow sufferer can be intensely meaningful, and almost dispel the pain under such circumstances, as when imprisoned Chilean women sang on Christmas Eve with all their might, so that their husbands in a nearby camp would hear them, and took comfort from their faint answering song. Torture closes the world of the prisoner and displaces conversation with interrogation, so any opening to such sympathy “counteracts the force with which a person in great pain or sickness can be swallowed alive by the body.”

“To acknowledge the radical subjectivity of pain is to acknowledge the simple and absolute incompatibility of pain and the world. The survival of each depends on its separation from the other.” Scarry uses this observation to pump hope into Amnesty International’s efforts at articulating and publicizing the stories of prisoners, in an attempt to end torture. However, I see a parallel between the process of interrogation in torture and how a medical examination might feel to a patient suffering from chronic pain. Often, after many failed attempts at medical treatment and objective diagnostic measures such as X-rays and scans, the patient is implicitly or explicitly blamed for their own pain and the doctor pulls to extract a confession of improvement, malingering, or psychological pain. Just like torture, the physical pain of the body is transformed into voice. There is no infliction of pain by the doctor, in fact the opposite. But the ‘radical subjectivity’ of pain is denied by the doctor in this interaction. Scarry wonders whether this structure of torture is premeditated, and concludes that it is largely unconscious, deriving perhaps from the nature of pain, the nature of power, and the interaction between their two sources – the body as the locus of pain, and the voice as the locus of power. She goes on to outline the three sequential steps of torture, some of which have parallels in the doctor-patient interaction.

The first step is the infliction of pain. This step is present in torture, but normally absent (or largely absent) from the doctor-patient interaction. The second step is the objectification of the subjective attributes of pain. Scarry lists eight attributes of pain, perhaps the core of her work insofar as it relates to my literature review project here. These attributes “belong equally to the felt experience of patient and prisoner, although it is only in the second context… that they become graspable from the outside.” The third and final step is “the translation of the objectified attributes of pain into the insignia of power”.

The first aspect of pain is its aversiveness. Pain cannot be experienced without wanting it to stop. The negative feelings of the person toward the pain are part of any philosophical discussion or physiological definition of pain itself. “The very content of pain is itself negation.” The second and third aspects are the dissonance of experiences in regard to agency over the pain. When a knife or a pin enters the body, the sufferer may experience internal agency, locating the pain in his or her own flesh. Conversely, pain without an external source is often described in terms of the absent weapon, as in ‘knifelike’, ‘stabbing’, ‘boring’, or ‘searing’ pains, externalizing the agency for the pain. The impact of the pain of torture on human consciousness is symbolized by the conversion of the cultural setting into a torture instrument.

The fourth aspect of physical pain is the conflation of the private and the public, expressed by Francis Bacon’s painting of a figure exposed not only because he is placed on a dais and framed by an arbitrary box in his nudity but also because “his melting body is turned inside out, revealing the most sacred and secret parts of him… During torture, the prisoner is forced to attend to the most intimate and interior facts of his body (pain, hunger, nausea, sexuality, excretion) at a time when there is no benign privacy…” Note that this experience is perhaps not very different from that of a hospital patient, except in the latter case for the hopefully benign and caring presence of nurses.

The fifth dimension is the ability of physical pain to destroy language and verbal objectification, the exact vehicle by which, according to Scarry, the pain could potentially be put out into the world and eliminated. Torturers often strive to eliminate the voice of their prisoners, through murder, mutilation, or by forcing the prisoner to cry only at their whim. The prisoner’s “betrayal” in a political context has its equivalent, in a non-political context, in the patient’s “complaints”, which are equally derided or discredited. Scarry quotes headlines from US newspapers in the 1970’s, when the problem of physical pain was first brought into the public eye, saying “A pain is a pain if you complain” and “Chronic pain can make you one.”

Pain obliterates the contents of consciousness, not only annihilating conscious thought and emotion but also other modes of sensory perception, as in “blinding pain”. This is Scarry’s sixth aspect of pain. The seventh is the totality of pain, which begins by feeling like “not oneself” and ends in the elimination of everything that is “not itself.” The world shrinks when one is in pain. Melzack writes that pain involves multiple areas of the brain, and is not isolated in a single ‘pain center’. S. W. Mitchell, a Civil War surgeon, probably describing what we would now call causalgia, wrote:

“Perhaps few persons who are not physicians can realize the influence which long-continued and unendurable pain may have upon both body and mind. The older books are full of cases in which, after lancet wounds, the most terrible pain and local spasms resulted. When these had lasted for days or weeks, the whole surface became hyperaesthetic, and the senses grew to be only avenues for fresh and increasing tortures, until every vibration, every change of light, and even… the effort to read brought on new agony.”

The eighth element of pain is its resistance to objectification. Although pain is supremely real to the sufferer, unless accompanied by bodily damage or a disease label it is unreal to other people. The lack of acknowledgement or recognition which, if present, could mitigate the pain, magnifies the pain itself, especially in torture where the prisoner’s pain is not only unacknowledged by another sentient human being but actually inflicted repeatedly by the torturer.

This denial of pain is the third step in the sequence on which torture is built. The symbol of the weapon illustrates how the prisoner’s pain is converted into the regime’s power. The torturer experiences the unfolding events exclusively from the non-vulnerable end of the weapon. The false motive of information helps the torturer remain focused if his attention begins to slip toward sympathy for the prisoner. False motives are common in other acts of political violence, such as overzealous arrests and punishment. Camus, in his essay on the guillotine in France, points out that the purpose of executions never publicly declared cannot be deterrence. Arendt, analyzing Hitler’s Germany, emphasizes that the war permitted but could never have caused the mass executions under his regime. Arendt quotes Himmler, saying “‘The order to solve the Jewish question, this was the most frightening order an organization could ever receive,’…So that instead of saying: What horrible things I did to people!, the murderers would be able to say: What horrible things I had to watch in the pursuance of my duties, how heavily the task weighed upon my shoulders!” Bruno Bettelheim wondered why concentration camp guards announced repeatedly to the prisoners “I’d shoot you with this gun but you’re not worth the three pfennig of the bullet,” a statement meaningless to him, until he understood that it was part of the SS training for the sake of the guards themselves. “If the guard’s awareness begins to follow the path of the bullet, that path itself can be bent so that he himself rather than the prisoner is the bullet’s destination: his movement toward a recognition of the internal experience of an exploding head and loss of life is interrupted and redirected toward a recognition of his loss of three pfennig.” (Scarry). While our goal in healthcare is very different from that of the concentration camp guards, we need to guard against this kind of denial in our practice which is too easily resorted to when our efforts to heal the patient fail. This is particularly true in the present era of managed care, when it can feel as though we need to justify every penny to the insurance company. Maimonides had cause for reciting his prayer, “May I never see in the patient anything but a fellow creature in pain.”

2.2. The Structure of War

Scarry goes on to discuss the structure of war. Of all her topics, this one seems the least relevant to our understanding of pain. And yet, many people see their relationship with pain and illness as that of a battle or a fight, and in the common idiom ‘painkillers’ are among the most popular drugs. So in this context, as well as observing the explicit treatment of pain, it might be interesting to consider her analysis of war.

Scarry identifies the main purpose of war as injuring. This is hard to contest, because injuring is so evidently the main outcome of war. Additionally, she points out that war is a contest. She goes on to analyze why, if war is a contest, it could not occur in some less harmful arena than injuring, for instance by means of a giant chess tournament or sports game. The problem would be that the loser would never capitulate. Clausewitz claims that “War is the continuation of politics by other means,” a statement Scarry hotly contests by analogizing it to “Dying is living only different; Bleeding is breathing only not exactly.” Clausewitz tries to show that injuring works by rendering the loser powerless, that a “decisive victory on the battlefield” would “carry the power of its own enforcement”, outshining Freud’s metaphor for war as one-on-one combat whose goal is killing rather than surrender. However, even Clausewitz’s formulation, by his own admission, fails to be confirmed by the evidence of many (if not most) wars, in which either one side was far stronger than the other, or one side backed down before a decisive victory had been accomplished.

Scarry concludes that the decisive quality of injuring, which renders it more suited to political contest than other games, comes from its symbolic meaning. She points out that the end of the war is demarcated by a truce or a peace treaty, which in primitive times might have been signed as an oath using the blood of an animal. Injuring is used to guarantee the truth of the bond by symbolically exposing the inside of the body. It makes real the political fictions of a regime which could otherwise be thrown into doubt by their encounter with the fictions of a different regime. This separable function of injuring is illustrated by the demarcation between Nazi Germany injuring on the battlefields, as part of the contest, and in the concentration camps, an act of injuring that had purely symbolic meaning in propping up the fictions of the Nazi regime. Injuring can be used to substantiate fictions, without regard to the benignity of those fictions, as for example in the Inquisition injuring to prop up the rather harmless myth of Christ, as compared with the Nazis propping up the myth of Aryan supremacy. In most wars, she contends, the functions of injuring as an arena for contest and as a symbolic sacrifice to make real the fictions of a political regime are inseparable from each other. She notes the difference between torture, in which the torturer’s fiction is made ‘as if’ it were reality through the prisoner’s pain, and war, in which the winner’s fiction actually becomes reality, as when for example the surviving citizens of the South themselves became proud citizens of the Union and believers in the abolition of slavery after the end of the American Civil War.

Scarry was writing at a time when the threat of nuclear war was immanent, and she considers this separately from conventional warfare. She notes that in a conventional war, just as each soldier has a choice on every day of action whether to stand by his commitment and fight or to defect, so each country has a choice whether to hold onto its political fictions as true and deny the ongoing injuring, or accept the reality of the injuring and succumb to another country’s political fictions. In nuclear warfare, which makes the contest of injuring vast and almost instantaneous, there is no time either for the citizens to consent or to evaluate the injuring versus the political beliefs on a gradual, ongoing basis. Scarry likens nuclear warfare, as it might be seen in the eyes of future generations if it happened, to our puzzlement over the pyramids. Why did slaves consent to give their pain and physical labor to the construction of another culture’s monuments, instead of giving their lives toward rebellion? For that matter, why did the prisoners of the concentration camps contribute their forced labor to the Nazi regime? I see these issues differently. I think that most people are very attached to their own survival, or the survival of their bodies, and will do almost anything to survive, explaining the pyramids etc. Because of this strong commitment to the survival of bodies, the threat of nuclear war was never materialized, and in fact may have prevented a conventional war between countries governed by Soviet and capitalist political fictions.

How does this analysis of war impact the metaphors of the ‘fight against pain’ or the ‘battle with cancer’ occurring within an individual person? Scarry neatly disproves Freud’s fiction of war between nations as a one-on-one fight on a larger scale, because war (especially in the modern world) so rarely results in outright killing that this can hardly have been its original goal. There are some parallels here, because pain can never be totally defeated – it has to be accepted as part of life and made peace with. Similarly, we talk of a cancer as being ‘in remission’. Nevertheless, these outcomes are sufficient to affirm the person’s fiction of health, of being healthy or having a healthy body rather than being sick or ill. Additionally, we are encouraged by the fictions of medical science to envisage our bodies as a battlefield between defending white blood cells, protective growth and repair mechanisms, mechanisms of feedback, regulation and homeostasis, and the invasion of alien infectious agents or antigens, ‘bad’ cancer cells, stress or the stress reaction, and fictions of pain that our bodies make up.

Sometimes the solution can be quite drastic, with high risks for both body and invading illness. The parallels are obvious between nuclear warfare and radiation treatment or chemotherapy, or radical transplants that carry a high risk of killing the patient as well as the disease. These treatments are often geared to kill off the patient’s own defenses to allow new tissue to grow, or to encourage the acceptance of an outside graft.

Scarry’s analysis of war makes evident the dual role of injuring, both as a contest and as a ritual essential to the contract that brings the war to a close. Similarly, surgery, while it evidently helps in the contest against disease by taking out (literally) diseased organs and tissues from the body, or ones that cause pain, might have a similar dual role. The opening (and injuring) of the body in surgery can serve as a contract for the person, both consciously and unconsciously, in bringing an end to the battle with the illness or pain. This might explain both the powerful placebo effect of surgery, evidenced by widespread elective surgery in this country, and the way that surgery can sometimes have a profound transformational effect on the person’s life by affirming their core inner beliefs about the self, and its fundamental value and goodness, just as the political fictions of a nation are affirmed when it wins a war.

2.3. Pain and Imagining

Scarry asks the reader to imagine (or believe) that imagining is the opposite of pain. She points out, as mentioned earlier, that pain is the only sensation, desire, or state of consciousness that has no object. Conversely, imagining is the only sensation, desire or state of consciousness that cannot exist without an object. She highlights the value of the imagination which, in philosophical discussions, is often thought of in regard to ‘frivolous’ mythical beasts like Pegasus or the unicorn, but it also gives rise to Sartre’s imagined characters of Pierre and Annie, his friends, keeping them alive in his mind while they are gone, and to the creation of invented objects like the train, telephone, and airplane, which all existed in the imagination before they were made into a physical reality. Pain is, according to Scarry, an ‘intentional state’ although it is suffered rather than willed, with no ‘intentional object’, whereas imagination is an ‘intentional object’ - an object of the will, with no experienceable intentional state. Thus, pain and imagination are the ‘framing events’ between which lie all other perceptual, somatic, emotional and mental states that can occur in the human psyche. She points out that vision, touch and hearing, can be perceived to occur in the outside world of their objects, or by bringing that outside world into the human mind, somewhere between these absolutes of pain and imagination. Imagination creates objects when they are not available in the world, as when a lonely person imagines a companion, or perhaps even in dreams, when the world is closed out to let the body rest, and the mind creates images, Scarry suggests, preserving this capacity for self-objectification during these “sleep-filled hours of sweet and dangerous bodily absorption.”

Scarry claims as evidence for her hypothesis that pain and the imagination are each other’s missing counterparts the fact that the word ‘work’ is at once a near synonym for ‘pain’ and for a created object (in English as in many other languages, including Hebrew and Greek which form the bedrock of our civilization). Slavery and poor working conditions highlight the proximity of work to pain, whereas expressions such as ‘work of art’ and one’s ‘life’s work’ stress the importance of the imagination. Insofar as work consists of an embodied physical act (and even non-physical labor engages the whole psyche) it resembles pain, and is perhaps almost as aversive as pain. Insofar as it involves the construction of artifacts, it engages the imagination.

Scarry distinguishes between a weapon and a tool, a distinction I found hard to agree with initially because it seemed so clear to me that ‘weapon’ is a subclass of the class of ‘tool’ that an outright categorical distinction was not only artificial but wrong, because it implies they are at the same level of classification. In Hebrew, ‘weapon’ is a subcategory of a word that means ‘vessel’ or ‘tool’. The word for weapon literally means ‘war tool’ or ‘vessel of destruction’. Another word means ‘tool of [arms]’, where the body part used to designate weaponry is the male member rather than the arms. Categorically distinguishing between a weapon and a tool is difficult, because a knife can be used to kill someone, to butter or cut bread and, in between, to slaughter an animal for food. The hand or fist itself can be used to deliver a painful punch, or to punch in bread. Where Scarry draws the line is that a weapon is used on a sentient surface, whereas a tool is used on a non-sentient surface. Does the surgeon’s knife become a weapon when it accidentally kills the patient? While she acknowledges the problematicity of such boundary conditions, this distinction between a weapon and a tool is seminal to Scarry’s entire thesis.

She describes both the weapon and tool as having in common that they have two ends, and act as a lever, to amplify the action of the person wielding the instrument on the object or sentient being that is being acted on. She points out that the small movement of a finger on the trigger of a gun can shatter a whole body on its other end. Large changes are experienced in the world by means of small experienced changes to the self, when using either a weapon or a tool. The act of the weapon or tool endures in the world, in the form of a wound or, for example, cut grain, for a long period of time without needing to repeat the action. The tool can be considered to have a delayed action on a sentient being, as when the grain is then ground, made into bread and eaten or, more directly, when the tool is used directly to make an artifact such as a chair that can be sat on, to carve a statue or write a story, an action that only completes is ultimate goal when the bread is eaten, the statue seen, or the story read. It is this ‘creative arc’ that ultimately distinguishes between a tool and a weapon, according to Scarry’s terminology.

In the next section of the book, she goes on to discuss some important created objects of our civilization: God and the economic and ideological structures of society. The God of the Jewish bible is interesting, because it is as close as human culture gets to pure imagining, God being explicitly denied the form of an image, although later Jewish and Christian thought relaxes that requirement. Scarry discusses the economic and ideological structures through the writings of Marx, interesting to reexamine in these times of economic collapse after the death of communism. God she discusses through her own reading of the Judeo-Christian scriptures, in which pain abounds.

2.4. The Structure of Belief and its Modulation into Material Making

Scarry understands the Judaic scriptures as a narrative whose main purpose is to separate the human body, and the disembodied voice of God. She observes the structure of the text as an alternation between stories and lists, for example the lists of ancestry such as so-and-so begat so-and-so begat so-and-so, etc., in the Pentateuch and beyond. As an aside, Scarry’s writing itself follows a similar structure, showing a fondness for retold narrative alternating with lists of attributes of the phenomena she wishes to describe, such as the eight attributes of physical pain, which make her book at once both powerfully persuasive, as an iterative and reiterative self-assertion, and difficult to summarize in the form of a linear argument.

The voice of God has two main capacities, or ways of asserting itself in the world. The first way is by anticipating human creation and particularly bodily procreation, in the form of commands such as ‘be fruitful and multiply’, and promises such as ‘I will make you a multitudinous and powerful nation’, which are then confirmed in the recitation of the ancestry lists. God’s power is asserted by the spread of His representation inside the imaginations of the multitudes who believe in Him. The second way is by wounding, injuring, or killing human bodies, ostensibly as punishment for disobedience but more significantly as the consequence of and remedy for doubt, thereby extending God’s symbolic power in the world by contracting the number and longevity of those who do not believe in him. These two capacities of God are movingly brought together in the story of Abraham’s sacrifice of Isaac which, although it occurs only in the imagination because in reality Isaac is substituted by a deer, nevertheless asserts God’s power over both the creative potential and the destructive potential of humanity.

Scarry’s reading of the Judaic scriptures is at its core a Christian one and I would like to add a couple of points here. In English the words ‘worship’ and ‘work’ sound etymologically related, but in Hebrew the two are literally one. Harking back to Scarry’s discussion of work as bringing together the experiences of pain and imagination, this is particularly striking when the ‘work’ is submission to an object of the imagination, whether God or the other gods and idols whose ‘work’ is explicitly forbidden in the ten commandments, and repeatedly punished by God throughout the Jewish bible. The second point I would like to make is that the sacrifice of Isaac has a dual significance to the Jewish people, because not only is Isaac replaced by a deer (a proud moment of moral maturity, sacrificing an animal instead of a human, anticipating the commandment ‘do not kill’) but Isaac (and Abraham) both submit to (and self-inflict) the circumcision, which is a lasting symbol of the wound, the ‘knife in the heart’ of Jewish thought, that links human bodily pain with procreation, because it is the sign of the circumcision which binds Abraham to his promised destiny as the father of a nation, through the mediation of a God who, as Scarry goes on to discuss, is a voice that is at once both formless and at the same time adamantly positioned on the other side of a weapon in its relation to humanity. As an aside, circumcision is thought to have originated in the practice of ancient herdsmen to circumcise cattle since it led to better sexual performance and reproductive success in certain breeds where the foreskin was actually an impediment to their fertility. The relevance of this note here is to highlight the cleverness of the creative imagination attributed to God, transforming His second capacity as a wounding weapon to eradicate doubt, directly into His first capacity as the instigator of pro-creation, by leaving the permanent mark of His weapon on the human reproductive organ.

God’s capacity to instigate procreation begins with His punishing Eve with the pains of childbirth, while at the same time retaining control over the birth of her offspring, a power recapitulated when He enables Sarah and other barren women throughout the Judaic scriptures to become pregnant, without claiming any material involvement in the process of reproduction. God carries the creative potential to make a human womb fertile, or to bring water to a dry well dug by human work. In turn, he commands the men he chooses to wander from one place to another, filling their imaginations not with their own imagined plans but instead with His commandments. In return, wherever they camp, they build an altar which is an inversion of the human body, at once symbolic of both the abandoned tradition of making idols and the abandoned tradition of human sacrifice, replacing them with the new tradition of filling the empty interior of the human imagination with the purely abstract presence of God.

At times when this wandering ceases, the risk that God will be forgotten increases, because the need to find water or fill the imagination with plans of where to go and what to do next are less preeminent. It is at these times that He manifests through the symbol of the wounding weapon. In the Pentateuch this occurs in the story of Moses, instantiated by the voice behind the burning bush, the ten plagues of Egypt, and the horrific killings, plagues and disasters that attended the Golden Calf and other moments of doubt. It is in my view the main theme of the Prophets, exposed in passages such as:

“Their flesh shall rot while they are still on their feet, their eyes shall rot in their sockets, and their tongues shall rot in their mouths. And on that day a great panic from the Lord shall fall on them, so that each will lay hold on the hand of his fellow, and the hand of one will be raised against the hand of the other; even Judah will fight against Jerusalem.” (Zechariah 14: 12-14)

“Behold the name of the Lord comes from far,

burning with his anger, and in thick rising smoke;

his lips are full of indignation,

and his tongue is like a devouring fire;

his breath is like an overflowing stream

that reaches up to the neck;

to sift the nations with the sieve of destruction,

and to place on the jaws of the peoples

a bridle that leads astray.” (Isaiah 30: 27,28)

Scarry cites the way in which the voice is relegated to God alone, in stories such as his anger at the complaints of the people in the desert, and the body is relegated to human beings, who are repeatedly punished and made to suffer pain for attempting to give God a body. God preserves the power of sentience, with none of its accompanying shortcomings, such as physical vulnerability to either spatial impacts or temporal decrepitude, or susceptibility to physical pain. She emphasizes that the banishment from the Garden is presented not as punishment for eating the fruit of the tree of knowledge, so much as prevention from then also eating from the tree of life, which is guarded by “a flaming sword which turned every way.” (Genesis 3: 24). “Absolute verbal purity is eternal life: the projected voice is the power of sentience separated from the fragility and vulnerability that attend sentience at its unprojected site and source.” (Scarry). Moreover, from the Jewish perspective, the words of the bible are literally the only direct, lasting product or manifestation of God and it is in relation to these words (and the masses of commentary that has accrued around them over the centuries) that our path in the world as a body of people, the Jewish People, is defined.

Scarry posits that the major innovation of Christianity has been to replace the sign of the weapon with the sign of Christ, and the cross. The cross is a weapon that unlike a knife, a fist, a gun, or in fact most weapons, has no clear shape or position for the person wielding the weapon, and although presumably there was an executioner his role is by this sign easily overlooked. As evidence for this idea that Christ replaces the weapon, Scarry sites the ease with which the image of Christ is replaced by the sign of the cross. Instead of asserting his power by wounding with a weapon, God is made substantial and tangible in the body of Christ, excruciatingly sentient in His suffering of physical pain. The voice heard by the exclusive few in the Judaic scriptures is replaced in the Christian ones by the universal ability to visually witness Christ, to touch Him, even to feel his wounds (as in the story of Doubting Thomas) and to incorporate his body into one’s own literally by eating it, as emblemized by the Last Supper and in the ritual of Communion.

As compared with the God of the Old Testament, who ‘has no like’, Christ offers “predicative generosity” – I am the resurrection, I am the way, I am the light of the world, I am the door of the sheep, I am the good shepherd, I am the bread of life. He is also eminently describable, His life is told in four versions in the Gospels. The sign of God’s power, where in the Old Testament it was wounding, is in the New Testament healing. Jesus restores sight to blind eyes, heals lepers, and feeds the hungry. In fact, he even does so on the Sabbath, in contradistinction to the one lasting structure the Jewish God imposed on the world of men, the commandment to rest and not work (or do no other work but worshipping God) on the seventh day, a totally arbitrary division of time.

Scarry quotes instances in which Jesus was mistaken for a laborer, a fisherman, or a carpenter, as well as the prevalence of those roles among his disciples, as evidence of the new respect for making as an occupation or way of life. By contrast, in the Jewish tradition, making is viewed distinctly with suspicion because of its proximity to icon-making. Instead, studying the law (in the scriptures and other written and oral traditions, which are held to be God made word) and living it are the valued ways to be in the world. Making is strictly regulated, as in the elaborate, detailed description of the tabernacle and the ark, anticipated by the instructions for Noah’s ark, and the detailed law regarding laying the fields to rest every seventh year, allocating a tenth of the produce to the poor and a tenth to the priests, sharing expensively reared domestic animals with the priests who have no land and make no material goods, but take first pickings of the meat when they offer it to God as a sacrifice, and so on. Disdain is shown for material goods both in the form of the Golden Calf and the trinkets and adornments that went into its making. The holiest thing in the tabernacle is not its rich ornaments but instead what lies behind the curtain, which only select priests of Aaron’s descent can touch without being burnt alive by God.

The new respect for the material, and for human making or creation, is according to Scarry and others the foundation of the materialist culture that later developed in Christian nations. The drive away from the hierarchical authoritarian structures of iconoclasm was furthered in every new splinter within the Christian tradition, from Catholicism to Lutheran Protestantism, and culminating perhaps in the Quakers who gave rise to the vision on which material culture rests in the United States.

It is easy to see how this emphasis on making, even making oneself, and ‘making it’ in the world brought forth new attitudes toward pain. Scarry goes on to talk later about the transition from weapon to tool, with its created object as the thing that acts upon sentience. Meanwhile, I would like to add that the different attitudes toward the self in relation to God and the world carry with them differing experiences of pain and its expression. In the Jewish world, pain is the ‘knife in the heart’ that we all carry as a sign. It is at once commonplace and incomprehensible. Complaining to God only makes Him angry, so we have to listen to each other. No wonder Maimonides and later Freud, stemming from this tradition, extolled the virtues of tears and other expressions of pain, and the value of listening. Meanwhile, in the Christian tradition, God heals. Only direct supplication to God guarantees a cure, and any residual suffering is a sign of impure faith or lack of grace. Whereas for Jews, the path to the tree of life is blocked, Christians can through faith and hard work achieve the promise of immortality and become, like Christ, resurrected.

Scarry emphasizes the importance of work, and making, in the development of human civilization, discussing an essay by Frederick Engels which conjectures that the evolution of the human hand, rather than the human brain, was the quintessential factor in the emergence of Homo Sapiens. She cites the paleontologist Stephen Jay Goulds’ support for Engel’s conjecture, by means of the fossil record. Interestingly, Engels had in mind Lamarckian evolution, by which the discovery of tools putatively led to the inheritance of more facile hands, a hypothesis that has no basis in modern knowledge of genetics. However, beyond the limits of Scarry’s text, I would like here to point out that although the discovery of tools could not perhaps influence genes in the way Engels had in mind, learning to use them better and better from one generation to the next by means of a transmitted culture is not only credible but likely.

The idea that tools changed the shape of our hands becomes more convincing if we look at it through the lens one of Scarry’s other suggestions, that chairs were invented out of the carpenter’s sympathy for his companion, in order to reduce her pain. The preference to sit in a chair or on the floor appears to be entirely cultural. Some cultures prefer chair sitting, and others prefer floor sitting. But if you take a person from one culture and put them in the other, they become uncomfortable and might even experience pain or be physically unable to sit either on the floor or on a chair in the conventional manner, whichever one they are unaccustomed to. It is easy to see how chairs have changed the human body, in the culture where they are used!

This is probably the case not only for tools, but also for human language, which is represented in the brain in a region close to the one that codes hand movements and gestures, not movements of the mouth, and in fact in other primates seems to serve this function. Homo Sapiens probably existed for thousands of years before spoken language was invented, and when it was it changed our brains, just as written language has a specified brain region that serves some other function in cultures with no writing. Conversely, the language one speaks changes the shape of one’s face. As a child growing up in an international city I used to play a game on the bus with my father, where we guessed what language someone would speak before they opened their mouth. Different muscles are used to enunciate the sounds of different languages.

Scarry illustrates the role of the body in the writings of Karl Marx with the following metaphor. She describes a heap of shiny coal sitting on a large plain. Two men walk toward the heap of coal, and touch it. When one man touches the coal, his body starts to grow. It becomes vast, and as it grows one can see small scratches and gaping wounds growing on his skin, opening the inside of his body. When the other man touches the coal, he starts to vanish, in fact he disappears completely and becomes mere spiritual presence. The first man is the worker, and the second is the capitalist. The labor of the first man provides heat not for himself, but only for the second man, making him impervious to the physical insults of cold which are battering the first man. Elsewhere on the plain is a heap of money. The money is less material, less real than the coal. Five men on one side of the heap of money grow when they touch it, while one man on the other side evaporates and becomes an even louder spiritual voice. People gather at a third site, where there is only a scribbled note. Fifty men on one side of the scribbled note grow vast in their wounding, and one man on the other side vanishes completely and becomes so loud that his voice echoes over the plain, omnipresent in its demands, philosophies and laws.

It is easy to see that what Marx envisaged is a recapitulation of the troubling situation in the Judaic scriptures, where a disembodied voice (in this case, the philosophies and demands of the capitalist system) wound an entire body of people, whose pain goes unheeded, and whose imaginative creation (whether the commodities of material labor or the stories of their own origins) become severed from their original site in the human imagination and gain a power of their own, whereby they prevent the work of the human bodies from benefiting (reducing the pain) of the human bodies themselves. Just as in the biblical tale, the workers and the commodities they help produce by extending themselves through tools and lands (or raw materials) become seen to be created and governed by the capitalist society, instead of the reverse.

Like the earlier writings, Marx’s texts are filled with detailed lists and examples, replacing the earlier lists of who begat whom, and grounding them to factual reality using a similar rhetorical device consisting of lists that detail the particular terrible living and working conditions on one street in London, the numbers of people living in each room, the size of the room in inches (length, width, height) and the hours they each labor. Just as Christianity broke from Judaism, replacing the sign of the weapon with the sign of the healer, so it was perhaps also instrumental in causing a return to the former state of affairs by stimulating the obsessive preoccupation with making that led to the prevalence of circulating goods and eventually the invention of money and capital as the earthly manifestations of spiritual immortality.

Scarry brings these different texts, the Judaic scriptures, the Christian scriptures, and the writings of Karl Marx, to the fore because of the attention they all devote to “the problem of creating” as the more expansive context in which we should view “the problem of suffering”.

The Worst of Evils

1. The Worst of Evils – The Fight Against Pain

This book by Thomas Dormandy is a history of pain relief.

1.1. A Gift of the Gods

In ancient times, physical pain was thought to be inextricably associated with emotional or mental anguish and sleeplessness. The Persian physician Avicenna stated that potions must accomplish three things: they must alleviate pain, calm the mind, and induce restful sleep. Similar views were expressed by Hippocrates in Ancient Greece, and by Hua T’o in China. The modern view is different. We still recognize that fear can transform discomfort into agony, that joy can quell a bout of indigestion, and that daytime niggles can become torture at night when one is trying to sleep. However, since the mid-nineteenth century there has been a shift in the understanding of pain as a result of the invention of anesthesia, which suppresses the acute pain of surgical operations without necessarily inducing relaxation or sleep.

Accounts by Homer, Virgil, and other Ancient Greek dramatists suggest that their civilization was aware of certain pain-killing potions, probably derived from the opium poppy. A papyrus from Egypt dated 1500 BC contains recipes for herbal, animal and mineral potions used to treat a variety of ailments, including pain. In Chinese medicine, in addition to drafts and potions, there is written evidence of acupuncture used for pain relief since 100 BC. Inhaled substances are thought to have been used for surgery in India from around the 6^th century BC. But this ancient knowledge was ignored through much of Western history.

1.2. The Grape and the Poppy

Alcohol has been used in tinctures for pain and a variety of ailments since Ancient Egypt and before. Beer brewed from malted barley was prescribed by Egyptian physicians from 2000 BC, and the Egyptians were also responsible for the cultivation of the wild grape around 4000 BC. In Egypt, Mesopotamia, and Ancient Greece, the garden poppy was cultivated for the production of opium, and the technique of tapping the pod and drying its juice was perfected. The Ancient Greeks were aware of the differing pharmacological properties of alcohol and opium:

“Wine tempers the spirit while opium lulls the body to rest. It revives our waning joys and is oil to the dying flame of life.” (The Banquet of Xenophon, c. 400 BC).

The word opium is Greek, and means the fresh juice of the poppy. Opium in Greece was used primarily by the upper classes, and Hannibal took his own life in 183 BC with an overdose of Egyptian poppy juice.

Aurelius Cornelius Celsus wrote a book on medicine in 30 AD and expressed a cautionary attitude toward pain relief:

“pills and potions that relieve pain are numerous; but, unless there is an overwhelming necessity, it is improper to use them.” They are “alien and harmful to the stomach.” Of opium, he says “it has been used to calm tempers and to induce pleasant dreams since the Trojan war and is still popular,” but “doctors should use it with circumspection.” He notes that “dreams can be sweet; but the sweeter they are, the rougher tends to be the awakening.”

Nevertheless, the Roman Emperor Claudius’ physician left detailed instructions on how the juice should be extracted and processed, and this method, publicized in the 1^st Century, is still in use today in many parts world. Galen, a famous Roman physician from the 2^nd Century, noted some of the dangers of opium, particularly digestive upsets, constipation and, occasionally, death – but the dangers of addiction were not mentioned by the Ancient Greeks or Romans, although the poppy was widely cultivated. Diocles, a dentist of the same period, prescribed an opium-based paste for toothache. He wrote:

“There is much that is still unknown about this wondrous flower. The potion prepared from its capsule will soothe some but cast others into melancholy. In some its effect will be immediate. In others, it may be delayed for many hours. In some the medication will be well tolerated. In others it will have unpleasant side-effects. Yet even when it does not abolish pain, the pain no longer preys on the person’s mind.”

1.3. Roots, Barks, Fruit and Leaves

Many different herbal remedies and potions were available in ancient times for the treatment of pain. These included cannabis, mandrake or mandragora, the milk of the mulberry tree, garden lettuces gathered when young and tender, hops, hemlock and ‘deadly nightshade’ (belladonna). Like opium, some of these plants could be deadly, and they were used with caution by physicians. Ancient Greek mythology expresses an association between sleep and death, Hypnos and Thanatos. Hypnotic or anesthetic agents were often used for humane executions, most famously Socrates’ death by hemlock, with his dying words “we owe a cock to Aesculapius” thanking his physician for the painlessness of his parting.

The effects of Cannabis indica were described by Herodotus in the 5^th century BC:

“The Scythians are given the seed of this hemp, creep under rugs and then throw the seeds on the red-hot stones. The seeds begin to smolder and send forth so much steam that no Greek vapor bath could surpass it. The wounded Scythians howl with relief and joy.”

Dioscorides was probably the first to use the word anesthesia in the modern, medical sense in the 1^st century AD: “One cyathus of the wine of mandragora is given to those who cannot sleep and such as are in grievous pan and those to be cut or cauterized, when it is wished to produce anesthesia.”

While pain-killing agents were available, their use by the healthy and brave was scorned. Plutarch mentions Gaius Marius, a famous dictator from the 2^nd Century BC, who was operated on by his army surgeon and endured the treatment for varicose veins “with steadfast countenance” but later refused surgery on the other leg, “judging that the cure was worse than the illness”.

1.4. Pain Denied

“The fakir sleeping peacefully on his bed of nails remains both the tired cartoonist’s standby and a fact.” (Dormandy, 2006). We live in a time and a place that ridicules miracles. We even doubt the evidence of our own senses unless validated by neurophysiological findings. But the empirical validity of ‘hypnosis’ and ‘auto-suggestion’ is undeniable, and has been shown in countless scientific studies, even though we are far from understanding the mechanisms involved. Most likely, they are the same as the stories from antiquity and the sixteenth century, the First and Second ages of Martyrs. According to Dormandy, ‘self-hypnosis’ is “a scientific tag which makes miracles acceptable to those who do not believe in miracles.”

Cosmas and Damian were twins and both practiced as doctors before they were martyred for their Christian faith in Aegina in 279. They smiled in the face of torture, and claimed “we suffer not” before they were eventually beheaded. Tacitus, who was critical of the Christians and called them fanatics, nevertheless expressed amazement at the serenity with which they suffered their fate.

More than a thousand years later, the Second Age of martyrs arrived with the splitting of the church between Protestants and Catholics. Astonishing denials of pain abounded on both sides. Archbishop Cranmer, formerly Henry VIII’s confessor, “burnt to appearance without motion or pain… he seemed to repel the suffering and overlook the torture.” John Foxe wrote of the burning of Bishop Hooper: “In the tyme oof which fire, euen as he first flame, he prayed, saying mildely and not very loud but as one with no paines: ‘O jesus the sonne of David haue mercy vpon me and receaue my soule…”

1.5. Pain Ignored

The Stoic school of philosophy, founded by Zeno in the 3^rd Century BC, claimed that passions like anger, fear, grief, and pain are no more than ‘irrational movements of the soul’ and should be suppressed. Zeno’s followers made the distinction between approved emotions, such as joy, watchfulness and caution, and destructive ones, including pain. The pain of physical injury was to be ignored.

Stoicism spread throughout the ancient world, following Alexander’s conquests in Europe and Asia, and became one of the most popular philosophies of the Roman Empire, especially among the upper classes of society. Emperor Marcus Aurelius, a stoic, wrote: “The pain which is intolerable carries us off; but that which lasts a long time is always tolerable; since the mind can maintain its own tranquility by retiring into itself… If you are pained by any external agent, it is not the agent that disturbs you but your own perception and judgment of it.” Following this example, the 18^th Century philosopher Emanuel Kant said that he overcame the pain of gout in his toe by thinking about the works of Cicero.

Unlike the Christian martyrs, stoics did not deny pain, they simply maintained that it was relatively unimportant. A myth concerning the early history of Rome claims that a young Roman, Gaius Mucius (later known as Scaevola or left-handed) was caught and sentenced to death by a neighboring king, Porsena. He promptly asked for a blazing brazier and thrust his right hand into the flames, unflinchingly telling Porsena that many young Romans as indifferent to pain as he was would stand in defense of their city if the king persevered with his attacks. Scaevola was released, and his story survived in the teaching of Classics at English public schools during the British Empire, contributing to the stoic stiff upper lip.

1.6. The Heresies

Dormandy disputes the view of pain as a ‘useful warning signal’. While pain following injury is of evolutionary significance, warning an animal with a broken leg to stop running, most pain serves no such function. Now we can utilize some pain symptoms to diagnose the patient and identify a cure, although often the pain of diseases such as cancer arrives too late for an effective one. In the past, there was nothing to be done about conditions like acute appendicitis, an ectopic pregnancy, or an ulcer, and the excruciating pain they caused was completely useless. Most people died in agony.

How did the early Christians reconcile this with their faith in an all-powerful, merciful God? According to the Manichean heresy, as well as God there operated in the world of men a power of evil or Satan, and pain was caused by particles of evil. They could be fought by a cult of priests called the electi, and by the slightly less pure auditori. St. Augustine was an auditor for eight years before converting to orthodoxy. Mani himself experienced no pain when he was cruelly flayed to death by the orthodox church. Today, we are in my view closet Manicheans, seeking to kill all pain with the aid of modern medicine, and physicians are our electi.

1.7. Healing and Holiness

The words healing and holiness come from the same root, and early Christians in the ‘Age of Faith’ (according to Dormandy) or the Dark Ages were among the first to found hospitals with the specific aim of caring for the sick. Faith imposed an order on society by the simple belief that souls were to be saved. St. Fabiola, a Christian convert, tended to the sick in Rome, washing wounds that, according to St. Jerome, “even men could hardly bear to look at” and carrying them on her back to shelter. She lived around 360. In 528 St. Benedict composed this rule for his order of monks: “The care of the sick is to be placed above our every other duty, as if indeed Christ were being directly served by waiting on them.” Monasteries opened infirmaries that became a refuge for the sick.

In the Old Testament, the wrath of God was often expressed in the form of pain and sickness, most commonly tzara’at, thought to be leprosy. The prophet Job expressed a masochistic attitude to suffering, saying: “Happy is the man whom God correcteth. Therefore despise not thou the chastening of the Almighty. For he maketh sore, and bindeth up. He woundeth, and his hands make whole.” Although not popular among Jews or Christians through the ages, this approach to pain was later to influence certain strains of protestanism.

The early Christian healers did not rely on miracles alone to cure the sick. St. Hilaire (Hilary of Poitier) wrote:

“The nature of our bodies is such, that when imbued with life and in conjunction with a sentient soul, they become more than inert matter. They feel when touched, suffer when pricked, shiver when cold, feel comfort in moderate warmth, waste with hunger and grow fat with eating. Above all, pervaded by the soul, but not when dead, they respond with pain and pleasure to their surroundings. Yet this is not true of the body as a whole or under all circumstances. Most of the sentient body responds with pain to being cut or pierced, but the nails and the hair can be cut without experiencing any discomfort. Also, in certain diseases, even before a limb becomes withered and discolored, it loses all sensation, so that it can be cut and burnt with impunity. Yet it is still part of a living body. Also, when through some grave necessity part of the body has to be cut or removed, the soul can be lulled to temporary sleep either as a whole or in part. Such a body will later return to life and remember no suffering… Some plants can produce death-like forgetfulness. After eating or drinking the extracts of such plants, limbs can be cut off without pain.” In another passage, Hilary refers to putting the limb to sleep by the application of prolonged pressure. Where St. Augustine spoke of ‘kindly harshness’ used to make unwilling souls yield, Hilary said that “Satan bursts with an axe and sword but the Savior knocks and speaks gently to the soul.” The early Christian religion was the cause of both much cruelty and kindness, inflicting unnecessary pain on unbelievers and those deemed hertics and yet caring for the sick.

1.8. Islam

It was the world of Islam, and not the Christian world of the Dark Ages, that was responsible for the preservation of Ancient Greek and Roman medical knowledge. Harun al Rashid, the Abbasid Caliph of Baghdad around 700, sent explorers to scour the ancient world for manuscripts, and employed translators to translate them all into Arabic. Arab scholars both admired and challenged the views of Galen, whose works on medical science were held in highest esteem. The Arab chemists, or alchemists as they became known in Europe, were experts in the processes of filtration, crystallization, sublimation and distillation of various potions derived from herbs, minerals, and animal products – such as the urine of a pregnant rhinoceros. Many Arabic words are still in use in chemistry as a result of their efforts – alkali, alcohol, syrup, sugar, and the word drug itself.

Famous Arab physicians included Rhazes (born 825) and Avicenna (born 980). Avicenna noted that “it is the body which generates pain but the brain which decides how much of it is tolerable.” He distinguished three approaches to pain. First, removing the cause, for example by splintering a fracture. Second, using measures which “counteract the acrimony of the humors” – for example Cannabis indica. Third, inebriants like poppy juice and mandragora were used to make severe pain bearable. He added recipes for tinctures containing both, to make somebody unconscious quickly and without harm. However, he noted that: “If even double the recommended dose does not work, it should be abandoned. The person should be encouraged to bear his affliction bravely…Most illnesses carry with them the seeds of their own cure and Nature must be given a chance… the patient must be comforted with kind words and the prospect of future happiness… no illness is without hope.” Whereas Christians accepted suffering as a manifestation of God’s inscrutable will, Islamic doctors believed that Allah created no illness without a remedy. If no potion was known, then verses of the Koran were recited in the hope of a miracle.

Jewish scholarship flourished in certain parts of the Islamic world. Most famous among physicians was Maimonides, who lived from 1135-1204. A contemporary writer noted that “Galen’s medicine is only for the body; but that of Maimonides is for both the body and the soul.” Maimonides’ medical writings were filled with practical advice, such as “Above all, a doctor must be understood.” He also believed that “The Lord gave us tears to shed… Do not try to stem their flow. When potions and vapors fail to ease the pain, lamentations often relieve the suffering.” He wrote: “May I never see in any of my patients anything but a fellow creature in pain.” This attitude of fellowship between the doctor and the patient was markedly different from that prevailing in Christian Europe, where the doctor was a giver and the patient a receiver of healing.

Islamic medical writings of this period included instructions on surgery, for which pain-killing potions and inhaled vapors were used as anesthesia. The Koran specifically requires the compassionate treatment of the insane, and physicians recommended various diets and inhalations for calming the mind, many including ‘bhang’ – probably Cannabis indica. “The effect will be soothing and sleep will usually be instantaneous.”

1.9. The Age of the Cathedrals

It was during the Middle Ages that hospitals were established in the major cities of Europe, St Barthelomew’s in London in 1134; St Thomas’s around 1215, and Sta Maria Nuova in Florence. In France, the hotels-Dieu remained primarily hostels for the poor. Around the same time, universities opened in Paris (1100), Bologna (1158), Oxford (1167), Montpelier (1181), Padua (1222), and Naples (1224). Medicine became an academic discipline in these establishments, but its study focused on book learning and philosophical debate. Surgery was practiced by surgeons, and barber surgeons, who knew how to apply leeches, pull teeth, and drain abscesses. It was only in the 13^th century that surgeons started writing books about their craft, and it became a part of medical study, with the works of Lefranc, and later Henri de Mondeville (who died in 1320), Guy de Chauliac and John of Arderne in England (14^th century). These surgeons wrote about pain, and revived the tradition of using pain-relieving and sleep-inducing herbs such as opium and mandragora, which had been forgotten in Christian Europe during the Dark Ages.

1.10. Pain Exalted

Towards the end of the Middle Ages, the Black Death arrived in Europe, heralding the spread of the flagellant movement which had began in the 11^th century and first became popular after the civil war in Perugia in 1235. Flagellants held the belief that God threatened to destroy sinful humanity, and that the Virgin Mary interceded to save those who joined the flagellant processions. Bands of flagellants traveled the land, visiting the cathedrals, worshipping the Mater dolorosa or Virgin of Sorrows as a cult by throwing themselves on the ground with their arms splayed out like a crucifix in front of churches and flogging themselves with metal-tipped leather scourges. History suggests that self-induced fatalities was rare and consisted mostly of children. However, this self torture frequently escalated into violent pogroms, killing Jews in Frankfurt, Mainz, Germany and Eastern Europe. The established Church had little control over the flagellants. Pope Clement VI ordered a procession of flagellants in Rome in 1348, following the ravages of the plague, but after a few days with the flood of thousands of flagellants into the city unabating and a steadily rising number of casualties, although the plague was gone, Clement was asked to join the procession himself. Instead, he issued a bull condemning both self-torture and the persecution of Jews. Flagellation slowly lost popularity. Flagellants were persecuted by the Inquisition, and hundreds were burnt at the stake in Sangerhausen in 1414. However, salvation through suffering remained a dominant motif in the Catholic Church and some other types of Christianity.

1.11. Rebirth, Rediscovery and Reform

The Renaissance was a time of return to the medical texts and potions of Ancient Greece and Rome, as well as the cross-fertilization of both diseases and cures between the Old and New Worlds. In the 16^th century, Johann Guinther von Andernach (a professor at the Paris Faculty of Medicine) wrote that “Medicine has been raised from the dead.” The works of Galen were re-translated into Latin and other European languages, revered by some and lambasted by others.

Paracelsus, born in Switzerland in 1493, began his lectures by publicly burning the works of Galen and Avicenna. While some revere him as the founder of experimental scientific medicine, Dormandy (2006) claims there is little evidence for this. Paracelsus’ fame came from his successful use of laudanum, a tincture or solid preparation made from opium, and from his bedside manner. He wrote: “Every physician must be rich in knowledge, not only of that which is written in books. His patients should be his book for they will never mislead him … and by them he will never be deceived. But he who is content with mere letters is like a dead man.”

Artists and doctors participated in the study and documentation of anatomy, going beyond the works of Galen to try and understand the workings of the human body. Anatomy as a discipline became the metaphor of the age, in works such as Robert Burton’s Anatomy of Melancholy and John Donne’s Anatomy of the World.

This was an age of emphasis on heroic depictions of pain in art, in place of Ancient and Classical depictions of heroism alone, and Medieval images of torture. In 1506 the Laocoon, a Hellenic sculpture from the 1^st century, was rediscovered in Rome and influenced Michelangelo’s Dying Slaves. Dormandy (2006) extols a crucifixion painted around the same time by Matthias Grunewald. Comparing and contrasting the two images, the Laocoon calls for compassion toward a man struggling against a terrible fate imposed by the gods on him and his people, whereas the crucifixion calls for compassion toward a god suffering calmly a torture imposed by humanity. This reversal, putting man in the driver’s seat, and replacing him with God as the object of compassion, is perhaps the essence of modernity and the seed of capitalism.

While Columbus and his crew exported chickenpox to the New World, wiping out whole civilizations, they imported syphilis to the Old World, although people at the time attributed it to the malign constellation of the planets. In attempts to combat this disease, cures probably worse than the illness itself became popular, such as the oral administration of mercury in large quantities, blood lettings, starvation, and ‘sweatings’ in purposely constructed ‘diaphoretic chambers’. Ulrich von Hutten suffered these treatments for 11 years, before publishing a book on the virtues of a newly discovered drug, guiacum, extracted from Caribbean beech wood. Although he died shortly after, this was not widely known, and demand for the magic wood made a fortune for the Fugger family of Augsburg, among the founders of Protestant capitalism.

Cocoa, jalap, sarsaparilla and sassafras were imported from the Americas and widely used as cures. Tobacco, cultivated by the French ambassador to Portugal, Jean Nicot, rapidly gained a reputation as the ‘holy herb’ or ‘God’s remedy’, used to cure ulcers, abscesses, fistulas, sores, polyps, headaches, and all kinds of aches and pains. Monardes wrote a book about it entitled Joyful News out of the New-Found World. Tobacco remained a popular medication until around 1800.

Botanical gardens opened in many of the cities in Europe, where the plants of both Ancient and New Worlds were carefully cultivated, and remedies for pain and all manner of ailments were published in meticulously illustrated books.

A German chemist or apothecary, Valerius Corbus (1515-1545, approx.) was the first person to synthesize ether out of a mixture of alcohol and sulfuric acid. His invention was published posthumously, and used, diluted with wine, by Robert Boyle and Isaac Newton as a remedy for coughs and chest pain. Originally named sweet oil of vitriol, it was renamed ‘spiritus aetherus’ (aka ether) by Frobenius in 1737, but its value as an anesthetic for use in surgery was not appreciated until the mid 19^th century, over 300 years later.

1.12. Going to War

During the Renaissance, more new medical schools were established in Britain (Oxford and Cambridge) and on the continent. Anatomy, as well as Galenic medicine, became part of the curriculum, and medical practitioners were awarded lengthy diplomas and professional qualifications. But most of the advances in medicine came from the field of surgery. Life and health expectancies were no lengthier in this period than in the Middle Ages, but with the widespread use of firearms and explosives in warfare, battlefield injuries became more gruesome and required greater skill in their treatment. In Germany and France, books were published recommending the use of cautery (with burning oil) in the treatment of gunshot wounds. Gunshot was believed to be poisonous, perhaps because of the high prevalence of infections following gunshot wounds, as compared with wounds incurred in swordfights. Antoine Paré began his career as an army surgeon on the Italian battlefront, and later became surgeon to the kings of France. He was an astute and unusually empirical observer of injuries and the effects of treatments. He noticed that when he ran out of hot oil on the battlefield, wounds treated instead with salve actually healed better, and therefore he abandoned the practice of burning wounded soldiers with cautery. Additionally, he recommended the application of a tourniquet, a tight bandage used to control bleeding, four or five minutes prior to performing an amputation. Although waiting such a long time on the battlefield might be risky, the pressure on the nerves probably provided some local anesthesia during this painful procedure. He was the first to write about what was later coined by Weir Mitchell phantom limb pain, the finding that after an amputation the patient may still experience the illusion of pain in the severed limb. Paré, like many other surgeons in his time, used concoctions of opium and other herbs to ease the pain of surgery. These were applied orally, on the skin, and also inhaled by means of anesthetic sponges. Paré recommended against the use of mandragora, because it was more poisonous than other soporific herbs, but its use remained widespread during this period. He noted that regardless of the clever use of herbal anesthesia, pain was almost inevitable, and if at all possible surgery should be postponed until the patient expressed suitable resolve to go ahead with it. Dormandy argues that the multiplicity of different anesthetic concoctions and recipes during this time suggests that none was particularly effective. This would be true of the present day also, but I would argue that the common fear of surgery during the Rennaisance and Reformation periods was even more indicative of inadequate results in anesthesia. Montaigne, a famous writer, refused surgery for his painful bladder stones out of fear, although such surgery was commonly and skillfully performed during this time, as evidenced by the personal account of a later writer, Samuel Pepys.

1.13. Foundations

William Harvey was a British physician of the 17^th Century famous for first describing the circulation of the blood. His discovery was preceded by accumulating evidence concerning the observation that blood flow in veins was controlled by valves, and that these valves somehow played a role in preventing the blood inside living creatures from sinking to the lower regions of the body, although this is what occurs in dead bodies. Michael Servetus was a 16^th Century heretic whom Calvin burned at the stake after rescuing him from the Inquisition. He suggested based on his reading of the bible and study of medical anatomy and physiology that the lungs were where God’s breath (in the air) intermingled with the human soul (in the blood). Although most copies of his book were also burnt, it seems likely that some reached the university of Padua, where Harvey later studied medicine. Harvey proposed that the heart is a pump that pushes blood through in two circles, one to and from the lungs, and one to and from the rest of the body. In spite of many attempts by dissection and vivisection, he was never able to find the route connecting arterial (from the heart) and venous (to the heart) flows, either in the lungs or elsewhere. This discovery had to await the invention of the microscope. But his theory was essentially correct, and revolutionized the understanding of the functioning of the mammalian body.

One way in which Harvey’s theory revolutionized the understanding of the body was through an appreciation of the role of the lungs in exchanging some substance with the air. Experiments were conducted by Boyle, Hook and others on live animals with a pump, demonstrating that fresh air was necessary for them to remain alive. Another application of Harvey’s theory more directly relevant to the relief of pain was the possibility of inducing anesthesia by means of opiates injected directly into a vein. Although such demonstrations sometimes came off well, an account by Samuel Pepys suggests that the skill and technology necessary to find the vein in the poor experimental animal, usually a dog, was sometimes lacking. It is not surprising that intravenous anesthesia was not commonly used in human surgery for a century or more.

The 17^th Century saw the introduction by Descartes of his famous dualistic theory of human existence. Using his explanation of pain as an example, Descartes proposed that a pain inducing stimulus such as a fire has an effect on the skin that pulls on a nerve fiber, which in turn ‘rings a bell’ somewhere in the brain. In essence, this remained the little-questioned metaphor for pain and how it worked over the next 300 or more years. While the underlying neurophysiology and the transmission of neural impulses became elucidated, the basic understanding of the mechanism of pain remained the same. Descartes’ conceptualization of a separation between mind (soul or espirit) and body (or matter) was both intuitively appealing and helpful in disentangling the complexities of earlier conceptual frameworks such as Paracelsus’. The theological underpinning of Descartes’ theory has been increasingly questioned since Darwin’s theory of evolution eliminated the necessity of a purposeful cause in understanding the world, leading to a demise in the popularity of the concept of . However it has only been in the past 30 years or so, with advances in computer technology and ideas of artificial intelligence, followed by advances in brain imaging technology and the detailed charting of functional neuroanatomy, that any credible alternatives have been available to afford a conceptual understanding of pain.

In addition to these two major advances, Harvey’s scientific theory of the circulation and Descartes’ conceptual breakthrough regarding the reframing of the spiritual and the corporeal, with the nervous system as an intermediary, Dormandy discusses changes in theological attitudes to pain that began in the 17^th Century. He recounts the story of a female saint who founded the movement of the Bleeding Heart of Jesus, following a vision that appeared to her when she was in the throes of pain from her polio and other illnesses. She and her followers propounded the idea common in the Catholic Church to this day that servitude to God can be attained by means of pain and suffering. She was officially made a saint in 1920.

1.14. Heavenly dreams

Thomas Sydenham was a relatively unknown British physician of the 17^th Century, but although he ministered to no kings or queens he invented the recipe for laudanum, an opium tincture that became the popular panacea of an era. Opium was readily available in Europe in Sydenham’s time, but it came in many different forms that varied greatly in their quality and price. These pure forms were frequently unpalatable and tended to produce unpleasant side effects such as nausea and constipation. Their effects on different individuals were unreliable, and they were sometimes fatal in children and the elderly or infirm. Charlatans mixed opium with other herbs in a range of even less reliable concoctions. Sydenham’s innovation was a simple recipe that involved boiling a measured two ounce of good quality opium of known provenance in a double boiler with a pint of sherry (later substituted by Canary wine), together with a ground stick of cinnamon and a ground clove. This preparation, which was cooked for a couple of days to give the tincture a uniform character, was highly palatable and relatively safe. Sydenham himself used it for his pain from gout, which he described in detail. In France and Vienna there was originally some resistance to laudanum, but prohibitions against opium only served to make it more popular. By the middle of the 18^th Century, all the notables in Europe were using it, and it was extolled by poets such as Coleridge and Wordsworth, becoming one of the icons of the Romantic Movement.

During this period in history, people started to gather in growing cities leading to epidemics of sickness and poor health. Smallpox spread widely until a vaccine was invented. There was malaria or ague, which could be cured with quinine derived from the bark of the cinchona tree found in Peru. Childbirth became increasingly medicalized in the cities, and combined with poor sanitation this led to increases in death by childbirth fever. Sydenham believed that medicine should seek specific cures by understanding distinct illnesses, like quinine for malaria and digitalis from foxglove that was beginning to be used for heart disease. However, his universal laudanum became popular in an age when people began to see themselves as suffering from nervous malaise caused perhaps by the pressures of urban living as well as by the real sickness and poor health that increasing urbanization produced.

The propensity of opium and laudanum to give rise to pleasure as well as mitigating pain was well described by Thomas de Quincy, who first purchased laudanum for a toothache while he was a student at Cambridge. He extolled the resultant euphoria which far surpassed the original goal of pain relief. John Jones, another 18^th Century writer, bashfully compared the pleasures of laudanum with those he was too modest to name. He was the first to write about the risk of addiction, and the ravages of withdrawal from opium, which included physical pain, insomnia, anxiety and frequently death. Suicide by opium overdose was common.

The Romantic Age was characterized by a conflation between pain and its relief, at a time when early death from tuberculosis was commonplace and frequently discussed. In a previous age leaders were respected for suffering while they still carried out their duty, like Philippe II of France who worked on paperwork during the months of his final illness and confessed for two days on his deathbed, resisting any mind-clouding administrations from his physicians. During the Romantic Age the poetry and art inspired by laudanum made it not only commonplace and acceptable but also a revered aspect of the practices around death and illness.

1.15. Mesmerism

Anton Mesmer was probably one of the most successful doctors of all time in the treatment of pain. He was born in France in 1735, and after studying to become a priest changed his path age 28 and went to Vienna to study medicine. With the help of his wealthy wife, he set up a medical practice, as well as participating in the cultural environment of 18^th Century Vienna. He was a friend and patron of Mozart and Gluck. He became fascinated by the demonstrations of Father Maximilian Hell, who effected cures by applying magnets to the sick. Hell was prevented by the local medical establishment from continuing his practice, since he was a priest and not a qualified medical practitioner. Mesmer did not suffer from such an impediment, and continued his experiments on ‘animal magnetism’. Mesmer became convinced in the existence of a fluidum (like Newton’s ether) that permeates all things and makes humans and animals particularly susceptible to magnetism. His early experiments with the rich and famous of Vienna were so successful that he attracted a following of patients from all socioeconomic classes, and treated them according to their means, testing and honing his methods. Mesmer acknowledged the importance of personal contact with the patient for the effectiveness of his technique. Sometimes physical touch was necessary, but often eye-contact was sufficient. He was forced to leave Vienna by the underimpressed medical establishment, in spite of (or perhaps because of) curing blindness in a young piano protégé. From there, he moved his practice to Paris, whence he was similarly eventually expunged by a panel of experts including the famous chemist Lavousier and the American Ambassador Ben Franklin. The panel discredited him on the ground that there was no evidence for the existence of fluidum, nor was the theory of animal magnetism defensible based on scientific observations. They were instructed not to look at Mesmer’s record in curing patients. Mesmer himself was devoted to his theory, and vehemently sought to distinguish his practices from those of religious healers such as Gessner. In a later age, Freud was to deny the parallels between his successful treatments of women with pain conditions similar to those treated successfully by Mesmer. Like Freud later, Mesmer recognized that it was essential for the patient to wish to be cured.

Mesmer’s followers, the Puysegur brothers, quietly dispensed with the magnets, bowls of magnetized water, and magnetized trees favored by Mesmer, replacing the term ‘animal magnetism’ with Mesmerism. Instead of the fits and convulsions favored by Mesmer’s patients, they tended to induce sleep or a somnambulist state in their patients, prior to effecting a cure, and Mesmerism gradually became known as hypnosis.

Dormandy contrasts Mesmerism with earlier examples of psychologically generated pain relief, based on either faith or philosophy, because Mesmerism involves a patient and a clinician, and is thus better adapted to the practice of medicine. He also compares the controversy around Mesmerism with the controversy around the placebo effect. The term placebo has been used by physicians since the 17^th Century to denote a cure effected by a treatment believed in by the patient, which the physician knows to be inert, such as a bread pill or colored water. Placebos were used in common medical practice, and Thomas Jefferson complained about the distinction between a ‘pious hoax’ played by his physician and an honest false cure believed in by both doctor and patient. The word placebo, in Chaucer’s Canterbury Tales, was the name of a prayer recited in Latin that professional mourners plied to the bereaved. Placebo effects abound in the history of analgesia or pain relief, and are the scourge of drug developers. They have only recently started to be scientifically studied as a genuine method of benign and effective treatment for pain. In the context of modern parallels to Mesmerism, Dormandy describes an experiment in London dental hospital, where ultrasound treatment was used for many years to produce effective pain relief and speed healing following painful surgery and extractions, only to be found to be equally effective when the machine was turned off (but still far better than no treatment at all).

1.16. Pneumatic Medicine

Harvey wrote about the double circulation of the blood toward the end of the 17^th Century, and Boyle experimented, with Hooke, on animals to show that fresh air was required in order to sustain life, but it was almost half a century before the process of respiration was understood. The reason for this was a popular but erroneous theory regarding combustion that had existed since the 16^th Century, which was popularized by the chemist Ernst Stahl. According to the phlogiston theory, combustion released something called phlogiston into the air, and the resultant burnt matter became ‘dephlogisticated’. It took a revolution in thought to realize that instead combustion used up something in the air, namely oxygen. Mayow, a student of Boyle’s, wrote a treatise on respiration before his death in 1679, in which he hypothesized that the lungs exchanged something from the air with the blood, which was the same thing required for combustion and fermentation. He showed that once a mouse had expired in a closed chamber, a candle placed there snuffed out. Mayow’s treatise was rediscovered and translated by the physician Thomas Beddoes in the mid 18^th Century, by which time oxygen had been discovered. Oxygen was discovered separately by the British intellectual Joseph Priestly, the eminent French chemist Lavousier, and an obscure Stockholm apothecary named Scheele. Joseph Priestly isolated oxygen from an oxide of mercury, and was surprised to discover on breathing it (after finding out that it was particularly inflammable) that unlike most gases he had concocted it actually relieved his asthma, instead of making it worse.

Thomas Beddoes practiced as a physician in Bristol, and was overwhelmed by the suffering of patients with consumption (tuberculosis), which became endemic in Britain during this period of industrialization as more and more people moved to the cities. There was a belief that consumption could eventually become cured or prevented by the advances in medicine, and because it was a disease of the lungs there was hope for a cure from the inhalation of gases and vapors. Ether was used as an inhalation, and while it did not cure consumption it provided some relief from the terrible pains caused by this disease. Thomas Beddoes experimented with ‘inflammable air’ (oxygen), and ‘fixed air’ (carbon dioxide), and found that the former eased breathing in patients with consumption, while the latter relieved chest pain. With the help of the wealthy industrialist John Wedgewood and the goal of curing consumption and other diseases by means of these newly discovered gases, he founded the Institute for Pneumatic Medicine in Bristol in 1799, probably the first ever medical research institute.

1.17. Laughing Gas

Humphry Davy was appointed superintendent of the new Institute at the young age of 21, and proceeded to experiment enthusiastically on the effects of gases upon animals, his friends, Beddoes’ patients, and last but not least himself. He noted that carbon dioxide made him sleepy, and that too much oxygen gave him a headache and could eventually kill animals forced to inhale the pure gas. Ignoring the advice of his elders, he experimented with inhaling hydrocarbon (carbon monoxide) noting its effects on patients in causing a ‘delightful pinking’ of the skin, and had to be rescued by another researcher who revived him with pure oxygen. Both Mayow and Priestly had isolated nitrous oxide as well as oxygen, but considered it a choking gas. Davy nevertheless experimented with it, and was surprised to find it produced pleasant exhilaration and laughter, like the inhalation of ether. He also noted that inhaling nitrous oxide killed the pain of his wisdom teeth and indigestion, although the pains returned after a while. In a book published in 1801 on the effects of gases, he noted that while not of prolonged benefit in chronic illness, nitrous oxide might be useful in relieving the temporary pain of surgical operations. Unfortunately, this was ignored for half a century. Davy also noticed that he was becoming addicted to the nitrous oxide and using it more and more. He was able to stop for a while, but then returned to his experiments. He moved to London in 1801 and became increasingly jealous and tyrannical, despite being appointed to the new Royal Institution of Science. He died in 1829 in an apoplectic fit. It is not clear whether his mental illness was the result of his experimentation with gases, or simply the outcome of his over-exuberant and charismatic personality.

Thomas Beddoes, meanwhile, continued to practice medicine in Bristol. The Pneumatic Institute closed shortly after Davy’s departure, and Beddoes opened instead a clinic for the prevention of disease, which dispensed advice and sometimes medication to the poor and sick, probably one of the first community clinics of this kind. Beddoes published a book on preventative healthcare for the affluent, noting the risks of obesity, overeating, a sedentary lifestyle and overindulgence in drink. He recommended a schedule of specific diets and exercises. He wrote another book for the poor, and was ahead of his time in his awareness of the role of contagion in the spread of diseases such as consumption, and the importance of nutrition and hygiene. He thought that the mind, as well as the body, played a role in the experience of pain. He advised checking the health of children, particularly teenage girls, instead of berating them for being lethargic and unhappy. When parents brought a child to his clinic, where children were treated for free, he always asked about the other children in the family and checked them too, because he noted that while children will complain of a sharp pain they will often ignore a dull pain that comes on slowly which might be an indication of illness.

1.18. The Terror of the Knife

Pre-anesthetic surgery was often a scene of horror for the patient, the surgeon, and the audience that gathered at the medical schools’ operating theaters. Speed was of the essence in performing a safe operation before the patient went into shock, but patients’ descriptions of the proceedings of nowadays simple surgeries like the removal of bladder stone, or a mastectomy, are horrific. These accounts tell of excruciating pain so terrible that words fail to describe it. Patients most commonly screamed during the surgery, and had to be held down by assistants, as the surgeon dreaded accidentally cutting through an artery and causing the patient to bleed to death. Surgeons practiced their craft on cadavers for hours in the morning before the afternoon’s surgery, like a pianist practicing for a concert. Surgeons were encouraged to talk to and mollify the patients during the entire proceedings, giving them strength to endure their pain and hardship. Many surgeons described having nightmares about their work, and waking up in a cold sweat. For some, this only got worse with time. A famous surgeon, nearing the end of a prestigious career, was observed to suffer from shivers and vomiting after his day in the operating theater. Other surgeons went on operating until they were in their 70’s and 80’s, seemingly addicted to their work. Relatives of the patient would complain many years later that they were still haunted by the cries and screams of the surgery. And yet, in spite of these horrors, advances were made in surgery as more was known about human anatomy, and deaths in the operating theater became a rare occurrence.

1.19. Hospital Disease

Hospital disease made a mockery of these advances in operative techniques. After a successful surgery, the patient left in the hospital bed to recover was likely as not to die of one of the many diseases later found to be caused by bacterial infection. Epidemics of ‘pyemia’ caused patients to die rapidly and painfully when after a spike of fever pus-filled boils appeared on their skin and inside their internal organs. The Hungarian obstetrician Semmelweis noticed in the 1840’s that childbed or puerperal fever rarely occurred in home births assisted by a midwife. When he suggested that it was a manifestation of the same illness, caused by noxious matter picked up by doctors at autopsies, he was ridiculed. ‘Septicemia’ was the cause of slow, painful death usually preceded by loss of consciousness as bacteria multiplied in the patient’s bloodstream. Erysipelas was similar, but accompanied by a rash emanating from the site of the wound or surgical incision. These diseases came and went in epidemics that caused the operating theaters and sometimes whole hospitals to be closed. Doctors and nurses were at risk as well as patients. The British parliament debated closing all the hospitals in London, and Florence Nightingale, famous for originating modern nursing during her service in the Crimean war, suggested building huts Hyde Park to isolate the patients and allow them to recuperate safely. In France, Louis Pasteur discovered bacteria by looking down a microscope, and demonstrated their role in fermentation. A Glasgow surgeon Joseph Lister made the connection between bacteria and ‘hospital disease’ and, in the 1860’s, introduced carbonic acid spray in the first attempts at antiseptic surgery.

1.20. To the Threshold

In his book, Thomas Dormandy hypothesizes that one of the reasons it took so long for well known drugs to be used for the elimination of pain during surgery was that until the middle of the 19^th Century society viewed pain as a normal part of life. When Ellioston, Ward and Topham, Braid and Esdaile conducted painless surgery in Britain and elsewhere around the British empire by means of hypnosis, they were viewed with incredulity. James Esdaile performed 950 pain free operations under hypnosis in India. Upon returning to his native Scotland in 1851, he found few were willing to undergo ‘mesmerism’ which had been discredited by the British medical establishment. He also noted that patients in Scotland were less susceptible than their Indian counterparts. James Braid published a book on ‘neurypnology’ in 1841 and coined the term hypnosis, deriding the ‘nonsense of animal magnetism’ but he himself only used it for dental work and the occasional excision of an abscess, not for more serious surgery. Larrey, a field surgeon to Napoleon, noted that in the snow of the Russian front amputations could be performed painlessly. He was interested when a young British doctor, Henry Hickman, wrote in 1824 about the use of asphyxiating gas (probably carbon dioxide) in performing an amputation on a sleeping dog, and remembered this later when in 1842 Horace Wells wrote to the Academie Scientifique in Paris about using nitrous oxide for surgery. However, there was a prevailing sensibility which held that ‘pain was necessary, even essential’ to healing. A young woman after a painless mastectomy conducted under hypnosis was noted to take longer than usual to recover. Cardinal Berlusconi in Milan delivered a sermon castigating those who sought to abolish the pain of surgery, which he held to be ‘one of the Almighty’s most merciful provisions’. In Britain, pain was not only endured but also inflicted mercilessly in the form of whippings and brandings, on criminals and the working poor but also on the children of the upper classes in boarding schools, and especially in the military. Hangings and lashings drew crowds of eager onlookers. Hundreds of people in Europe were killed each year in duels. Pain provided the foundation of the social order. It was only when this situation was reversed by Thomas Arnold’s reformation of public schools (still brutal by modern standards), and by the Factory Act of 1833 and the Mines Act of 1842, that pain began to be viewed as undesirable. Slavery was abolished, and sports such as cock-fighting and bare-fist fighting went underground. Sir Charles Bell, a famous physician, wrote ‘When pain will be taken out of surgery, the earth and lives of all who dwell on it will have changed’.

1.21. A Gentleman from the South

Crawford Williamson Long, a rural gentleman doctor from Georgia, was probably the first to use ether anesthesia in 1842 and continued to use it throughout his long career, but never succeeded in publishing his findings. Nitrous gas ‘frolics’ were a popular entertainment in the puritanical South, promulgated by charlatans and quacks such as Henry Colt, who used the proceeds to finance the patent for his more famous six-barreled gun. As town physician and pharmacist, Long occasionally synthesized nitrous oxide for the amusement of his teenaged assistants. On one occasion, he ran out of the requisite raw materials, and suggested trying ‘ether frolics’ instead. He noted that when he woke up from the ether he was often covered in bruises, but could not remember falling about and hurting himself in his intoxicated state. One of his patients, reluctant to undergo surgery for a tumor on his back for fear of the pain, agreed to do so under the influence of ether, which he had already sampled as entertainment. After this first surgery under ether anesthesia, Long performed many more in operations lasting as long as 20 minutes, which he documented meticulously. This was much safer than nitrous oxide, which could only be used for brief surgery because of the danger from anoxia (eventually it was mixed with pure oxygen rather than air to make it safe). Long was cautious, awaiting publication until he had obtained results from many different patients. The Civil War intervened, and he became too poor to travel or publicize his results, although he continued to use ether for surgery and difficult births until his death in 1878.

1.22. This Yankee Dodge

The historical origins of ether and nitrous oxide anesthesia are marred in controversy. According to Dormandy, a young Boston dentist by the name of Howard Wells attended in 1844 a lecture on nitrous oxide by a quack and businessman, Quincy Colton. During the demonstration, a participant ran into some furniture and bruised his leg badly, and was later surprised to find his leg bleeding and said he had experienced no pain. After the talk, Wells asked Colton if he would be willing to try the gas in some dental surgery, and Colton agreed. Wells himself was the subject, and his assistant Riggs extracted a diseased tooth without pain. Wells was impressed with the results, and confided in William Morton, his former student. Together, they went to talk with Charles Jackson, a famous professor. Jackson was unimpressed by the prospects of painless surgery. Warren, the chief surgeon at Massachusetts General Hospital, allowed Wells to demonstrate his painless tooth extraction in the operating theater. This demonstration was a failure. Morton went back to Jackson, who suggested trying sulfuric ether in place of nitrous oxide. He recommended a pharmacist who could prepare the pure product, which was commonly sold as a cough remedy at the time but often diluted with other substances. Morton again appealed to Warren, and in October 1846 the gas was used in surgery for the removal of a tumor. The operation came off well, and Warren declared: ‘Gentlemen, this is no humbug’. There followed a battle over recognition in the United States and in Europe for the invention of surgical anesthesia. Wells became obsessed with this and with his daily experiments on himself using nitrous oxide, ether and chloroform. On his way back from traveling to France in 1847 he was arrested in New York in 1848, accused of throwing acid at passersby on Broadway while in a crazed state. He killed himself in jail shortly after by severing his femoral artery after he had inhaled chloroform to dull the pain, missing the arrival of a letter informing him that the French Academie des Science credited him with the discovery of anesthesia. Congress awarded a prize to Warren and Morton, rescinding it following an appeal on behalf of Wells’ destitute widow, and the evidence of dozens of depositions in support of Wells by patients, including his own daughter, who had their teeth extracted under anesthesia prior to Morton’s demonstration. Morton’s claim was recognized by Bigelow, the chief surgeon succeeding Warren at Massachusetts General Hospital. However, Morton’s attempt to make money from colored sulfuric ether was thrown out of court by a judge who deemed that ether could no more be patented than Ben Franklin’s ‘celestial electricity’. Jackson published a book on etherization in 1861, in which he claimed to have experimented on patients at an asylum where he himself was admitted a few years later. What is without doubt is that, at Warren’s behest, the word anesthesia was coined by the famous Harvard physician and scholar Oliver Wendell Holmes. It is comes from the root ‘aisthesis’ meaning sensation.

The reason for narrating this history here is its relevance to the pharmaceutical industry today. Ether was a bane to humanity, but its use as a surgical anesthetic could not easily be credited to one person, nor could it be used to make money. What is more surprising is that ether was readily available for hundreds of years, and nitrous oxide for decades, and yet although they were used recreationally as well as therapeutically their usefulness in surgery remained unrecognized for so long. I disagree with Dormandy that this was because of a prevailing acceptance of pain. I think it was a problem of mindset, how these substances were categorized in the minds of physicians and others. Nowadays the drug industry attempts to make profits by re-marketing and re-patenting drugs for previously off-label uses, and unlike the wise judge in Morton’s patent case the legal system allows this. Safe and effective uses of widely available natural substances are shunned and relegated by the medical establishment to the role of alternative quackery because nobody stands to make money from them. I wonder if, in the present pharmaco-economic climate, the use of a common panacea such as sulfuric ether in surgery might have taken much longer to gain hold in the medical establishment, and what this means for future advances in the treatment of pain. It is also worth noting that most of the credit went to Morton, who was the least qualified but shouted loudest, and none to Dr. Long, by far the best scientist and clinician in this story.

1.23. In Gower Street

In the 19^th Century, news of medical discoveries traveled fast. Letters about the Boston demonstrations of surgical anesthesia reached London, and Dr. Francis Boott, a Gower Street physician, decided to try it out for himself. In December 1846, he used his homemade sulfuric ether administered by means of a perfume vaporizer to assist in a tooth extraction by a local dentist. Shortly after, Robert Liston, surgeon to University College London, was persuaded to try ether in surgery, and successfully amputated a leg without causing pain. In astonishment, he exclaimed that ‘this Yankee dodge sure beats mesmerism hollow’.

1.24. And Beyond

One of the first uses of anesthesia in continental Europe was for veterinary surgery. In Vienna, several stallions were castrated under the influence of ether vapor without need of restraint, and were ‘ready to be put to harness the same day’ according to the Wiener Journal. By January 1847, 20 operations under ether anesthesia had been performed at the Academie des Science in Paris. By the summer of 1847, ether anesthesia was being used for surgery in Australia and New Zealand.

1.25. Chloroform

The controversial Scottish obstetrician James Simpson began experimenting with the use of ether to control the pains of childbirth days after hearing of Liston’s successful anesthetic surgery in London. He was not entirely satisfied with the results, and worried that ether inhalation made both the mother and onlookers sick. With a small covey of friends, he would gather after dinner to inhale different oils and substances in search for a safer alternative. Eventually, in November 1847, he came across chloroform, reported by a Liverpool chemist, David Waldie, to cause ‘dopiness’. Chloroform was first synthesized around 1830 by three different chemists, one in the United States, one in France, and one in Germany. Simpson and his friends collapsed into a mirthful stupor, and Simpson immediately put chloroform to use in his obstetric practice, convincing the first mother using it to name her baby Anaesthesia. There followed great moral controversy, because labor pains had according to the Church been ordained by God, as written in Genesis: ‘in sorrow will you give birth’. In spite of this many women including Queen Victoria rushed to request chloroform to ease their labor.

1.26. The Shape of Dreams

The use of opium in Britain increased rapidly during the first half of the 19^th Century, with imports rising from about 60,000 lb per year in 1825 to over 250,000 in 1850. The quality of the opium was variable, and later analysis showed the morphine content varied from about 10-14% in the Turkish variety down to 4-6% in opium from India and Persia (including today’s Afghanistan). About a third was used for export, mostly to the United States, and the rest used for home consumption. Poppies were grown for opium throughout the fertile regions of Europe, including the Fens in England, the Auvergne in France and the Po Valley in Italy. Farmers competed for prizes on their high yield, despite the low morphine content of only 4-5%. In the Fens opium use was so common that a chemist described a typical Kings Lynn farmer visiting his store three times per day for his draft of laudanum, and an enterprising brewer added it directly to his beer, which sold well at a premium cost. A grocer in the small village of Holbeach netted £800 from opium in one year. Opium was useful not only in the relief of pain and the mental anguish of poverty but also for combating diarrhea, and in large doses it prevented death from cholera epidemics of 1830-31 and 1848-49 as well as the milder outbreaks of summer dysentery that killed many infants each year. Sold as chlorodyne in the 1850s, it generated profits in excess of £50,000 for its makers, at the time more than the income of a small German principality. In the US potions containing opium were for the first time marketed not only as medicines targeted for specific illnesses but also as generic remedies for pain, such as Perry Davis’ ‘Celebrated Pain Killer’. The targeted age range continued to expand, and a variety of ‘baby-calmers’ were on the market, popular not only among parents and nannies but also the new breed of baby-minders whose mothers had to work in the factories of the industrial revolution. Victor Hugo bemoaned the toddlers who ‘had shrunk up like old men, wizened like little yellow monkeys’ after their doping relieved them also of the pains of hunger and the mixed blessing among the urban poor of a healthy appetite.

I wonder whether we are seeing a parallel to this in the present day expansion of the market for drugs such as anti-depressants and neuroleptics targeted at children as well as adults and dressed in new labels and new indications, including anxiety and pain, promoted directly to the public.

The German chemist Setürner who was the first to isolate morphine, the most potent constituent of opium, was well aware of its potential dangers when he wrote in 1812 ‘I consider it my duty to attract attention to the terrible effects of this new substance’. Experimenting on himself in his spare time, he identified among the anticipated acidic constituents of morphine this alkaline substance and named it ‘morphium’ from the Greek, inspired by the Romantic writers of the time to call it ‘the shape of dreams’ or ‘shapes’. Eventually, in 1817, Setürner’s publication attracted the attention of Louis Gay-Lussac in Paris, and inspired a flurry of chemical research because prior to this only acids (and not alkalis) were thought to be biologically active. This led to the discoveries of caffeine and nicotine in the 1820’s. The French physician Magendie was among the first to use morphine in medical practice, for a terminal cancer patient who was intolerant of opium. Codeine and thebaine, two other opium constituents, were isolated in the 1830’s. During the 1850’s morphine competed with laudanum and other opium preparations in both medical and recreational uses, although at this time morphine began to be administered subcutaneously by means of a syringe and in much larger doses than available through eating opium. An inventor of this method, Alexander Wood, thought that this route of administration would combat the ‘appetite’ for the drug by eliminating the act of swallowing. His wife was one of the first victims of accidental overdose in 1854. Morphine addiction became common during the Crimean war, and was prevalent among soldiers fighting on both sides in the Civil War.

1.27. Mr. Anesthetist

John Snow was a dedicated General Practitioner as well as a scientist. He was probably the first anesthetist. By careful research he was able to track the spread of cholera in the epidemic of 1848-49 in London, and his insistence on the removal of the handle of an infected pump helped prevent the wider spread of an outbreak in 1854. The same meticulous numerical methods allowed him to administer ether and chloroform effectively and safely for the famous surgeons in London, including Liston and Fergusson, from as early as January 1847. Snow appreciated the importance of temperature both in the vaporization of the inhaled liquids and their absorption in the bloodstream. He recognized that their potency depended on their miscibility with blood, and that monitoring the blood concentration of the anesthetic was a good guide to the depth of anesthesia. He insisted on the purity of the compounds he used, one of the first instances of purity standards in medication. Snow’s careful administration of chloroform to Queen Victoria during her confinement in 1853 won him and anesthesia a huge following in Britain and overseas.

1.28. Conflicting Views

In London and Edinburgh’s teaching hospitals, ether and chloroform anesthesia were rapidly put to use and became the norm by the 1850’s. However, many general practitioners and rural surgeons took time to adopt these new methods, sometimes because they were conservative and cautious in their thinking, but most often because they simply hadn’t heard of them. Following Queen Victoria’s advocacy of anesthesia, it was often the patients who requested to be ‘put to sleep’ for surgery, not only patients of the upper and middle-classes but ‘even those of the vagrant classes’ according to hospital admission notes from 1849. A number of doctors and ministers in Britain and France wrote letters to the press about the moral lassitude of anesthesia used in surgery but their complaints were countered by Snow’s statistics published in medical journals showing the safety of these new techniques.

1.29. The Rights of Pain

Surprisingly, perhaps, it was in the United States, the birthplace of anesthesia that the medical and dental establishments proved more conservative. As late as 1860, at least a third of operations at Massachusetts General Hospital were performed without anesthesia, and this picture was typical not only of public hospitals but also the more lucrative private medical scene. Dentists wrote about the dangers of anesthesia in making patients, especially women, susceptible to rape and abuse by quack surgeons. Obstetricians wrote about the propensity of anesthesia in childbirth to replace God-given pain with ‘sexual orgasm’. The poet Ralph Waldo Emerson declared that all bodily pains carried a spiritual reward, and Emily Dickinson wrote that ‘Power is only Pain’. William Atkinson, president of the American Dental Association, pronounced that ‘anesthesia is of the devil’. America was open to a broader range of views than Europe, and the German ideas of homeopathy and hydrotherapy gained root here, leading to the opinion propounded by the likes of Kellog and Graham that health could and should be maintained through asceticism and exercise, and that ‘in a state of health no natural process is painful’ (Nicholls, from a book on obstetric hydrotherapy), rendering anesthesia unnecessary as well as sinful. The United States of the 19^th Century was at once both the cauldron in which anesthesia and the idea of marketing universal ‘painkillers’ were fomented, and a hotbed for new philosophies that held pain and suffering to be unnatural.

1.30. Who Needs an Anesthetic

To bridge the gap between these contrasting views and perhaps also to carve a niche for the practice of medicine among this plethora of technologies and opinions, Oliver Wendell Holmes and others originated what became known as ‘conservative medicine’. When the Declaration of Independence was signed by the physician Dr. Rushmore, all he needed to practice medicine was a general view that diseases were born of too much ‘bad stuff’ and could be cured by letting it out, by means of blood lettings, leeches, cuppings and purges. Any sensible, intelligent person could act as medical advisor to his own family. Suddenly, around the middle of the 19^th Century, there was an abundance of available cures promoted by quacks and charlatans of all kinds, and doctors needed to distinguish themselves by means of their education and superior knowledge. The goal of conservative medicine was to replace universal panaceas with individual treatments, and ideally come up with a classification system for all the different kinds of patients.

In regard to pain, it was generally held that against the standard of the white male, women suffered more, and that old, black and indigenous people suffered less. There was controversy as to the suffering of children and animals. Some doctors believed that experience and learning were required to suffer pain, whereas others saw children and infants as closer to women in their general delicacy and tendency to complain. The cause of lesser suffering was variously framed as brutish ‘insensitivity’ (bad) or Christian ‘endurance’ (good). The greater sensitivity of woman was attributed to physiological causes. The rise of Darwinism caused concern over the superior fitness of primitive people who were less sensitive to pain. This was coupled with a misunderstanding of heredity and the notion that although the ‘insensitivity’ of black and indigenous peoples may have been caused by their brutal treatment by whites, this ‘insensitivity’ would be transmitted to future generations. Some American doctors, anticipating the Nazis, conducted cruel experiments on black slaves and Native Americans. Anesthetics and painkillers were most frequently administered to white women, who were led by male doctors to believe in their own delicate sensitivity, a notion that endures to this day.

1.31. The New Physiology

The 19^th Century was a period when many new facts were discovered concerning both the human body and the nature of disease, and Dormandy attempts to separate and outline these two areas of advance in this and the next chapter of his book. Dormandy speculates that the invention of anesthesia profoundly changed the conceptual scheme in which pain was viewed. Prior to anesthesia, pain was always associated with a particular part of the body that was injured or diseased and therefore hurt. It was not necessarily obvious that a headache, a stomachache, and a toothache were all the same kind of thing. Some had suggested that pain is simply an exaggeration of other sensations, pointing to the fine line between a nice warm bath and a scalding, which differ only by degree. After the discovery of anesthesia, most doctors came to believe that pain was an experience in its own right, one uniquely susceptible to anesthetics, which must have its own purpose.

Charles Bell was the first in 1811 to distinguish between two kinds of nerve fiber, one carrying signals from the periphery to the brain and the other carrying signals from the brain to the muscles of the body. Francois Magendie, in France, came to a similar conclusion. Johannes Müller wrote a comprehensive textbook on human physiology in 1844, where he hypothesized that pain is a particular kind of sensation conveyed to the brain by specialized nerve fibers. He speculated that in the brain, the sensation of pain had to be interpreted. Müller found that the signals carried by different nerves to the brain depended on the peripheral origins of the nerves, so that stimulation of the optic nerve whether by light, pressure, or heat, always produced visual sensations. This led to his theory of specific nerve energies. It required special pain receptors distributed throughout the skin and the internal organs to account for sensations of pain, an advance building on Descartes’ notion of a bell and a bell-pull.

Led by Hermann von Helmholtz, Müller’s students took this notion a step further when the published a Physiological Manifesto in 1847 announcing that the aim of the life sciences is to explain all biology in terms of physical and chemical laws, leaving behind Müller’s own notions of vitalism. Müller had suggested that nerve impulses were probably electrical. In the years that followed, Helmholtz not only proved this to be correct but also measured their speed of conduction, which he estimated at 20 meters per second. He invented the ophthalmoscope, an instrument that allowed him to see the human retina, at the back of the eye, and identify the optic disc where the optic nerve exits. Emil du Bois-Reymond, another of Müller’s students, was also fond of inventing instruments and designed the ‘algometer’ a device that generated current with the aim of measuring sensitivity to pain. This was put to use by Havelock Ellis and Cesare Lombroso, who claimed to show that criminals and ‘mental defectives’ were less sensitive to pain than others. According to Dormandy, the instrument is still used in medical schools for the study of pain sensitivity.

Ernst Brücke in Vienna was a student of Müller, and Sigmund Freud’s mentor. He began experimenting with cocaine, and while he never realized it could be used as a local anesthetic he showed that it blocked the transmission of impulses from motor nerves to the muscles.

Karl Ludwig, who became the director of the Physiological Institute in Leipzig, held that the study of physiology was quintessential to medicine, because all illnesses were normal functions gone awry. He invented the kymograph, the first instrument used to visually chart physiological measures such as temperature and blood pressure. Ludwig emphasized the importance of the brain in interpreting pain signals, and suggested that pain ‘involved the production of specific chemical agents’. He wrote in 1856 that ‘the brain secretes sensations and thoughts as the stomach secretes gastric juice, or the liver secretes bile. Pain is a substance. It is waiting to be identified.’ Ludwig was the first to suggest that the brain contained warring algesics and analgesics modulating the experience of pain, an idea vindicated more than a century later.

Theodor Schwann identified the cell as the basic unit of all living organisms, including both plants and animals. He characterized the cells of the nervous system and noted that nerves were coated in an electrically insulating sheath, speculating about the possible consequences of damage to this ‘protective coating’. Rudolf Virchow, another of Müller’s students, identified the pus cells as white blood cells and founded modern cellular pathology.

In France, Clause Bernard followed in the footsteps of Magendie. His friend Louis Pasteur once described him as ‘French physiology personified’. Bernard clarified the anesthetic properties of carbon dioxide, first described by Henry Hickman. He showed how general anesthetics such as ether and chloroform are distributed throughout the body, and found that they do not affect peripheral nerves directly but only through their distribution to the brain via the spinal cord. Studying the South American poison curare, he found that it acted selectively to still motor nerves, the opposite of strychnine, which caused convulsions by selectively activating the motor nerves. Curare only affected voluntary muscle, not autonomous muscles such as the heart. This led to his discovery of the ‘autonomic’ nervous system that carries signals from the internal organs and serves to regulate heart rate, blood flow, sweating, and the movements of the gut. Bernard noted that while the action of the autonomic sensory nerves was normally unconscious, they could convey the pain of angina pectoris, ‘the fierce sensation of constriction of the chest’ accompanied by a ‘terrifying sense of impending dissolution’ when blood supply to the heart was insufficient, as well as the pains of intestinal and renal colic. He speculated that the goal of much physiological activity, including pain, was the maintenance of the milieu intérieur, a process which later became known as homeostasis.

Spinal reflexes were discovered in the 18^th Century through experiments on decapitated frogs, followed by the work of Marshal Hall in the 19^th Century who showed that transection of the spinal cord in frogs resulted in a loss of voluntary movement and an enhancement of reflex actions in the hind legs. Hall suggested that the spinal cord was superior to the brain, since ‘it needed no sleep but was always ready to function’. He was aware that reflexes caused blinking, coughing, and other protective reactions, and was the first to observe that spinal reflexes were responsible for most actions of the newborn, claiming that ‘without spinal reflexes no neonate would survive’. The discovery of reflexes impacted Darwin’s theory of evolution as well as the ‘Gate Control’ theory of pain in the twentieth century.

The pathways nerves follow through the body and to the brain were elucidated by Augustus Waller, who experimented with severing the nerves and showed degeneration of the distal portion, and by Charles Edouard Brown-Séquard who studied the course of nerve tracts and correlated them with the changes observed after strokes. He found that the left side of the brain crossed to the right spinal cord and vice versa, contrary to the Victorian notion that ‘nature is never unnecessarily complicated’. Cerebral localization emerged from the pseudoscience of phrenology, and Franz Joseph Gall’s claim in the late 18^th century that the mental functions of different parts of the brain could be detected by palpating bumps and dents on the skull. Flourens discovered that removal of a pigeon’s cerebellum and hindbrain led to loss of balance and muscular coordination, but the bird could still see and hear. He suggested that conscious sensation and pain were in the cerebrum, and the cerebellum served for ‘purposeful movement and hidden feelings’. Legallois localized the respiratory center in the medulla of a patient who suffered damage to the hindbrain in a duel. Dormandy tells the tale of Philip Gage, a Conneticut quarryman, who had a crowbar passed through the front of his skull in an accident and lived for another ten years, the only noticeable change in his demeanor a loss of his violent temper and alcoholism.

This latter story makes me wonder about the quality of some of Dormandy’s facts. The story exists in several different versions. According to the more familiar one, the name of the protagonist was Phineas P. Gage, and he was a railroad worker hit by a tamping iron while blasting rock. Harlow, the physician who treated him after the accident described a childish man of uncontrollable urges and a strong desire to return home. For a time, Gage made public appearances in New York and around New England, showing off the tamping iron as well as the hole in his skull. This included a visit to Boston, where he met with Dr. Bigelow at Harvard, leaving the tamping iron with him and later reclaiming it. Gage moved to Chile and worked for a time as a stage coach, before he became violently ill with convulsions that eventually led to his death. While contemporary accounts suggest he functioned reasonably well, Harlow and Bigelow both later wrote about his loss of functioning and deleterious changes in character following the accident, so profound that prior acquaintances said he was ‘no longer Gage’. The fits of rage and propensity for swearing and alcohol came after the accident. The fact it is possible to survive such brain mutilation is the only association with frontal lobotomy introduced in the 1930’s to try and improve the personality of the severely mentally ill. MacMillan (2000) has researched and written extensively about Gage’s case. Dormandy’s reversal of this story, together with other inaccuracies such as reporting the date of England’s cholera epidemic variously as 1830-31 and 1831-32 in different chapters, makes me suspect that minor historical facts and details have been twisted around, misremembered or insufficiently evaluated in favor of supporting a particular argument or viewpoint.

Hitzig and Fritsch continued the exploration of functional localization in the brain, studying soldiers who had parts of their skulls damaged. Using electrical stimulation in these patients and in animals, they identified the motor cortex of the brain, which was named by David Ferrier in London. Robert Caton discovered the sensory cortex by recording electrical currents from the brain. Nobody was able to identify a pain center. The spikes of current evoked by heat, pressure and electrical potentials all showed the same patterns, and were at most attenuated by general anesthesia. How general anesthesia works remains a mystery.

This lengthy review indicates that during the 19^th century new treatments were discovered for pain and its prevention, some of which are still not understood. Contrary to the way in which modern medical science portrays itself as proceeding from an understanding of physiology, or the functioning of the healthy body, to an understanding of disease, followed by the creation of a cure, physiology, pathology and treatments were discovered side by side as parts of a massive flowering of empirical science that was based as much on the consistent observation, dissemination and putting together of previously overlooked facts as on the invention of new technologies. It was during this time that physiologists first articulated the goal of basing their science entirely on physics and chemistry. At the same time, doctors began to propound rhetoric basing their treatments on an exhaustive classification of patients.

1.32. The New Pathology

Helmholtz declared that ‘every disease was a physiological experiment, and every physiological experiment was a model of a disease’ (Dormandy, 2006). Some diseases were effectively characterized and understood before the 19^th Century. Wepfer showed in the 17^th Century that strokes were associated with blood clots in the brain, and suggested that the location of the clot might determine the patterns of pain and paralysis. James Parkinson, in the 18^th Century, described the shaking, tremors and stiffness of the disease which is now named after him, hypothesizing that as ‘sensibility’ was not affected it might be the result of damage to parts of the brain where muscle actions are ‘harmonized’.

A major advance in the 19^th Century was the description by Romberg of all the specific neurological signs of ‘General Paralysis of the Insane’ which was later found to be caused by syphilis. The symptoms started with searing pains in the feet and calf muscles, which were barely relieved by morphine. There followed tingling and pins and needles in the toes. Eventually, feeling might be lost all over the chest, and over a ‘butterfly area’ surrounding the bridge of the nose, which became known as the ‘masque tabetique’. After months or years, these symptoms were followed by weakness, paralysis and eventually mental illness. Duchenne described these advancing symptoms in terms of the associated spreading damage to the spinal columns caused by syphilis, and in France the illness became known as Duchenne’s disease. It took almost 100 years to find an effective treatment.

Dejerine, a contemporary of Duchenne, investigated another pain condition – one that was caused by degeneration of the peripheral nerves. It resulted in symmetrical spreading of tenderness, altered sensations and muscle weakness, starting normally from the feet and hands. Dejerne described the symptoms as following a ‘glove and stocking’ distribution. This condition was commonly the result of alcoholism and vitamin B deficiency but could also be caused by diabetes, and different toxic conditions from poisoning with lead or other metals.

Jean-Martin Charcot, head of the famous Salpêtrière hospital in Paris, became adept at discriminating between ‘real’ neurological conditions and their ‘hysterical’ manifestations. He did not, according to Dormandy, believe that the pain of the hysterics was any less real than that of the neurological patients, it just warranted a different treatment approach. Charcot became famous for his demonstrations curing hysterical women by means of medical hypnosis. The women all showed signs mimicking other illnesses. Charcot also studied epilepsy, spastic conditions, sensory syndromes, and neurosyphilis, discovering the degeneration of bones and joints in the advanced stages of ‘tabes dorsalis’ which resulted from loss of pain sensation deep inside the body.

Dormandy devotes much space in this chapter to a description of the miracle of Lourdes. It warrants a mention because coming as it did right in the middle of the 19^th Century, it seems to go against the tide away from faith healing and towards modern medical science, and yet patients flocked and continue to flock to Lourdes, many of them obtaining relief from their pains. There was an outcry in the medical establishment at the time against the veracity of these purported healings, and yet the quality of the empirical evidence for them was no worse than the evidence for the effectiveness of medical treatments such as ether and morphine, nor was the mechanism of drug treatment any better understood by the physiologists of the time than the mechanism of faith healing. Charcot probably recognized the parallels with his own hypnotic cures when he refused to condemn outright the happenings at Lourdes.

Cruvelhier outlined the symptoms of multiple sclerosis and tried to classify other pain syndromes. Broca examined the damage in aphasias and identified the area in the left hemisphere of the brain which is now named after him as responsible for speech. Jackson in England identified the symptoms of focal epilepsy and discriminated between sensory and motor aphasia. Bastien in France and Wernicke in Germany found the area of the brain responsible for the former which became known as Wernicke’s area.

Kraepelin devised a new taxonomy of mental illnesses, noting the longitudinal association between mania and depression, and contrasting it with the cognitive decline in dementia praecox (later called schizophrenia). He wrote about the association between pain and mental illness, noting that mental illnesses and particularly depression could sometimes exaggerate and sometimes diminish painful experiences.

Alzheimer, a student and colleague of Kraepelin, described a case of pre-senile dementia, distinguishing it from the ‘melancholy and depression of old age’ by a ‘disinclination to remember facts and retain impressions’.

With Charcot’s example, medical hypnosis became fashionable among his followers, such as the young Sigmund Freud. At least hysterical conditions could sometimes be cured. While a lot was known about neurological diseases by the end of the 19^th century, not much could be done about them.

1.33. The Acute Abdomen

The availability of anesthetics made longer surgery than ever before possible. Until 1860 the terrible pain of appendicitis could be said to serve no useful function. That suddenly changed. Appendicitis, which begins with sharp pains in the upper abdomen, fevers and vomiting, due to a swelling of the appendix normally caused by a blockage, progresses untreated to peritonitis, a swelling and irritation of the inner lining of the abdominal cavity as it becomes filled with blood and pus after the appendix bursts. The peritoneum is one of the most densely innervated surfaces inside or outside the body, and is acutely sensitive to pain. An ‘acute abdomen’ was one of the most excruciating ways to die in the days before anesthetic surgery. Ectopic pregnancies where the fetus is embedded in a fallopian tube instead of the uterus were an equally common cause of the ‘acute abdomen’. When the tube burst the abdomen became filled with blood. Operations inside the abdominal cavity which would formerly have been fatal because of the risk of infection were made safe by the antiseptic methods newly invented by Joseph Lister. Lister read Pasteur’s account of germs and not only associated them correctly with hospital disease but also came up with a solution, which was to spray everything in the operating theater during before and after each surgery with carbolic acid. Carbolic acid had a foul odor and inhaling the spray caused rasping coughs in all those present but the adoption of his technique rapidly made hospitals safer and improved the reputations of the surgeons using it. Another method common at the time was washing everything with water and soap. According to Dormandy, this tradition developed independent from any understanding of germs, but like antisepsis it led to more successful surgical outcomes. Both techniques were soon supplanted by asepsis. In the days before anesthesia, when operations had to be timed in seconds before the patient went into shock, antisepsis would never have been possible. Surgery for the acute abdomen and appendicitis was so safe that the death rate approached 1 in 10,000 for a condition that was previously almost always fatal and extremely painful.

There followed a craze for abdominal surgery in a range of different conditions, from ‘chronic remunerative constipation’ as a friend jokingly described the condition that led Sir Arbuthnot Lane of Guy’s hospital to perform a thousand colectomies by his retirement in 1908, to ‘hitching up’ the ‘floating’ kidneys believed to cause lower back pain, and removing kinks in the bowel to ameliorate or even prevent digestive complaints. If visiting Lourdes could cure chronic pain in the faithful, how much more so undergoing major surgery, with the concomitant consciousness altering experience of general anesthesia.

1.34. Old Drugs, New Drugs

The mid to late 19^th Century saw an exponential expansion in the range of available analgesics. Besides the many opium-based and morphine-based preparations, cannabis enjoyed a revival following the 1842 publication of a research article by William O’Shaughnessy, who was ‘surgeon to Bengal’ as part of his work for the East India Company. He experimented with the effects of extracts made from the cannabis plant, a commonly used local drug, first on dogs, who started ‘staggering about in a positively blissful way’ and then on ‘numerous patients with rheumatism, tetanus, cholera and epilepsy’. He described it as an ‘anticonvulsant, sedative and analgesic remedy of the greatest value’, and noted it was exceptionally safe. After Queen Victoria was prescribed a tincture made from the extract for ‘women’s cramp’, it was listed in a number of British, European and American Pharmacopeias from the 1850’s until the 1920’s.

Thomas Lauder Brunton, a student of Ludwig’s at Leipzig, discovered in 1864 while he was working as a clerk at Edinburgh’s Royal Infirmary that the compound amyl nitrite could be used to relieve the pain of angina pectoris. Attacks of angina were experienced as severe pain in the upper arms or chest, accompanied by a sense of constriction and feelings of ‘impending dissolution’. Angina had long been thought of as a condition where the arteries of the heart are constricted, and Brunton noticed that attacks were often accompanied by a rise in blood pressure. Amyl nitrite was synthesized by the chemist Antoine-Jerome Balard in France in 1844, and he noted that it made him blush and eventually faint upon vigorous inhalation, effects he put down to an increase in peripheral circulation and a drop in blood pressure. After Brunton’s application of the drug in angina, it became immensely popular and was carried around by Victorian ladies in delicate glass pearls that could be crushed in a handkerchief. The British Prime minister, Mr. Gladstone, was noted to place a tablet under his tongue in the middle of a long speech. Amyl nitrite remains popular today. It relieves the pain of angina without curing the disease or necessarily prolonging life.

Another popular remedy of the 19^th Century was bromine and its compounds, bromides. Bromine too was first discovered by Balard. He hoped it might replace the expensive iodine in the treatment of goiter, and found instead that it relieved anxieties, facilitating sleep in those who lay in bed worrying. It had fewer side effects than the available opium derivatives, and was effective as an anticonvulsant in epilepsy, although it sometimes caused an unpleasant rash. Bromides remained in use until the introduction of the more effective but also more toxic barbiturates.

Chloral hydrate was introduced by the German physician Johann Liebreich in 1862 as an alternative to bromine. Its foul taste was thought to add moral uplift to the relief of pain, especially for children. Like opium, it was often addictive, and notable addicts were the artists Dante Gabriel Rosetti and Amadeo Modigliani, and the composer Claude Debussy. Chloral hydrate was marketed under a number of different names, as were some other chemically similar compounds.

Phenacetin was introduced in the 1880’s, in the form of ‘little blue pills’ which neither tasted nor smelled foul, and could relieve fevers as well as reducing the pain of headaches, toothaches and sore joints. It was the first drug made by businessmen rather than quacks, chemists or physicians. The primary goal of Phenacetin for its inventors in Germany was not to cure patients or relieve pain but to make money. It was expensive, but users such as the famous author Henry James swore it was ‘worth every penny’.

1.35. The Bark of the Willow

Phenacetin was rapidly superseded by another pain relieving remedy, which would become the best selling drug in history. Aspirin had its origins in an ancient remedy for fever, using the bark of the willow tree. In the 18^th Century there was an epidemic of ‘ague’ or malaria in Britain, and a vicar, the Reverend Edward Stone in Oxfordshire revived this ancient remedy as a substitute for the rare and expensive bark of the cinchona tree, which at the time could only be grown in South America. He published his findings in the Transactions of the Royal Society in 1763. A number of chemists in Europe then isolated the active compounds, salicin or salicylic acid, discovering in the 19^th Century that it was very similar to the active ingredient in the meadowsweet flower, Spiraea ulmaria, used for pains and rheumatism in Switzerland.

Bayer and Westcott established their chemical factory in the 1860’s, and were soon succeeded by a series of aspiring young chemists. Carl Duisberg headed the pharmaceutical division after the success of his drug phenacetin, which was manufacture from a waste product of the coal tar dye industry. Another such waste product, acetaniline, had been marketed successfully by two Strasburg doctors as ‘Antifebrin’ which gave Duisberg the idea of testing para-nitrophenol (‘phenacetin’) as an anti-pyretic. Felix Hoffman, working with Arthur Eichengrün and Heinrich Dreser at Bayer’s, successfully acetylated salicylic acid in 1897. The name Aspirin, after Spirea for meadowsweet, was coined by Eichengrün, who was later written out of Bayer’s history although he survived a period in a Nazi concentration camp.

In fact, salicylic acid had been acetylated previously by two chemists, Charles Gerhard in Montpellier and Herman Kolbe in Marburg. Both died in the 1870’s. A student, Freidrich von Heyden, established a small factory to try and exploit their process, but it failed because the product lacked medical credibility. In the intervening period, a paper was published by Thomas Maclagen in the Lancet demonstrating the effects of salicin rheumatic fever, a terrible and usually fatal illness afflicting many children around that time, which caused severe joint pain and swelling as well as a high fever, followed by congestion and heart disease. Salicin in large doses relieved the pains of ‘acute rheumatism’ but caused complications such as gastric irritation and bleeding. Maclagen’s exacting study received a supportive reaction from readers who were already experimenting with salicin and salicylic acid. By the 1890’s, the reinvented Aspirin, with reduced side effects, already had an eagerly awaiting market.

One complication in the marketing of Aspirin was that Duisberg and Dreser, the senior chemists at Bayer’s, were more interested in promoting diacetylmorphine, which had been synthesized in 1874 by a British chemist, C.R. Alder Wright. They rebranded the compound ‘heroin’ after the heroic effects it had on some factory workers who tried it. The plan was to market it as an alternative to codeine in the treatment of coughs because it was more effective and less toxic. They also estimated that as a pain killer it was more potent and less habit forming than morphine. Hoffmann and Eichengrün went ahead with their promotion of Aspirin in clinical trials by the rich and famous, and eventually heroin was dropped after some of the subjects started developing severe cravings for the drug.

1.36. Cocaine

Cocaine was another wonder-drug of the late 1800’s. Coca leaves were widely used in Peru when it was first explored by Europeans in the 16^th century, and the conquerors continued to exploit it as a cheap alternative to food or money in paying the native workers. Hasskarl and Markham, exploring South America in search of cinchona, tried to interest Europe in this new stimulant ‘more effective than coffee’ as did Don Antonio Julian, a Jesuit priest, in 1695 and Abraham Cowly, a British physician and poet, in 1662. Interest in Europe started in the mid 19^th century with the publication of a book extolling the effects of coca by an Italian doctor, Paolo Montegazza, on his return from Peru. Albert Niemann isolated cocaine around this time, and by the 1870’s a stream of articles began to appear in the Lancet and the British Medical Journal praising the action of the leaves on fatigue, depression, hunger, and even shyness.

Freud was among the many young doctors in Vienna of the 1880’s to experiment with cocaine, using it to wean his friend Von Fleischl-Marxow off morphine, although he later died of his cocaine addiction. It was Freud’s colleague Carl Koller who first noted the numbing effect of cocaine on the tongue, and decided to explore this further. He found that cocaine could be used as a local anesthetic in eye-surgery, numbing the sensitive cornea of the eye for periods of up to 20 minutes. Koller had to leave Vienna in a hurry after he injured a rival in a duel, eventually becoming a noted ophthalmologist in New York. William Steward Halstead, another New York doctor, began to experiment with injecting cocaine, and found that when injected along a sensory nerve it numbed the peripheral course of that nerve and all its fibers. He and his colleagues soon became addicted. Some died. Halstead himself became a successful surgeon, substituting a morphine habit for the injections of cocaine, the reverse of Freud’s friend Von-Fleischl Marxow.

James Leonard Corning, a New York surgeon, first injected cocaine into the spine of a patient suffering from ‘spinal weakness, seminal incontinence and masturbation addiction’. He was surprised to find that the patient’s legs ‘went sleepy and remained that way for an hour’. A German surgeon, August Bier, performed the first painless amputation using local anesthesia in 1898. Stovaine was the first non-toxic substitute for cocaine, synthesized by a French chemist, Ernest Forneau, in 1901. This was soon followed by procaine, better known as ‘Novocain’, created by Alfred Einhorn two years later and the most widely used local and spinal anesthetic for half a century. In 1940, William Thomas Lemmon discovered a new method for inserting a soft needle into the subarachnoid space of the spine so that the anesthetic could be topped up during operations, a method that became known as the epidural.

Coca and cocaine remained popular until the turn of the 20^th century. Coca-Cola was marketed in ‘dry’ states as ‘the supreme remedy for all ailments’. Alfred Conan Doyle’s Sherlock Holmes reflects the changing tide of concern about addiction when by the 1890’s he refers to the syringe as ‘an instrument of evil’ and Watson mutters darkly about the ‘drug craze’. In the United States, public anxiety about ‘the black coke fiend’ intent on raping white women, and impervious to ‘ordinary shootin’ (Everybody’s Magazine, 1902) added impetus to the new segregation laws. Cocaine addiction among the poorer classes began to cause concern in Europe when soldiers became unruly during World War I. Laws were introduced to ‘stamp out the use of cocaine world-wide’ but global cocaine production nevertheless rose from 10 tons in 1918 to over 1000 tons in 2005.

1.37. High Victorian Pain

During the nineteenth century, accounts of pain enjoyed a brief period of popularity and this was when, according to Dormandy, the modern construct of illness emerged. Before that, private suffering and anguish clearly existed, but they were of little social or cultural significance. Death among the aristocracy was tragic if it interfered with the continuation of the lineage, and otherwise insignificant. For the masses, what mattered was survival. The horrendous suffering from the plagues that regularly swept across Europe was like the suffering of a natural disaster or a war. It was only in the eighteenth century, with the rise and expansion of the middle classes, that individual destiny became a matter of public attention and concern. Dormandy contrasts two portraits of young women dying of tuberculosis, Ingres’ Princesse de Broglie gracefully expiring on her bed of luxury after having provided two heirs to the dukedom, and Edvard Munch’s haunting depiction of his much-loved sister The Sick Child visibly suffering from the pains of her illness and the shattering loss of all her hopes and dreams.

A large part of the chapter is devoted to the life and illnesses of Mary Ward, a famous Victorian writer and philanthropist, granddaughter of Thomas Arnold (the reformer of Rugby school) and aunt of the famous Julian and Aldous Huxley. In her heyday, Mrs. Ward was the most successful female author in England, playing host to Mr. Gladstone, Henry James, Oscar Wilde and others, and feted by Theodore Roosevelt on her book tour to the United States. She was a committed anti-suffragette, founded the first children’s day center in England, and was active in her support of disabled children, lobbying for their provision in the first Education Bill in 1917. At the same time, she was sickly all her life, from her school days spent mostly in Miss Emily Davies’ sanatorium, where she was rewarded for several hours of suffering by a medicine for girls, probably based on laudanum, that made the young Mary ‘dopey but happy’. She spent hours dreaming of stories in which she was the heroine. She had suffered from constant colds and coughs since her childhood in Tasmania, and was actually sent to boarding school in England in the hope this would improve her health. Her toothaches were so bad that she would try dunking her head in a bucket of icy cold water, she suffered from facial neuralgia, and by age 55 had lost all her teeth. She started having ‘terrible rheumatic ailments’ in her hands and back when she was in her twenties, and as a result some of her novels were actually written with her left hand. Her father (brother of the poet Matthew Arnold), her sister Julia Huxley and her daughter Dorothy, who became her constant companion, were all similarly afflicted. In her forties, she developed piles and severe abdominal pain which was eventually diagnosed as gallstones, and an intermittent affliction which she called her ‘sides’, an ‘obscure but vicious neuralgia in the right breast and side’. These might also have been due to the gallstones, but she was considered too frail to benefit from the surgical removal of the gallbladder.

Naming one’s pain was a favorite Victorian and Edwardian pastime. Nietzsche famously called his tabetic crises ‘mein Hund’, Churchill referred to the ‘black dog’ of his depressions, and Austro-Hungarain Queen-Empress Elizabeth called her migraines ‘visits from Torquemada’.

Mary Ward developed a brief infatuation with cocaine, which she took in the form of lozenges that had ‘the most wonderful effect’ when she visited Paris to give literary speeches. By 1900 she stopped using it, and became a vocal advocate of its ‘scheduling’. Instead she began to take large quantities of quinine and started to inject herself with morphine, which worried her having seen the effects of addiction on her brother who suffered from tabes. Following William James’ recommendation, she tried phenacetin, and appreciated the benefits of Aspirin when it became available. She was accompanied by doctors all her life, and attempted various diets and exercise regimens, herbal remedies and ‘electric vibrations’. One thing she found helpful was ‘gentle stroking’ at first by a Swedish professional and later by her daughter Dorothy. She eventually died of ‘pulmonary disease’ age seventy-one, having suffered from a ‘weak heart’ all her life, a condition that ran in the family.

Dormandy contrasts this heroic tale of personal illness and suffering by a member of the upper-middle class with a case-report in the Lancet about a young working-class girl with hysteria by Edward Kershaw, a general practitioner and doctor to a workhouse hospital in Barnsley. Dr. Kershaw describes his patient as a 12-year old girl with a ‘pinched hungry face’ who first presented with gastrointestinal distress, which he attributed to a poor diet. She had recently nursed her brother through scarlet fever, and was responsible for most of the housework. He prescribed mild purgatives and opium, which had helped her in the past. Some weeks later, he was called back to the house, because she was in ‘fits’. He arrived to find her screaming and kicking, her back arched in an imitation of tetanus (a deadly bacterial infection of the motor nerves in the spinal cord from contaminated wounds that causes the whole body to arch in a painful spasm) or tetany (spasms of the hands and feet due to calcium imbalance, most commonly caused by Vitamin D depletion in rickets and prevalent among malnourished children). A small injection of morphine had no effect. After visiting the house several times, Dr. Kershaw suspected hysteria, and sent his patient a placebo of burnt sugar with water, to which she responded well. On his final visit, he talked in her hearing about bringing her to the workhouse if the attacks continued. He did not hear from the family again.

By around 1890, pain and illness were falling out of fashion. Kershaw’s view of hysteria as a kind of malingering differs notably from Charcot’s sympathetic treatment of hysterics in the 1870’s, and his insistence on the reality of their pain. The new attitude to pain is expressed by Lord Henry in Oscar Wilde’s 1891 novel The Picture of Dorian Gray: ‘there is something terribly morbid in the modern sympathy with pain … The Nineteenth Century has gone bankrupt through an overexpenditure of sympathy’.

1.38. The Power of Pain Control

Now that effective drugs for relieving pain were on the market, there was public concern and debate about how they should best be managed. Regulatory bodies sprang up in Britain, Europe, Russia and the United States. Concern over the power to abuse patients by taking control of their pain was expressed in fiction in George du Maurier’s bestselling 1894 novel Trilby, and in history with the rise of Rasputin, the famous hypnotist and faith healer installed to care for Prince Alexis, the hemophiliac heir to the Russian throne later murdered by Bolsheviks with the rest of his family. Lister was one of the few who thought that the new drugs should be made available to everybody or banned, and not ‘doled out at the whim of doctors’. After the Pharmacy Act of 1868 in Britain, opium and morphine remained available to consumers, and opium-based patent medications could be bought over the counter until the 1920’s. Eventually the medical profession gained control over the legal provision of all powerful painkillers, although they continued to be available on the black market through rising organized crime.

1.39. Seminal Years

The decades immediately before and after the turn of the 20^th century were also a time of new discoveries in the emerging field of neurophysiology. Separate from and parallel to the development of new drugs, the structure and function of the nervous system was being unraveled and together with it some understanding of the bodily mechanisms of pain began to emerge.

The Czech physiologist Jan Purkinje was the first to investigate brain cells under the microscope and describe them. He died in 1869. But it was only with the introduction of a silver nitrate stain by Camillo Golgi in the 1870’s that their internal structure and extensive, stellating outgrowth of multiple thin processes were revealed. Golgi thought that the brain was an interconnected lattice or network of such fibers. It was his contemporary and competitor, Santiago Ramón y Cajal, who showed using Golgi’s staining method that in fact the cells were physically disjoint, although the gaps between them were too small to be seen before the invention of the electron microscope. He further investigated the structure of the brain cells and identified and named the incoming dendron (Greek for tree), its branching dendrites, and the outgoing axon.

The brain typically contains about a trillion of these neurons, with the cell bodies located in the grey matter of the cortex and in a few small subcortical nuclei, and the fibers extending into the white matter, coated with electrically insulating myelin sheaths composed of Schwann cells. In between there are even more numerous glial cells (named after the Greek word for glue) that support and nourish the neurons. Axons from the motor neurons descend the spinal cord in bundles or tracts, and axons from gray matter in the spinal cord ascend to the brain. Around the turn of the 20^th century, the German physiologist Max Von Frey described in detail microscopic ‘pain receptors’ in the skin thought to connect with the dendrites of these spinal sensory neurons. They featured in the illustrations of medical textbooks until the 1950’s, when they were finally discredited. In fact, open-ended nerve fibers are the receptors for pain.

Charles Scott Sherrington investigated the functions of the nervous system, whose structure had been laid out by Golgi and Cajal. He showed that all voluntary and involuntary movement depends on the synchronous activation of opposing muscle pairs at the joints. Such cooperative movements also govern posture and muscle tone, as well as the peristaltic waves of the gut and sphincters, controlled mostly through spinal reflexes which are ultimately under the influence of subcortical basal nuclei and also the cerebral cortex. Sherrington named the gap between neurons a synapse and coined the adjective synaptic, from the Greek word for clasping, following the suggestion of a friendly Classics scholar. His classic textbook The Integrative Action of the Nervous System was published in 1906.

In Russia, Pavlov experimented with dogs and showed that their reflex secretions of saliva and gastric fluids were easily conditioned by environmental stimuli such as a bell ring, with which they had become associated. He presented his results in 1903, and they became the basis for the subsequent materialistic understanding of all psychological processes governing behavior in humans and other animals. He was awarded the Nobel Prize in 1904, whereas Golgi and Cajal had to wait until 1906.

Ernest Starling coined the word ‘hormones’ to describe a class of compounds secreted in different parts of the body, and in 1904 T. R. Elliott suggested that some nerve fibers communicate by means of small amounts of the hormone adrenaline (epinephrine). Henry Dale and Otto Loewi, working in Starling’s Department of Physiology in London, discovered (respectively) acetylcholine and norepinephrine (noradrenalin), the first two neurotransmitters. Acetylcholine acts mainly on the parasympathetic nervous system, whereas norepinephrine acts on the sympathetic branch of the autonomic nervous system. This led the way to the discovery of more neurotransmitters in the brain, including dopamine, serotonin and in the 1960’s and 70’s several amino-acids and peptides, such as GABA (gamma-aminobutyric acid). The action of norepinephrine in the brain increases wakefulness and reduces sensitivity to pain, like stimulants such as cocaine and amphetamines, and the related neurotransmitter dopamine. The secretion of serotonin also modulates sleep and pain, and plays a crucial role in the action of new mood and anxiety controlling drugs that impact chronic pain. Neurotransmitters, according to Dormandy, complicate the picture of the brain acting like a giant computer with switches, because their actions are graded and their presence influences targets beyond the synapse into which they are released.

Jules Déjérine and Gustave Roussy described in 1906 a syndrome of hypersensitivity to pain caused by lesions in the thalamus. They suggested that the thalamus functions as a primitive brain. Henry Head and Gordon Holmes refined this theory in 1911, noting that not only responses to pain but all emotional reactions were affected by thalamic lesions. They suggested a role for the thalamus in the evocation of pleasure and pain.

Head classified the sensations as ‘visceral’ (from the internal organs), ‘protopathic’ (dominant and crude) and ‘epicritical’ (fine and discriminatory). He demonstrated by cutting and sewing back together his own radial nerve that painful ‘protopathic’ sensations were regained first, followed slowly (if at all) by fine ‘epicritical’ sensations.

Walter Canon in Harvard showed how pain, hunger and fear could trigger ‘drastic alterations in body economy, adapted to the individual’s welfare or even survival’. ‘Alarm’ triggered changes in blood flow and endocrine systems. This response was labeled by MacDougal in 1908 a ‘fight or flight reaction’, and became the basis of the phenomenon known as stress.

1.40. The Gift of Saint Barbara

Johann Adolf von Baeyer first synthesized ‘barbituric acid’ from urea and malonic acid in 1863, naming it after the feast day of Saint Barbara on which it was discovered. There was little interest in the compound until two of his students Emil Fischer and Josef von Mering tested a derivative, ‘barbital’, among a list of potential pain-killing drugs in 1900. The results on rabbits were promising, and they offered it to Merck & Co., with Fischer suggesting the more attractive brand name ‘Veronal’. Over the next half a century, dozens of new barbiturates, all chemically related, were successfully introduced and marketed, varying in their solubility and duration of action. Sodium amytal was the first to be used as an intravenous anesthetic in 1929, and beginning in 1934 thiopentone or pentothal became the most common form of surgical anesthesia, in spite of a disastrous experiment in the aftermath of Pearl Harbor where it caused the death from bleeding and anoxia of 30 wounded soldiers because oxygen was not available. Phenobarbitone was so effective in controlling epilepsy that convulsions became a rarity, and most children growing up in the 1950’s or later had never seen a fit. But by far the commonest use of barbiturates was the ever-increasing market for the many various colored pills because, like Avicenna’s pre-requisites for an effective potion, they not only killed pain but also calmed the mind and induced restful sleep.

Dormandy believes that emotional and physical pain are indistinguishable, and uses the success of drugs such as barbiturates to argue for his viewpoint in this matter. He acknowledges that this is an issue people feel strongly about, with some such as the famous philosopher Karl Popper siding like him with ‘monism’ and others firm ‘dualists’ in regard to the distinction between mental (or emotional) and physical pain. Dormandy’s argument seems frail to me. Antidepressant drugs like Elavil are used against dyspepsia, simply because there are as many or more receptors for serotonin in the gut as there are in the brain. One would not therefore infer that dyspepsia is indistinguishable from depression, or indeed that they even share the same mechanisms. My view is that emotional pain is metaphorically related to physical pain. We use our experiences of physical pain to understand and perhaps even to experience emotional pain, but the two experiences are phenomenally distinct most of the time, like the difference between seeing a real scene and seeing what we know to be a picture or image. This is discussed further in Chapter 2.

Amphetamines were introduced in the 1930’s, originally marketed as over the counter decongestants. Their stimulant properties quickly became evident, and they were lavishly doled out by both sides during the Spanish Civil War and soon after World War II. A headline in the 1941 Evening News read ‘Methedrine wins the Battle of London’. When Japan surrendered in 1945, an estimated 100 billion tablets disappeared from military warehouses, flooding the streets of Tokyo and then the United States. Adverts for Dextroamphetamine read ‘Shrug off your discomforts! Shrug off your exhaustion! Shrug off your pain!’ The risk to athletes became evident in the 1950’s with the death of a cyclist training for the Tour de France and the sickness of 10 others. Amphetamines were blamed for 100,000 suicides as well as half the murders in California.

Starting in the late 1930’s, synthetic opiates were synthesized. First Meperidine, better known as Pethidine or Dolantin, was sold over the counter in the United States for five years as a non-addictive analgesic. After reclassification it continued to be popular. Methadone was discovered in Germany in 1942 and named Dolofin by Hitler. It was tried on inmates at Dachau concentration camp deemed ‘unpredictable’ but quickly found its way to the black market. By 1960 seventy similar compounds, many more potent than heroin, had been marketed for some years as ‘unrelated to opium and therefore non-addictive’. The most harmful was perhaps thalidomide, advertised in 1957 as particularly suited to pregnant women, causing horrific birth defects in thousands of babies born around the world but not in the United States. Its licensing was blocked by a careful FDA employee who was sacked and then acclaimed a year later as ‘Woman of the Year’.

Albert Hofman first synthesized diethylamide of lysergic acid, known as LSD, from a common mould fungus in 1943. After the war, Sandoz marketed it as Delsyd, distributing thousands of samples as free gifts to psychiatrists and psychotherapists around the world ‘to provoke liberation of repressed psychic material in the patient, to provide mental relaxation … and to induce short-term experimental psychosis in normal subjects’. The Chemicals Division of the CIA experimented with it from 1956-1960, concluding in the end it had no military potential and only produced ‘a joyous disturbance of the ego function’. Aldous Huxley, a famous proponent of the drug, thought that it would bring world peace and used it as terminal therapy when he was dying of cancer in 1967.

Barbiturates remained the market leaders in mind-altering and pain-relieving substances until the late 1960’s. Suicides and accidental overdose were common risks, but attempts at legal restriction were fiercely opposed by the pharmaceutical industry. In 1971 the US Controlled Substances Act divided barbiturates, narcotics and analgesics according to their potential for abuse and habit-formation, listing the longer-acting drugs as more dangerous. In Britain, a government advertising and education campaign in the early 1970’s may have been successful in reducing hospital admissions due to overdose, although more likely this was because by then safer similar drugs were available.

1.41. Tic Douloureux

Tic Douloureux is a particularly painful and rare type of neuralgia. The term neuralgia has been used since the early 19^th century to refer to a pain which is caused by damage to the sensory system responsible for the sensation of pain. This type of pain is often particularly severe and difficult to treat. Tic Douloureux is caused by damage to the trigeminal nuclei, and specifically the 5^th cranial nerve. The nerves serving the head and face pass through these nuclei instead of the spine. The term ‘tic doulourex’ was coined by the French surgeon Nicolas André, who described it in 1757 as ‘an atrocious pain accompanied by hideous grimaces which create an irremovable obstacle to the intake of food, which prevent sleep and which inhibit speech’. The condition was described in detail by a Yorkshire physician, Samuel Fothergill.

The pain comes on suddenly and is excruciating. Each pain lasts for a short time, perhaps a quarter or half a minute, but then returns at irregular intervals, the whole attack lasting for quarter or even half an hour. There may be two, three or more repetitions during a day … The attacks are more frequent during the day than in the night, probably from there being fewer triggers of irritation; and they are more frequent during conversation than silence; and still more frequent at times of mastication… Talking or the least motion of the muscles of the face affects others. The gentlest touch of the hand or a handkerchief will sometimes bring it on while strong pressure may have no effect… There is no known way of terminating the attack.

Patients have described the experience as ‘fireworks exploding inside my face’. Some take their own lives. Because of the severity of this condition and its non-responsiveness to pain relieving medications, it became one of the first targets for neurosurgery. Initial attempts, sectioning the nerves as they emerge from the skull, were unsuccessful – even if an attempt was made to divide sensory from motor nerves. James Syme of Edinburgh wrote in 1858 that ‘the profession now being fully convinced of the inefficacy of dividing nerves for tic douloureux have abandoned all such attempts…’ However, many continued to attempt surgery. The first success was by Victor Horsley in London, who developed in the 1890’s a procedure to cut open the skull and temporary lift the temporal lobe of the brain in order to cut the nerve as it emerges from the ganglion. The first patient died of shock, but two survived. Fedor Krause in Germany and Harvey Cushing in the United States further developed this method. In 1902 Pitres injected alcohol into the Gasserian ganglion, and later glycerol was used. This resulted in temporary relief. More recent innovations allow intersecting irradiation to be focused on the ganglion to partially destroy it. Although rare, trigeminal neuralgia led the way to neurosurgery for pain relief as well as providing crucial information on the neurophysiology of pain.

1.42. Twilight Sleep

For a brief period, between 1906 and World War I, ‘painless childbirth’ became all the rage. This was achieved by the administration of a cocktail of morphine and scopolamine in small amounts, carefully titrated by the obstetrician to eliminate memory without causing loss of consciousness. Scopolamine is a poison that has been known since ancient times. The method had been tried before, but after the publication in 1906 of a study from two doctors in Freiburg, Carl Gauss and Bernhardt Krönig, on 500 cases, with famous mothers testifying that they woke with a baby lying beside them, society women flocked from the United States to the clinic in Freiburg. A movement the National Twilight Sleep Association sprang up, cutting across the United States and all social classes, bemoaning doctors’ reluctance to administer the procedure here in all cases. Eventually, the movement lost ground with the accidental death in childbirth of one of the advocates, and the start of World War I which impeded travel to Freiburg. The procedure, while probably safe, had a tendency to prolong labor from an average of 1-2 hours to over 6 hours, and had to be administered by carefully trained staff in a secluded environment. It did not actually reduce pain, it simply erased the memory of it.

1.43. Dolorism

Dolorism was a bizarre philosophical movement that emerged between the two World Wars and like the flagellant movement of the middle ages advocated physical suffering instead of the alternative. The term was coined in a 1919 review of Georges Duhamel’s war novel La Possession du Monde, and gained popularity after Julien Teppe published his Apologie pour l’anormal or Manifest du dolorism in 1937. The manifesto claimed that creative power and identity itself were all inspired by physical pain, supporting this idea with quotations from Ecclesiastes to Rimbaud. It heralded the publication of the Revue doloriste, a periodical whose contributors numbered Gide, Valéry, Benda, Colette… all the famous French poets and writers of the age. More on these ideas will be discussed in Chapter 2.

Dormandy rejects outright the ‘dolorist creed’. He claims that three arguments exist in favor of physical pain: 1) Pain is a precondition of life, a ‘warning bell’ that we cannot do without. 2) Pain relieved is intensely gratifying. This he names the ‘lost penny found’ argument. 3) Pain ennobles the sufferer.

Evidence for the first argument comes from the finding that those who suffer from a lack of pain sensation, as in congenital analgesia, secondary syphilis, leprosy or neuropathy, become injured as a result of their insensitivity to pain. However, while an animal with a broken bone will rest the injured limb and let it heal, the pain of a burst appendix was useless until modern anesthetic surgery. Additionally, many pathological conditions that might be treatable, such as certain cancers, go undiagnosed until it is too late because they often cause little or no pain. So pain as a ‘warning bell’ is very ineffective. While it results in some hits, these are probably far outnumbered by misses and false alarms.

Milton called pain ‘the worst of evils’ and Dormandy acknowledges the possibility of a mixed blessing but generally believes that the ‘lost penny found’ argument for pain is irrational, while acknowledging that this response is biologically ingrained.

Many writers have extolled the ennobling virtues of pain. C. S. Lewis quotes a doctor saying that ‘Pain provides an opportunity for heroism’. Hemingway wrote to Scott Fitzgerald that ‘You have to hurt like hell before you can write seriously’. While Dormandy acknowledges the inspiration many artists have found in the painful coughs and low grade fevers of tuberculosis, for example, he points out that ‘no great poem has been written by a poet in the grips of renal colic’. Dormandy attributes the social advantages of pain more to the opportunities for compassion and love, rather than for heroism. He points out that ‘It is suffering which makes people sufferable’ and it is shared suffering which can establish the closest bond between two unrelated individuals not actually in love’.

My own view is rather more pragmatic. Pain is a given, and rather than fantasize about what life might be like without it, we can examine instead how it functions. In my view, physical pain serves to bind us to our identities in our bodies, in a way that other sensations and feelings do not. This doesn’t mean that it has to be sought out because pain, while unpleasant, is usually unavoidable.

Dormandy goes on to discuss how some people seem to be more prone to pain than others, just as some are accident prone and trip over rugs or burn their hands on kettles. He notes that people prone to physical pain frequently blame their pain on other people around them. In the extreme, some people suffer hypochondria or conversion disorder, the modern term for what used to be known as hysteria. Dormandy draws a clear distinction between these two conditions. Hypochondriacs are, as Thornton Wilder put ‘people who listen to their body as if it were a Stradivarius’. They are easy to diagnose but impossible to treat, stuck in their obsessions. People with conversion disorder, by contrast, convert their emotional pain into real and sometimes serious physical symptoms, such as blindness, backache and paralysis, which they often suffer in silence with the calm resignation called by Charcot la belle indifference. They are hard to diagnose without ruling out many possible real physical illnesses. Dormandy recommends a 1944 article by I. Douglas-Wilson in making this diagnosis, and claims that conversion disorders respond well to care, compassion and psychotherapy.

1.44. Renoir

Dormandy is at his most passionate while writing about the life of the artist Auguste Renoir. Renoir suffered from crippling rheumatoid arthritis from the early years of his success and marriage with Aline Charigot, when he was in his 50’s. He sat in a wheelchair to paint, and brushes were strapped to his hands with gauze so as not to bruise the skin. The Bernheims, his wealthy American patrons, brought the world’s most expensive specialist Rudolf Schade from Vienna to care for Renoir, and after some weeks under his regime Renoir took his first steps in years from his wheelchair, but said that if he chose to walk he would have no energy to paint. Late in life, Renoir was persuaded by the sculptor Maillol to take up modeling in clay, with the aid of an assistant. In a conversation recorded by another artist, Renoir claimed: ‘Pressing into clay never hurt anyone. It makes the pain better, did you not know?’ Jean Renoir wrote a moving account of his father’s later years:

While my father is put in position the model takes her place on the flower-spangled grass. Somebody prepares his palette while he adjusts his stricken body to the hard seat. It is painful but it allows him to keep upright and a certain amount of movement. The piece of protective lint is folded into his palm and he points to a brush. ‘That one there… no, the other one’. It is given to him. Flies circle in a shaft of sunlight. ‘Ah, those flies,’ he exclaims in rage, ‘they can smell a corpse.. or not a corpse but a body in pain…’ But then they stop bothering him; and for a moment or two he seems somnolent, hypnotized by a butterfly or the distant sound of cicadas. ‘It is intoxicating.’ He slowly stretches out his arm and dips theh brush into turpentine. But the movement is terribly painful. He waits for a few seconds as if askin g’why not give up?’ ‘Is it worth it?’ But then a glance at the scene in front of him restores his courage. He traces on the canvas a mark of madder red that only he understands. ‘Jean please push that curtain aside a little more’. Then, in a stronger voice: ‘Ahe yes, it is divine.’ He smiles as he calls everybody to witness the conspiracy which has just been arranged between the grass, the olive trees, the sunlight, the model and himself. Another day of happiness has begun for him, a day as wonderful as the one which had preceded it and the one which will surely follow.

Dormandy claims that accounts such as this one demonstrate the effectiveness of life, joy and creativity in overcoming and relieving pain, rather than pain as an inspiration for courage, but to me these seem to be two sides of the same coin. Renoir shunned powerful painkillers such as morphine and opium, contenting himself with small doses of salicylates and his work. Rheumatoid arthritis was first described in the 19^th century and over the course of that century replaced gout as the common complaint of middle and old age. Osteoarthritis is an unrelated condition that causes similar symptoms, and was distinguished from rheumatoid arthritis in the 1880’s. The systemic complications of rheumatoid arthritis which are feared today might be the result of vigorous treatment with steroids and other powerful medications rather than the illness itself. In spite of his illness, Renoir fathered a happy family when he was in his 50’s and led an ascetic life well into his 80’s weighing less than 80 lb during his last years.

1.45. Pills and Poisons

Most patients are neither as courageous as Renoir in working to overcome pain, nor as timid about trying new treatments and medications. The infamous drug Vioxx used by millions to treat the pains of arthritis was developed on the basis of an emerging understanding of the actions of all non-steroidal anti-inflammatory drugs. It turns out that drugs such as aspirin typically act by suppressing the a particular enzyme, cycloxigenase 2 (COX-2) which normally promotes inflammation by converting arachidonic acid into a hormone, prostaglandin. The inflammatory reaction is the defense reaction of bodily tissues to injury. Prostaglandins cause vascular changes related to inflammation as well as stimulating neural impulses that are perceived as pain. Unfortunately, the side effect of this class of painkillers known as ‘non-steroidal anti-inflammatory drugs’ (NSAIDs) is to suppress the entire inflammatory reaction, not only the pain caused by this reaction. Thereby they can also impede the body’s ability to defend and repair damaged tissue. Vioxx was a new drug designed specifically to target COX-2. While it was hailed as a wonder in relieving intense arthritic pain, it also led to an increase in strokes and heart attacks, and was taken off the market when the developer Merck was held responsible for punitive damages against the victims.

Most NSAIDs were discovered or developed before their mode of action was understood. One of the first was acetaminophen, developed by Bayer in Germany after World War II from the earlier drug phenacetin. During the war, Bayer supplied the Nazis with the lethal gas used in the gas chambers to murder Jewish and other victims of the holocaust. Bayer was also a major financial supporter of the Nazi party from the early 1930’s, and one of the first companies in Germany to lay off Jewish employees, at the same time writing Eichengrün out of the history of aspirin’s development. Bayer’s production chief Fritz ter Meer was imprisoned as a result of the Nuremberg War Crimes Tribunal in 1944, but soon became the company’s new chairman after his release. Acetaminophen was discovered by scientists at Yale and New York as a metabolite of phenacetin and found by Bayer researchers in Germany to be itself an effective painkiller. This new drug was marketed in Europe as ‘Paracetamol’ or ‘Panadol’. In the United States, Bayer chose not to compete against their market leader aspirin, and acetaminophen was marketed by McNeil Laboratories in the form of syrup for children, distributed in toy fire engines, and later reconstituted into tablets branded Tylenol when this firm was bought by Johnson and Johnson. The precise mode of action of acetaminophen remains a mystery.

The drive to develop an alternative to aspirin came from the finding that the tablets were incompletely broken down during digestion, and fragments were found in some patients clinging to the stomach lining in little pools of blood. This led to anemia in habitual users. Harold Scruton, an industrial chemist in England, found that aspirin could be made more soluble by mixing it with chalk, a product marketed as Disprin from 1948. Aspirin variants were soon eclipsed by acetaminophen, until in the 1970’s it was discovered to inhibit a particular prostaglandin, thromboxane A2, which normally promotes the aggregation of blood platelets. In low doses, aspirin can inhibit coronary and cerebral thrombosis and is now to prevent these complications of heart disease.

While there are over 100 NSAIDs, some of them the same drug under different brand names, the third market leader ibuprofen is unrelated to aspirin or acetaminophen. It was developed by Boots the British pharmacy chain from a simple compound propionic acid and launched as Brufen in 1962. Particularly effective against the musculoskeletal aches and pains of rheumatoid arthritis, it was marketed in the United States as Advil or Motrin and found to be relatively free from unpleasant complications.

Alongside the development of popular painkillers came advances in surgical anesthesia. The ‘rag and bottle’ method of administering chloroform in John Snow’s day was replaced by gas cylinders and gages to measure and precisely administer the drugs. Edmund Andrews in Chicago showed that nitrous oxide mixed with oxygen instead of air provided safe anesthesia for lengthy procedures without the risk of anoxia. Friedrich Trandelenburg introduced the tracheotomy for blowing anesthetic gases directly into the lungs toward the end of the 19^th century, enabling him to perform complicated facial surgery. The invention of the laryngoscope at the start of the 20^th century enabled surgeons to pass a tube down through the larynx into the trachea. The South American poison curare found through trial and error a usage as a muscle relaxant during complicated abdominal surgery, although initial experiments led to respiratory paralysis.

1.46. The Surgery of Pain

The surgery of pain was promoted by the French vascular surgeon René Leriche in his book La Chirurgie de la douleur published in 1937, and Dormandy is a fan. It was Leriche who said ‘Let us reject this concept of ‘beneficial pain’ with all our might’, rallying in support of the new medical sciences: ‘Let it be right to cry out when a neuralgia or even the imaginary specters of madness seem unbearable. It is the doctor’s and nurse’s Hippocratic duty to help such people, not to preach heroism and self-control’.

Leriche was a popular surgeon, and he developed a procedure for removing the ganglia of the sympathetic nervous system to prevent the pains of angina and colic as well as resting pains in the lower limbs. It probably worked by blocking vasoconstriction and thereby improving the blood supply to the internal organs and affected limbs. Leriche believed that his procedure might interrupt pain fibers to the brain and also influence chemical activity. He questioned the idea of ‘referred pain’, believing that patients have direct access to sensations in their internal organs. Both these notions were subsequently disproved and yet people traveled from all over Europe for his operations.

The pain pathways of the body were mapped out through experiments with animals and postmortem analyses of cases where sensation and pain were lost in the lower limbs and abdomen as a result of disseminated tuberculosis. By 1911 the first ‘cordotomy’ was performed on a terminally ill cancer patient who was relieved of his pain, and in 1912 Beer performed a similar operation for ‘intolerable pain due to metastases in the nervous plexus in front of the lower spine’ enabling his patient to walk again some days later. Surgery became possible inside the skull (see 1.41) and in spite of the high mortality rate such operations provided relief from otherwise untreatable pain.

Frontal lobotomies enjoyed a spate of popularity in the treatment of chronic pain and phantom limb syndrome during the 1940’s, although it was unclear whether they cured the pain or simply made the patients impervious to it. The justification was that ‘dissociation between pain perception and reaction to pain can be induced not only by drugs and by strong religious beliefs but also by cerebral damage’ according to Wolff’s Harvey lecture in 1943. Because of distressing mental complications, the lobotomy was replaced by the more conservative topectomy or the unilateral lobotomy. Today neurosurgery tends to be less drastic and pain can sometimes be alleviated by selectively stimulating certain pathways as in deep brain stimulation, or implanting a pump for delivering opium based drugs directly into the spinal cord and ventricles of the brain.

1.47. The Schism

The real break in medicine came not with the invention of anesthetic surgery or the synthesis and promotion of new painkillers but instead with the discovery of antibiotics. Penicillin was discovered (or rediscovered) by Alexander Fleming in 1928, and its antibiotic properties were shown by Howard Florey and others at Oxford in 1939. It went into production during World War II, and changed the goal of doctors from caring for patients to curing diseases. Modern medical science was born. Antibiotics saved lives and killed perhaps forever the pains of hospital disease or puerperal fever, tuberculosis, syphilis, diphtheria, rheumatic fever and many other illnesses. People still caught the flu but few died of pneumonia afterwards, unlike the pandemic of 1919 that killed more people than World War I. In my own experience, I remember being taken back to hospital after the birth of my youngest child, suffering from the incomparable abdominal pain of puerperal fever which the nitrous oxide on the ambulance did nothing to still, and the relief after receiving an intravenous antibiotic. Antibiotics made diseases curable.

The second major advance in medication was the development of cortisone in 1949. Original promotional movies showed crippled and deformed patients barely able to take a step transformed into smiling people climbing stairs and swinging their arms. Steroids proved to have unpleasant and even dangerous complications, but they provided considerable relief from the pains of rheumatoid arthritis.

In 1949 Laborit noticed the calming effects of antihistamine sedatives, and by 1952 a French drug company started to develop chlorpromazine, a drug used to effectively control the emotional pain of schizophrenia. Patients could safely be released from mental institutions. The physical methods used to treat severe mental illness such as electric shock, insulin coma and lobotomy eventually became a thing of the past.

Reconstructive joint surgery for osteoarthritis was introduced with hip replacements in 1961. During the 1960’s and 1970’s kidney transplantation and coronary bypass operations became available, effectively curing previously chronic and painful illnesses such as angina.

These advances came at a cost. Patients who could not be cured became a problem to medical science. Pain was no longer interesting, to the degree that it was barely mentioned in medical textbooks. In all 620 pages of a British 1960’s textbook The Principles and Practice of Medicine for Student Doctors the only mention of pain was that for patients with advanced carcinoma ‘analgesics should be given to control pain but without leading to undue dependence or addiction.’ There was no discussion of how or why dependence and addiction should be avoided in such cases. Helen Neal, a health journalist working at the National Institutes of Health in Bethesda in the 1964, found nobody who could help her brother with the pains of throat cancer and chemotherapy. No one at the time in the whole of the NIH was conducting any research on pain. In 1979 she wrote a book on The Politics of Pain which came at a time that Pain Clinics were beginning to emerge. But the inattention to pain in conventional medicine had already caused a rift between doctors and patients, with patients being covertly or openly blamed for the failure of the latest drug cocktail and feeling or even being told ‘your pain is all in the mind’. Alternative medicine began to enjoy a vogue in the late 1950’s that has been increasing ever since. As Dormandy puts it: ‘Almost symbolically, in most ‘with-it’ hospitals the kindly ‘consultants in physical medicine’, expert in massage, hot and cold compresses, poultices, remedial exercises, mineral baths, mild electrical stimulation and a host of other excellent but old-fashioned remedies were being replaced by ‘rheumatologists’, often as toxic in their arrogance as they were in their up-to-date treatment.’

At least in part as a result of these advances in medicine, people began to live longer than ever before, and while some of the new treatments targeted the diseases of old age, aging and death remained as painful as they have always been. Within conventional medicine, the gap left by the schism began to be filled with the emergence of specialized multidisciplinary Pain Clinics and by the hospice movement and palliative care. New technologies in neuroscience facilitated the study of the biology of pain, with the hope that this might lead to better treatments.

1.48. Pain Mechanisms

The renewed interest in pain stemmed new definitions. The one adopted by the International Association for the Study of Pain was coined by a group of ‘concerned scientists and doctors’ headed by Harold Mersky at the University of Western Ontario in 1979:

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

Several comments are appended to this definition, including the following:

Many people report pain in the absence of tissue damage of any likely pathological cause. Usually this happens for psychological reasons. There is no way to distinguish their experience from that due to real tissue damage, if we take the subjective report. If they regard their experience as pain caused by tissue damage, it should be accepted as pain.

Activity induced by nociceptors and nociceptive pathways by noxious stimuli is not pain. Pain is always a psychological state, even though we may appreciate that it often has a proximate physical cause.

In other words, pain is a state of mind whose content is bodily damage. It can be stimulated by actual tissue damage or by the activation of particular sensory pathways specific to pain, but each of these three conditions (pain, tissue damage, and activation of neural pathways for pain) can also exist independently.

Sensory nerves in the skin and throughout the body have endings sensitive to changes in pressure, temperature, acidity, and certain chemicals. They are particularly sensitive to ‘free radicals’ a class of chemicals released by damaged tissue. When the nerve fiber is stimulated (either at the ending or by pressure somewhere along its course) a nerve impulse or burst of impulses travels toward the spinal cord. There are at least two kinds of fibers, fast A fibers where the speed of the impulse reaches up to 100 meters per second, and slow C fibers where it is only 0.25 meters per second. Impulses caused by tissue damage are called ‘nociceptive’. Dormandy complains that Descartes might have called these impulses dolorous but since he is out of fashion scientists are prone to ‘long-winded mystification’. A local anesthetic applied anywhere along the course of the nerve fiber prevents the impulse from reaching the spinal cord. The molecular mechanisms for this action of local anesthetics remain unclear.

Sensory impulses traveling toward the central nervous system (the brain and spinal cord) and the fibers carrying them are termed ‘afferent’, whereas the fibers and impulses carrying motor commands from the central nervous system are termed ‘efferent’. The cell bodies of the afferent sensory fibers are bunched in pea-size ganglia that form two vertical chains on either side and in front of the spinal cord. Short fibers from these cell bodies enter the spinal cord via the ‘anterior nerve roots’. The gray matter in the spinal cord is arranged in an X shaped cross section, with two anterior (pointing forward) horns and two posterior (pointing back) horns. In the anterior horns, the anterior nerve roots synapse with a second set of neurons that sends fibers to the subcortical nuclei of the brain and the sensory cortex. The ascending fibers form white matter tracts around the gray matter of the spinal cord.

P. D. Wall and Ronald Melzack showed in the 1960’s that pain messages reaching the spinal cord interact with synchronous impulses from other fibers and also with impulses descending from the brain, so that they do not necessarily travel further. They proposed the ‘Gate Control’ theory of pain.

It had long been known that tissue damage does not necessarily result in the sensation of pain. David Livingston wrote this 1859 description of being mauled by a lion, who before being shot and killed ‘besides crunching the bone into splinters… left eleven teeth wounds on my upper arm.’

The lion caught my shoulder as he sprang and we both came to the ground below together. Growling horribly close to my ear, he shook me as a terrier dog does a rat. The shock produced a stupor similar to that which seems to be felt by a mouse after the first shake of the cat. It was a sort of dreaminess in which there was no sense of pain nor feeling of terror, though quite conscious of all that was happening. It was like what patients partially under the influence of chloroform describe, who see all the operation but see not the knife. This singular condition was not a mental process… The peculiar state is probably induced in all animals killed by carnivore, and, if so, is a merciful provision by our benevolent Creator for lessening the pain of death.

Gate Control also helps explain the pain of phantom limbs and other conditions that cause ‘deafferentiation’, the loss of incoming sensory stimulation at the level of the anterior horn. Besides amputation, this can be caused by injury, for example a motor cycle accident tearing away the plexus of nerves in the armpit, by nerve damage due to a viral infection, for example post-herpetic conditions after infection with the herpes virus, or by metabolic abnormalities such as diabetes. The cell bodies that normally receive their input from the deafferentiated fibers can go into a frenzy of activity due to the lack of a context by which to interpret the residual incoming signals. The picture is like suddenly turning the lights off – every flicker looks like it might be an obstacle. Deafferentiation pains rarely respond to anelgesics, and surgery is usually futile. As Leriche said, ‘the pain always runs ahead of the knife’, because down the line there are always more nerves whose input is being cut. A new technique currently under clinical investigation is the transcutaneous electrical stimulation of peripheral nerves, to try and restore the context of spinal nerve activity. Perhaps this accounts for some of the effects of acupuncture, which might set up calming signals by acting along deafferentiated fibers.

Congenital analgesia, the condition of being born with the absence of pain sensations, is still a mystery. It suggests, perhaps, the existence of a specific enzyme or neurotransmitter concerned with the transmission of pain signals, whose mutation deprives the body of the sensations of pain.

Scientists were surprised to discover in the 1970’s receptor sites in the brain specific to molecules such as morphine and heroin. As one of them remarked, this was ‘like an intrepid explorer entering an unexplored cave in the middle of nowhere and finding a friendly cup of tea waiting for him inside’. In 1973 the first naturally occurring endorphin was identified by Candace Pert. Endorphins (or enkephalins) are chemicals whose action was mimicked by the plant-derived opiates. They are concerned with the modulation of the pain response in different parts of the central nervous system. It has been suggested that they are responsible for the exhilaration experienced by joggers and other athletes, and for the addictiveness of vigorous exercise. Natural endorphins are released in minute doses at specific receptor sites and then rapidly metabolized. Drugs act everywhere and are broken down slowly, causing permanent changes. Nonetheless Dormandy argues that as with joggers, the danger of addiction is greater for those who take opiates for their general well-being as opposed to the specific treatment of pain.

1.49. Pain Clinics

Pain clinics were introduced by John Bonica, a professor of anesthesia who opened the first pain clinic in Seattle with the nurse Dorothy Crowley and the neurosurgeon Lowell White. Bonica was born in Sicily and financed medical school by taking up exhibition wrestling under the name Johnny Bull, a career that left him with chronic joint aches that added personal authority to his pronouncements on pain. In his 1953 book The Management of Pain he wrote ‘I have declared war on pain’. Pain clinics opened the door to a multidisciplinary approach, in places like London’s teaching hospitals where ‘a consultant surgeon in a career spanning fifty years had probably never exchanged a word with a physiotherapist to whose care he regularly referred his patients, a social worker (who often had to cope with his failures as well as successes), a psychologist or a clinical biochemist, let alone members of the demi-monde like osteopaths, herbalist, reflexologists, acupuncturists or homeopaths. Professional relations between doctors and nurses were close but rigidly formalized in the mould set for all eternity by Florence Nightingale’ (Dormandy). At first such teams struggled to find a common language, doctors for example eschewing personal observations about patients and nurses describing them in such terms, but ultimately the sense of common purpose led to the success of several renowned pain clinics. While they sometimes became the sink for ‘difficult patients’, nobody is labeled as untreatable and these clinics have raised awareness of the growing problem of chronic pain.

1.50. Hospices

The modern hospice movement was started in the 1950’s by Cicely Saunders, a British nurse and later a doctor. After her nursing training at St Thomas’ hospital’s Florence Nightingale School of Nursing, she was struck by the needless suffering of those in the final stages of cancer and other illnesses. She went back and completed her medical training in 1957 age 39, and published two historic papers, ‘Dying of Cancer’ and ‘Care of the Dying’. Her study included 900 patients at St Joseph’s Hospice. She wrote:

Our study clearly shows that opiates are not addictive for patients with advanced cancer; that the regular giving of opiates does not cause a major problem of tolerance; that giving oral morphine works and that it does so not by causing indifference to pain but by relieving it. Set alongside the prevailing myths of tolerance and addiction, it is not surprising that a patient arriving at St Joseph’s should say: ‘The pain in the other hospital was so bad that if anyone came into the room, I would scream: “Don’t touch me! Don’t come near me!” [With] regular treatment with morphine balanced to her need… she became alert and cheerful… and maintained her composure until her death a few weeks later.

With the support of some of her patients and by raising money from the British government and the Churches, she founded the St Christopher’s Hospice near London in 1967. Palliative care became an up and coming area of research, instead of being shunned by doctors as symptomatic medicine. The modern hospice movement places an emphasis on a whole person approach, treating what Cicely Saunders called ‘total pain’. Terminally ill patients often suffer from anxiety and depression, and these can act as modulators of physical pain as well as sources of emotional pain. The hospice movement includes effective care not only for patients but also for their friends and families, and the staff caring for them.