“You really want to?” he said. “To canoe?”
I remembered how he had looked across the pond to the far shore, wrinkling his nose with disdain at the dark distance. But he had swum with me, and so everything began.
“Okay, Pioneer Girl.” He sighed.
We had been dating for several years, but it still felt as if we were nowhere. The relationship sometimes seemed as attenuated as Kurt complained my body was now, his concern laced with irritation. I dimly associated the feeling of nowhereness with the fact that we never did anything together—or nothing that seemed “real.” We went to movies and watched simulations of people’s lives. We went out to dinner and ate food other people had cooked. We talked, endlessly, about our hypothetical future: about whether to spend our lives together. But it never felt as if we were already together, as if the building of a life had begun. Whenever I left his house in Providence and took the train back to New York, I felt as if I was finally home. We had a thousand and one dates, but we never cooperated on a task or an errand or even went grocery shopping together. Now, perhaps, we could make a tent-home in the wilderness.
“If you say so,” he said.
The night before we left, I reminded him of the problem with my arm. “I told you about my arm,” I said carefully. “So I might not be able to paddle that much.”
“Why does this not surprise me?”
“Or at all.”
“Don’t worry,” he said curtly. “I’ll handle it.”
I sat in the front of the boat on the river, sunshine pouring around my big straw hat with a bow on the brim, while he maneuvered the boat. I beamed at him. I felt a happiness that was as light and dappled as the trembling green lace of the trees. The boat with Cynthia and her husband was just ahead. I could hear them laughing.
“You look pretty in your floppy hat,” Kurt said. “Like a heroine in a Venetian gondola in a Merchant-Ivory movie.” But he hated Merchant-Ivory movies—he refused to go to them with me. The boat drifted sideways as he paused. He struggled to right it against the current. Although he had let go for only a moment, it took several minutes to correct.
“It’s funny how hard it is to get on track once you lose your course,” he said. “Doesn’t that seem resonant?”
“Of my whole life,” I said. Until I met you, I wanted to add because I knew it would be a sweet thing to say. But I was silenced by the thought that perhaps being with him was the ultimate wrong turn and that, weakened as I was now, I might never be strong enough to set myself back on course. Anyone would want to be with him. His beautiful face and mind, his brilliance, his wit, his blue-gray eyes. The thought of his desirability confused me, as it had confused me for the length of the relationship. The longing I felt for him still ran as quick as it always had. Yet somehow, the force of the relationship pulled me away—away from health and strength and capableness and honesty. Here I was, now: almost crippled, a person who couldn’t paddle or even open a jar of jam some mornings—and then who pretended not to want jam. I was always anxious about presenting myself poorly—seeming pathetic or pitiful—and burdening or irritating him. So many things irritated him.
“You’ll set up a good, snug tent for us tonight, Pioneer Girl,” he said. He leaned on the paddle, his face flushed. The first drops of rain began to fall. “Promise me you’ll take care of it.”
“I’ll take care of it.”
It was raining steadily as I set up our tent in the last light. It had been difficult to carry the equipment up the bank to the highest ground. Kurt looked for firewood as I threaded the silvery rods through the pale green nylon. The tent puffed up, soft and fluffy as a mushroom. I was about to secure the tent when I dropped the stakes into the muddy grass. I unzipped the tent and sat inside to keep it from blowing away while I leaned out and searched. But without stakes to hold them taut, the metal rods bumped and twisted against one another, and then the cloth deflated and slowly, suffocatingly billowed down around me.
I lay on my back and laughed helplessly.
“Goddamn it,” Kurt said. “Our tent is wet.” He pushed the folds off my face. I squinted against the rain.
“So I’m a bad pioneer,” I said.
“That’s not good enough,” he snapped. “What if you were a pioneer? What are you going to contribute to society?”
“I’m a writer.”
“There are no writers. Everyone is struggling to survive.” He leaned in close. “What is your function? You can’t paddle, and you can’t build us a home to keep us dry. Everyone contributes to the community’s survival—or they die.”
He pinned my wrists on the fallen floor.
“You’re hurting me.” The weight of his body pressed into my shoulder, which felt as unstable as the tent poles.
“You’re starving. What is your function?”
“I don’t know.”
“What is your function?”
“I’m a prostitute.” Tears mixed with rain on my face.
He let my wrists go and knelt in the grass, looking for the missing stakes.
Sitting around the campfire later, I told the group the story of the leper I had seen in Addis Ababa.
“He was laughing,” I said. As I pictured him, he laughed at me again.
“Perhaps he wasn’t in pain,” suggested Cynthia’s husband, Jim, a physician.
“His hand was falling off.”
“Well, leprosy creates peripheral neuropathies. The bacteria eat away at the peripheral nerves, so the person becomes insensate. Without the protection of pain, limbs get damaged.”
The leper stopped laughing. To the extent that I thought of leprosy at all, it dimly stood in my mind as a biblical curse or an inexplicable horror. I had never thought to consider it as a disease and wonder about its mechanisms rather than its metaphors. The leper hadn’t transcended pain; he wasn’t in pain. I was in pain. When we returned to civilization, I decided, I would get an MRI and find out why.
III
THE SPELL OF SURGICAL SLEEP:
Pain as History
CONQUERING PAIN
At a particular juncture in the mid-nineteenth century, pain was transformed from the spiritual signifier it had always been to a merely biological phenomenon, in light of a single medical discovery. This particular discovery changed not only thinking about pain, but separated medicine itself from its ancient embrace of religion and situated it in the realm of science.
“WE HAVE CONQUERED PAIN,” announced The People’s Journal of London in 1847, with capital-lettered jubilance at the discovery that surgical anesthesia could be achieved through the inhalation of ether gas. “Oh, what delight for every feeling heart to find the new year ushered in with the announcement of this noble discovery of the power to still the sense of pain, and veil the eye and memory from all the horrors of an operation,” it waxed. In that giddy hour, it seemed that not merely surgical pain, but all pain would soon bow to human ingenuity.
The development of anesthesia, scholars have suggested, resulted from cultural changes in the late eighteenth and early nineteenth centuries that demanded pain’s abolition. The German romantic poet Heinrich Heine’s ironic comment about his experience of dental work seems to embody this change of attitude: “Psychic pain is easier to endure than physical, and if I had to choose between an evil conscience and an aching tooth, I would prefer the former,” he grumbled. “Ah! there is nothing so horrible as toothache.”
From ancient times, cultures had always entwined the spiritual and material realms, as in the myth of the Babylonian tooth worm. While primitive, Greco-Roman, karmically based, and Judeo-Christian views of pain differed in their interpretations, they all had in common the belief that pain required interpretation because physical pain was never simply physical, but was suffused with metaphysical meaning. For them to decouple the two, as Heine did—flippantly privileging a bad tooth over an evil conscience—would have made no sense, since toothache was believed to reflect moral decay. On this theory, solutions for the form
er would necessarily have to address the latter.
The astonishing efficacy of anesthesia, however, seemed to belie this. Science’s new ability to dispel the pain of saints and sinners alike disenchanted pain of its ancient meanings. Stolen from the province of the gods, pain was no longer poena, passion, or ordeal, but simply a biological function that could be controlled by men. Anesthesia, followed by Darwin’s theory of evolution, resituated man in the cosmos. Although religion itself did not die out, of course, secular scientific modes of thought became the culturally dominant ways of regarding the body.
Interest in synthetic chemistry and atmospheric gases in the late eighteenth century led to experimentation with ether, nitrous oxide, and chloroform. Coincidentally, it was observed that the inhalation of these gases induced giddiness and excitation, which were quickly followed by a brief yet extraordinarily deep sleep—a sleep from which the patient could not be roused.
Ordinarily, the sleep-arousal mechanism in the brain is highly responsive and can be activated by as little as a caress—not to mention the serious assault on bodily integrity of a surgeon’s knife. Only in the case of grave neurological injury does the brain shut down enough to disable this mechanism and leave the body vulnerable to assault. Inhalation anesthesia (the precursor to modern anesthesia) used ether, nitrous oxide, or chloroform to allow for the creation of a coma-at-will: a predictable faux coma, as it were, with none of coma’s ill effects.
It was an effect physicians had been trying to achieve for centuries, with desperate attempts such as “concussion anesthesia,” which involved knocking the patient out through a blow to the jaw or by placing his head in a leather helmet and hitting it with a wooden hammer! Occasionally, concussion anesthesia worked. But most of the time, patients only incurred a head injury without losing consciousness, or they lost consciousness and woke in the middle of the surgery—or never again. Interestingly, ether and nitrous oxide were well known and had been used recreationally (sometimes even in the treatment of disease) since the early nineteenth century—almost a half century before they were used in surgery. During that time, changes in cultural conditions that had begun in the eighteenth century accelerated in ways that rendered the horror of surgical pain increasingly intolerable.
Pain—whether inflicted by nature or man—has always been an ordinary part of life. Indeed, beholding the pain of others, in the form of surgeries or executions, was once rabble-rousing entertainment. “Out to Charing Cross to see Major-general Harrison, hanged, drawn and quartered,” the great literary raconteur Samuel Pepys recorded in his seventeenth-century diary of London life, adding wittily that the major general himself (who had the misfortune to side with Parliament in the English civil war) was “looking as cheerful as any man could do in that condition.” Afterward Pepys took friends “to the Sun Tavern, and did give them some oysters.” The prisoner himself was forced to be a spectator to his own dismemberment by being only partially asphyxiated during the hanging, so as to be conscious while being drawn and quartered (the details of which I will spare the reader).
Brutality began to recede from daily life during the late eighteenth and nineteenth centuries. The practice of capital punishment declined in England. Torturing convicts to death became less acceptable. In 1814, it was decreed that a prisoner should be hanged until dead before being drawn and quartered, but by 1870, even mutilating a corpse came to be seen as indecent, and the entire practice of drawing and quartering was prohibited. Women who murdered their husbands were no longer burned at the stake. Slavery was abolished in America and in the British colonies. Other humanitarian reforms addressed labor and the welfare of women and children.
The American and French revolutions ushered in a new preoccupation with individual rights. Along with the rights of man, there arrived a radical concept: the right to happiness. The novelty of this idea—a cornerstone of the modern ethos—is lost to us. Certainly, nowhere in the Bible does God enjoin man to pursue happiness; to the contrary, Adam and Eve are cursed to a life of thorns. Most other religions agree with the Buddha’s First Noble Truth that life is dukkha— suffering, grief, and pain (and not just any pain, but burning pain, from the Sanskrit root du, “to be burned or consumed by fire”). Acceptance of suffering is a central task of the faithful (a principle of great utility to governments!).
In the modern self created by the Romantic movement, however, identity ceased to derive from connection to God and community, but from individualism, according to which happiness was valued over self-sacrifice and self-transcendence. And happiness seemed increasingly possible as the Industrial Revolution spread prosperity, creating a large middle class for the first time in England and America. People began to expect alleviation from pain.
The Christian conception of the necessity of pain was undercut by the Darwinian (and later the Freudian) template of human nature as driven to seek pleasure and avoid pain. Far from divinely ordained, pain and suffering in Darwin’s theory were simply part of the process of evolution, contingent on environment and physiology. And Christianity itself was influenced by the intellectual currents of the day. Reflecting the humanistic tradition that saw man as essentially good, Victorian Christianity posited a more benevolent God than that of earlier ages, a loving father figure who would not inflict poena upon His children—at least not the obedient ones. Although good characters die in Victorian novels, they die painlessly—especially children (Charlotte Brontë’s Helen Burns, Harriet Beecher Stowe’s Eva St. Clare). Dickens extolled Little Nell’s corpse as “so free from trace of pain, so fair to look upon. She seemed . . . not one who had lived and suffered death,” as if death were an ordeal her virtue allowed her to painlessly pass.
Pharmacies helped relieve pain by providing a huge, cheap supply of unregulated opiate-alcohol concoctions, such as Mrs. Winslow’s Soothing Syrup, with which many Victorians kept themselves and their children continually dosed. Even so, opiates were insufficient (except in dangerous doses) to banish the agony of surgery.
With the vast migration to the cities, medicine began to industrialize. Physicians had been trusted community leaders with long, intimate knowledge of their patients and many means of healing, few of which were physiological. The new breed of doctor in the hospital or city clinic could only ask, “Where does it hurt?” and hope that a description of tissue damage would point to a deeper cause. It frequently failed to do so, of course. But developing an understanding of why—and of all the pain phenomena that defy such a model, such as the twin Victorian fads of mesmerism (pain relief through no apparent physiological mechanism) and hysteria (pain with no apparent physiological cause)—would take another century. Although the mechanisms of anesthesia were not understood (and curiously remain poorly understood even today), the simplicity of its effect made pain itself seem simple and—momentarily, thrillingly—conquerable.
THE CRAFT AND ITS TERRORS
Our craft has, once for all, been robbed of its terrors,” announced Dr. Henry Bigelow on October 16, 1846, as he rose, agape, from the audience at the first successful demonstration of surgical anesthesia using ether gas.
How terrible surgery had been, “ensanguined like a slaughter-yard, the air rent with the shrieks of the unhappy victims quivering under the knife,” as another surgeon later recalled. Surgeries were public spectacles, like executions, at which crowds gathered in operating theaters to watch a surgeon who—as the Scottish anatomist John Hunter described—resembled “an armed savage who attempts to get that by force which a civilized man would get by stratagem.”
No stratagems were possible as long as the body’s integrity was so well guarded by pain. The field of surgery had reached an impasse. Before anesthesia, the body’s surface remained opaque, with the glimpses afforded by the carving knife brief and blurry. Anesthesia allowed surgeons to carefully study the inside of a living body and meticulously fix its problems. Surgeons knew how to perform delicate operations, such as removing stomachs or lungs, on the corpses of humans and animals. But
the difference—as a surgeon at the time put it—between “moving, bleeding flesh and a passive carcass” meant that they could not perform such operations while patients screamed and thrashed about. Although patients were frequently blindfolded and gagged—and although some medical textbooks typically included recommendations for the number of able-bodied assistants required to restrain patients (four, in most cases)—it was impossible to fully immobilize a conscious person.
Speed was the crucial factor in a surgeon’s skill; the Napoleonic surgeon Langeback bragged that he could “amputate a shoulder in the time it took to take a pinch of snuff.” Tellingly, surgeons originally belonged to the guild of barbers (in England, the Company of Barber-Surgeons), as if snipping locks and limbs entailed a single skill. Botched operations were the rule: in 1834 a surgeon generated controversy when he was quoted saying candidly that before a man could successfully perform cataract surgeries, he must first “spoil a hatful of eyes.” But it was true. About a third of patients died from such surgeries.
The invention of anesthesia (along with, at about the same time, the adoption of antiseptic techniques, such as sterilizing instruments, to prevent infection) had a startling effect on patient mortality. As part of a crusade to win social acceptance for the practice, the Scottish obstetrician Sir James Young Simpson compiled statistics to show that anesthesia had reduced mortality owing to amputation at the thigh—a particularly perilous operation—from one in two to one in three.
“How often have I dreaded that some unfortunate struggle of the patient would deviate the knife a little from its proper course,” the prominent Columbia University surgeon Valentine Mott wrote of his practice before the use of anesthesia, “and that I, who fain would be the deliverer, should involuntarily become the executioner, seeing my patient perish in my hands by the most appalling form of death!” Not infrequently an artery would be accidentally severed, causing the patient to bleed to death on the table.
The Pain Chronicles Page 9
