The Pain Chronicles (11 page)

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 initially 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”?

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.