The Pain Chronicles

by Melanie Thernstrom

  Prior to the nineteenth century, surgeons were typically of the lower class; an occupation that entailed torture seemed hardly fit for a gentleman—and, indeed, repulsed the compassionate of every class. In fact, it was the violence of surgery that helped dissuade Charles Darwin from choosing a medical career. While in medical school in 1820s Edinburgh, Darwin witnessed two operations in an amphitheater—one on a child—and rushed from the room in horror. The memory, he wrote later, “fairly haunted me for many a long year.”

  A tolerance for inflicting pain was required of surgeons. A surgeon had to have a mind “resolute and merciless,” Ambroise Paré declared in the sixteenth century, so that “he be not moved to make more haste than the thing requires, or to cut less than is needful, but does all things as if he were not affected by their cries.” Yet, Paré—royal surgeon to four French kings—recognized the importance of the physician’s relationship with his patient. He wrote persuasively that the “indications of the patient’s state of mind, determination and strength must take precedence over everything else. If he is weak or in terror, it is necessary to forsake all other things in order to be helpful to him. If the patient lacks the necessary strength of mind, operations should be postponed—if possible. Nothing can be gained from surgery if the patient is unwilling to face his ordeal.”

  How? How did anyone have the strength of mind to face such an ordeal when, for example, the surgeon arrived the day before to draw on the patient’s body a diagram of the incisions to come, leaving him to contemplate the map of his own dismemberment?

  Surgeons’ records lament the great number of patients who preferred to die, succumbing to infections such as gangrene, rather than suffer an amputation knowing that many of those who submitted to the agony of an operation perished anyway. Fear of pain often trumped fear of death. Of the many experiences of premodern life inaccessible to us now in the developed world, few seem more so than preanesthetic surgery (although, shockingly, in China and Africa and during wartime, such surgeries still sometimes take place). In the West, remarkably few pathographies (patient accounts) of the experience of premodern surgery exist. Studies of nineteenth-century surgeons’ records rarely include the mention of a patient’s pain; the few allusions that exist limit themselves to comments such as, concerning an 1832 amputation, “during the operation the patient did not seem to suffer greatly”! How little suffering could sawing through the two bones of the forearm to amputate an arm above the elbow joint have involved?

  Surgeons liked to make a point of recounting stories of patients who refrained from burdening them with their pain, such as one who cajoled a seven-year-old boy, “I suppose, my little fellow, that you would not mind having this knee removed, which pained you so much and made you so very ill.” The boy replied, “Oh no, for mammy has told me that I ought.”

  One might imagine that such patients endured agony by “blanking out” via shock or some other mechanism that rendered them oblivious to their plight. In fact, however, intense pain creates extraordinarily clear awareness of surroundings; as people sense mortal danger, they become hyperalert, fixing details in memory. Time seems to slow (a sensation familiar to people who’ve been in car accidents). And, as ascetics attest, intense pain can also create a sense of disassociation, in which one is merely observing one’s own agony. For example, far from being distracted by the pain of his testicle’s amputation, a patient of Dr. Robert Keate’s attended with keen awareness to the attitude of the surgeon’s assistants, watching as one of them paused during the operation to dab at a spot of blood on his own white pants! Although the patient had intended to tip the assistant twenty guineas, he told Dr. Keate afterward that, as the fellow “regarded the purity of his trousers as more important than my sufferings, I will not give him a farthing.”

  While the details of the environment surrounding the person in pain remain seared in memory, the actual sensation of the pain is hard not only to describe, but even to recollect, since the rupture it creates in the self cannot be integrated into memory of the self. George Wilson’s description of the amputation of his foot in 1842 (just four years prior to the invention of anesthesia) illuminates the relationship between pain, memory, and language—how, as Wilson said, “at the extremities of human experience, we can observe only a kind of silence.” But whereas the sensory quality of pain disappears from memory, the emotions surrounding it do not.

  Wilson was then a twenty-four-year-old medical student in Edinburgh, and his ankle had become infected. “During the operation, in spite of the pain it occasioned, my senses were preternaturally acute,” he wrote in a letter to Sir James Young Simpson. “I watched all that the surgeons did with a fascinated intensity. Of the agony it occasioned, I will say nothing. Suffering so great as I underwent cannot be expressed in words, and thus fortunately cannot be recalled. The particular pangs are now forgotten; but the black whirlwind of emotion, the horror of great darkness, and the sense of desertion by God and man, bordering close upon despair, which swept through my mind and overwhelmed my heart, I can never forget, however gladly I would do so.”

  A TERROR THAT SURPASSES ALL DESCRIPTION

  One of the very few attempts to recall and express “particular pangs” is to be found in an 1812 letter by the English novelist and memoirist Fanny Burney to her sister, describing the mastectomy she had undergone in Paris the year before. Fanny Burney’s letter is considered one of the most vivid pieces of writing on physical pain of any era.

  A painful abscess had developed in Fanny’s right breast almost twenty years earlier. She had fasted, drunk asses’ milk, and rested, and it had gone away. In 1810 the pain returned. Her “doom” was pronounced by three doctors: she was “formally condemned to an operation.” She was “as much astonished as disappointed,” for “the poor breast was no where discoloured, & not much larger than its healthy neighbor.” Fanny herself may have been the only one in possession of this knowledge, for the mores of the time meant that the doctors most likely did not actually examine her breast. Indeed, the first time they touched it was probably with their scalpels. Fanny was spared, however, the opinion of subsequent historians that she did not, in fact, have a malignant tumor (else she would not have survived with it for two decades before and three afterward), but rather an inflammatory condition that did not require a mastectomy.

  As the wife of a French nobleman, Fanny was operated on by Napoleon’s chief surgeon, Baron Dominique-Jean Larrey, who (fortunately—or not) happened temporarily to be between wars. This respite offered the baron the leisure to operate meticulously. At the Battle of Borodino in Russia, in contrast, he recorded in his memoir, he performed some two hundred amputations in one twenty-four-hour period! Fanny wrote about the operation as a medieval morality play in which the pain is an evil that the doctors must exorcise; indeed, she “felt the evil to be deep, so deep, that I often thought if it could not be dissolved, it could only with life be extirpated.” Fanny’s letter testifies to the importance of a strong surgeon-patient relationship prior to anesthesia, one in which the patient can balance the sensory experience of the torture of surgery against belief in the physician’s benevolence. Viewing the pain as an evil required turning Dr. Larrey into a savior. Yet the extreme nature of the experience makes help and harm both merge and split, as images of the physician as savior, saint, healer, and torturer, butcher, executioner, compete and become confused and conflated. She wrote that “the good Dr. Larrey . . . had now tears in his eyes,” yet her descriptions of the operation suggest an assault, a rape, and an execution.

  Dr. Larrey refused to tell Fanny what day they would operate and to let her make preparations for it, promising only four hours’ warning (a strategy surgeons employed to prevent patients from committing suicide on the eve of an operation). “After sentence thus passed, I was in hourly expectation of a summons to execution,” she wrote. “Judge, then, my surprise to be suffered to go on [a] full 3 weeks in the same state!”

  Then one morning, a letter from Dr. Larr
ey was delivered to her bedside, informing her that he would arrive shortly. She arranged for a pretext to cause her husband to leave the house, in order to spare him “the unavailing wretchedness of witnessing what I must go through.” She was alone when the team of doctors and assistants—“7 Men in black”—arrived. The doctors told her “to mount the Bedstead. I stood, suspended, for a moment, whether I should abruptly escape—I looked at the door, the windows—I felt desperate.”

  The maid and one of the nurses ran off in terror. The doctor began to issue commands, using military language. Fanny was compelled to take off her long dressing gown, which she had somehow imagined she might retain. No attempt at analgesia was made: in an era when nursing mothers would smear opium concoctions on their nipples to quiet their babies, Fanny’s breast was lopped off after giving her only a wine cordial to sip.

  She threw herself into her fate. Finally, she “mounted, unbidden, the Bed,” and the doctor spread a cambric handkerchief upon her face. “Bright through the cambric” she glimpsed “the glitter of polished Steel.” She watched as—without touching her—the doctor made the sign of a cross and a circle with his finger over her breast “intimating that the Whole was to be taken off.”

  She threw off the handkerchief and protested that the breast hurt in only one place. The doctors veiled her face again. She saw one doctor make the gesture a second time, and she “closed once more [her] Eyes, relinquishing all watching, all resistance, all interference & sadly resolute to be wholly resigned.”

  An 1837 medical textbook instructed that in the case of mastectomies, “no half-measures will answer . . . the duration of the proceeding must not for once be considered. Many operations can be done quickly and well . . . this is not one of them.”

  Fanny’s operation was anything but quick. She felt:

  a terror that surpasses all description & the most torturing pain . . . when the dreadful steel was plunged into the breast—cutting through veins—arteries, flesh, nerves . . . I began a scream that lasted unintermittingly during the whole time of the incision, and I almost marvel that it rings not in my Ears still! So excruciating was the agony . . . When the wound was made and the instrument withdrawn, the pain seemed undiminished, for the air that suddenly rushed into those delicate parts felt like a mass of minute but sharp poniards that were tearing the edges of the wound—but when again I felt the instrument, describing a curve, cutting against the grain . . . while the flesh resisted in a manner so forcible as to oppose and tire the hand . . . then, indeed, I thought I must have expired.

  She lost consciousness twice during the operation. Even when no one was touching her, the finger of the doctor “literally felt elevated over the wound . . . so indescribably sensitive was the spot.” The operation lasted a full twenty minutes. She tried to bear it as courageously as she could, she writes, and “never moved, nor stopt them, nor resisted nor remonstrated, nor spoke,” except to piteously thank the doctors for their attention. When she opened her eyes, she saw that the “good Dr. Larrey himself was pale nearly as myself, his face streaked with blood, and its expression depicting grief, apprehension, & almost horrour.”

  Afterward, “not for days, not for Weeks, but for Months I could not speak of this terrible business without nearly again going through it! . . . I have a headache from going on with this account! & this miserable account, which I began 3 Months ago, at least, I dare not revise, nor read, the recollection is still so painful.”

  DROWSY POTIONS

  By the time of Fanny Burney’s operation, many techniques for mitigating pain during surgery had been experimented with throughout the ages, but all were dangerous, insufficient, or both. In his 1812 memoir, Dominique-Jean Larrey—Fanny Burney’s surgeon—related the anecdote of operating on a colonel during a battle by punching him on the chin. Dr. Larrey also wrote of employing “refrigeration anesthesia” (snow or ice), noting that the frozen conditions of the Russian battlefields eased the pain of operations. But while cold interferes with nerve conduction, freezing flesh makes it difficult to cut and puts a patient at risk of frostbite, leading to infection. The ideal was a “drowsy syrup” that would cause the patient to sleep through the surgery, but what elixir would allow (as the thirteenth-century Catalan alchemist and physician Arnold of Villanova bragged of his own potion) a patient to be “cut and [he] will feel nothing, as though he were dead” without being dead?

  Like Villanova, many healers claimed such powers, of course, but they were all wise enough to keep their recipes secret. The most powerful secret ingredient was doubtless placebo. It’s interesting to imagine what the history of medicine would be like without the placebo effect: in a sense, there might not have been a history of medicine before modern times without the placebo effect, because it would have been obvious that most treatments made no difference. Disease might have been relegated, like earthquakes and volcanoes, to the province of religion, seen as something that could not reliably be manipulated (even if the gods might be implored to ameliorate it). While the tendency of a disease toward resolution might sometimes have been mistaken for the effectiveness of a medical intervention, only the placebo effect granted healers uncanny power.

  Pain relief is the task for which placebo is most effective. Unlike modern physicians, who focus on curing disease, ancient healers were primarily renowned for their anodynes. And when healers achieved relief, they enhanced their reputations, which might yield a stronger placebo effect for the next patient, which could in turn further enhance the physicians’ reputations, maintaining a positive feedback loop.

  What were the medicinal substances of the ancient world? Of all the plant anodynes, only a few were true analgesics: opium from poppies, alcohol, cocaine from the coca plant, henbane, mandrake (mandragora), deadly nightshade (belladonna), cannabis (marijuana), and salicylic acid (similar to aspirin) found in willow bark or dried myrtle leaves.

  Willow bark was commended by Hippocrates to reduce the pain of childbirth and fever. The ancient remedy was rediscovered by the Reverend Edmund Stone one evening in 1758 when he was strolling in a meadow in Chipping Norton, England. Stone was a believer in the “general maxim that many natural maladies carry their cures along with them, or that their remedies lie not far from their causes,” as he later wrote to the Royal Society. As the willow grew in wet soil, which was widely believed to give rise to disease, Stone surmised that the willow might provide an antidote. Breaking off a bit of bark, he found that its bitter taste reminded him of a costly imported medicine made from the bark of the South American cinchona, dubbed the fever bark tree, which contained quinine and had been discovered to have an extraordinary effect on a particular ague—malaria.

  This daft chain of thought led to a real discovery. Stone gathered and dried willow bark and ground it into a powder that he tested on fifty of his parishioners. It was effective, he discovered, not only against fevers but as a general anodyne against pains of all sorts. Thereafter, willow bark medicine—crushed, powdered, and mixed into alcohol—led to such a craze in England that the willow population declined until stripping its bark was outlawed. (At the end of the Victorian era, a synthesized form of salicylic acid became the first popular synthesized drug, in the form of aspirin, beginning the modern pharmaceutical industry.)

  Still, although aspirin could mitigate the inflammation that followed surgery, it could not ease the pain of surgery itself. Many plants’ components are mildly soporific, but only henbane, mandrake, and opium could create a drowsy potion sufficient for surgery. Henbane and mandrake were too dangerous: both are intimately related to poisons. Although deadly nightshade was also poisonous, combined with opium it produced a twilight sleep that blurred the memory of pain. (These may have been the ingredients in nepenthe—Helen of Troy’s wine potion that brought forgetfulness of pain and sorrow.)

  Opium is the oldest and most important medicinal substance, the discovery of which is believed to predate even that of alcohol. Because opium has various effects (like alcohol, it initia
lly has a stimulating effect that eventually turns to drowsiness), it could be used to kindle bravery in battle, as well as for celebrations, sacred rites, divinations, and to induce prophetic dreams. In some societies, opium’s use was restricted to shamans and priests. In the Victorian age, Infants’ Quietness and other “soothing syrups” of opium dissolved in alcohol—each of which possessed its own signature twist, from frog sperm to witch hazel—were prescribed for pains of all sorts, ranging from teething to neurasthenia, the fashionable ailment of Victorian women. Because, like alcohol, opiates depress respiration, they were useful in stilling the agonizing cough of tuberculosis. They could also stop life-threatening diarrhea by stilling contractions of the intestines, and they could alleviate the chronic pain of malnutrition by depressing appetite.

  By inducing feelings of well-being, the syrups could soothe the cares of both the upper and lower classes. They also functioned as babysitters; although they jaundiced children’s skin, they also kept them docile. Elizabeth Gaskell’s novel Mary Barton, about the poor of Manchester, England, praised opium as “mother’s mercy” for its ability to soothe the pangs of starving children: “Many a penny that would have gone little way enough in oatmeal or potatoes, bought opium to still the hungry little ones, and make them forget their uneasiness in heavy troubled sleep.” Eventually, however, concerns about (among other things) the number of infants who were lulled to death after being dosed with such effective “baby-calmers” led to the first regulations on opiates in England in the late nineteenth century and America in the early twentieth.

  The most potent analgesic in opium had been isolated early in the nineteenth century by a German chemist who named it morphine after the Greek word for shapes. (It is often erroneously thought to allude to Morpheus, the god of dreams; in fact, the chemist originally called it “the shape of dreams,” shortened to “shapes,” or morphine). Yet the mystery of how it worked lingered. In the fourth century B.C.E., Diocles of Carystos, a Greek physician, mused about the “wondrous flower” that refused to “give up its secrets.” Why did it “soothe some, but cast others into melancholy”? Why was its effect on some immediate and on others delayed? Why did it have a curious effect such that “even when it does not abolish pain, the pain no longer preys on the person’s mind”?