TLS: On Subject of Pain

Ouch!
Druin Burch

review of
WORST OF EVILS. The fight against pain. By Thomas Dormandy. 560pp. Yale University Press. Pounds 19.99 ($35). 0 300 11322 6
Years ago, New Scientist invited readers to propose Standard International units for beauty. A "Helen" was the most popular suggestion, with a "milli-Helen" defined as enough beauty to launch a single ship. Like beauty, pain is not a sense to which objective units can be applied, units of heat or light, pressure or frequency. It used to be widely believed that nerve cells were hollow tubes through which packets of "sensation" passed. A lump of sound travelled along an auditory nerve, a portion of light along a visual one. Pain was usually considered to be an excess of another sensation -the eyes hurt when they received too much light, a punch felt unpleasant because the sense of touch was overwhelmed. But early in the twentieth century, all sensory nerves were shown to transmit largely uniform pulses of electrical depolarization.
Sensory stimuli, regardless of their nature, are in fact transduced by nerve cells into waves of electrical charge that are conducted towards the brain.
Whether a person becomes conscious of the impulse depends on the context. Tread on a pin while running for your life from an axe-wielding maniac and you may not feel it, just as rugby players occasionally manage to break bones without immediately knowing. But stand on the pin while walking in a relaxed fashion to the bathroom and you are likely to notice. In both cases, the sensory impulse from your foot will have been the same. Pressure sensors will have picked up the force of the pin, but they can only lead to an experience of pressure, not pain. There is nothing in the electrical depolarization itself that can clue the brain in to understanding something about the modality of sensation: that depends on labelled-line coding. Nerves arriving at the brain's visual cortex, for example, are "labelled" as supplying information about sight. Trigger them by rubbing your eyes hard and you "see" the result. The brain has no way of knowing that the impulses were actually caused by pressure. Pain is not an excess of another sensation, and awareness of it depends on specialized sensors, ones designed to pick up signs of tissue damage. But they are not pain fibres, since what they sense is not pain -that quality only exists within our consciousness. Bump your knee and it might not hurt until you notice the blood -tissue damage itself does not cause a predictable emotional response. The fibres that sense damage are called nociceptive, referring to their sensibility to noxious stimuli. Pain, like beauty, really is all in the mind.
Thinking about the physiological reality of pain is not helped by the peddling of misinformation at primary schools. Aristotle thought that there were five senses, but he also believed that men had more teeth than women. It is not clear why one of these mistakes is still cheerfully passed down. Nor is it something that particularly interests Thomas Dormandy in his book Worst of Evils: The fight against pain. His mind is not on the mechanisms of pain: his chapter on the topic is eight pages long, and he is dismissive enough to regard the distinction between pain sensors and nociceptors as pedantic. Like the other (infrequent) mistakes in his lengthy book, this reflects neither ignorance nor stupidity. Dormandy is quite capable of grasping whatever he chooses to focus on; his trouble is only that he finds so many things clamouring for his attention. Worst of Evils is partly a wholesale history of medicine and partly an account of medical and cultural approaches to pain.
Chiefly, though, it is an almost six-hundred-page collection of human lives, a dazzlingly random compendium of stories, facts and footnotes, which add little to the main thrust of the narrative. The chief glory and failing of this haphazard and fascinating book is an overwhelming delight in trawling through history to scoop up the fun bits.
Dormandy begins with the Ancient Greeks and Romans, for whom he has something of a schoolboy's reverence: "Freud never missed a chance to display his familiarity with the Classics", reads a footnote, and Dormandy suffers from the same affliction. His generalizations are provocative, entertaining -and sweeping. It is plainly wrong, for example, that initiation ceremonies are always male and always painful, and hard to believe that "After the annexation of Egypt the regularity of bowel movements became a prime concern of every Roman citizen".
Dormandy's review of Classical accounts of pain pays as much attention to myths as to treatments, and it takes little care to differentiate the two: "The garden lettuce gathered when young and tender had an established reputation as a mollifier of grief. But it could also encourage frenzy". Dormandy talks of the Greeks and Romans having "a plethora of effective painkillers" without convincingly establishing that they actually did. Dioscorides may well have been familiar with the bark of the willow tree, and he may well have used it to try to ease pain, but this is not to say he used it skilfully enough for the aspirin within it to help anybody. Later in his book, Dormandy shows himself fully aware that pre-modern painkillers were pretty useless, but it doesn't get in the way of him relishing the detail of two millennia of mostly potty treatments. Partly these stories get covered because they tell us something about contemporary beliefs; mainly because Dormandy finds them too juicy to resist.
After the glories of Graeco-Roman lettuces come the Dark Ages of European saints, a God-given opportunity to tell tales of miracles, as well as to spend time discussing the emotional and moral meanings of pain. "O how happy am I to be in pain!" cries out St Therese of Lisieux, and Dormandy suggests that the cult of contempt for the body, of spurning pleasure and welcoming pain, undermined the development of attitudes and therapies that would have reduced the mass of human suffering. Maimonides, the twelfth-century Jewish refugee who became a successful doctor in Saladin's Middle Eastern Empire, is on Dormandy's side: "The Lord gave us tears to shed . . . . Do not try to stem their flow.
When potions and vapours fail to ease the pain, lamentations often relieve the suffering". Dormandy applauds him (not least because Maimonides provides a good excuse to dip into twelfth-century history) without exploring the thought much further. Weeping can be a way of experiencing and digesting pain, or it can be a technique for evacuating it: the difference is important. But Dormandy prefers biographical narratives to philosophy, so instead of pursuing this, we learn -with potted life histories of everyone involved -that Celsus, Galen and Rhazes did not divide pain into qualitative categories, whereas Avicenna, the great Shia scholar, split it into fifteen.
"Medical stagnation during the High Middle Ages is sometimes attributed to the hostile attitude of the Church", Dormandy announces, dismissing this existing generalization and replacing it with one of his own. He enjoys it all so much he quite overlooks the fact that, in practical terms, medicine had been entirely stagnant pretty much since it began. As David Wootton's recent Bad Medicine (reviewed in the TLS, September 15, 2006) has so pithily argued, the whole idea of Ancient medical history is a myth. Doctors may have changed their fashions, but their treatments were, by and large, consistently worthless. It took science to change everything, and science had certainly not arrived during the High Middle Ages. So what should a historian talk about? The thirteenth century, for example, provides little by way of genuine advancements in pain control. Dormandy doesn't pause for a moment.
He simply picks up the efforts of the Italian Lanfranc in the field of cosmetic ointments, and argues that people are miserable if they look bad and that misery is a form of pain. This is infuriatingly correct, but as Dormandy repeats the strategy -randomly selecting the bits of human history he wishes to relate to pain -it undermines him. If cosmetic appearances are relevant in the thirteenth century, why do we never hear of them again? What, for that matter, about the pain of being made fun of in the playground, or of being persecuted for the colour of your skin? To call something psychosomatic, James Thurber once pointed out, is like referring to a female wife.
Dormandy briefly plays with the idea that emotional and physical pains cannot be separated, but soon he flees back towards conventional stories of medical history.
Accounts of the discovery of the circulatory and respiratory systems add to the tempting illusion that Dormandy gives of steady medical progress. But neither discovery brought health or relief to the suffering, and they belong in a history of physiology rather than one of pain. Dormandy knows this. He notes that William Harvey's discoveries brought no benefits with them, but tells us all about them anyway. Likewise, Wren may well have been an architect, and Malpighi the discoverer of the filtering apparatus of the kidney, but how is either fact relevant to the subject of pain? The history of syphilis is a diversion; opium provides the excuse for launching off all over the place about the role of drugs in art. Opiates do more than relieve dysphoria, they also induce euphoria: "What a resurrection", Dormandy quotes from Thomas de Quincey, "from the lowest depth of the inner spirit! . . . That my pain had vanished was now a trifle in my eyes; this negative effect was swallowed up in the abyss of divine enjoyment thus suddenly revealed". The effect is to suggest that pain can hardly be considered without thinking about pleasure; yet Dormandy fails to follow up these wider suggestions, and The Worst of Evils frequently seems hamstrung by its overly medical perspective. Opium was used to ward off the pangs of living as much as the specific pains of the body: Dormandy describes it being used to soothe the terrors of babyhood and the miseries of living in Norfolk. It is enough to make the reader hungry to hear something profound just in time for Dormandy to retreat back into hospitals and surgeries. He writes at length about drugs that ease angina or treat malaria, he talks of heart transplants and cancer cures and hospital-acquired infections. Infections, like angina and malaria and cancer, all cause pain. But disappointments as well as diseases do this, and having raised his eyes beyond medicine, it is disappointing that Dormandy rushes reflexively back to it.
For all of his breadth, Dormandy leaves a huge amount unsaid. The evolutionary context of pain comes in for a review that is frustratingly brief: "Pain as a stop command is of great evolutionary significance". He points out that pains can helpfully cause us to rest or to lay off rich food, but that they can also exceed in magnitude anything that would be useful. The pain of peritonitis saves no one from death; it only makes that death more horrible, largely because evolution has no impetus to make life tolerable for those about to die.
What happens in the final moments of human life is not subject to natural selection. We remain at the whims of processes designed for other purposes, of what Darwin called the "ineluctable consequences of structural design".
Nevertheless, there are some points to be made about our evolutionary capacity for pain. Visceral pains are vague things, as people quickly discover if they try accurately to describe them.
The nature of the pain is uncertain -is it a gripe, a burn, a stabbing? -and they are poorly localized in time and space. It is hard to say exactly when they started or to locate them with a fingertip. The evolutionary and mechanical reasons -the ultimate and proximal causes -for this poor spatial and temporal resolution are interesting. Many people are familiar with the homunculi of movement and sensation, the hugely distorted human figures that represent the level of detail with which different bits of our bodies are represented in our brains (massive faces, tongues, lips, hands and genitals, sparse limbs and backs and bellies). Dormandy could profitably have reviewed this information, and compared it to the maps of pain that evolution has left us with.
Dormandy launches into a whole chapter about Renoir and the relationship between his art and the pain of his rheumatoid arthritis; he discusses centuries of theories about the relationship between pain and spirituality, good and evil, and human development. No "Victory over Pain", he concludes, "can be celebrated until the treatment of mental hurt has advanced at least as far as has the treatment of physical suffering". He is right, but his assumption that medicine is the field on which this battle will be won is mistaken, and seems flat against his magnificent ability to take an interest in the lives and eccentricities of a host of cultures and characters. Philosophy, economics and art can have more impact on mental hurt than pills -and more on physical health, too, when it comes to it. Dormandy could have written so much more, or disciplined himself to write so much less, and have profited from either choice. Instead he settles for something in between. Worst of Evils is written with a lack of focus, and a wealth of gusto. It is a stylish, frustrating, disappointing pleasure.