From lesion to metaphor: chronic pain in British, French and German medical writings, 1800-1914.

This is the first monograph devoted to the history of chronic pain. A novel methodology is used. Examining responses to a problem that remained stable over time anchors a survey of shifting terms and theories and leaves the historical invariance of the clinical syndrome open to textual research. Writings by medical authors from a wide range of professional backgrounds are examined including surgeons, physicians, psychiatrists, neurophysiologists, neurologists and psychoanalysts. Early responses to the problem of chronic pain without structural lesion were the appearance of neuralgia, a neuro-anatomical rewriting of traditional sympathies, extension of the concept of lesion to embrace disturbance of function and appeals to cenesthesis. Later in the century distinctions were drawn between hysterical and neuralgic pain, and between ideogenic, psychogenic and neurogenic pain. Some argued for the physiological equivalence of chronic pain and melancholia, while pain was central to Freud's original notion of conversion. This evidence of continuous discussion of lesionless pain throughout the century challenges the orthodox historical view that the rise of neuroscience meant such pain was simply dismissed as imaginary. The historical invariance of a syndrome of chronic pain without lesion speaks against histories of lesionless syndromes premised on social constructionism. The historical findings are relevant to contemporary debates about the nosology and nature of chronic pain.