The wounds that serve?

The History of Pain
May 17, 1996

When did you last stub your toe? Pointless or providential, pain punctuates our daily lives, an intrusive, unwelcome but all too familiar guest. He comes in many guises: acute but trivial (the throbbing toe), acute and urgent (the burst appendix), chronic and visible (the tense rheumatic joint), and chronic but elusive (the heartache of depression). With rare exceptions, mostly perverse, we would much prefer him to leave. There is surely something odd about the notion of a history of this regrettable fact of life.

Moreover, pain has arguably changed little in the course of human history. The patients of Galen, imperial physician of second-century Rome, complained of "throbbing, pressing, stretching and lancinating" pains, and so do ours. While most sufferers leave no report of their subjective agonies, indirect evidence can be eloquent enough: "Of what the patient actually endured during the operation we have no record other than that it was necesary to tie his ankles and legs by passing a rope around his neck and tying his hands against his knees I he had to be held securely by four men, 'strong, not fearful or shy'".

The historian of pain must therefore look beyond the private experience of pain, and chronicle the progress of its scientific exploration, management and cultural significance. There are, in principle, many fascinating stories to be told: a large part of the history of neuroscience is to the point; so are the discoveries of remedies, from aspirin to anaesthesia, the changing attitudes of the church and of physicians, and the developing philosophical analysis of pain. An ambitious historian might even move on from the human history of pain to chart its natural history, in neural evolution. For, as Roselyne Rey points out, her subject lies at the crossroads between biology and culture. But reading this awkward translation of her French original, I felt that Rey's book only partly realised the great promise of its subject.

Her own attitude to pain is straightforward. She concludes her closing historical chapter approvingly with a quotation from Rene Leriche, a surgeon who saw too much of pain during the first world war: "Pain is always a sinister bequest I and a doctor's most pressing duty is to do his utmost to suppress it if he can - always". Rey identifies several sources of resistance to this view.

Pain has been close to the heart of Christianity. The medieval church taught that it was to be endured as a divine gift, a sacrificial offering or a means of redemption, and indeed in the 1940s a French theologian wrote: "Suffering has always been one of the Church's major riches". Some 18th-century physicians also argued the case for pain: like fever it "required expression", and "in childbirth, the pains I although very strong, are absolutely necessary". Most contemporary sympathies will lie with Leriche, but we should grant that pain sometimes "wounds us in order to serve us". Indeed this must be a crucial part of its biological explanation. Insensitivity to pain leads to terrible mutilation.

Whatever the improving or protective powers of pain, much ingenuity has always been devoted to ameliorating it. One of the pleasures of medical history is the recurrent realisation that most discoveries are older than we thought, and were usually made several times. Pliny's Natural History describes a substance which "has not only soporific qualities, but I can even cause death during sleep if taken in too large amounts. We call it opium." Likewise, "the oil of life or artificial melancholy", noted to be capable of inducing sleep in chickens, was known in the 16th century, but the true "benefits, wonderful benefits" of ether were to remain unsuspected for 300 years.

Rey writes well on the history of the scientific exploration of the neural mechanisms of pain, emphasising the French contribution. As she explains, a succession of attempts to isolate physiological systems specific for pain, including "pain receptors" in the skin, "pain fibres" transmitting signals from them and "pain centres" in the brain, has hugely increased our knowledge but these efforts have always turned out to be "insufficient and surpassable".

Although there is much to enjoy in and learn from this scholarly survey, I found it an unsatisfactory read overall. The historical narrative is sometimes monotonous, and, particularly in the early chapters, fails to pick out themes of interest. The chronological approach has the odd consequence that the chapters increase in length exponentially as the pace of discovery quickens. The translation requires a special mention. Bizarre vocabulary, and convoluted, sometimes plain ungrammatical sentences repeatedly mar this book. I can recommend it without reservation only to ardent students of pain. Even they will not receive undiluted pleasure.

Adam Zeman is senior registrar in neurology, Addenbrooke's Hospital, Cambridge and the Norfolk and Norwich Hospital, Norwich.

The History of Pain

Author - Roselyne Rey
ISBN - 0 674 39967 6
Publisher - Harvard University Press
Price - £25.50
Pages - 394

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