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Spinal Irritation is characterized by multiple tender spots distributed over the female body, probably caused by sexual excess.... A couple of leeches to the inside of the nostrils are remarkably efficacious [and as for] counter-irritants, such as blisters, croton oil, tartarized antimony, and the actual cautery, cases every now and then appear in which they seem to be of service... I suppose the most generally advantageous agent of the kind is the actual cautery very lightly applied to the nuchae.
William A Hammond, Spinal Irritation, 1886 (2)
1990 ACR Criteria for the Classification of Fibromyalgia 1. History of widespread pain... 2. Pain in 11 of 18 tender point sites on digital palpation... Digital palpation should be performed with an approximate force of 4 kg. For a tender point to be considered "positive" the subject must state that the palpation was painful. Tender is not to be considered "painful."
Wolfe et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee (1)
TENDER POINTS
For almost two centuries, doctors (traditionally male) have been responding to unexplained aches and pains of their patients (traditionally female) by tweaking various tender or painful points on their bodies. Once a particular constellation of points is elicited, a diagnosis is made and treatment applied. The women have been in real pain, current treatments have sometimes worked, but the end-results have varied little over the years. Early in the 19th century, based on their recent discovery of the reflex arc, doctors named the syndrome of unexplained aches and pains "Spinal lrritation (3)
." As described by Dr. Hammond, it was managed by applications of leeches or by hot iron cauteries applied to the back of the neck (the nuchae).
Nowadays, of course, we are much wiser. Reflexology has been left to the medically untutored and we attribute the slings and arrows of daily pain—now called fibromyalgia—to a "central hypersensitivity to nociception (4)
". Experts in the field suggest that
Persistent or intense nociception can lead to transcriptional and translational changes in the spinal cord and brain resulting in central sensitization and pain. This mechanism represents a hallmark of fibromyalgia and many other chronic pain syndromes, including irritable bowel syndrome, temporomandibular disorder, migraine, etc. (4)
To some with fibromyalgia, the perception of pain is so intense, its duration so debilitating, that they have been driven to extremes. A dozen years ago, Judith Curren, a 42 year old nurse from Pembroke, Massachusetts, traveled to Michigan with her husband, a psychiatrist, to have her suicide "assisted" by Dr. Jack Kevorkian. Her death, according to The New York Times ended "an extreme state of suffering" due to "fibromyalgia, a painful nerve and muscle disease, chronic fatigue syndrome and other opportunistic ailments (5)
." The medical examiner at Dr. Kevorkian’s hearing found that "there was no indication that the patient had a medical disease." The finding is in keeping with the opinions of other medical and social scientists that there is no obvious somatic basis for the diagnosis of fibromyalgia (3
, 6
). That view has been summarized by George Ehrlich:
The symptoms exist, some of the epiphenomena may represent contributions or reactions to the pain, and overlying everything is a sociological construct that accounts for the diagnosis and reporting in some, mainly urban, cultures, mainly in advanced and industrialized nations, and a dearth of diagnosis and reporting in developing countries and rural areas (7)
Skeptics point out that electron microscopy of those tender points has shown neither inflammation of connective tissue (fibro) nor of muscle (myo) (8)
. But whether or not fibromyalgia is a sociological construct or truly a "medical" disease, the pain (algia) that can drive a patient to suicide is real.
Since the days of spinal irritation, many of the molecular pathways and neurotransmitters of pain have been identified as targets for effective drugs (9)
. In consequence, fibromyalgia is now treated with agents directed at these targets in the brain and spinal cord. Recently, several such drugs have undergone double-blind, placebo-controlled study in academic medical centers and passed the scrutiny of peer review. These include include duloxetine, a serotonin and norepinephrine reuptake inhibitor (10)
; tropisetron a serotonin receptor blocker (11)
; and the newly FDA-approved pregabalin, which targets the 
2
subunit of a voltage-dependent calcium channel (12)
.
A puzzle arises. It seems that even homeopathic medication has survived the rigors of a double-blind, placebo-controlled study. In 1989 the British Medical Journal published results of a successful trial of homeopathic medicine for fibromyalgia. Supervised by an eminent English rheumatologist, the patients were given an infinitesimal dilution of rhus toxidendron (from poison oak). The tincture had been diluted 1:99 in ethanol and "then vigorously shaken." The process was repeated 6 times to give a dilution of 1012 of the original tincture and further admixed 2% v/w in lactose pills. Thus by the time this "medication" had been distributed in the body no single molecule of the original material could have reached brain or spinal cord.
And the puzzle remains. Homeopathy for fibromyalgia was neither better nor worse than treatment with pharmacologically active agents. In the latest study of an FDA approved agent, 29% of a treated group had their pain halved (on a scale of 1–10) vs. 13% reduction of pain in the control group—drug had beaten placebo (12)
. But the British homeopathic study reported that 53% of patients given infinite dilutions of poison oak had relief of pain and sleep disturbance vs. 27% in the control group. Placebo had beaten out placebo (13)
.
TENDER BUTTONS
The British homeopaths noted that the improvement in tender or painful spots, "which is the best discriminator of the disease" was particularly impressive (13)
. Their report appeared almost simultaneously with the ACR criteria which required doctors to tweak their patients’ buttocks and nuchae with pressure sufficient to produce pain: "tender" is not considered "painful," warned the criteria framers. In advocating 18 bouts of hard poking at women, they were following an example set by nasty predecessors in the pain game... as in "Vee haff vays of making you tawk!"
Perhaps the earliest directions for eliciting the tender points of "spinal irritation" were given by Walter Johnston in his 1849 Essay on the Diseases of Young Women:
The examiner stands behind the patient, and, commencing just below the neck, makes firm pressure with his knuckles successively on each projecting ridge [of] the spinal column. Less usually he tries the effect of scalding the patient by a sponge dipped in hot water. In the course of his investigations it frequently happens that as soon as he presses or scalds one particular ridge or vertebra, he perceives his patient wince or give some evidence of pain. "Aha!" says the physician, "there it is (14)
It is difficult to resist the Freudian connotations of this sort of examination, nowadays often conducted with the aid of a "dolorimeter," a hand-held device that measures the pressure at which tenderness or pain is provoked (15)
. Some of the fibromyalgia doctors have broadened their purview by means of a similar device, a "vulvodolorimeter," which is used measure pain in the female genitals (16)
. One is reminded of Gertrude Stein’s Tender Buttons, a volume in which "slyly erotic references" to "pain soup" celebrate her domestic arrangements with Alice B. Toklas (17)
.
THE THREE GRACES
The astonishing image of "The Three Graces" that illustrates the ACR criteria (see page 327) neither reflects the somatotype of Gertrude Stein, nor of most sufferers from fibromyalgia. It has been noted that patients afflicted with fibromyalgia, as were patients with "spinal irritation" in years past, are significantly more corpulent than their sisters. Indeed, both the number of tender points and the extent of pain in fibromyalgia tend to vary with the body mass index (18)
. Poor Judith Curren, who died for her disease, was doubly afflicted. "I think this one was a tragedy," the medical examiner told reporters. "I have no doubt she was tired. When someone is 260 pounds, you easily get tired. When someone is depressed, you get tired." Mrs. Curren was 5 feet, 1 inch tall (5)
.
An argument in favor of the social construct theory is as handy as the Google image bank of The Three Graces. Depiction of those paragons of female grace and beauty, of Aglaia (the radiant), Euphrosyne (the joyful), and Thalia, (the flowering) vary as widely with time and fashion as society itself. The ACR trio is a very trimmed-down, 1990 version of a far plumper set of Graces by Henri Alexandre Georges Regnault, now in the Louvre (19)
. The Regnault ladies advertise the glorious results of wining and dining in mid-19th century France. Far slimmer graces were carved in stone earlier in the century by Thorvaldsen and Canova, the neoclassic period favored cleaner lines and smaller poitrines (20)
. The neoclassic Graces are eclipsed in BMI by the gusty Flemish amazons of Peter Paul Rubens (21)
; his age favored fuller bodies and flacons of brew. As ever, the Renaissance combined a flowering of beauty with the radiance of joy: the graces of Raphael and Botticelli carry immortality on gossamer wings (22)
. The squalid warrens of 21st century art and dolorimetry are well represented by the grotesques of Philip Pearlstein and the hermaphrodites of Joel-Peter Witkin (23)
.
We might conclude that society constructs the form and function not only of real, but also ideal, women.
LINCOLN’S SURGEON GENERAL
Edward Shorter addressed the construction of disease in the context of spinal irritation, focusing on the days of Regnault and William Hammond:
Reflex theory ... claimed a scientific basis in the pseudoscientific doctrine of "irritation" and in the genuinely scientific notion of reflex arcs in the spine. Yet the popularity of reflex theory among physicians was probably a result of their pejorative beliefs about women—beliefs that male physicians held in common with other males of the nineteenth century. (3)
The diagnosis of spinal irritation and its treatment by counter-irritation reached its zenith in the 1886 book Spinal Irritation, by Dr. William A. Hammond of New York who routinely found "multiple tender spots" in women suffering from spinal irritation and ascribed some of the cases to sexual excess or, so he was convinced, masturbation. In keeping with his contemporaries, he advocated treatment with "counterirritants" such as dry heat, scalding water, or croton oil extracts. William Alexander Hammond had been for a short time Lincoln’s Surgeon General of the United States. He attained the distinction, unique for that rank, of being court-martialed during the Civil War after acrimonious squabbles with Secretary of War Stanton and bureaucrats of the career Medical Service (24)
. His chief problem, aside from a personal lapse in petty finance, seems to have been that he was too closely affiliated with the reformers of the Sanitary Commission.
But Hammond was able to recover from political infamy; eventually his reputation was cleansed and his rank restored by the U.S. Senate. He went on to become one of the founders not only of the American Neurological Association, but also of the New York University Postgraduate Medical School, in the library of which his books are now quietly disintegrating. Hammond’s magisterial A Treatise on Diseases of the Nervous System (1871), the first American textbook of neurology, is an extensive tome, published a scant seven years after his fall from official grace. The treatise is filled with outmoded rituals and jaw-breaking syndromes. Scattered among this dross are neatly described case histories and new observations, but the volume is tough slogging.
Much like the folk who today play with "dolorimeters" or "vulvodolorimeters," Hammond had his own patented machine for neurological diagnosis, the "dynamograph (25)
." On April 25, 1870, at the court of General Sessions, New York City, Hammond, testified on behalf of Daniel McFarland, a patient of his, who had shot to death the famous journalist Albert Richardson. Hammond told the jury he had "devoted the last five years of his professional life exclusively to the study of the mind," and that he had diagnosed McFarland’s cerebral hyperemia by means of his "dynamograph." machine. Hammond assured the jury that the machine’s test of Hammond’s flawed motor responses provided "full and decided evidence" that McFarland could not control his will (25)
.
Among his patients with "spinal irritation" was poor Miss A.W., whose diagnosis was tough to unravel. One of her symptoms was the habit of swallowing pins by the dozen to stop her pains. Hammond discusses the puzzling diagnosis and, in charged phrases, describes a neurologist arriving at the true diagnosis:
... he is baffled, but then instead of [giving up], he will begin to punch or hammer the vertebrae, as he before pressed them. In this way it very rarely happens but that he at last succeeds in finding some sensitive spot, which he can assume to be the seat of the disease. He now feels it a clear duty to apply leeches to the culprit vertebra, or mercurial inunction, or a blister, or an issue or seton [a few silk threads inserted into a surgical incision in the skin, to excite pus], and strictly enjoins perfect quiet and the recumbent position (26)
Happily, and perhaps in consequence, Miss A.W. later extruded these pins from her skin, her nose, and various nether orifices (surely the first documented case of pins envy).
Nevertheless, Hammond shows some warmth and empathy for his mentally ill patients, regarding them in the tolerant, bemused fashion of a Victorian author displaying his fictional creatures. But woe to the patient who failed to respond to "moral means," the talking cure. She—for it was usually a female patient—was in for leeches or counter-irritants. Hammond was convinced that all neurological diseases were due to either "hyper-" or "hypo-emia" and that the cautery and leeches would restore the balance between too much or too little blood in the spine. Since mainly women were subject to these measures, it is fair to ask whether sexism, historical folly, or medical science were at work.
The world of Hammond and the spinal irritation doctors seems so far away, viewed from our privileged decade of molecular medicine, of sono- and angiograms, of cyclo- and cephalosporins, of liposomes and liposuction. The day-to-day medicine of the 1830s to the 1930s appears to have been futile, groping, and—let’s face it, quackish. All that laying on of hands, thumping of the chest, leeches, calomel, glycerine, cautery! In 1871, Oliver Wendell Holmes gave the students at Hammond’s medical school a vision of medical science which transcends the fashionable diagnoses and drugs of the day; it will remain true when dolorimetry will have gone the way of the cautery, and pressure points the way of calomel:
If the cinchona trees all died out ... and the arsenic mines were exhausted, and the sulphur regions were burned up, if every drug from the vegetable, animal, and mineral kingdom were to disappear from the market, a body of enlightened men, organized as a distinct profession, would be required just as much as now, and respected and trusted as now, whose province should be to guard against the causes of disease, to eliminate them if possible when still present, ... and to give those predictions of the course of disease which only experience can warrant, and which in so many cases relieve the exaggerated fears of sufferers and their friends or warn them in season of impending danger (27)
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FOOTNOTES
The 18 "Pressure Points" of Fibromyalgia was reprinted with permission of Wiley-Liss, Inc., a subsidiary of John Wiley & Sons, Inc.
The opinions expressed in editorials, essays, letters to the editor, and other articles comprising the Up Front section are those of the authors and do not necessarily reflect the opinions of FASEB or its constituent societies. The FASEB Journal welcomes all points of view and many voices. We look forward to hearing these in the form of op-ed pieces and/or letters from its readers addressed to journals{at}faseb.org.
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