Medical science and practice evolves in a three-step dance: innovation, counterinnovation and assimilation. Lasting change in most intellectual arenas, including philosophy, science, religion, military conflict and technology, progresses through these steps. Yet in retrospect, in examining the salient factors and the time, the outcome seems to have been inevitable all along. However, in the middle of change, the outcome is anything but certain or inevitable. Consideration of paradigm shifts in the context of their unique contemporary society is instructive for understanding the current evolution of the medical specialty now termed “pain medicine.” The older term, “pain management,” conjures up images of apartment-complex management, not the focused practice of a medical specialty by specifically licensed physicians.

The 18th century, like the Renaissance centuries before, was an age of confidence in new knowledge, invention and philosophy. It has been described as the “encyclopedic century” as it set the stage for new inquiry into the human condition, including the medical treatment of pain. When mesmerism arrived in England from Europe in the late 1820s and early 1830s, it was received by ambitious medical reformers hungry for innovations in medical treatment. Based on the work of Franz Anton Mesmer (1734-1815), physical symptoms were treated by magnetization and focused attention on the patient; only later was the disparaging term “mesmerism” given by the press.

In 1828, 64-year-old Madame Plantin felt no pain after being mesmerized for a procedure to remove her right breast. Although the operation was considered a success, she died soon after. Image courtesy of Women’s Health in Primary Care

Half a century earlier, animal magnetism, a precursor of mesmerism, had a checkered reputation with talk of “magnetic spies standing on the shores of France radiating submission into the minds of honest British yeomen.”¹ Clinical application of these theories was quickly dismissed in the late 1700s by both the Académie des Sciences and the Académie de Médecine. Wild dreamers and poets such as Robert Southey, Percy Bysshe Shelley and others were the next to experiment with some of these novel techniques. Their speculations and experimentation, however, became cast in the public mind as a radical philosophy and died a quiet death.

It was not until 50 years later that Victorian England was ripe for this resurrected philosophy. Physiognomy, natural philosophy, morphology, phrenology and mesmerism were all based on the application of rational causes of natural phenomenon rather than supernatural or religious explanations of the external world. This resulted in phrenologists linking brain physiology with personality, physiognomists describing the reflex arcs between nerves and behavior and practitioners of electrical medicine describing the body as a battery that dispensed electrical impulses. Mesmerism was a new and exciting way to control medical symptoms and pain that contrasted with the prevailing medical philosophy of the quiet acceptance of Fate, which was governed by supernatural forces.

Mesmerism in Victorian England produced in many subjects an altered consciousness that allowed relaxation, visualization and, in some cases, even pain control. It gave many people some degree of power over their unconscious mind. Mesmeric societies sprang up, journals devoted to the psychic were published, and applications and techniques were described to produce everything from surgical analgesia to the treatment of sciatica, neuroses, gastrointestinal afflictions and menstrual troubles.²

A most striking event was the case of Madame Plantin and her amputation by the mesmerist surgeon Jules Cloquet in 1828, which was attended by a dozen witnesses. The operation was considered an amazing success despite the patient’s death shortly thereafter. Published in France in 1831, it was not translated into English until 1833 by Scottish mesmerist and attorney J.C. Colquhoun.³ A similar lag-time from demonstration to publication also was experienced in the United States in Georgia by one Crawford W. Long, M.D.

Reports followed of the salutary experts’ efforts of mesmerism for both surgical analgesia and chronic pain states, and it is no fluke that the reported comment by Robert Liston, M.D., after the successful administration of ether anesthetic in an above-knee amputation was, “This Yankee dodge beats mesmerism hollow.”⁴ Thus, after the successful introduction of ether for surgical anesthesia, the gauntlet was dropped for a bitter conflict between mesmerism and inhalational anesthesia with charges flying from both sides.

Robert Liston, M.D. Image courtesy of the Wood Library-Museum of Anesthesiology

The mesmerists likened ether anesthesia to alcohol intoxication, which resounded with temperance advocates who described a patient under ether anesthesia as being rendered “dead drunk.” The physiologist William Bennet Carpenter, M.D., editor of the Medico-Chirurgical Review, censured “indiscriminate” use of ether by people within and outside of the medical profession. He railed against signs in London shops proclaiming, “Painless extraction of teeth,” and in Paris, “Ici on etherize,”⁵ which, roughly translated, means “etherization here.” The attempted commercialization of ether by William T.G. Morton and others selling patent use rights and the commonly held public, circus-like theatrical displays and recreational ether frolics also weighed heavily against inhaled anesthetics as a “scientific” medical treatment.⁶

On the other side, ether proponents were quick to publicize their experience in the medical and surgical journals of the day, particularly as compared to the three- to five-year lag-time in reporting the surgery of Madame Plantin under mesmerism. After the public introduction of ether anesthesia on October 16, 1846 by Morton at the Massachusetts General Hospital, news of the event spread rapidly to England. In the first six months of 1847, the British journal Lancet alone published 112 articles on ether.⁷

The next step, assimilation, would begin thereafter. Mesmerists tried to add ether inhalation to their armamentarium. A prominent Edinburgh chemistry professor, William Gregory, deplored these mesmerists who espoused ether as an adjunct to their practice^w rather than recognizing it as the eventual replacement it was to become. The dramatic struggle for who controls the battlefield of surgical anesthesia — who controls the administration, methods, qualifications and credentialing, teaching programs, reimbursement and a host of other conflicts — continues even to this day but with different partisans. Who should be licensed to administer anesthetics, where and under what circumstances and how they should be reimbursed are questions that continue to absorb an inordinate amount of energy in professional societies even now.

Like surgical anesthesia in 1847, pain medicine is in the early childhood, or the innovative phase, of its development as a medical specialty. Advances in science, medications and a host of new interventional treatment options in the last decade alone foreshadow a rapid growth phase over the next few years. Some theoretical paradigms and clinical pathways will flourish and stand the test of time. Others will wither and fall away.

Counterinnovation, then, is on the horizon. Who will control this new specialty? Issues in training and education, perspectives in scientific basis and theories, credentialing of practitioners, licensing and board certification and, in our century, economic success and failure loom large and will need to be resolved in this current generation of pain medicine specialists.

After these battles are fought, blood is shed and resolution finally ensues, the great rebuilding process of assimilation will determine the future direction of pain medicine — at least until more provocative innovations overtake us.

Doris K. Cope, M.D., is Professor of Anesthesiology, University of Pittsburgh Medical Center (UPMC), and Clinical Director of UPMC St. Margaret Pain Medicine Center, Pittsburgh, Pennsylvania.