Pain Without Lesion : Debate Among American Neurologists , 1850 – 1900

The central claim of this paper is that neurologists in mid-to-late nineteenth-century America generally denied the possibility that pain could exist in the absence of material lesion. There is ongoing debate over the medical status of pain sufferers in mid-to-late nineteenth-century America, with some arguing that what we might now term “chronic pain” became invisible during the period; others assert that physicians of the time were acutely aware of and sensitive to the suffering of their patients from a variety of pain experiences. Drawing on prior work related to the social and cultural efficacy produced in fin-de-siecle American culture by imaging the visible lesion, I argue that these apparently divergent views are both correct. On the one hand, there is little support in the primary sources for the idea that mid-to-late nineteenth-century American physicians ignored or trivialized the pain experiences of their patients. Indeed, given the Victorian emphasis on suffering and sympathy, such behaviour would have been especially taboo, at least with regards to socially privileged patients. On the other hand, the fact that American physicians of the time were aware of and sensitive to their patients’ pain does not imply that the physicians allowed that such pain could exist in the absence of a material (morbid) lesion. I contend that American neurologists followed their European counterparts in repeatedly insisting that if the patient experiences pain, then such a lesion must perforce exist, even if imaging techniques of the time simply did not permit discernment of the lesion itself. This finding has several implications. First, it fills a gap in the relevant literature inasmuch as there is little sustained historical analysis of the attitudes, practices, and beliefs of mid-to-late nineteenth-century American physicians regarding pain without lesion. Second, it contributes to the historiography demonstrating the power and significance that the increasing emphasis on discrete objects of disease had in mid-to-late nineteenth-century America. Third, it suggests some possible lessons for thinking about the continuing importance of the visible lesion in the widespread undertreatment of pain in the contemporary USA.


Introduction
In his 1887 treatise on spinal irritation, American neurologist William A. Hammond observed that he would endeavour 'not to claim too much for a pathological condition which I am very sure exists, and which I therefore think is entitled to recognition'. 1 The fact that Hammond, who was unquestionably one of the most important physicians in the USA during the latter half of the nineteenth century, begins his exposition by assuring readers that spinal irritation does in fact exist implies his awareness that some members of his intended audience might harbour doubts. Moreover, Hammond's choice of language is critical; he does not assert a nosological claim, that the disease of spinal irritation exists, but rather advances a morphological/anatomical claim, that the 'pathological condition exists'. The linking of the disease entity to its pathological condition suggests that the nosological reality is a function of its pathological anatomy. Where a discrete, material lesion exists that can be clinically correlated with a patient's illness complaint, the disease exists and is entitled to recognition. Charles Rosenberg captures this framework when he observes that, by the end of the nineteenth century in the USA, the social legitimacy of disease presumed 'somatic identity'. 2 The central claim of this paper is that during the late nineteenth century, leading neurologists generally denied the possibility that pain could exist in the absence of material lesion. There is ongoing debate over the medical status of pain sufferers in the mid-to late nineteenth-century West, with some arguing that what we might now term 'chronic pain' became invisible during the period; 3 others assert that physicians of the time were acutely aware of and sensitive to the suffering of their patients from a variety of pain experiences. 4 I argue that these apparently divergent views are both correct. On the one hand, there is little support for the idea that American physicians of the time ignored or trivialized the pain experiences of their patients. Indeed, given the Victorian emphasis on suffering and sympathy, such behaviour would have been especially taboo, at least with regards to socially privileged patients. On the other hand, the fact that American neurologists were aware of and sensitive to their patients' pain does not imply that they The dearth of extant narrative experiences of pain is one justification for this article's focus on the attitudes, practices, and beliefs of physicians regarding pain. In examining the intellectual constructs through which leading American neurologists understood pain that presented without discernible lesions, there is no intention to minimize or invalidate the patients' experiences. Rather, the assumption is merely that understanding what physicians thought about their patients' pain without lesion is a worthy subject of inquiry in its own right, especially as there is little doubt that the neurologists' conceptions of such pain strongly influenced the nature of the therapies and remedies deployed, including the decision of whether any intervention at all was appropriate. If a physician disbelieved the existence of an underlying disease marked by the patient's pain symptoms, it was far less likely that treatment of any kind would be prescribed. If the disease did not exist, why would clinical interventions be warranted?
To the best of my knowledge, there are no historical analyses focusing on ideas regarding pain without lesion among American physicians of the mid-to late nineteenth century. 7 It is well known that pain is far and away the most common complaint contemporary American patients bring to their physicians; there is little reason to believe that pain was significantly less common an experience for people living in the nineteenth century. The argument, therefore, is that understanding something about the attitudes and beliefs of the physicians treating them merits study. Understanding these attitudes and beliefs in turn requires a basic understanding of the sea-changes in Western allopathic medicine that occurred during the nineteenth century.

Pathological Anatomy and the Birth of the Clinic
In The Birth of the Clinic, Michel Foucault argues that, at the turn of the nineteenth century, in one of the centres of Western medicine (Paris), a group of scientists and physicians began to formulate a model of health and disease that would come to be called the anatomoclinical method. 8 Foucault's answer to the implicit question in the title of his The emphasis on the illness sufferer's life-world, on a holistic notion of the interplay between subject and illness, is also evident in humoral understandings of pain.
Lisa Wynne Smith's analysis of several sets of eighteenth-century medical consultations confirms the general medical cosmologies attributed here to a humoral schema. The language of pain in these letters 'was extraordinarily descriptive and personal.
Humoralism fundamentally shaped sufferers' experience of their bodies, as revealed by descriptions of internal sensations and mind/body overlap.' 11 Specifically, suffering had a flexible vocabulary, concurrently describing physical and emotional pains in ways that underscore the anxiety surrounding illness. This emphasizes the extent to which body and mind were inseparable in the early eighteenth century; pain involved one's whole being, both body and soul. Patients and their doctors often referred to emotional states as symptoms. (p.

463)
Thus one early modern physician linked his clinical diagnosis 'with the patient's perceptions, which appear plainly -"sinking at the heart". While it was a physical problem, the term also indicated an emotion when alongside symptoms like "heavy disposition" and "dejection of spirit"' (p. 465). This early modern linkage of body and soul in context of pain has older roots.
Esther Cohen observes that 'all major late medieval discourses on pain -in theology, medicine, and law -viewed "physical" pain as a function of the soul'. 12 Erected primarily on Augustinian foundations, pain was inextricably linked with guilt and fear. 13 Augustine explained the martyrs' lack of pain on this basis: they, like the Virgin Mary herself, did not suffer pain because they were free of guilt and fear: 'The message was clear: pain lay in the soul; it resulted from the soul's sin and guilt, and its awareness of that guilt, of the ensuing retribution, and of the fear thereof' (Cohen, 'Animated Pain', p.

45).
The key point in the humoral conception of pain was the fundamental enmeshment of 'physical' and 'emotional' pain, of mind, body, and soul. 14 Consistent with humoral medical cosmologies, the subjectivity of the patient's lived experiences was inseparable from illness and pain. However, this is not to suggest that the concept of pain in humoral schemes was unproblematic. The connection between expressions of pain and truth challenged persons and communities from the Middle Ages to the early modern period, and the best evidence of this is in the practice of torture. 15  However, while the interplay between pain, suffering, guilt, and truth are complex and challenging, there is in humoralism a unity between 'physical' pain and mental or emotional experiences such as suffering, guilt, and fear. In comparison, the importance of pathological anatomy to the practice of medicine during the nineteenth century signals a sea-change. Disease began to be conceptualized in a different sense, and a novel medical cosmology predicated on local, discrete entities as the cause of disease began to be not simply studied, but practised. 16 Foucault observes that at a very early stage historians linked the new medical spirit with the discovery of pathological anatomy, which seemed to define it in its essentials, to bear it and overlap it, to form both its most vital expression and its deepest reason. 17 While there is general acceptance among historians that anatomy gradually became more important during the early modern era, it was not until the nineteenth century that it would begin to take on a central role in defining medical practice. 18 Foucault even terms the new method the 'anatomoclinical' method, and his locution remains the norm.
Foucault characterizes this change: The appearance of the clinic as a historical fact must be identified with the system of these reorganizations. This new structure is indicated -but not, of course, exhausted -by the minute but decisive change, whereby the question: 'What is the matter with you?', with which the eighteenth-century dialogue between doctor and patient began (a dialogue possessing its own grammar and style), was replaced by that other question: 'Where does it hurt?', in which we recognize the operation of the clinic and the principle of its entire discourse. (p. xvi) Foucault's point is that the birth of the clinic is linked with the capacity to localize discrete agents of disease to specific places, structures, and tissues inside the body. Whereas prior to the nineteenth century, tissues were far less important than the hollow channels through which humours flowed, this conceptual geography was inverted during the nineteenth century. 19 This inversion shows the importance of pathological anatomy to the birth of clinical method. Indeed, Martensen goes so far as to suggest that 'Western learned medicine's most distinctive knowledge-making feature has been its historic reliance on anatomy' (p. 95). In a particularly revealing passage, Elizabeth Hurren notes the changing conceptions of cadavers in the Oxford anatomy department of the late nineteenth century: When the department opened, every body taken for dissection was named, and funeral expenses were recorded individually. After ten years, during which the department expanded, the bodies were no longer named but instead were numbered. Finally not meant to be taken literally; the importance of physically seeing the signs of illness was understood long before the nineteenth century. 20 But the clinical gaze itself did mark something fundamentally distinct from the medical cosmologies that preceded it. As historian Roselyne Ray observes in context of pain, at the dawn of the nineteenth century, physicians were looking for a pure sign which would remove the ambiguities inherent in symptoms. They wished to find a sign, the meaning of which would be as certain as that provided by the lesion found at dissection. 21 Within this context, I now turn to an analysis of how pain without lesion was conceived of among leading neurologists in mid-to late nineteenth-century America. The nineteenthcentury changes in medical culture had dramatic effects on the way pain was conceptualized.

III The Invisibility of Pain
Literature scholar David Morris picks up the Foucauldian interpretation of the birth of the clinic and connects these nineteenth-century changes to pain in context of a revolutionary readjustment in the realms of the visible and the invisible. In effect, while a new clinically based scientific medical perception begins to make pain increasingly visible inside the body, pain outside the nervous system and outside the clinic begins to seem correspondingly invisible. 22 His point is that the focus on tissue pathologies and structural lesions that shaped the anatomoclinical method meant that pain that was not visible inside the body began to vanish from sight. Morris  The first step to understanding how this reconciliation is possible is assessing the impact of the specificity theory as to pain, a theory that was connected to developments in experimental physiology and electricity. Many nineteenth-century physicians and scientists discussed the potential and capacity of electricity to treat various kinds of pain. 24 Some of the most significant conceptual work regarding electrophysiology was done by Johannes Müller, whose findings were also critical to the conceptualization of pain during the nineteenth century. His discovery of the specialization of nerve fibres and the electrochemical conduction of signals is crucial because it facilitated the development of the specificity theory with regard to pain. 25 The specificity theory is not one account, but is rather a general framework for the physiology of the nervous system. In its most basic form, the idea is that specific nerve fibres respond to specific stimuli and convey particular sensations related to the stimulus.
This means that the application of cold, heat, and pain result in the activation of certain nerve fibres, but not others (Ray, which excites the muscles to contraction is conveyed only by the anterior roots. We therefore have a separate localization of sensation and motion in this part of the nervous system; and it is easy accordingly to understand how one may be impaired without injury to the other. 26 Similarly, in an early treatise on 'spinal irritation', which, as we shall see, was a topic of great interest to leading late nineteenth-century American neurologists, Philadelphia Given the significance of pathological anatomy to nineteenth-century medical thought, it is unsurprising that nineteenth-century neurologists found pain caused by gross lesions easy to diagnose (though not necessarily easy to treat). 36 This is at least in part because gross cerebral lesions tended to produce a number of other symptoms that contributed to the differential diagnosis, including 'progressive loss of muscular power, vertigo, visual impairment and derangement of the faculty of recollection'. 37 But what of pain that tended to occur in the absence of discoverable lesions? Corning observes in two of his texts that 'organic disease is by no means as frequent a cause of headache as might be imagined from the percentage of gross cerebral lesions'. 38 How did leading neurologists conceive of pain without lesion during this period?
If one understands the term 'lesion' as more than the gross cerebral lesions that physicians had long known of, then the best answer is that leading neurologists did not conceive of it at all. This is certainly not to suggest that nineteenth-century American physicians were ignorant of pain without lesion, nor that they trivialized it. 39 Indeed, there is little support in virtually any primary sources for the proposition that physicians typically invalidated their patients' pain.
However, this observation must be qualified: it is socially privileged patients whose pain was more likely to be legitimized and acknowledged. Like most forms of medical care, nineteenth-century regard and treatment for pain was distributed according to a number of different social strata, including class, race, age, gender, occupation, and other indicia of social status and hierarchy. Thus, for example, Martin Pernick pointed out over a generation ago that a complex moral calculus governed the dispensation of analgesia in nineteenth-century America, and predictably, that members of marginalized groups in American society (for example, African-Americans and the poor) were less likely to be administered analgesia. 40 Furthermore, while it is generally correct to note that socially privileged patients' pain was not ignored by nineteenth-century physicians in either Europe or in the USA, there are well-documented exceptions, such as the case of railway spine or spinal concussion. In both Great Britain and the USA, many physicians and neurologists rejected injured workers and railway passengers' complaints of injury following railway accidents. 41 But even with these qualifications, the general proposition that nineteenth-century neurologists did not ignore or trivialize their socially privileged patients' pain is generally correct. However, the claim Morris advances is that pain without lesion becomes invisible during the nineteenth century. A number of leading nineteenth-century physicians and neurologists suggested that even pain which seemed to appear in the absence of any lesions must nevertheless feature such lesions. As an object of inquiry, then, pain without pathology in some kind of tissue ceases to exist in the clinical gaze.
One of the best sources for locating this view is Hammond's treatise on spinal irritation. Hammond was one of the progenitors of American neurology and the founder of the American Neurology Association. 42 His views on pain without lesion are therefore particularly important. Nineteenth-century physicians were quite aware of the existence of pain that seemed to persist in the absence of any identifiable lesion. Accordingly, Hammond has no patience for those who reject the disease known as 'spinal irritation': It must be admitted that there are not wanting those who refuse to believe in the existence of such a disorder. Such persons must necessarily belong to one or the other of the following categories: Their experience must have been very limited, and therefore they cannot see; or they must have been endowed either with restricted powers of observation or with minds so constituted as to cause them wilfully to close their eyes to the facts that they did not care to see. (Spinal Irritation, p. 19) In referring to those who 'cannot see', who have 'restricted powers of observation', and who 'close their eyes to the facts that they did not care to see', Hammond emphasizes the power of clinical sight in validating spinal irritation. 43 Yet, the fact that Hammond undoubtedly believed in the existence of spinal irritation does not imply that he countenanced the existence of pain without any material pathology.
According to Hammond, the general cause of spinal irritation is anaemia of the spinal cord, which in late nineteenth-century terminology generally translated as 'weakness' of some sort. 44  Owing to the fact that spinal irritation is not per se a fatal disease, we rarely have the opportunity to verify any views we may hold in regard to its pathology. In the few cases in which post-mortem examinations were made nothing abnormal was found, a circumstance, however, far more compatible with the idea I have expressed than with any other.
In all cases in which the patho-anatomy of a disease cannot be positively ascertained, we are warranted in constructing a hypothesis of its real nature from such data as is at our command. It is better to do this, even if the view we enunciate is not absolutely sufficient to account for all the observed phenomena, than to shut up our opinions in our own minds, or, worse still, form none whatever. (p. 53) And what is true of the spinal cord is true of other organs of the body. There is not one which may not be the seat of a morbid process in some exceedingly limited part, while the remainder of its tissue presents no evidence of disease. Indeed, the reverse is the exceptional condition. (p. 57) As such, the general failure to locate the lesion that causes spinal irritation at post-mortem does not imply its non-existence. On the contrary, given the localization of lesions, it is likely that the seat of disease exists at some specific region in the spinal cord or central nervous system.
Thus, Hammond's argument is that the seat of spinal irritation is localizable in a lesion that exists somewhere in the spinal cord, but whose precise location and character has not yet been ascertained. Hammond confirms this: From all these points it appears to me that the pathology of spinal irritation is as clearly made out as that of any other disease in which we do not have the opportunity of making post-mortem examinations, or in which, having such opportunities, the lesion remains undiscovered. (pp. 67-68) The power of the lesion in the construction of pain is such that the possibility that pain might exist without a lesion is not tenable for Hammond. This does not mean that Similarly, Parrish notes (decades earlier) in his 1832 discussion of spinal irritation that 'many chronic nervous disorders have a local and determinate seat in some portion of the spinal marrow or great sympathetic ganglia, and hence that these obstinate diseases are most effectually treated by applications directed to spinal column'. 45 As historian Bonnie Ellen Blustein points out, however, Hammond was a particularly committed reductionist as to the role material structure played in defining illness. 46   A great deal of energy has been spent in discussion as to whether neuralgia is due to changes in the central cells of the sensory nerves, in the nerve-fibres themselves, or in the end-organs […]. It is useless to go into these differences of opinion, because they are entirely speculative, with scarcely a respectable fact to prop any one of them up. The truth of the matter is, that we do not know of the molecular changes which constitute neuralgia, and we shall never know until we have instruments delicate enough to enable us to dip down into a living cell of cord or skin and have a microscopic view of molecular life. 50 Putzel and Gray's emphasis on the technical gaps preventing visibility of the lesions presages the importance of the subsequent use of medical imaging techniques in illuminating features of the inner body that were previously undiscoverable -X-rays, electroencephalography, tomographic techniques, and, of late, fMRI.
What these sources demonstrate regarding the notion of pain without lesion is its incoherence. Severe chronic pain most certainly 'existed' in the eyes of these healers, and the general humanitarian impulse of the nineteenth century prompted widespread social and cultural concern with pain and suffering itself. 51 The key point is neither that pain without lesion was ignored or trivialized nor that American physicians failed to appreciate the depth of their patients' suffering. Rather, the crucial point is the link between material tissue pathology and pain. That chronic, intractable, difficult pain could exist without lesion as a primary causal factor was untenable, so much so that leading American neurologists were prepared simply to assume the existence of a lesion in a specific location in the body. Pain itself becomes a material problem, in the sense that its existence seemed to be predicated on the existence of a localized tissue pathology that causes the pain.
I have argued in this paper that many primary American sources do support that "molecular changes in its structure" must be present'. 56 Finally, Charcot maintained that for any report of pain, 'a dynamic lesion was present in the cortical domain corresponding to the region of the body implicated by the patient's ideas'. 57 Ultimately, much of the evidence Hodgkiss cites supports Morris's (and my) claim that while pain without lesion was neither ignored nor trivialized, the possibility that severe and persistent pain could exist without a correlative pathology in some material structure in the body, be it brain, nervous system, organ, or other, was simply untenable.

Conclusion
In this paper, I have offered one possible means of resolving the historical debate regarding the medical status of persons experiencing pain without lesion in mid-to late nineteenth-century America. The dispute has centred on the question of whether pain without lesion became invisible during this period. I have argued that there is a very real sense in which pain without lesion ceased to exist; namely, the idea that pain could exist in the absence of a discrete, material pathology became increasingly untenable during the long nineteenth century. This interpretation differed from earlier constructions of pain in