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Journal of the History of Medicine and Allied Sciences 57.3 (2002) 364-366



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Book Review

From Lesion to Metaphor:
Chronic Pain in British, French, and German Medical Writings, 1800–1914


Andrew Hodgkiss. From Lesion to Metaphor: Chronic Pain in British, French, and German Medical Writings, 1800–1914. Clio Medica 58/Wellcome Series in the History of Medicine. Atlanta, Georgia and Amsterdam, Rodopi, 2000. iii, 218 pp. $51 (cloth), $17 (paper).

Andrew Hodgkiss, a British psychoanalyst and liaison psychiatrist, takes issue in this well-researched book with the history of chronic pain presented [End Page 364] by Harold Merskey and Graham Spear (Pain: Psychological and Psychiatric Aspects, 1967), David Morris (The Culture of Pain, 1991), and Roselyne Rey (The History of Pain, 1991) and accepted by most previous writers. The reader need not agree fully with his conclusions to appreciate his scholarship and incisive analysis. Chronic pain not associated with a recognized illness or injury was as enigmatic in the nineteenth century as it is in the twenty first. The standard historiography has asserted that, by the 1840s, “lesionless pain” was viewed by physiologists and clinicians as imaginary, the creation of a liar or a neurotic. Historians have built this narrative from two strands. First, as described by Foucault, the French school’s emphasis on localization of disease and association of clinical signs with autopsy findings devalued the patient’s report of subjective symptoms such as pain early in the century. Then, within a few decades, the localization and tracing of the somatosensory nerve pathways to the spinal cord and brain, beginning with the work of Charles Bell and François Magendie, had reduced the definition of “real” pain to the sensory response to an external stimuli. Hodgkiss instead presents lesionless pain as an unresolved problem that “drove medical authors to improvise at the limits of current medical theory time and again” (p. 132). He demonstrates, through careful reading of British, German, and French texts, including the work of several authors not well known today, that debate over the origins, nature, and meaning of lesionless pain continued throughout the century. Recognizing the anomaly of pain without lesion in the new anatomo-pathological medicine of the French school, François J. V. Broussais developed the concept of functional lesions (developing pathologies not yet visible as structural damage), which he attributed to visceral irritation, and Benjamin Brodie attributed to spinal irritation. To explain the difficulty of localizing such lesions, French and British physicians described the phenomena of radiation (along the nerve fibers to other parts of the body) and eccentricity (a pain originating within the body and is interpreted by the brain as a signal from the periphery).

Johannes Müller, the great German physiologist who presented the influential theory of “specific nerve energies” in 1838, has often been cited as the first to describe “real” pain as the simple sensory response of dedicated nerves to noxious stimuli. Hodgkiss argues that Muller’s thinking about pain should instead be placed within the school of Gemeingefühl, or cenesthesis, the organism’s ability to perceive its own sensory states. Müller wrote, “We do not feel the knife which gives us pain, but the painful state of our own nerves” (p. 79); thus he suggested that “real” lesion-based pain and subjective pain, a disorder of cenesthesis, were physiologically equivalent in terms of the state and activity of the nervous system. What actually began to separate “real” pain from lesionless pain, in Hodgkiss’s story, were not the findings of physiologists in laboratories, but the sensory examinations [End Page 365] of clinicians at the bedside. As neurologists defined the parameters of their field and improved their diagnostic skills and recognition of clinical signs, they gradually excluded “neurasthenia” and many forms of “neuralgia” from their practice as subjective disorders best treated by alienists. Hodgkiss traces this process through the work of Romberg, Charcot, and Gowers, among others. The work of Freud on hysteria marks a final turning point. Soon after the...

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