WE GO TO THE DOCTOR TO HAVE OUR PAIN named. But who names pain for the doctor? It was time to slip across the border into the world of pure science, where the idea of pain—the how and why of it—is under radical revision.
The Ninth World Congress of the International Association for the Study of Pain was scheduled to take place in Vienna. The combination of this particular gathering in this venue, the city where Freud first inhaled cocaine, was one I found impossible to resist. It would be a chance to crawl under the big top with several thousand of the world’s leading pain scientists and researchers. Part of me was curious to observe the social habits of pain experts at play, too. What could be more relaxing (I wrongly assumed) than a cocktail party of anesthesiologists?
I’m sure Vienna was chosen for its convention facilities rather than its own history of wounds and woundings, but it seemed to me that there were unavoidable ironies involved. In this most civilized of cities, anti-Semitism and extreme right-wing politics have flourished, too. It’s a culture that has produced the music of Mozart, the gilded melancholy of Gustav Klimt’s painting, and the frank anguish of Egon Schiele’s hollow-eyed portraits. Hitler dreamed his dreams here, along with Freud, Trotsky, Brahms, and Wittgenstein (a pain expert himself). Talk about a civic mind-body split.
The World Congress on Pain, an event that takes place every three years in different corners of the globe, is mostly a gathering of pure scientists and researchers rather than clinicians. It is pain at its most theoretical, original, and abstract. Perfect for the city where Freud struggled to create not just a theory but a science, a neobiology, of the unconscious. Perhaps it was the Viennese coffee—strong and very good—but I found that the congress and the city both conspired to produce thoughts on the same imperial scale as the art museums and the virile rooftop statuary. Everything was very big; dinky thoughts were out of the question.
It was possible to die of dehydration, for instance, before getting from one end of the famed Kunsthistorische Museum to the other. I was looking for a particular Brueghel painting, an apotheosis of pain called The Murder of the Children in Bethlehem. A postcard of the painting is tacked on my Wall of Pain, which features Frida Kahlo, Betty Goodwin, and this particular eerie portrait of infanticide by Brueghel the Elder. But after backpacking through a dozen art-stuffed salons, I had an attack of museum fatigue and postponed my search.
I stayed in an old-fashioned third-floor pension near the museums. The place had seen better days, but I loved its creaking, crate-sized lift, and the wide staircase where decades of feet had worn shallow curves into the stone. My room was spartan but absolutely vast (of course), with high ceilings, a huge armoire, and a balcony that let in an ocean of light. It was August, and the weather had a military uniformity—clear, sunny, and blue every day. This was not a slipshod town.
Breakfasts were served in the pension’s old-world dining room by a shy, mousy waitress. They never varied—a bun, some marmalade, thin, damp sheets of cheese, and an indeterminate cold cut.
But I came to appreciate all that protein, because the days at the congress were long, and the cafeteria was heavy on almond torte. My fellow pensioneers were for the most part genteel professors doing research. It was the perfect spot for an academic gate-crasher like me.
I had a day to kill before the congress got under way, and since Vienna invented the concept of the coffeehouse, I betook myself to one. I ordered a mélange in the Café Centrale, a palatial hangout that Freud and Trotsky favored, but it seemed to have devolved into a tourist spot. I made my way across the cobbled Karlsplatz, where I remembered that I am afraid of large squares, and scurried down the closest narrow street. There I took a seat at the equally legendary but still bohemian Café Hawelka. It was a dark and pleasantly shabby cubbyhole, with worn velvet banquettes, inky wooden floors, and waiters in white shirts and black waistcoats who carried small silver trays. The Hawelka served only coffee and two items of food, both cake: the marble and the plum sponge. Each thick-lipped cup of coffee arrived with a silver spoon balanced across the top. A few dollars for a coffee mostly buys time—hours of idle sitting, thinking (a Viennese specialty), reading, or even sleeping. Across the room a blond American traveler was slumped over her backpack, napping, and the girl beside me in cat’s-eye glasses was marking up the galleys of her book. I ate my swirly marble cake, drank my rich coffee, and decided that I was going to have to suspend my whipped-cream embargo while in Vienna.
From the city, I commuted across the Danube River to the vast, circular convention center where the congress was being held. The first session I attended was a workshop on philosophy and pain, a “refresher” course intended to broaden scientific horizons. The panel included Ned Block, a hotshot New York philosopher, and Mark Sullivan, a psychiatrist and philosopher from Seattle. The room was full, and for the first time I heard people address all those questions that medicine doesn’t touch, questions that explore the relationship of pain to consciousness, memory, and identity.
I was half-lost—philosophers can be as technical in their terms as molecular biologists—but totally exhilarated.
There was a long and spirited discussion of qualia, the things we think we feel we know. Block’s example was orgasms. It’s possible to describe one in perfect, recognizable detail, but there’s something missing that only the experience of an orgasm can deliver. Qualia seem to be the leprechauns of the philosophical world: Many swear to their existence, but no one has actually seen one. Pain is rife with qualia. Mark Sullivan got up to speak, and established a different frame of reference. He talked about how we take a “first-person state” (“I hurt”) to the doctor, where it is turned into a “third-person state” (“your disease”). He thought it was time to consider looking at pain as a “second-person state” instead—as something closer to a dialogue. “When you know someone is in pain,” he pointed out, “your first question isn’t ‘How do you know that?’ but ‘Why are you telling me this?’ ” Sullivan agrees with Wittgenstein, a son of Vienna, who said that pain is not essentially private, but “an invitation to a dialogue.”
Pain excites philosophers, because it seems to erase the border between the subjective and the objective. But perhaps the body event we call pain is so synonymous with our emotional experience of it that any distinction becomes irrelevant. Block’s cheery bottom line was “I think everything is physical.”
Simon Vulfsons, a ponytailed doctor from Israel, argued that hypnotism is one example of a treatment that turns a first-person state—“My hip hurts”—into a third-person, dissociative state: “There is a hip that hurts that appears to be mine.” Vulfsons found that hypnotism helped his patients in chronic pain. It’s not often that you find yourself in a room where hypnotists and philosophers can agree.
I took copious notes about “the blueness of blue” and other pressing matters, but the minute I left the session, all the sense evaporated out of them, like champagne bubbles. It was so easy to lose your grip on the pure pursuit of pure pain.
When I interviewed Sullivan the next day, he seemed dispirited. Perhaps it was exasperation with my questions, or the sense of irrelevance that a philosopher might feel in a convention heavy on rats-and-mice science. Although the congress was theoretically an ideal blend of hard and soft science, of nurses, dental workers, and psychologists with neurologists, geneticists, and cellular biologists, in practice, the hard sciences prevailed. The focus was more on the mechanisms of pain than on its possible meanings.
At the press conference for the congress, Dr. Allen Basbaum, a neurobiologist from San Francisco, was the most picturesque speaker. “I think of pain as a disease,” he said, “but it’s invisible. There are memories of injuries that cause a reorganization of the brain. Pain does not work like a telegraph, but like voice mail—it leaves messages. These messages alter the way pain is processed.” He even ventured an analogy between pain and beauty. “You can’t see where beauty is. One person will look at a Mondrian painting, and the tears will well up, and they’ll take out their checkbook and want to buy it. Another person will look at it and go … pffft. It’s the same stimulus, but with two very different reactions. There is an emotional quality to pain.”
In scientific circles, this was news.
THAT NIGHT I TAGGED along with a cadre of Israeli doctors who embarked on a pub crawl in the “Bermuda Triangle” nightclub quarter of Vienna. A pretty young physiotherapist from South Africa was part of the group. When she overheard me talking to someone else about the importance of uncovering the meaning or story that underlies someone’s pain, she sidled over to me and took my arm. “I’m so glad to hear you say that,” she said, “that’s what I found in my work. A word, a certain kind of touch will bring the tears, and people in pain need to let those emotions come to the surface. It’s not so much what you do, as the quality of the contact.” She said she was doing more and more “laying on of hands” as part of her therapeutic work. But we spoke almost furtively, as we walked through the streets behind her physician friends. Therapeutic touch doesn’t yet have a seat at the high table of science.
Over the next few days, I attended as many workshops as I could squeeze in. I had high hopes for “Sex, Gender and Pain,” but it was largely about methodology in gathering statistics, and its findings were inconclusive. Women report more pain than men, but the question of whether they feel more pain than men is still up for debate. Another crowd-pleaser was the workshop on the use of cannabinoids for pain, which told us what most people already know: Marijuana can be a good pain reliever for certain conditions, but there are legal hurdles. (The use of marijuana for medical purposes, including pain relief, has now been legalized in Canada.) I went along to the migraine workshop, where the speaker used his laser pointer to run through a chart of the newest triptans. I was surprised to find that I already knew everything he was talking about, so I left.
What did strike me was the aesthetics of the science world. Each day for five days people buzzed about from workshop to workshop in a triple-tiered hive of halls, all of them offering a performance of sorts. Experts needled one another and traded in-jokes. Most workshops were conducted as panels made up of three or so international experts, who would address the topic at hand: possibly “The Role of Neighboring Intact Dorsal Root Ganglion Neurons in a Rat Neuropathic Pain Model.” The congress abstracts alone were as thick as dictionaries. Most of the speakers wielded a laser pointer, directing its jittery red light to diagrams or charts on the screen. Cartoons were popular, too. The congress was dedicated to Patrick Wall, who happened not to have much hair. But in one cartoon Wall was shown with his “hair gene” altered to create a pompadour look. And the highest praise for a scientific study was the fashion word elegant. An elegant study, I gathered, arrived at its conclusion cleanly and inevitably, like a diver entering the water with no perceptible splash. This contrasted oppressively with my own task of writing about pain from every possible angle. In my case, a great deal of splashing was involved.
It seemed I was the only “cultural journalist” on board, a role that was so detached that I might as well have been a scientist myself. The convention brought together a number of different disciplines, and each cabal traveled mostly among their own: gene people with gene people, cancer folk with cancer folk, and so on. The science reporters filed their stories daily from the press center, where I tapped away, too—a spy in the house of pain.
But the workshop on back pain was more down to earth. As well it should be. Low-back pain is the leading cause of workplace disability, affecting 60 to 80 percent of the working population, and a staggering 93 percent of low-back cases are idiopathic—without any identified cause. It costs the economy billions of dollars a year in lost work, and we spend billions more on therapies and curious devices to cure it. What was striking about the session was that all the experts agreed that they didn’t have a clue how to fix back pain.
The room was packed to overflowing, and the moderator, London pain expert Dr. Chris Wells, began the session with a quote from Chekhov: “Where many remedies exist, you can be sure there is no cure.” The panel participants included Nikolai Bogduk, an Australian doctor with a booming voice, a somewhat Elizabethan vocabulary, and a reputation as a respected high-tech back-pain expert with no time for touchy-feely therapies; Gordon Waddell, a Glasgow orthopedic surgeon “by profession if not by nature” and the author of The Back Pain Revolution; and Chris Mains, an English psychologist and pain specialist.
Dr. Wells introduced the Glaswegian Waddell by suggesting that the English view a Scot “like a case of hemorrhoids. Those that come down are all right so long as they go back up. It’s the ones that come down and stay down that cause the problems.” (Only an Englishman and a doctor could get away with this sortie.) Then they laid out the premise for the debate: You’re on a desert island with severe back pain, you do not know what you know now, and you want some advice to help you cope with the pain. A hot-air balloon is being sent to help you. There is only so much room in the hot-air balloon, and a whole spectrum of back experts to choose from. So who would you allow on board?
Although Bogduk has a reputation for having all the answers and being a bit of a “needle jockey” who travels everywhere with his little vial of painkilling bivucaine, his presentation in Vienna surprised his colleagues. Instead of talking up the latest surgical intervention, he spoke about addressing the patients’ fears and anxieties, and “getting inside their heads.” He emphasized that what was most important was to first eliminate “red-flag conditions” that might be (but probably weren’t) causing the back pain, and then to reassure the patient that the back would most probably get better and not worse. He still believed in judicious painkilling, but what was more important in treating back pain, he had found, was communication and reassurance. Preventing acute pain from turning into chronic pain was often a matter of “treating the patient nice and convincing him that there is nothing so horribly wrong.”
The psychologist Mains, not surprisingly, said that chronic pain arose from our beliefs and attitudes toward pain. “The problem of pain is psychological,” he summed up, “and chronic incapacity is psychologically mediated. … It doesn’t mean you’re crazy, it means you’re a human being. In order for you to overcome what has been a dreadful physical problem, you understand that it’s necessary to regain control over the impact it has on your life.” His hypothetical treatment involved a patient who gradually educated himself about pain, attended a pain-management clinic, and got on with his life. “When you break down back pain, a lot of the time you will find that you can cope with it.”
But the surgeon Waddell was the most outspoken. “I’m an orthopedic surgeon, so I can give you a bigger, better screw than Nik Bogduk can,” he began, in true surgeon style, to laughter. Waddell, whose book is one of the bibles of back pain, is a defector from his own profession. He told the story of a friend who calls his orthopedic surgeon a white rhino, “because he’s thick-skinned, difficult to find, and likes to charge a lot.”
“Surgery is not the answer for back pain, and it doesn’t work,” he went on, “so I’m now going to jump out of this hot-air balloon and leave the other two hot-air experts to battle it out. But the trouble is, it’s very easy for back specialists to set themselves up as experts. Beware of amateur experts who step out with their own specialty. Beware of high-tech experts who blind you with science or pseudoscience. And beware most of all of the bullshit artist who can sell the idea to you and convince you that their treatment is better than everyone else’s—odds are, they’re wrong. So throw out the experts and fill up the balloon with malt whiskey, which will probably do your back more good than the experts.”
When the professionals in the audience jumped into the discussion, a physiotherapist reminded the doctors that there was “no laying on of hands” at the congress, or mention of the role of exercise and manual manipulation. He pointed out the importance of working with posture and exercises to help prevent future injuries. So the physiotherapist was voted on board. But “dry needling” (a euphemism for what amounts to doctorly acupuncture) was nixed. The congress does not have much truck with popular but unproven alternative therapies. Even something as mainstream as physiotherapy was pretty marginal here.
But what was surprising was how the high-tech experts were willing to admit failure in their treatment of back pain. Most ordinary back pain will resolve itself in two or three months. But when backs get better, anything and everything can be credited as the magic wand. These doctors, who had long experience with people in pain in addition to their traditional training and schooling, had discovered that nothing happens without communication, treatment based on evidence of outcome, and what used to be called a good bedside manner.
“Be aware,” Bogduk addressed the congress, “that simple intervention—the time spent with a patient—is a very powerful ingredient of the patient-doctor contract. The evidence is against the traditions such as surgery being true—the evidence says it doesn’t work.” This new focus on the relationship between doctor and patient, as opposed to the drive to cure an isolated symptom, was a radical change of tune for the doctors. And this was one of several workshops that touted “evidence-based medicine,” an approach that judges different treatments based on how well they work. Hasn’t anyone thought to look at outcomes as a logical way to figure out what really works? Not until recently. That tells you how far out of the picture the patient has been.
Down in the cafeteria, debating once again whether to eat another sausage or a slice of cake, I ran into Dr. Basbaum, who had dared to include an analogy to art in his press conference address. Basbaum, a Canadian who is now director of anatomy at UCLA, is a large, ruddy man with a sharp wit. He is a leader in the hot science of studying transgenic mice in order to locate the proteins involved in the transmission of pain. As a student, he worked with both Ronald Melzack and Patrick Wall; the subject of his graduate thesis was “mice and cats who could be conditioned not to kill.” But he never published it, he added. Why not, I asked. “The Vietnam war was on, and it didn’t seem to be the right time.” Basbaum is a former director of the congress, and pain has occupied his whole career. His wife happens to be a leading expert on cystic fibrosis, he added, “and so when people see us coming, they say, ‘Oh, here comes Pain and Mucus.’ ”
At the top rung of science, I was beginning to notice, you will find researchers who have a surplus of intellectual mischief and warmth in them. Melzack and Wall have these qualities, I would discover, and so do the gene guys, Jeff Mogil and Basbaum. I asked Basbaum what it was like to study under Melzack and Wall.
“Wall is really a scientist, he has never let go of research, and he is a sweet guy. But if he disagrees with you, he’ll needle you. He finds the brain-imaging people a little too narrow in their focus, and he lets them know it. Melzack is right off the scale in terms of nice-ness, and he would never say anything bad about anyone.”
I shuttled back to my pension that night and went to a restaurant full of carousing university students. They ordered steins of beer and plate-sized schnitzels—the gargantuan theme again—and I followed suit, while making notes.
Vienna Pain Diary
DAY ONE: Headache (jet lag), sore shoulder (heavy bag—too many abstracts), stiff neck (sleeping upright on plane). Notice that jet lag seems to disarm my own “endogenous painkillers.” What role hormones? Cf. Melatonin as anti-jet-lag remedy. Did not bring melatonin. Right shin has neuritis. Right hip aches. Wrong shoes! Last-minute veto on sneakers as too “Canadian.” Why only stilettos and platform mules? What was I thinking?
DAY TWO: Front door of pension massive and very heavy, like a vault. Almost crushed when trying to quickly get in before it slammed shut. Viennese diet of coffee, almond torte, sausage, and cheese not exactly high-fiber. Amazed that Viennese not all massive.
DAY THREE: Decide once again that I am crooked and misaligned. Stiffness all down right side. Must try to carry bags on left side instead.
DAY FOUR: Fillings of teeth flaking off. Grinding, no doubt (technical term: bruxism). Sore right forearm from taking notes longhand. Laptop shoulders—hotel desks are never the right height for typing. Blister on left ankle, raw, unsightly. Catastrophizing somewhat over that—good entry for staph infection? Flesh-eating disease? Luckily, many, many doctors readily available in town.
THERE IS A DEFINING moment in The Graduate, when Dustin Hoffman’s character is cornered by a stockbrokerish guy at a cocktail party. He wants to give Hoffman some life advice. “One word,” the man says. “Plastics.”
It’s hot-tip, commodities language, and I heard an echo of it on another night out on the town at the congress. I was sitting with a table of pain doctors who, I was learning, are no strangers to pleasure. We were occupying some picnic tables close to the Danube River; I could feel a slight chill coming off the water. Beside me was a British pain specialist slightly in his cups. To make conversation, I asked him what the new star was in the firmament of pain treatment. He leaned over.
“Botox,” he slurred. “It’s huge.”
This was well before The New Yorker magazine featured the fashionable wrinkle-eraser in a cartoon. (A husband carries his wife under his arm like a stiff cardboard cutout; the caption reads “I think you should probably lay off the Botox for now.”)
“It’s a biological toxin,” he continued dreamily. “It paralyzes the muscles so they can’t go into spasm.”
Botox is the trade name for a botulinum toxin type A that is produced from the bacterium Clostridium botulinum. The product was first developed in 1989 for use in several neurological disorders affecting the eyes. Then doctors discovered that Botox had the alluring side effect of paralyzing the facial muscles that contribute to lines and furrows. Botox has since taken off as an alternative to cosmetic surgery. When it’s injected into the muscle, it blocks the release of a neurotransmitter called acetylcholine, which causes muscle contraction. Botox temporarily mummifies the muscles it targets. It does erase lines, although it might be impossible to frown or lift your brow. One injection lasts six to twelve months.
Now doctors are using Botox to treat migraine, back problems, and the sort of chronic pain related to muscular tension or spasm (myofascial pain).
The pain approach is to zap a little Botox into the traumatized, contracted muscles and then follow up with diligent physiotherapy. If you can get over the idea of doctors charging money to inject people in pain with toxic bacteria, it sounds reasonable, maybe even better than living on painkillers.
The congress, like any professional convention, was also a bazaar of commercial products: sleek new opioids, drug delivery systems, electrostimulating machines, and all the other gizmos that might offer relief from pain. The stuff was kept downstairs. On the last day of the conference, I took the escalator down into this hopeful Hades of pain products, where I ran into Mr. Botox again, beside the Botox booth. Commuting back and forth between how we see pain and how we sell it turned out to be illuminating.
The first thing I saw was a long line of people waiting for free T-shirts stamped with their own handprint, from the makers of Tramal, a synthetic opioid. Their slogan is “Tramal—as individual as pain is diverse.” I wove through a souk of pills, potions, and devices from the Bristol-Myerses, Parke-Davises, ASTA Medicas, and Aller-gans of the world. (The IASP gratefully acknowledges up front “educational grant support” from sixteen pharmaceutical companies.)
I could feel a headache coming on from the buzzing lights and information overkill so I strolled over to the Zomig booth, hoping for a handout of triptans. No free samples. There was an array of TENS (transcutaneous electrical nerve stimulation) devices, little boxes with electrode patches that deliver a mild electric current, and there were neurostimulation systems that deliver drugs straight to the spinal cord, like the one that Lori Biduke, Dr. Mailis’s patient, had had implanted in her abdomen.
Much of the new technology of pain treatment is quite mechanical and involves more efficient ways of getting the same drugs into a narrower target area. Despite the promise of the previous congress to take pain studies “beyond morphine,” the bazaar was overwhelmingly devoted to pills and machines. There were few signs of the alternative world of massage, shiatsu, biofeedback devices, magnetic therapy, herbs, hypnotism, cognitive approaches, or even the widely accepted elder of the nonmedical world, acupuncture.
Actually, acupuncture was there in theory, but not in name. In the doctor world, acupuncture is sometimes reconfigured as “dry needling” or “electrostimulation,” to get around the lingering bias against its Chinese origins. One company sold something called an “AS Super 4 needle stimulator,” which simply adds a current of electricity to needles inserted into the traditional acupuncture points, along with the reassuring contours of a stereo amplifier. If you can attach a little appliance with multiple dials to an ancient therapy, North Americans tend to have more faith in it.
The favored advertising image was a body part—hand, arm, or face—attached by wires to a mysterious box with control dials. Just you and your pain machine.
Here was the familiar Cartesian dichotomy at work. Upstairs, at the congress workshops, it was pure science. Upstairs, you could lose yourself in “elegant” studies of the molecular, genetic, or neurochemical behavior of pain. Upstairs, the body of the noisome pain patient had been successfully amputated.
Downstairs was where they kept the corpse. Here was an old-fashioned, mechanistic world of pills and powders, needles and unguents, all designed for the dull, thick world of physical pain. The pain bazaar was not about working with pain in the world, but about modifying or blocking “pain impulses,” either with drugs or counterstimulation. The more integrative approaches to pain, which might combine physiotherapy with hypnotism and a morphine patch, too, were mostly missing. This is partly because most alternative pain treatment is a process rather than a product.
Powerful pharmaceutical companies are still the engines that drive gatherings like this one. The narrowing gap between research and profit has affected even the most august medical journals, the Journal of the American Medical Association and the New England Journal of Medicine. The editors recently announced that they would no longer publish articles based on research funded by pharmaceutical companies, because they had become alarmed that these studies were not unbiased. Sometimes there is more science than meets the eye in the alternative therapies and less than we want to believe in “controlled studies.”
The basement was also reserved for a charming scientific tradition—the poster sessions. Here, in an area that resembles a bustling high-school science fair, researchers are able to post their individual papers, often on hand-lettered pieces of bristol board that address topics like “Rat Tail Withdrawal Tests.” This is where students get their first exposure and where the most marginal, original work can be found. The rows and rows of homemade posters create a scientific shantytown, where, at certain hours of the day, the authors stand by their posters, ready to discuss or argue their work with the crowd.
When I wandered into the poster hall late on the second day, only a few of the presenters still stood wearily by their work. Most of it was incomprehensible to me, but not being hooked into the detail let me register the bigger themes. Each corridor was reserved for different areas of study: gene expression, inflammation, analgesics, neuropathic pain, myofascial pain, “illness behavior,” opioid therapies. It was as stunning a spectrum as the biggest, brightest supermarket where you can buy everything from car mats to star fruit in one visit. All of pain was here, atomized into the tiniest of fragments:
“Effects of Midazolam in the Spinal Nerve Ligation
Model of Neuropathic Pain in Rats”
“Pain Coping Strategies in an Iranian Population of
Chronic Pain Sufferers”
“Heterogeneity in the Electrophysiological Properties of
Tetrodotoxin-Resistant (TTX-R) C-Fibers of the
Frog Sciatic Nerve”
“Non-verbal Expressions That Nurses Use to Determine
Pain in Individuals with Severe or Profound
Cognitive Impairment”
“Gabapentin Potentiates NMDA Responses in Gabergic
Dorsal Horn Neurons”
“Migraine in Tunisia”
“Pain in Painting Art” (from Norway, Edvard Munch’s
home)
How odd it was to wander these corridors thick with data and realize at the same time how little we know about easing pain. It wasn’t a futile feeling—people were already benefiting from the work reflected on these hopeful squares of bristol board and Magic Marker. But it wasn’t a hopeful feeling, either.
What would a person in pain think, wandering through these halls? He might conclude that pain was the provenance of scientists, and that science could be as exclusive as a golf club. He would surmise that his favorite physiotherapist or masseuse would not feel terribly valued here, and that the role of diet in pain treatment was not nearly as sexy as gene research. He would surely recognize that the pure science of pain is his first hope for some relief, next month or next year. But as someone moving slowly down the aisles, as a figure who represents both the human side and the unfixable nature of pain, he might feel out of place.
ON MY LAST DAY in Vienna I did some gawking around St. Stephen’s cathedral in the Graben, the city’s main gathering place. Sometime after buying a tourist torte at Demel’s, the former confectioner to the emperor, my wallet was pickpocketed out of my backpack. My flight home was early the next morning and I had no money left. Upon hearing my story, two strangers at the congress immediately forked over $150. This was my double-blind study on empathy among pain scientists, and I found the results reassuring. Then I hustled back to the congress, where Ronald Melzack and Patrick Wall were signing copies of the fourth edition of their textbook on pain. Yes, even the pain world has celebrity signings.
Melzack was pacing around the booth. He looked a bit like Marshall McLuhan, with more hooded eyes. I chatted with him and asked him what the focus of the congress would be in ten years. “Oh, the brain,” he said, waving a hand. “Pain is in the brain.” He introduced me to his protégé Jeff Mogil, a psychologist and gene researcher, and said, “But this is where the action is—genetics.” It was crowded and noisy in the hall and I didn’t feel equipped to interview Melzack in depth, so I stepped out of the fray.
Over by the wall, I noticed Patrick Wall sitting with his tea by the Lancet booth. An old buddy with a hearing aid sat beside him. Tall and lanky, Wall was the very picture of a Shavian intellectual, or perhaps a Chekhovian actor playing the philosopher-doctor. He drew on a cigarette, relighting it whenever it went out, and balanced a cup and saucer of tea on his leg, tipping his ash into the saucer. He was in his seventies and had prostate cancer. He looked a bit papery and frail, but when I introduced myself, his face crinkled up genially. I asked him to sign my copy of his book Pain: The Science of Suffering and complimented him on its subversive nature. “Well, that was the idea, to wake people up,” he said. I asked him why there weren’t more workshops on the social and political issues around pain.
“Because the old are all in pain,” he said, with a slight brow lift that acknowledged his own membership in this club, “and when they don’t feel like going out anymore and voting, they have no voice.” I made a joke that the next congress might be overthrown by an insurrection of lab rats, and he laughed at that. I was, in fact, waiting for someone to point out the obvious and unpleasant irony of the congress, that is, inflicting pain on animals in order to study how to erase it in humans, but it never happened.
When the gate-control theory of pain developed by Wall and Melzack was first published in 1965, it was roundly attacked for flawed physiology. Critics now agree that a few details were off, but the general concept was sound. Wall wasn’t admitted to the Royal College of Physicians and Surgeons until he was sixty-four. When I encountered him, he still had the air of a gentleman renegade. In the summer of 2001, at the age of seventy-six, Pat Wall died.
BY THE END OF my week in Vienna, I had a pocketful of generalizations about the scientific study of pain. Science can quite successfully cocoon you from suffering, and the gap between knowledge and application was exasperating. Scientists doing research into pain get to tinker in their labs with specially bred mice, far away from the frustrations of treating pain patients in clinics. Even in the space of a week, I found myself almost seduced by the Elysian Fields of pain studies. It is so elegant, unlike the crude reality of pain. The best pioneers in pain studies—the John Bonicas and Cecily Saunderses and other pain revolutionaries—never lost sight of the patient in their research. Once the patient slips out the picture, “pure” science risks pursuing nothing more than pleasing arabesques of reason and conjecture.
Given the congress’s multidisciplinary philosophy, I was surprised by the absence of alternative pain approaches—the whole spectrum of cranial-sacral massage, healing-touch therapy, and other hands-on skills that are a lifeline to many people with chronic pain. Alternative therapies are hard to evaluate, but that’s no reason not to explore them. The other omission was a deeper consideration of the cultural dimension of pain. Well, the congress was about science, not art. But writers and artists have articulated pain in ways that science is only catching up to now.
I had just enough time left to stalk Brueghel again before I left Vienna. I hustled into town to the Kunsthistorische Museum, paid my hundred schillings, and in my foolish footwear mounted the stairs, oppressed on all sides by marble, gilt, and swagged drapery. There is no such thing as “casual Friday” in the Kunsthistorische. I made my way from one claustral salon to another, pausing at the Caravaggios, until I was rewarded.
In salon ten were the paintings of Brueghel the Elder in all their surface calm and swarming, happy-nasty humanity. Skies that looked like a recipe for a tornado. Lapidary landscapes with small figures tucked into them. I took in The Tower of Babel, which seemed to have some relevance to my week at the congress, with its cold-faced king striding in among his groveling stone masons. Then I turned to the surprisingly small canvas entitled The Murder of the Children in Bethlehem. From a distance the painting looks almost festive, like a village celebration on a snowy day. The figures could be skaters on a pond, except that they are soldiers killing people. Up close, you see that they are not dancing but bending backward in disbelief and despair as their children are killed. Men in uniforms rip infants out of mothers’ arms. The spectacle is beautiful until you inspect the details of it. The composition is as serene as a constellation of stars.
“About suffering they were never wrong, the old masters,” wrote the poet W. H. Auden on the subject of a Brueghel painting. He was right. It was only a picture, but I needed to see pain put back in some context, even such a horrific one as this. I wanted to be reminded of the ability of the artist to look and not turn away. Then I staggered out. We’re really not meant to see that much art at once; it’s like downing ten eggnogs in a row. The ideal gallery would show only four paintings, one for each vast wall. As I made my way out of the gallery, onto the football field of the grounds, I stuck my hand through the pruned borders of the topiary, right into the dense tangle of branches.
Perhaps pure science, I thought, practices a kind of intellectual topiary—nature translated into the mind’s cool geometry. In its own way, the congress had been a gallery, too, as Basbaum’s link between pain and painting had suggested. The evening air in the gardens felt good. I had been inside too much. Navigating by several naked rooftop sculptures that I now recognized, I found my way back to the pension, where my passport and plane ticket home were safe inside my enormous armoire.