The Worst of Evils: The Fight Against Pain (review)

"Pain is perfect misery, the worst of evils," proclaimed John Milton in book 6 of Paradise Lost. Human suffering resounds throughout the great numbers of individual "fights against pain" that form the substance of this book. Drawing on material from literature, art, music, history, and science, Thomas Dormandy explores the myriad theories, therapies, and techniques that have been used since the earliest times to alleviate physical pain, and seeks to place each of these within its wider cultural context. Pain is considered in all its aspects. The history of anesthesia and of analgesics rightly occupies much of the book—but the less obvious facets of physical suffering are also explored. We learn of the excruciating boils caused by "hospital disease" through the story of the Scottishwoman Allie, who in 1830 endured the removal of a tumor in her breast but developed infection postoperatively and died. The work of the Berlin neurologist Moritz Romberg in the 1850s on the "lightning pain" caused by tabes dorsalis—a degenerative disease of the spinal cord caused by syphilis—highlights the way in which the new pathology of the nineteenth century took great interest in the causes and mechanisms of pain. Yet, as Dormandy stresses, diagnosis and the classification of symptoms did not necessarily bring relief for the patients.

Dormandy is aware that his chosen structure is not unproblematic, and he warns in the introduction of the forthcoming "blips, bumps, backtrackings and digressions" (p. 4). In some instances this serves to diminish rather than strengthen his arguments. For example, one way of making sense of the preanesthetic period, which Dormandy characterizes as moving "to the threshold" (p. 189), is to recognize the radical ways in which the medical model of the body and its systems changed between the 1790s, when Humphry Davy and Thomas Beddoes were experimenting with nitrous oxide gas, and the introduction of ether anesthesia in 1846. Davy could not conceive of a way in which the body's sensibility might be suspended without jeopardizing life—but by the 1840s, new anatomical and physiological work showed that sensibility could be suspended without compromising the functions of respiration and circulation. This was the physiological model that John Snow used to integrate the Yankee dodge with ether into the framework of scientific medicine, and it goes some way toward explaining the history of nitrous oxide and ether and their use as anesthetics. Dormandy's discussion of the new physiology is placed several chapters beyond those covering the introduction of anesthesia, and thus the implications of this new knowledge are missed.

There are a few minor slips. The details of anesthetist John Snow's visit to Buckingham Palace in advance of his first administration of chloroform to Queen Victoria are confused with his later attendance at St. James's Palace in 1857 for a court levee. Herbert Snow, the London surgeon who developed the Brompton cocktail (a mixture of morphine and cocaine) that relieved the pain of advanced cancer, is referred to as John Snow. Nevertheless, this work is an important addition to the literature on the history of pain, and Dormandy's potent summary of the current challenges facing medicine rightly emphasizes that the subject is a matter of "hope—but not triumph" (p. 500). Though we may have found many effective solutions to the problem of physical pain, it should not be forgotten that the medical management of mental suffering is in its infancy. Milton may well have been thinking of the corporeal aspects of pain, but those enduring the torment of depression and other psychiatric disorders in the twenty-first century know full well the "perfect misery" of mental pain.

The Worst of Evils will be enjoyed by general readers as an erudite and thought-provoking book; historians will perhaps be stimulated to flesh out some parts of this still-neglected topic in the history of medicine; and doctors may even be inspired in their search for new avenues for pain...