The Pain Chronicles

by Melanie Thernstrom

  It was not until the discovery of the opiate receptor in 1972 that the pod began to yield its secrets. The belief that opium was “God’s own medicine” turned out to capture a biological truth: opiates work by mimicking the chemicals in the body’s own pain-modulating system. The chemical structure of opiates is sufficiently similar that they can bind to the same receptor on nerve cells in the brain and spinal cord, where they change the way those neurons function, interfering with the transmission of pain signals in the spinal cord.

  The effect of opiates is different from that of anesthetic agents, such as ether, that render people completely unconscious. A person on opiates seems to have all his senses about him—he can still run a marathon and will still cry out in pain if he falls and hurts himself—yet his relationship to pain is strangely altered. In addition to blocking the transmission of pain signals, opiates—as Diocles of Carystos observed—change one’s relation to pain, so that the pain no longer preys on one’s mind. This more complicated effect may be due to the way in which opiates boost the level of dopamine in the brain, creating a sense of pleasantness or even euphoria.

  Yet despite its wondrous properties, opium was a perilous analgesic for surgery. Because opiate receptors are distributed in many parts of our bodies, opiates affect multiple systems throughout the body in addition to pain modulation, including those governing respiration, heartbeat, blood vessels, and the cough reflex. Opium increases bleeding by dilating blood vessels, which counteracts the body’s way of adaptively responding to injury by constricting blood vessels and directing blood toward the vital organs. Opium shares the same perils as alcohol. They both induce nausea, putting the patient at risk of vomiting stomach acid onto the delicate lining of her lungs and fatally asphyxiating. Most perilously, by depressing respiration, as a sixteenth-century medical text cautioned, opium “causeth deepe deadly sleapes.”

  Of all the ancient remedies, only cocaine was suitable for surgery. In addition to the psychotropic effects with which we associate it today, cocaine is a topical anesthetic that acts on peripheral nerves (inhibiting the transmission of nociceptive impulses between cells) to cause localized numbness. The ancient Incans used the leaves of the sacred coca plant to perform operations such as trepanations. As they bored holes into their patients’ skulls to allow the illness-causing demons to escape, the shamans chewed the leaves so that the cocaine dissolved in their saliva, and then they spit into wounds—a perfect double treatment, as the cocaine both inspired and focused the shamans and numbed their victims’ peripheral nerves. While European trepanations in the eighteenth and early nineteenth centuries usually resulted in the patients’ deaths, archaeological evidence reveals a surprisingly higher survival rate after ancient Peruvian trepanations (an examination found that the majority of trepanned skulls showed signs of healing). The success of the prehistoric trepanations is thought to stem from the sterilizing effect of cocaine.

  The conquistadores figured out that cocaine was a useful addiction for their slaves: it acted as both a stimulant and an appetite depressant, energizing the starving natives and spurring on hard labor in the gold mines, for which the conquistadores would compensate their slaves with more cocaine. For unclear reasons, however, the plant was not exported and arrived in Europe only in the late nineteenth century, after the discovery of general anesthetics made it largely medically irrelevant (although it was and still is sometimes used as a local anesthetic in eye and throat surgery).

  MESMERIZED

  The most effective treatment for pain relief prior to anesthesia lay in the mind itself. It was long known that religious belief could assuage pain. Muhammad tells the faithful, “When anyone suffers from toothache, let him lay a finger upon the sore spot and recite the sixth sura.” Thomas Aquinas writes how “the blessed delight which comes from the contemplation of divine things suffices to reduce bodily pain.” Hindu Yogis cultivate indifference to pain as well as to pleasure. A typical tale from a book of Yogic philosophy involves a master who refuses anesthetic before an operation and then proceeds to calmly expound upon his philosophy to all present throughout the procedure. Afterward, when the dumbstruck surgeon asks if he felt any pain, he replies, “How could I? I was absent from that part of the Universe where you were working. I was present in this part where I discussed philosophy.”

  Contemplation of philosophy itself (philosophers claim) may equally suffice. In “On the Power of the Mind to Master Morbid Feelings by Sheer Resolution,” Immanuel Kant writes of how, one night, kept awake by the pain of gout in his swollen toes, “I soon had recourse to my Stoic remedy of fixing my thought forcibly on some neutral object that I chose at random (for example, the name Cicero, which contains many associated ideas), and so diverting my attention from that sensation. The result was that the sensation was dulled, even quickly so, and outweighed by drowsiness; and I can repeat this procedure with equally good results every time that attacks of this kind recur.”

  How does an ordinary person achieve such control? At the time of Fanny Burney’s surgery, a form of hypnotism known as mesmerism or animal magnetism (whose legacy is the verb mesmerize) had already been shown to induce analgesia, as well as to heal patients of other ills. Of all the techniques (opium, alcohol, freezing, inducing concussion, and so forth) that might have been used in Burney’s parlor, mesmerism would have been the best—and indeed, in 1829 it was successfully used during another mastectomy in France. Following the undisputed success of that operation, performed by the surgeon Jules Cloquet in front of a dozen witnesses, mesmerism went on to be successfully used in several hundred surgeries. Unfortunately, however, it never achieved acceptance in mainstream medicine, and most surgeries continued to be performed without it—or any other analgesia—until the discovery of ether anesthesia.

  Like a shaman, Franz Mesmer, a German physician trained in Vienna, used various impressive-looking props to induce a trance in his subjects, after which he would declare them healed. Instead of religious belief, however, his methods were wrapped in a dressing of Enlightenment science. Chief among them was the idea of a vital spirit or life force animating all beings (as well as planets and the earth), a biological correlate of the soul that (as with the Eastern idea of chi) was believed to be blocked in sickness. Following their mid-eighteenth-century commercialization, magnets and their invisible force were objects of particular scientific interest. Mesmer believed that just as a magnet could compel a piece of metal to move through space, channeling magnetic fluidum could restore the flow of vitality in a body and dissipate disease.

  In 1774 Mesmer had a patient swallow a mixture that contained iron, and then he attached magnets to various parts of her body. The patient reported that she felt “streams of fluid” running through her body, which relieved her of pain for several hours. Soon, however, Mesmer discovered that he was able to achieve the same effects simply by touching patients, and he posited that the healing resulted from the transfer of his own magnetism to the patient. Notably, he recorded two conditions of success as necessary for hypnosis, which are true (and relevant to placebo in general): first, that the patient have a desire to be healed, and second, that the healer have a personal relationship with the patient.

  Overwhelmed with individual patients, Mesmer took to treating people in groups. Clad like a magician in a violet-colored silk robe, he presided over wooden tubs he called “banquets” that were filled with water and iron rods, in which the sick could be magnetized. The patients would fall into a trance, sometimes even hallucinating or convulsing, which Mesmer referred to as a “crisis.” Afterward, he would declare the patients cured and play music on a glass harmonica. He was even summoned by Queen Marie Antoinette to magnetize her poodle, Marionette.

  The greater mesmerism’s popular success, the more hostility it faced from the medical establishment. In her book Mesmerized: Powers of Mind in Victorian Britain, Alison Winter argues that the competition from mesmerists was actually the catalyst for the development of inhalation anesthesia. The
extent to which the two were in competition is evident in the British surgeon Robert Liston’s famous (if perhaps apocryphal) quip upon first using the new ether anesthesia from America during an amputation: “This Yankee dodge beats mesmerism hollow . . . Hurray! Rejoice! Mesmerism and its professors have met with a heavy blow.”

  To the dismay of physicians who saw the technique as competition, mesmerism swept through Europe, eventually spreading to Britain and America. Mesmer moved his practice from Vienna to Paris, where he set about trying to obtain the endorsement of the French scientific community. Mesmer’s opportunity for validation came in 1784, when King Louis XVI appointed an investigative committee composed of prominent members of the Faculty of Medicine and the Royal Academy of Sciences. The committee considered not the effects of Mesmer’s technique on patients, but only the theory by which he explained it, which they swiftly debunked. After all, the eighteenth century had seen great advances in the study of anatomy, yet none of it had turned up magnetic forces or vital fluid. Mesmer left Paris just before the French Revolution, and mesmerism died with him in exile. It enjoyed a revival in the 1830s and ’40s. Public demonstrations by traveling mesmerists became popular in England and America; they would put a subject (usually a comely young woman) in a trance, then show that she would remain unresponsive to smelling salts, pinpricks, or even acid poured on her skin!

  More startling were reports of almost three hundred painless surgeries performed under mesmerism. In 1842 a Nottinghamshire surgeon amputated the leg of a farm laborer. A skeptical lawyer named William Topham witnessed the operation. Topham watched as the surgeon plunged the knife into the laborer’s thigh, all the way down to the bone, while the laborer continued to sleep, moaning softly at times. Topham was stunned: “I saw” and “was convinced . . . There can be few, even of the most bigoted objectors, who will deny its powers,” he wrote.

  Yet they did. After debate, the Royal Medical and Chirurgical Society declared Topham’s account “humbug” and censured him. A medical professor at the University College Hospital defended his interest in mesmerism, writing, “These phenomena I know to be real . . . independent of imagination . . . of the most interesting, most extraordinary & important character.” He was ridiculed as a “tom-fool” and forced to resign.

  The Enlightenment yielded a binary opposition between the subjective experiences of magic and faith healing on one hand and, on the other, the ideal of objective medical treatment having the same effect on every patient, regardless of whether they believed in it. There was no understanding that belief and other subjective mental states—and the role a healer could have in conjuring them—could themselves be objective phenomena, real yet also dependent on imagination.

  Trance states were also seen as morally degrading. An 1851 article in Blackwood’s Edinburgh Magazine denounced mesmerism as requiring “a ready abandonment of the will” along with “every endowment which makes man human” and concluded that it was “a disgusting condition which is characteristic only of the most abject specimens of our species.” Some surgeons attempted mesmerism, but the patients failed to fall into a trance, or the trance did not last and they woke up screaming partway through the surgery. For a patient to achieve a trance, practice is usually required (and not everyone is able to learn it). Moreover, the crowded amphitheaters in which surgeries were typically performed in Europe were not conducive to achieving such a state. Horribly surprised, doctor and patient alike joined the backlash when mesmerism failed.

  With the development of anesthesia, mesmerism was permanently abandoned. However, in the mid-nineteenth century, the Scottish physician James Braid (although he criticized the “immoral tendency” of “the irresistible power of . . . the mesmerizers”) revived the practice of employing the trance to treat disease, naming it hypnotism. Self-hypnotism has been shown to be of use during medical procedures and to reduce the amount of anesthesia required.

  Although ether was accompanied by more risks and side effects than mesmerism was, it was clearly a superior mechanism for controlling pain, because it did not require a particular mental state on the part of the surgeon or the patient. Yet the puzzle lingered for those who had witnessed operations or public demonstrations under mesmerism. How did mesmerism actually work? How had the knife been plunged painlessly to the bone or acid poured on the somnolent demonstrator’s skin?

  The puzzle would have to wait for the invention of brain imaging to see how the hypnotized brain can block (or create) pain, and why some people are susceptible to hypnotism while others are not. Mesmer’s magnetic fluidum might not exist, but the phenomena he observed are indeed real.

  A CHIMERA NOT PERMITTED

  The puzzle of the history of anesthesia—one on which every medical history speculates to incomplete effect—is why it wasn’t practiced earlier. By the time of Fanny Burney’s operation in 1812, the anesthetic effects of inhaling the gases ether and nitrous oxide had long been known by British chemists. Yet decades of gruesome surgeries would transpire before an American dentist finally brought the gases into the operating room.

  In his book Romance, Poetry, and Surgical Sleep, the distinguished anesthesiologist E. M. Papper theorizes that anesthesia could only have been invented in America because its development depended on a democratic society in which the pain and suffering of the masses mattered. But many Americans lived in misery, and regardless, the suffering of certain Englishmen certainly counted in the British mind. So why didn’t the elite demand anesthesia?

  Part of the answer seems to involve opposition from surgeons. Throughout British medical history, pain and surgery had been linked, and thus, attempts at uncoupling them struck many as impossible, unnatural, or dangerous. The profession required people who were willing to inflict severe pain on others, and who—having done so—were invested in seeing that pain as appropriate. Pain is “necessary to our existence,” argued the Scottish surgeon Sir Charles Bell in 1806. “To imagine the absence of pain is not only to imagine a new state of being, but a change in the earth and all upon it.”

  The idea of such a change was viewed with alarm. “To escape pain in surgical operations is a chimera which it is idle to follow up today,” declared the great French surgeon Alfred Velpeau in 1839. “Knife and pain in surgery are two words which are always inseparable in the minds of patients, and this necessary association must be conceded.”

  It is worth contemplating what Velpeau means by chimera. Is painless surgery a chimera in the sense of a mythical creature that does not exist, even if we wish it did, or a chimera in the sense of a monstrous creature that should not exist—a goat with a lion’s head—whose very existence is a subversion of the natural order? After the Fall, aren’t we supposed to suffer pain?

  Every surgeon was familiar with the moment at which a patient became eerily quiet. Because unconsciousness usually prefigures death (both imitating and presaging it), crying was considered a sign of health, a manifestation of the vital spirit. Moreover, consciousness was considered an emanation of the soul; to extinguish consciousness was to play God and temporarily kill the patient.

  Long after the means of anesthesia had become available, many scientists either didn’t understand its potential application or were unsuccessful in convincing others of it, so the story of anesthesia’s development is often told as an allegory of the difficulty of progress, the tenacity of suffering, and the conflict between science and religion. Sir Humphry Davy discovered the anesthetic properties of nitrous oxide (which he termed “laughing gas”) at the turn of the nineteenth century while working at the Pneumatic Institute—a clinic that attempted to treat diseases such as TB and asthma with nitrous oxide and ether gases. One day when Davy was suffering from a terrible toothache, he experimented on himself with the gas. Suddenly, to his surprise, his pain seemed quite amusing. In his book Nitrous Oxide, he wrote that as the gas “appears capable of destroying physical pain, it may probably be used with advantage during surgical operations in which no great effusion of blood tak
es place.” His apprentice, Michael Faraday, reached similar conclusions regarding ether. But when pneumatic medicine was discredited and the clinic closed, Davy lost interest in nitrous oxide and went on to be knighted for other discoveries.

  The gases became popular among Romantic poets such as Samuel Taylor Coleridge and Robert Southey, who wrote of nitrous oxide as “the air in heaven this wonder working gas of delight.” Ether frolics became the rage; traveling shows would demonstrate the gas’s effects and invite the audience to partake. As in the case of alcohol, the effects of the gases occur in two stages: Initially it creates arousal and exhilaration, which is followed by deep sleep. The first stage seemed inappropriate for surgery: What place could a party trick have in the operating room? The doses administered at shows were usually sufficient to cause giddiness, but not to take subjects into the sleep phase befitting surgery.

  BY WHOM PAIN IN SURGERY WAS AVERTED AND ANNULLED

  In science the credit goes to the man who convinces the world, not to the man to whom the idea first occurs,” observed the botanist Francis Darwin, son of Charles Darwin. William T. G. Morton’s tombstone reads, “Inventor and Revealer of Anesthetic Inhalation. Before Whom, in All Time, Surgery was Agony. By Whom Pain in Surgery was Averted and Annulled. Since Whom Science has Control of Pain.” Dr. Morton did not discover any new agents, but by persuading the medical establishment of ether’s utility during an operation at Massachusetts General Hospital on October 16, 1846, he bifurcated medical history forever.