From Lesion to Metaphor: Chronic Pain in British, French and German Medical Writings, 1800-1914 (review)

Andrew Hodgkiss. From Lesion to Metaphor: Chronic Pain in British, French and German Medical Writings, 1800-1914. Clio Medica, vol. 58. Wellcome Institute Series in the History of Medicine. Amsterdam: Editions Rodopi, 2000. iii + 218 pp. $51.00 (cloth), $17.00 (paperbound); Hfl. 120.00 (cloth), 40.00 (paperbound); £36.00 (cloth, 90-420-0831-8), £12.00 (paperbound, 90-420-0821-0).

This book makes a valuable, if limited, contribution to the nineteenth-century history of pain--specifically, to what Andrew Hodgkiss calls "pain without lesion." He begins by evoking the familiar clinical gaze that transforms prescientific medicine through a focus on localized lesions. "It occurred to me," he writes, "that pain without any lesion must have constituted a major difficulty for nineteenth-century physicians adopting such a praxis" (p. 2). The conundrum of lesionless pain in the era of lesions prompts Hodgkiss to write "an unashamed history of ideas with the emphasis on elite medical theory, diagnostics and nosology" (p. 187).

The title requires modest translation, because nineteenth-century lesionless pain is not identical with the broader modern category of chronic pain. It opens a Pandora's box of vague illnesses: "The terms used to name the clinical phenomenon of chronic pain without lesion varied very widely over the course of the century. An abbreviated list would include: sympathetic pain, neuralgia, hysteria, local hysteria, hypochondria, spinal irritation, railway spine, neurasthenic pain, hystero-neurasthenia, ideogenic pain, psychogenic pain and cenesthopathic pain" (p. 184). Despite problems of terminology and focus, it is useful to have a study that sets such common nineteenth-century afflictions within the larger histories of pain.

Hodgkiss proves most useful in providing brief, lucid discussions of important medico-scientific texts dealing with aspects of pain, by authors from Bichat, Broussais, Bell, Magendie, Charcot, Briquet, Brown-Séquard, Handfield-Jones, Gowers, and Tuke to Griesinger, Breuer, and Freud. Numerous minor writers and writings also help him explore variations both within and beyond the nineteenth-century Anglo-French tradition that interpreted pain as a marker of lesion. Hodgkiss not only discusses divergent voices within this tradition but also draws attention to an important German Romantic tradition (associated with the work of Müller) that understands pain differently. He shows that nineteenth-century scientific and medical views on pain are too diverse to fit into a monological system.

This account of medical and scientific diversity includes a tendentious side, or asides. Hodgkiss opposes the "historical orthodoxy" (p. 184) that emphasizes the nineteenth-century rise of reductionist neurophysiology--an emphasis that ignores attention to psychological dimensions of pain, which nineteenth-century practitioners and theorists by no means always dismissed as "imaginary." His arguments and evidence turn less persuasive, however, when he opposes the orthodox view that nineteenth-century lesionless pains are "socially constructed." (Social construction, in my view, requires a biological substrate.) He contends that the clinical picture of lesionless pain demonstrates "historical invariance" (p. i); later, he hedges his description as "rather historically invariant" (p. 8); and later, as showing "some historical invariance" (p. 184). He is aware of other drawbacks: "I have written a book about a problem very close to the history of hysteria," he concludes, "without discussing feminist histories of hysteria" (p. 187). The deliberate "omission" (p. 188) of feminist thought is emblematic of a history that construes ideas, too narrowly, as independent of the social contexts in which they circulate, alter, and absorb the multileveled historical contact of institutional, political, and cultural life.

Hodgkiss's book is more satisfying as a welcome survey of important and often neglected nineteenth-century medical writings on pain, with or without lesions, than as a historical argument showing (as he claims) how pain holds "a central place" (p. 184) in "driving" two revolutions: the birth of the anatomoclinical method around 1800, and, in the 1890s, the invention...