September 13, 2016

On Sympathy

There are only about six weeks left before Science of Sympathy is unleashed on the world. I’ve been living with this book for years and waiting impatiently for the publication machinery to grind slowly towards its end. My fifth book, it’s certainly been the most interesting from an editorial and production point of view. I’ve nothing but praise for the old-fashioned professionalism on show at the University of Illinois Press. In general, the world of academic publishing has out-sourced copy editing, loaded editorial burdens on to the authors themselves, given up on marketing, and adopted pricing policies that make academic books unaffordable for anyone save well-endowed university libraries. This publishing model can boast success if a title sells 150 copies. Publishers make their profits. Authors make nothing or next to nothing. A standard academic contract for a monograph has a royalty rate of between 0 and 2.5% for the author.

Happily, Illinois is publishing a hardback and a paperback of Science of Sympathy at the same time, hitting that university library market at the same time as making the book affordable for everyone else. Every step of the way I’ve dealt with different in-house employees responsible for copy, marketing, artwork, production, website, and so on. Most impressive from my point of view was the production of the jacket blurb. The vast majority of text you read on the back of books, talking about how innovative and brilliant the contents are, is written by the authors themselves as part of pro-forma marketing questionnaires. It’s tough to do. When you’ve spent seven years putting together a complex argument, it’s often difficult to sum it all up in one paragraph, let alone to find the distance to say why it is good in pithy prose. To my amazement, the person responsible for marketing copy at Illinois actually read my book and wrote the blurb for me. What a strange feeling to have someone else sum up what your book is about and what it does. This is serious, professional, almost lost editorial practice, and I’m a fan!

I’ll post some bits and pieces about the book in the coming weeks, but for now, here’s that blurb:

In his Descent of Man, Charles Darwin placed sympathy at the crux of morality in a civilized human society. His idea buttressed the belief that white, upper-class, educated men deserved their sense of superiority by virtue of good breeding. It also implied that societal progress could be steered by envisioning a new blueprint for sympathy that redefined moral actions carried out in sympathy's name.

Rob Boddice joins a daring intellectual history of sympathy to a portrait of how the first Darwinists defined and employed it. As Boddice shows, their interpretations of Darwin's ideas sparked a cacophonous discourse intent on displacing previous notions of sympathy. Scientific and medical progress demanded that "cruel" practices like vivisection and compulsory vaccination be seen as moral for their ultimate goal of alleviating suffering. Some even saw the so-called unfit--natural targets of sympathy--as a danger to society and encouraged procreation by the "fit" alone. Right or wrong, these early Darwinists formed a moral economy that acted on a new system of ethics, reconceptualized obligations, and executed new duties. Boddice persuasively argues that the bizarre, even dangerous formulations of sympathy they invented influence society and civilization in the present day.

Science of Sympathy is available for pre-order here (US) and here (UK).

January 21, 2016

Edward Jenner and the Politics of Smallpox Vaccination

Transcript of a paper read at the Department of Social Studies of Medicine, McGill University, January 20, 2016.
You can purchase Edward Jenner: Pocket Giant here, with free delivery worldwide.

Edward Jenner needs little introduction, at least in terms of his international repute. The ‘father of immunology’ is credited – usually – with the discovery of the cowpox vaccine in 1796 and, more importantly, with its propagation. Smallpox was, after a concerted global effort by the WHO, eliminated in 1979. Jenner is typically considered to be the progenitor of a process that took almost two centuries. He is the conqueror of smallpox, saviour of millions of lives. Such is the hero narrative that I remember learning in school, aged 9, and which still gets trotted out every year for kids of a similar age, at least in the UK.

For those with a more involved awareness of the history of vaccination there is another standard narrative, centring at first on the disputed claims at discovery of the vaccine and the ways in which colloquial knowledge coalesces and gains momentum, becoming formal knowledge through professional appropriation. What follows is a Kuhnian explanation of the rise of the vaccine, with a crisis among the medical establishment (whose fortunes depended on the forerunner of vaccination – inoculation with actual smallpox), followed by the fairly rapid acceptance of the vaccine as various studies and surveys seemed to prove its efficacy, and as prominent personages lent it support. Key moments tend to get mentioned as guarantors of this medical revolution – the adoption of vaccination by Napoleon for his military forces; the world voyage of Francis Xavier Balmis, successfully introducing vaccination to the entire Spanish Empire as well as to China by 1806; the orders of the King of Denmark to vaccinate soldiers, their families, sailors, students and the poor free of charge; and in Jenner’s homeland, two parliamentary grants acknowledging his discovery, amounting to £30,000, the second of which, in 1807, coming after a laudatory report on the practice by the Royal College of Physicians. Each of these signs of success stands for empirical proof of the medical efficacy of vaccination. By a slightly more complex route, Edward Jenner is again enthroned as a humanitarian and medical hero.

I want to disrupt this Kuhnian narrative and complicate it. The first observation is that, on Jenner’s death in 1823, the practice of vaccination, at least in England, seemed in fact to be waning. Jenner’s last days were spent still ardently trying to get the message out about his particular method of vaccination, as the only efficacious means of performing the procedure. He went to his grave ambivalent about his own reputation – yes there had been successes, but by no means was the vaccine revolution complete, and especially not in his own country. I will spend some time analysing Jenner’s own efforts to try to bring about his revolution, showing that discourse within the medical establishment often had precious little to do with the efficacy of vaccination strictly in terms of medical outcomes. Vaccine debates pivoted around issues of fear, moral panic and trust, with trust in Jenner himself being a key marker of continued uncertainty about the practice of vaccination. Jenner’s personality and his own actions in the formative years of vaccination often get neglected in the success story of the vaccine, but his character and his politicking are extremely important influences in what turns out to be a very messy beginning.

The tenor of the medical exchanges over vaccination are doubly important because of the public nature of the vaccine controversy. In significant ways, medical debate was publicly performed to an enormous audience for whom smallpox remained a real and ever-present danger to life. The traditional markers of vaccine success that I just listed didn’t necessarily affect the public mood in a positive way, and indeed I would argue that the difficult first few decades of vaccination were defined by the rhetorical failures of those in favour of the vaccine effectively to influence a prevalent atmosphere of fear and mistrust. This second line of argument takes me beyond Jenner’s death to the broader anti-vaccination movement of the nineteenth century, and the ways in which fear tends to trump fact in public discourse.

The disruption is necessary because the standard narrative does not explain why Jenner was, by the middle of the nineteenth century, almost an anti-hero, championed by the medical establishment, but despised by many public-opinion makers and by much of the public at large. Jenner was memorialised by a statue in Trafalgar Square in the late 1850s, thanks largely to funds from the USA and from Russia, but after only fours years he was removed and stored out of the way in Kensington Gardens. One of those who argued for his removal in Parliament noted that Jenner had no place ‘among statues of our naval and military heroes’, for not only were medical innovations themselves not the stuff of heroes, but Jenner’s particular innovations were considered to be dubious at best. Sixty years after Jenner had published his Inquiry into the Causes and Effects of the Variolae Vaccinae, he was denounced in the House of Commons as the ‘promulgator of cow-pock nonsense’.

At the same time, and paradoxically, vaccination was made compulsory for all newborn children in Britain, with failure to comply punishable by fine and imprisonment for the parents. The first government intervention in public health with the threat of penal action came at a time when the public mood was decisively anti-Jennerian. Despite rafts of testimony from physicians around the world in favour of vaccination – demonstrating that the paradigm had indeed shifted from smallpox inoculation to vaccination among the medical community – the public remained unconvinced and afraid. Whole towns revolted against the vaccination laws, and smallpox still frequently reached epidemic proportions across England, killing thousands through the 1870s and 1880s. It seems to make sense, then, to emplot the story of Jenner and the politics of vaccination, at least in Britain, as one of failure, if considered from the point of view of public reception and compliance.

Edward Jenner’s certainty that vaccination safely and effectively immunised against smallpox was based, in the first instance, on limited empirical testing and, later, on deeply held belief. In his lifetime neither he nor anyone else could explain why vaccination worked. Indeed, the reason for the efficacy of vaccination remained mysterious throughout the nineteenth century. This fundamental gap in knowledge allowed for the creation of myths on both sides of the vaccine debate. Jenner himself was the progenitor of a number of vaccine myths that ultimately hurt his cause. What began as postulation ended up as part of the dogma of Jennerian vaccination.

The first piece of dogma was that cowpox in turn came from a disease in horses’ heels called ‘grease’, and that the effectiveness of the vaccine lay in the common animal origins of both cowpox and smallpox. Smallpox was, as far as Jenner was concerned, a result of the close and unnatural interactions of humans with animals, and could only be cured – uncannily enough – by other matter taken from an animal. Jenner’s key achievement lay in taking matter from a cowpox pustule on the arm of Sarah Nelmes and then inoculating James Phipps with it, and thereafter testing James for immunity against smallpox by trying, repeatedly, to give him the disease. Nothing in this depended on establishing an origin for the cowpox in horse grease. Yet Jenner insisted on it. By the time he realised that there was no connection whatever, this error was used frequently as a stick with which to beat him. Jenner’s opening salvo in the establishment of vaccination contained an error sufficient to establish doubt in his reasoning, his methods and his reputation.

The second piece of dogma was that vaccination was good for life. Once administered to a child, the cowpox afforded unlimited protection against smallpox. This was Jenner’s greatest assumption. He had no way of knowing that it could be true, but he was absolutely convinced that it was, and he held onto this belief for the rest of his life. Increasing numbers of cases of adult smallpox in those who had been vaccinated as children were used by opponents of vaccination to point out that vaccination did not work at all. A second element of doubt was therefore also original to Jenner’s publication of his vaccine success, calling into question Jenner’s trustworthiness and his motives.

Both of these errors might perhaps have been inconsequential had the debate about vaccination taken place out of the public eye, among the medical establishment, and if the motive of those involved had been the elimination of smallpox. But from the very first the debate had been in the public and, importantly, for the public. Jenner had self-published his Inquiry, avoiding the painstaking processes of the Transactions of the Royal Society, in the interests of getting the discovery into as many hands as possible. This is often interpreted as a sign of Jenner’s humanitarian spirit, literally giving away what could have been a lucrative and proprietary method. I think Jenner had other ambitions, beyond the mere accumulation of wealth. Jenner was outside of the establishment medical circles in London, a city he hated, and saw an opportunity for fame without having to sacrifice his bucolic repose. As it turned out, that did not work, but in any case Jenner did not enamour himself to those who might have championed his cause. He did not think it necessary to hold any medical credentials to perform vaccination, so long as his precise instructions were followed. This, at one stroke, annoyed the medical community at large, especially those whose livelihoods depended on charging high fees for elaborate rituals of smallpox inoculation, and identified the practice of vaccination with Jenner himself. He was not merely the discoverer of a biomedical miracle, but the architect of the precise delivery system of that miracle, sending vaccine matter through the post to whoever wanted it, along with instructions.

The public announcement of the discovery resulted in it being publicly maligned. If there was a crisis of medical knowledge in the first few years of the nineteenth century, it took the form of the whipping up of public fear and moral panic, with the response on the vaccine side being an equal storm of fear mongering about the dangers of traditional variolation combined with some extraordinary gutter-press character assassinations. Worst of all, those who might have been Jenner’s allies in the establishment of his reputation soon turned out to be the biggest threat to it. Dr William Woodville of the London Smallpox and Inoculation Hospital, together with a budding fan of Jenner’s Inquiry, George Pearson, found a source of cowpox within London and set out to test it at the Smallpox Hospital. The cowpox was almost immediately cross-contaminated with smallpox and the results were at variance with what Jenner had seen. Nevertheless, seeing a chance for fame, Woodville and Pearson broadcast their success and subsequently sent threads dipped in smallpox matter across the country and to Europe, claiming to be distributing the cowpox vaccine. They were likely the direct cause of a smallpox epidemic in Geneva. It was an extraordinary blunder that caused a personal rift between Jenner and Pearson that would endure until Jenner’s death.

Jenner wrote to Pearson that their names could not be entangled in the practice of vaccination. If, Jenner said, ‘vaccine inoculation, from unguarded conduct, should sink into disrepute… I alone must bear the odium’. This was as early as 1802. Already by that date Jenner had bound his reputation to the practice and it was the safeguarding of his reputation, rather than the spread of vaccination per se, that seemed to motivate him the most. Those who saw in Jenner’s success the potential to lose out did their best to destroy that reputation, challenging both Jenner’s innovation in the first place, and the efficacy of vaccination per se.

Less well-known piece by Charles Williams, 1802, showing a horned and tailed Jenner feeding children into the mouth of a pestilent beast, which excretes them as monstrous waste. The knights of truth in anti-vaccinism muster on the horizon.

The prominent physician Benjamin Moseley was the culprit in chief, responding to the ‘Cowmania’ in 1800 with a series of concerns. While Jenner had styled cowpox Variolae Vaccinae, smallpox of the cow, Moseley called it Lues Bovilla, bovine syphilis, with all the long-term mental and nervous consequences of the human ‘pox’. He asked:

Can any person say what may be the consequence of introducing the Lues Bovilla, a bestial humour – into the human frame, after a long lapse of years? Who knows, besides, what ideas may rise in the course of time, from a brutal fever having excited its incongruous impressions on the brain? Who knows, also, but that the human character may undergo strange mutations from quadrupedan sympathy and that some modern Pasiphaë may rival the fables of old?

His classical reference might pass us by, but the invocation of bestiality would have been obvious to the educated in 1800. Pasiphaë, cursed by Poseidon, had copulated with a bull. Having built a wooden cow and covered it with cowhide, she had hidden inside it in order to receive her desired mate. She later gave birth to the Minotaur. Moseley played not only on the taint of venereal disease, but also on the fragility and sanctity of the human, warning of a hybrid and brutal progeny. Vaccination was not only dangerous, it was immoral. Jenner’s name was singularly attached to the spread of this immorality.

This is the background to the famous Gillray image, which is familiar to many but often misunderstood. Jenner stands centrally, penetrating the arm of a terrified patient with ‘vaccine pock, hot from ye cow’. The patient has previously been ‘opened’ by a special brew. To the right, those already vaccinated undergo a series of horrors caused by contamination with animal disease. The image is shot through with innuendo about sexual transgression (communing with the beast) and venereal disease (syphilis). The pregnant hag on the extreme right seems at once to vomit and give birth to bovine progeny, while behind her another matron sprouts the satyr-like horns of the beast. The breeches of a bumpkin are breached. The faces of others are marked by monstrous eruptions of ‘the pox’.

Jenner didn’t respond to the satire. The general impression we have of Jenner is that given to us by his friend and biographer, John Baron, who styled Jenner as high-minded, a tool of providence, immune to whatever nonsense was spoken in the gutter. By no means would he stoop so low as to engage the trash talkers. This wasn’t true, but it’s been repeated so often it has become orthodox. The problem for Jenner was that, after Moseley’s nonsensical allusions to the coming of a modern minotaur and Gillray’s visualisation of it, another of Jenner’s opponents went out of his way to show it was real. In 1805 Dr Rowley, who derived his living from the impugned technique of inoculating with smallpox, claimed to have found it and to have showed it to Moseley. Moseley marked the animalistic transformation and Rowley published exaggerated portraits of Gillray-esque figures, supposedly drawn from life. The ‘Ox-faced boy’ and the ‘Mange girl’ were presented as tangible proof of the brutal result of bestial infection, in a pamphlet titled Cow-Pox Inoculation No Security Against Small-Pox Infection.

Jenner scholars have long known that Jenner penned a reply, because Baron saw it and mentioned it in his biography. But Baron denied that it was ever published, presumably to safeguard Jenner’s reputation. A ‘serious reply to such disgusting observations as characterised their [the anti-vaccinist] productions would indeed have been quite unworthy’ of Jenner, Baron wrote. However, he knew that Jenner valued ridicule as ‘a weapon that might be fairly and effectually wielded’. Jenner’s manuscript was styled, according to Baron, as a ‘letter to one of the chief anti-vaccinists’, filled with ‘genuine wit and polished irony’. Jenner clearly thought it worthy of a public airing. A letter survives that clearly indicates the existence of a substantial manuscript, too long for quarto form, which Jenner sent to an unscrupulous agent called Dibdin. Jenner demanded complete secrecy in employing Dibdin to find a publisher. The pamphlet Letters to Dr Rowley appeared in 1805, in octavo form, published by H.D. Symonds (a publisher regularly favoured by Jenner’s allies).

I have pieced together the evidence to the point that I can confidently attribute this pamphlet to Jenner. Under the veil of anonymity, Jenner poured scorn on his critics and tarnished them with ‘proof of insupportable vanity and self-conceit’. Jenner compares their argumentation to the ramblings of an old woman, who appears in this pamphlet, purchasing a copy of Gillray’s print. But though it poked fun at the arguments of vaccination’s detractors, it did not positively do much good for the cause of vaccination itself. A prior concern was Jenner’s good name, which he was highly motivated to uphold, and purposefully active in so doing by means that cut across the grain of the image of himself he wished to portray – that of a gentleman in repose, above the clamour.

Further evidence of this is to be found in the management of the institutions established to further the cause of vaccination in his name. But whereas his anonymous pamphleteering was a dirty fight in the yellow press, his institutional tactics involved the societal elite. George Pearson, the man who spoiled the broth at the Smallpox Hospital, quickly tried to grab the momentum and establish the first vaccine institution, which Jenner immediately moved to destroy. He was able to do this through the connections he had made after the publication of his Inquiry, which had even gained him an entrée at Court and an audience with the King, and through his petitioning for his first Parliamentary grant. Pearson had canvassed opinion to try to prevent Jenner receiving that money – £10,000 in 1802 – but failed. Jenner had been acclaimed as the discoverer of the vaccine by the highest authority, and he planned to use this renown to capitalise on his advantage. His first move was to seek an audience with the Duke of York, who had offered patronage to Pearson’s institution, and demand that he withdraw it. The Duke of York did so, offering it to Jenner instead. The whiff of dishonour that attached to Pearson in losing the support of such an eminent sponsor caused all those interested in vaccination – public figures and the medical establishment – to come to Jenner’s cause. The Jennerian Society, which in short order became the Royal Jennerian Society, was established in 1803.

The point of the Society was to promote vaccination across the globe, to provide the instructions and means to vaccinate, wherever it was called for, and to offer free vaccination at various stations around London. It should have been the institutional guarantor of Jenner’s success, but its short existence was mired by personal grievances, inside and outside the institution, and Jenner’s increasingly personal response to even the slightest deviations from his word and lore. Jenner was, typically, absent from London and managing by correspondence, leaving the institution to rot from the inside. The everyday rancour of the Society is evidence of the ways in which banalities get in the way of, or even take precedence over, medical practice. The chief vaccinator of the Society, John Walker, was involved in a number of disputes, being accused by the secretary of breaking the seals on his mail, while in turn accusing the secretary of abusing his mail-franking privileges. Walker was heavily censured by Jenner, who then sought ways to remove him. Walker, vaccinating on a daily basis, found it practical to deviate slightly from Jenner’s iron-clad rules about when lymph could be taken from the cowpox pustule on the arm, for insertion into the arm of another. Walker’s mistake was to publish this account, thinking that the how of vaccination was still in development. Jenner was enraged. He wrote to the committee complaining bitterly of Walker’s incompetence and, even though Walker’s own opinions on vaccination had hardly been noticed in public, said that the society had been ‘disgraced’. Claiming that he, Jenner, would be held responsible for Walker’s conduct, he threatened to resign from the Society unless Walker was immediately sacked. There were protests, held in open-court sessions of the Society, and the whole affair was a public disaster. Walker, not without support, was ousted. He immediately set up his own vaccine institution, next door to Jenner’s, and then stood on the street diverting parents and children into his own premises. Jenner immediately instructed the Society to write and rally MPs, peers, bishops and other clergy to his side, again wielding power in the form of patronage. But even though he could, for a while, call on an influential army, the taint of scandal and impetuousness was wearing. The Society was running out of money and was wound up. A new National Vaccine Establishment was on the horizon, with government backing. Jenner thought it should be his crowning glory, but it was his worst humiliation.

For more than five months of 1808, Jenner was detained in London, hating every minute. Paranoid about his personal safety, he felt isolated from friends, exposed to enemies and inadequate to the task in hand, namely, in his words, ‘to erect a state Pillar, without any knowledge of such kind of Architecture’. He described his heart and spirit as being ‘broken from the cruel privations of London’ and saw ‘by the most abominable falsities’ the ‘ruin of [his] private character’. The role that he had carved out for himself of being chief consultant on the organisation and procedures of the new Establishment were suddenly perceived as ‘the galling fetters which the Public have forged’ for him. When eventually the Establishment came into being, Jenner was named Director, but he felt himself to be the ‘Director directed’. Out of eight names he put forward to fill the principal vaccinating stations, all but two were rejected. Of those who were named, one was associated with George Pearson, and Jenner felt that to be a despicable insult. In my estimation it was no longer the status of vaccination that was on the line, but the perceived honour of Edward Jenner. He wrote a friend:

what am I but an underling in an Institution in which Pearson will, thro his agents virtually take the lead; and to resist & thereby gain my point, will throw me upon a bed of Vipers; for not only those who by a struggle on my part may be dismiss’d, but their numerous adherents, will be forever wounding me with their Fangs.

He resigned immediately, having found no sympathy among exasperated friends. His prognosis was as follows:

I am to be torn limb from limb it seems by Government & the College of Phys: but I hope my Executors will collect my scatterd remains and give me Christian burial. Hostilities are about to commence, & the odds against me would be fearful if my Heart was not well shielded – but I have nothing to reproach myself with, tho much to be vext at… the new Institution is disgraceful to the Nation & degrading to me.

Actually, with Jenner out of the way, the National Vaccine Establishment fared reasonably well. But while the Board was quite pleased to have vaccinated just over 3,000 in 1811, and to have distributed vaccine lymph to nearly 24,000 across the country and beyond, these numbers remained a drop in the ocean considering both the population size and the fact that smallpox inoculation was still ongoing. In that year, a non-epidemic year, 751 deaths from smallpox were recorded in the London Bills of Mortality. Despite the best efforts of the Vaccine Establishment and of Jenner, smallpox inoculation remained a common practice, in competition with vaccination, and was not outlawed until 1840, after a three-year epidemic that claimed 6,400 lives in London. Yet vaccination still carried the taint of mistrust and moral uncertainty. It took another 13 years after the prohibition of smallpox inoculation to establish compulsory vaccination. By this point, although the medical establishment had secured a firm footing in government, Jenner’s stock was at a national low. Compulsion, which came with ever more stringent enforcement, was nevertheless resisted. The epidemic of 1871-2 claimed 50,000 lives in Britain and Ireland, part of a five-year pandemic across Europe that claimed half a million lives.

The virulent strain of anti-vaccinism, supported by such luminaries as Alfred Russel Wallace, made frequent use of Jenner’s founding mistakes to point out the ineffectiveness of vaccination.

Jenner had been mistaken about what cowpox was, and who yet could say exactly how vaccination was supposed to work? Wallace even went so far as to say that the fear of vaccination was actually causing smallpox. Moreover, it had become abundantly clear that re-vaccination was required for lifelong immunity, but after decades of denial from the medical establishment, based largely on Jenner’s absolute conviction that such an admission would kill the vaccine movement, this was an extremely hard sell. Throughout the 1880s, whole towns – most notably Leicester – remained in open defiance of the vaccination laws, with the complicity of local Guardians. The fear and moral panic that had been original to Jenner’s early fame was ever present in the public discourse about vaccination in the last quarter of the nineteenth century. Vaccination caused syphilis or other diseases; vaccination killed or maimed children; vaccination was animal taint or impure. After compulsion was introduced, vaccination was an infringement of liberty and parental authority, un-English, and a portent of government that would not scruple to meddle in private lives. Kernels of doubt, about the stuff of the vaccine and about the people who administered it, were swelled into bushels of fear. Such fear was impervious to reasoned argument, precisely because those arguments came from mistrusted sources. In short, the idiom and structure of fear with which we still contend was created in the first two generations of vaccination, and was associated directly with Jenner himself.

This stuff has been written about, but the primary assumption is that Edward Jenner successfully introduced vaccination into the world and that government compulsion was a necessary step for the sake of public health, perhaps the first step on the road to social medicine. Within that context of an overarching success story, some have pointed out the extent to which liberties were trampled and rights overlooked by heavy-handed government, directed from within the Board of Health and the Privy Council. I rather think that it is easier to understand the introduction of compulsory vaccination from the standpoint of failure, in the context of the ‘promulgator of cow-pock nonsense’ having his statue removed from the Pantheon of heroes. Uptake of the procedure had been slow, and even the threat of repeated fines and imprisonment, sometimes with hard labour, couldn’t persuade some to hand their children over to the man with the lancet. Jenner, in his lifetime, had persuaded the medical establishment of the effectiveness of vaccination, and the large majority of physicians subscribed to it throughout the nineteenth century. But from day one, vaccination was a public concern, and from day one, the anti-vaccinists had had the better of the public discourse. The whipping up of fear and moral panic was far easier to manage and perpetuate than the rival cause of persuading the public of the efficacy of the new procedure. Jenner, in his time, was mired in concerns with institutionalising his own reputation, his honour, and his fame, perhaps thinking that in securing these he would secure the fate of vaccination. In the short term, at least, he failed in both. Removed from the institution of vaccination just as it gained government backing, Jenner’s attempts to control the message, procedures and personnel of vaccination had pretty much come to nothing, at least at home. The smallpox success story, in fact, is a twentieth-century story. We can still make Edward Jenner the hero of that story, if you like, but in that case the story probably needs a new plot.

Credits: Images 1-3,; 4-10, Wellcome Library, London; 11,

December 02, 2015

The History of Emotions: Foundations

Every now and again I run into a wall. Great and sustained bursts of writing resolve themselves into deep depressions of inactivity. The marathon runner in me knows the importance of rest and recovery after a hard slog, but that knowledge makes the days of low productivity no less easy to deal with. It’s always a bit of a mystery to me how the spark gets to be reignited. I think one has to look for inspiration, not wait for it to come.

At the moment I’m trying to come up with a rigorous justification of, and outline for, the history of emotions. At the same time I am documenting the modern origins of the notion that emotions are historical. It seems, of late, that every time I think that emotional historicism is gaining some traction among emotions scholars, someone comes along and hits me over the head with the most rank essentialism. I am mining rich seams of historical evidence for emotional change over time; others simply point to their endocrine systems, spilling their guts about biological determinism. The experience is dispiriting.

It is, therefore, somewhat joyous to find an historical source to break me out of a funk. George Henry Lewes – life partner of George Eliot, critic, private experimentalist, radical, polymath – foreshadowed the debates that preoccupy emotions scholars as long ago as 1879. He saw the essentialising tendencies in psychology and physiology; he understood the links between emotions and morality. He was, perhaps better than most of his contemporaries, well versed in evolutionism and sensibly critical of it, though he recognised that humans were humans wherever and however one found them. Is not the passage below an elegant and still relevant statement of both the historicity of emotions and a compelling justification for studying the history of emotions? 
Because Psychology is interpreted through Sociology, and Experience acquires its development mainly through social influences, we must always take History into account. It shares with Society the distinctive character of progress. It is for ever germinating, for ever evolving. The physiologist recognises the same organs and functions in the savage and the civilized, in Greek, Hindoo, old German, or modern European; but not the same thoughts and sentiments. The brain of a cultivated Englishman of our day, compared with the brain of a Greek of the age of Pericles, would not present any appreciable differences, yet the differences between the moral and intellectual activities of the two would be many and vast. These are not to be assigned to the organism and its functions. The co-ordination of sensory processes in the brain of the Greek was doubtless as perfect as that in the brain of the Englishman; but the quality of the moral feelings and the range of conceptions, so far as we could test them objectively, would be very different…. Thus, while the laws of the sentient functions must be studied in Physiology, the laws of the sentient faculties, especially the moral and intellectual faculties, must be studied in History. The true logic of Science is only made apparent in the history of Science.
George Henry Lewes, Problems of Life and Mind
3rd series, 1 (London: Trübner & Co., 1879) 

November 24, 2015

Pain: The Forgotten Emotion

[Transcript of a paper given at the University of Melbourne, Australia, November 18, 2015]

Today I want simply to give you a brief insight into the work I’ve been doing over the past few years on the subject of pain, its history and its present, with a few suggestions for the potential practical relevance of the history of emotions for contemporary medical practice. This work began life in 2011 within the framework of the history of emotions, as part of a postdoc at the Languages of Emotion Excellence Cluster at Freie Universitaet Berlin, in conjunction with what has turned out to be a long stay at the Centre for the History of Emotions at the Max Planck Institute for Human Development. I was, ostensibly, working on the history of sympathy and compassion at the beginning of that project, having previously carried out research on the history of cruelty and pain in animals. But I was obliged to make some connections that weren’t immediately obvious to me when Joanna Bourke invited me to be a Pain Fellow at the Birkbeck Pain Project in London in 2012. The focus there was supposed to be bodily pain, but I quickly realised that a mind/body dualistic approach wasn’t going to work, and that the work I’d been doing on sympathy was in fact a close and informative bedfellow of pain.

What has followed has been a bit of an adventure, which has taken me out of my modern-historian comfort zone in a number of different directions. I’ve engaged many different disciplinary approaches to pain, gone back through the ages to examine the wealth of historical literature on pain, and scrutinised many more recent historical and contemporary medical journals than I’d ever thought likely. I’ve talked with anaesthetists, plastic surgeons, bioethicists, art practitioners, lawyers and anthropologists in a bid to try and join up the thinking on pain.

The first result of all this was an edited volume that came out last year, called Pain and Emotion in Modern History, which makes one titular compromise that I would now like to undo. I’d like to swap out the ‘and’ and replace it with ‘as’. As it stands the book attempts to collapse the distinction between physical and emotional and to reassess some well worn historiographical paths by taking seriously historical claims that feelings hurt. I think I’m right in saying that for modern historians at least, this was novel and unexpected, and came with a heavy burden of proof. But I was aware that for early modernists and medievalists these claims were perhaps already in the mainstream, and indeed for some within contemporary neuroscientific research the emotional nature of pain was driving experimentation. What I couldn’t see – at all – was any sense that any of these distinct fields were aware of each other, let alone talking to one another. I saw huge potential in reassessing the historical narrative in the light of some of the latest neuroscientific research, and indeed reassessing some of that neuro-research in the light of the historiography.

That led me to take on another project, which I’m finishing up in Melbourne, to write Pain: A Very Short Introduction, which rather terrifyingly is to cover the history of pain from antiquity to the present, and to include an analysis of contemporary medical and scientific understandings of pain, all in 35,000 words. What you’re getting today is sort of a precis of the argument in that book, and I hope to at least convey my main points: first, that pain is an emotion or, if that is too stark, that pain is meaningless without emotion; second, that if emotional experience is historical, contextually contingent, mutable, then so must be the experience of pain; third, if this is true, then pain necessarily resists a definition, and treatment and management must be carried out with an attention to any sufferer’s subjective appraisal of their own pain and the cultural context in which pain is expressed.

Why do I call pain a ‘forgotten’ emotion? Well, as I combed the historical record I found that, with remarkable consistency across time and place, people seemed instinctively to know that bodily pain and emotional pain were of the same order, and while historians have carefully pointed out this fact they have done so through the lens of modernity, which has been characterised by a dualistic approach that has mechanised pain in the body and made pain of the mind a distinct kind of disorder. The effect: historical actors’ own conceptualisations of pain have been treated as novel and re-constructible on the one hand, but exotic, unfamiliar and wrong, strictly speaking. At the same time, the neuroscientific research that is convincingly demonstrating how pain is contextually and emotionally experienced has no connection whatsoever to this long view. Ostensibly, neuroscientists are confirming what the colloquial expressions of ordinary people suggest was already known – in fact continues to be known in everyday experience – but which had been forgotten in scientific and academic bowers since the time of Descartes. Meanwhile, current medical approaches to pain in clinical settings are largely disconnected from both these strands of research, still underemphasise the substantive interrelationship of body, brain and society in the construction of meaningful experiences of pain, and therefore still tend to treat people in pain according to presentations of bodily lesion or mental disturbance. If medicine could be inspired to remember that pain is an emotion or made meaningful only through emotion, then pain management would radically change.

I begin the book with a conceptual analysis of pain in history, examining how the language of pain has tended to conflate body and soul, body and mind, and physical and emotional. These are common expressions of pain that betray a fundamental fuzziness of the category of pain. The ancient Greeks had a number of words for pain and suffering that tended to overlap. Chief among these terms was άλγος (algos), which denoted physical pain as well as woe, ill, or misery. The Greeks did have a way of isolating bodily pain, if necessary, although it was only ever a short elision to a more general concept of suffering. In the Iliad, talk of όδύνη (odune) is never far away from the general state of anguish that undergirds the epic, and the same is true of the famous Herculean scream in Sophocles’ Trachiniae. The poisoned robe that slowly kills the hero in a prolonged fit of agony puts Heracles interchangeably in bodily pain and woeful misery (όδύνη and άλγος). 

The Greek term πάθος (pathos) denotes suffering or experience and, in its original meaning, the adjective ‘pathetic’ was an appeal at an emotional level. In Aristotle’s rhetoric, pathos causes pleasure or pain in an audience, as well as in its producer, depending on which emotions are mobilised. The possibility of pain without injury is clear, and it is closely entangled with affective states. As a central element of the rhetorical triad that included ethos and logos, we can assume that through pathos the potential for the feeling of painful woe was built into rhetorical emotional appeals. Aristotle goes so far as to say that the person who is angry ‘suffers pain’ (λυπεῖται). Here we see the elision of grief or vexation with bodily pain in the word λύπη (lupé). If we pursue this further, finding the Latin derivation of pathos, through πάσχειν (pashein), in the word passio, we see the continued conflation of the emotional and the physical, of suffering and pain. If the Romans emphasised the emotional level of pain through passio, they also, like the Greeks, had a generally holistic approach to the concept of pain that included what we have tended to divide into mental and physical categories. The Latin dolor is preserved in the French douleur, the Spanish dolor, and the Italian dolore. Originally, it could stand for physical pain, as well as grief, anguish, sorrow and resentment. To some extent, this conflation has been preserved in the vernacular.

The categorical vernacular conflation of old is not limited to Western civilisation. In Late Imperial China, for example, there is a rich overlapping of physical, emotional, sensational and moral categories, with an interplay of characters such as (tong), (ku), and the portmanteau 痛苦 (tongku), denoting respectively ‘painful’, ‘suffering’ and together, something like ‘anguish’. In India, the Hindi word दर्द (dard) stands for a raft of different degrees of suffering, from uneasiness to torture and from mental distress to grief to anguish. A correlate would be the word दुःख (duḥkh), which often translates as sorrow or grief, but which can signify pain just the same. It has ancient roots in Sanskrit, connoting suffering on a spiritual level, but when deployed in compound terms can indicate the whole range of pain from a cut to a cramp to a calamity. I begin with this semantic journey to emphasise both an enduring conceptual continuity in the understanding of pain, and to highlight the seismic rupture in this understanding that radically altered what it meant to be in pain, to be treated for pain, and to treat for pain (medically) in modernity. That rupture indicates an historical separation of vernacular knowledge of pain from medical specialism about pain.

Before reaching that separation I will say a few words on pain in the religious and theological context of medieval and early modern Europe up to the time of the rupture. Ecce Homo – behold the man – are the words associated with Pontius Pilate upon presenting the bloodied, tortured and pained body of Christ to the assembled masses, prior to crucifixion (John 19:5). The images associated with this scene became emblematic of virtuous suffering, and of the theological importance for humans to endure bodily pain. The representation of Christ’s passion in this moment has been preserved by the art world in the figure of the vir dolorum, or the man of pains, which has reached us variously in Europe as the ‘man of sorrows’ or the Schmerzensmann, which depicts a hurt beyond the mere physical. The wounds, the blood, the instruments of torture are all figures that invite reflection on a suffering that goes beyond the mortification of flesh.

Pain was a central pillar in Christian religious practice from the Roman world to the Counter Reformation, and arguably beyond. As Javier Moscoso and others have pointed out, pain was foundational for medieval and early modern piety, as part of an ascetic quest to imitate the ultimate pain in Christ’s passion. It was a pain not merely to be endured, but to be sought after, enhanced in any way imaginable, and, sometimes literally, sanctified. The imitation of the passion was celebrated in the lives of the Christian martyrs, whose placid countenances in the face of horrible tortures served as proof of the intervention of the saints. Meanwhile, such tortures informed medieval and early modern systems of justice and punishment. Long before pain came to be considered useful from an evolutionary point of view, pain was considered useful from moral, spiritual and judicial points of view. Religious life was dominated by the meaningful fact of being and coming to be in pain. No human pain could reach the extent of Christ’s suffering on behalf of humanity, but to embrace pain after the fashion of Christ was to offset sin and therefore reduce the amount of suffering after death. In this sense, pain was considered by many to be a blessing, or an unmitigated good, since it promised a swifter route to redemption in the afterlife. It would have been heretical, given this view, to seek to desensitise oneself to pain. Instead, people were to steel themselves to live with and through pain. As Esther Cohen has pointed out, this theological stance was the only way to resolve a tangible and all too readily observable ubiquity of suffering with the notion of an omnipresent Providence.

Doubtless this narrative is familiar, but I hope you acknowledge that already we have an account of pain that differs markedly from the kind of mechanistic or utilitarian discourse that would have all pain be bad or unpleasant, and reducible to the nervous system. I contend that the experience of being in pain in this context must have been completely different to the experience of being in pain in a secular, modern, medical context. Neuroscience is providing us with extremely convincing evidence to suggest that what pain feels like – that is, the meaning ascribed to being in pain that defines how pain is experienced – is affectively constructed. We should seriously entertain the notion of pain as ecstasy, pain as piety or a feeling of closeness to God, and pain as pleasure. When such things crop up in the historical record they should be entertained at face value and not merely as rhetorical. I’ll say more about this in a couple of minutes.

The rupture in conceptual understandings of pain is usually ascribed to Descartes, but I want to do him some justice before condemning him. Descartes’ human was, in fact, not a separable entity of body and soul so long as the body was alive, but a union of body-mind or body-soul, which could not be reduced to its components. True, in his Meditations, Descartes insisted that the thinking thing (res cogitans) did not depend on a body, but when Descartes’ body was affected by pain, he felt it; that is, at the level of the rational soul – a thinking thing – there was a disturbance (of thought), caused by the disruption or injury of the body with which the soul was conjoined. He talked of an ‘admixture’ (permixtione) of mind and body when it came to the senses (e.g. hunger or pain). The human body in pain was not merely a reflex mechanism akin to a bell on the end of a rope, but a body-mind that only felt pain because the mind was inseparable from its corporeal seat. If it were otherwise, according to Descartes, the human thinking thing would look upon bodily injury (lesion) as the pilot of a vessel would look upon a damaged boat. This account is complex, rich, and useful.

But. This image, added to the Meditations later, in combination with what Descartes said about animals being like clocks or soulless automata, prevailed. A simplistic reading of the image, contrary to what Descartes actually wrote about pain, has been enormously influential in modern medical science, beginning the search for a mechanical pain pathway. It rests on the assumption that injury = pain and that reactionary movements away from the cause of pain are the results of nervous stimulation, like a bell on the end of a rope suddenly being pulled. As science became increasingly secular and as the soul retreated into the background, so the primacy of physical pain emerged. We have lived with this vision more or less ever since. Ironically, science’s loss of interest in the soul allowed animals into the realm of beings that feel pain, but when physiologists recognised that pain was an unpleasant experience in humans and animals alike, they nevertheless set out on Descartes’ path to find the ‘wheels and springs’ that made pain work.

Modern biomedical theories of pain were preoccupied with the ‘pain pathway’ – the specific mechanism by which pain is detected in the periphery and transmitted, via the spinal cord, to the brain. It was based on assumptions that intensity of injury directly correlated with intensity of pain, and that certain nerves were specifically involved in sending pain messages to the brain. There is a kind of comfortable intuitiveness about such assumptions, but they have been conclusively found to be completely incorrect. Essentially what we see in modern medicine is the parceling out of physical pain related to injury and mental pain, which really did not belong to biomedical concerns. Even though this began to change in the 1960s, we are essentially still living with this dualism in the way medicine is practiced. It has been to the detriment of countless millions of people suffering with chronic pain syndromes and, throughout the twentieth century, saw the moral fibre or character of the war wounded called into question as they continued to suffer from the traumatic effects of combat, whether physically injured or not. Pick up a standard medical text book on pain and you will still find, as a sort of rhetorical Cartesian hangover, a tendency to label nerves that detect injury as pain detectors, which send pain signals to the brain. Such rhetorical slippages have been unsupported since 1965, but they persist and they continue to affect medical practice.

What happened in 1965? Ronald Melzack and Patrick Wall published their new theory of the ‘gate control mechanism’, which in turn fostered neuroscientific research that revolutionised understandings of what pain is. Here is the circuit-board in the spinal cord. But the mechanism was coupled with a fuzzier idea that promised the reintroduction of something immaterial, or beyond the human, to make sense of the variability of pain experience. The gate control is essentially a processing centre in the spinal cord that processes signals coming from the periphery in conjunction with signals descending from the brain. It determines what signals make it to the brain to be interpreted as pain. Crucially, the receipt of injury signals from the periphery are only allowed through the gate in conjunction with evaluative cognitive and emotional involvement. The social context and an appraisal of threat determine how pain feels: what it meaningfully is. Pain is indistinguishable from the fear, anxiety, anger, or ecstasy that comes with it.
This has been confirmed by study of those people with rare cases of pain asymbolia, or congenital analgesia. This is a genetic condition that renders its ‘sufferer’ unable to ascribe any meaning to painful states. Injurious stimuli are perceived plainly as pressure, cutting, cramping, etc., but the person who perceives these things is indifferent to them. Research has shown that so-called ‘pain centres’ in the brain do, in fact, ‘fire’ in these people when given painful stimuli, but their ‘affective centres’ do not. It is precisely because there is no emotional context to the physical problem that the pain does not register as a problem. Far from being advantageous, people with congenital analgesia tend not to live very long, precisely because they are indifferent to the pain that comes after injury. If there is an evolutionary benefit for pain it is in restricting movement and in protecting those parts that need time to heal. A person with congenital analgesia does not limp when wounded in the leg, and would indifferently go on throwing a ball with a broken arm. This failure to conserve an injury – an affective failure – has the effect of wearing out bones, joints and muscles at a much greater rate than somebody who could feel pain in a ‘normal’ way. Pain, to put it in plain terms, keeps us alive. It depends, when ordinarily perceived, on what the neuroscientists call affect.

Neuroscientists have provided further evidence of this by demonstrating that specific brain activity typically observed when painfully injured roughly corresponds with brain activity when feeling ‘social pain’. Despite some worthy and necessary scepticism about what we are seeing when we look at an fMRI scan of a brain, there can be no question that parts of the brain strongly related to affective or emotional behaviour are involved in pain states, and that these parts of the brain are also involved under stimuli that replicate the affective conditions of pain, but which do not involve any physical harm. In other words, the thing that gives pain meaning – that makes pain painful – can be observed in situations where the body is completely uncompromised. In a now famous test Naomi Eisenberger tested the effect of social exclusion among a peer group. Using a computer game of ‘cyberball’, in which players passed a ball to each other while being scanned, Eisenberger was able to show that being excluded from the game caused brain activity similar to what one would expect to see in conditions of physical pain. Those who felt excluded went through an emotional ordeal that looked, for all intents and purposes, the same as physical pain. The meaning-making processes that are part and parcel of experiencing physical pain are the same when experiencing such things as exclusion, bullying, grief. A broken heart – the archetypical cliché of emotional pain – turns out to be painful in the same sense as a broken leg (although with different consequences, of course). If hurt feelings have been, since time immemorial, a colloquial commonplace, contemporary medicine has started down the road of providing neuroscientific verification of this fact. Ronald Melzack has, much more recently, pushed the implications of his research even further, and coined the neuromatrix theory of pain. Key to this theory is the insistence that experience is not present anywhere, but is created in the brain.

Pain is output of the brain, not input from the periphery. Melzack forcefully states that injury is not pain. Pain is a quality produced in the brain, and is not reconcilable with, or reducible to, injury per se. The neuromatrix theory posits the production of a neurosignature of the whole body – an internal neuro ‘image’ or ‘pattern’ of the body understood as the self – which is ever-present. While the particulars of an individual’s neuromatrix may be genetically programmed, it is nevertheless plastic, being formed and informed by a number of factors that together produce a sense of the self: sensory inputs, including aural and visual, are components; affective and emotional states, which are themselves forged in the crucible of culture, play a part; the meanings and values attached to body parts, proportions, postures, and movements – some of it instinctive, some of it culturally prescribed – are factored in. All these inputs are processed and, in Melzack’s analogy, ‘arranged’ into a symphonic output that equates to the body-self. A cut in the leg may or may not be painful, but I know it is a cut in my leg because of the neurosignature imprint of my neuromatrix. The neuromatrix promises the collapse of both Cartesian dualism and the distance between biomedicine and phenomenology. The brain is not merely a machine, an automaton, or a computer. The brain is plastic, subject to change, and influenced by the world in which it is situated.

This research, I think, casts the history of pain – replete with seemingly inaccessible allusions to religious ecstasy, sexual pleasure and agonies of the soul – into a new light. What might seem like metaphor or rhetoric on face value might actually be a faithful recording of the experience of pain from distinct historical and subjective perspectives. The history of pain is so rich – I’ve barely skimmed the surface of a tiny fraction of it here, that I think it bears re-visiting with a commitment to embrace the unfamiliar as, for want of a better word, authentic. Moreover, that rich history should be sufficient for biomedicine to give up its quest for a definition of pain. It is emotional, historical, contextual. This observation thrusts the emphasis back on to the subjective experience of pain. Doctors’ most reliable source for what their patients are going through is not an fMRI scanner, a prescribed pain questionnaire, or a premeditated search for a lesion, but lies in who the patient is and in what they say and do, combined with an appreciation of their circumstances and the societal prescriptions for what can and should be expressed and what cannot. In short, doctors need to become literate in the pain practices – which is to say the emotional practices – of the people around them. Maybe historians of emotion can help with that.

Pictures: Bernard Picart, The Death of Hercules, 1733; Lucas Cranach the Elder, Christ as Man of Sorrows [Schmerzensmann], before 1537; The pain pathway, from René Descartes, Traite de l’homme, 1664; Gate Control Mechanism, Melzack and Wall, Science, 1965; ‘Social and Physical Pain Produce Similar Brain Responses’, Eisenberger, Lieberman and Williams, Science, 2003; ‘Pain and the Neuromatrix’, Melzack, Journal of Dental Education, 2001.

October 18, 2015

A Shot in the Arm

Juggling multiple projects, it is perhaps unsurprising that one sometimes tries to catch all the knives in one hand. The release of a policy position-paper from the World Health Organisation on pain mitigation during child-vaccination procedures brought everything into focus recently, making me think there’s a unifying principle to my work after all.

The release of Edward Jenner is only two weeks away (that makes him sound like a hell hound, which maybe is apt), so I’ve become a sort of vaccine activist in the form of Jenner’s ghost (@EdwdJenner on Twitter). In the meantime I’m finishing off a book on pain for Oxford University Press, due in December. Lurking in the background is the daunting prospect of writing the first textbook on the history of emotions for Manchester University Press, due at the end of next year. And my book on the practical applications of Darwinian sympathy is done, dusted and on its way to the University of Illinois Press, replete with a chapter on the evolutionary rationale for compulsory vaccination.

Concerned that anxiety increases the pain of childhood vaccination, which in turn leads to fall-off rates for immunization programmes, the WHO sets out guidelines for a smooth and pain-reduced process. Interestingly, they don’t think that topical anaesthetics are worth the cost and find no evidence that orally ingested painkillers make any difference to the pain of being injected. Rather, a programme of calmness, distraction and neutral language is promoted. Caregivers are to be present throughout. Where appropriate, infants should be breastfed immediately prior to injection. Vaccinators should be even-tempered and well-informed. They should stick to straightforward speech that neither alarms nor falsely reassures (we can all see through it). There ought to be a plentiful supply of toys. It’s essentially a recipe for anxiety elimination for the reduction of pain.

Probably not what the WHO has in mind: Major and Mrs Padmore inoculating against plague in the bazaar in Mandalay, Burma, now Myanmar, 1906. Wellcome Library, London
What is striking about the WHO’s advice is the degree to which they accept and endorse a working definition of pain that includes, in fact depends on, emotion. I’ve been beating a drum for a while now about the way humans make meaning out of pain, arguing that things hurt according to the extent to which we fear them. Pain is not simply a mechanical nervous circuit, where pain experience is directly proportional to painful stimulus. Humans make pain according to emotional appraisals of the meaning of bodily harm, and this dynamic involves both the affective processes of the brain and an understanding of the world and its particular and contingent articles of anxiety. There is no universal elicitor of fear; no object that is intrinsically fearful. Meaning is made – pain is made – in cultural and historical context.

David Hume knew all this in the 1730s:
Were I present at any of the more terrible operations of surgery, ’tis certain that even before it begun, the preparation of the instruments, the laying of the bandages in order, the heating of the irons, with all the signs of anxiety and concern in the patients and assistants, wou’d have a great effect upon my mind, and excite the strongest sentiments of pity and terror. No passion of another discovers itself immediately to the mind. We are only sensible of its causes and effects. From these we infer the passion: And consequently these give rise to our sympathy.
Watching someone about to endure pain is, in itself, painful to the witness. Anxiety is well known to be ‘contagious’. In turn, the subject of the ‘terrible operation’ sees only victimhood, feeding on the anxious atmosphere at hand. In such circumstances, without something to deaden the sensibilities, doubtless the pain would be heightened. It is heartening to know the WHO has a handle on this, with a complex understanding of the ways in which the management of anxiety will diminish the likelihood of painful experience.

Vaccines, Pain, Emotions: my world to a tee, in an episode from the doctors WHO.
Related Posts with Thumbnails