Although the patient's experience and expectation of pain are among the most universal and enduring aspects of medical, surgical and dental practice, the direct representation of physical pain is hardly ever encountered in medical films, videos or television programmes. Physical pain is a highly subjective experience, and as such does not readily lend itself to direct portrayal. Phenomena as diverse as trance, fire-walking and some forms of hysteria clearly show that the relationship between painful stimuli and painful feelings is notoriously variable and uncertain, while even the facial expressions associated with pain are generally less clear-cut and distinctive than, for example, those associated with fear or terror.

Partly because of this, pain in medicine has not usually been ascribed much diagnostic or prognostic value, and because of its potential to interfere with therapeutic interventions, it has normally been regarded as something to be suppressed rather than studied.

Moreover, the objective audiovisual recording of painful experiences, without any attempts to modify them, is as problematic ethically as the gratuitous infliction of pain. It is not surprising, then, that the direct representation of painful bodily states has never formed part of the standard repertoire of medical film-making.

However, the Medical Film and Audio Collections of the Wellcome Library do contain a number of film and video titles that shed indirect light on medical and surgical pain, ranging from broadcast television documentaries on the development of dental and surgical anaesthesia to nonbroadcast medical information programmes on the use of analgesic agents in childbirth. Among these is one of the earliest films in the collections, a German film entitled Unterschenkel-amputation, published by the Institut für den Wissenschaftlichen Film (IWF) in 1957, which shows the amputation of a lower (left) leg by Prof.-Dr Ernst von Bergmann (1836-1907) of the University of Berlin in around 1903.

The film is silent, black-and-white, lasts for barely one minute 30 seconds and originally had no opening titles or intertitles to help the viewer understand its content. The patient is, of course, anonymous; we know nothing of the case history, why the operation had to be performed or, indeed, why this film record was made, yet much can still be gleaned from this brief and rather cryptic glimpse of early 20th-century surgical practice.

The contemporary viewer will immediately be struck by the fact that none of the six doctors and nurses is wearing surgical masks or gloves. The film opens as the surgeon is already making the initial deep rotational cuts. As it was made long before the medical film-making convention of explaining the case history and showing the instruments and pre-operative preparations, we see only the climax, so to speak, of the operation. Because filming was still limited to single fixed-camera positions, the whole procedure is shown frontally in medium shot, with no close-ups, multiple views or overhead shots as would now be normal.

However, perhaps the most striking feature of the procedure is the sheer speed with which it is performed. Indeed, the whole point of the film appears not to be the demonstration of any fine points of surgical technique, but simply the alacrity with which it could be carried out. Although filmed half a century after the general adoption of surgical anaesthesia, in what was then one of the world's leading teaching hospitals, the whole operation is performed almost as if surgical anaesthesia had never been invented - an effect reinforced by the camera position, which largely conceals the anaesthetist and his apparatus from view.

The surgeon, Dr von Bergmann, is very tall, powerfully built, and wields his instruments with great speed and force, just as a surgeon would have done in pre-anaesthetic days when operations had to be carried out as speedily as possible to reduce blood loss, operative shock, and, not least, the duration of the patient's agony. Dr von Bergmann was already nearly 70 when he performed this operation, and as a young man had probably witnessed or even assisted at operations before surgical anaesthesia was generally adopted in the early 1850s.

Consequently, watching Unterschenkel-amputation is rather like looking back through a window in time to the pre-anaesthetic era of surgery, for which, of course, we have no actual film records. But the spectacle of suffering has been expunged, thanks to the (almost invisible) anaesthetist and his agents. The terror, fear and pain that a patient would once have felt no longer have the power to interfere with the surgeon's therapeutic action; and consequently the speed and apparent brutality of the operation now appear highly anachronistic and inappropriate.

Michael Clark is Head of the Medical Film and Audio Collections at the Wellcome Library. A clip from the amputation film is featured on the CD-ROM produced by the Wellcome Trust for its 'Pain' exhibition at the Science Museum.

See also

• 'Pain' exhibition at the Science Museum: Further details
• Feature article on pain research entitled Dissecting pain
• News article entitled The many sides of pain on the associated materials produced to accompany the 'Pain' exhibition
• Medical Film and Audio Collections at the Wellcome Library