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Coordinación y producción editorial: EDIDE, S.L.
ISBN•edición original: 0-443-07287-6
ISBN edición española:
ISBN-13: 978-84-8174-949-6
ISBN-10: 84-8174-949-4
Depósito legal: M-41.770-2006
Impreso en España por Liberdúplex,•S.L.
ADVERTENCIA
La medicina es un área en constante evolución. Aunque deben seguirse unas precauciones de seguridad estándar, a medida que aumenten nuestros conocimientos gracias a la investigación básica y clínica habrá que introducir cambios en los tratamientos y en los fármacos. En consecuencia, se recomienda a los lectores que analicen los últimos datos aportados por los fabricantes sobre cada fármaco para comprobar la dosis recomendada, la vía y duración de la administración y las contraindicaciones. Es responsabilidad ineludible del médico determinar las dosis y el tratamiento más indicado para cada paciente, en función de su experiencia y del conocimiento de cada caso concreto. Ni los editores ni los directores asumen responsabilidad alguna por los daños que pudieran generarse a personas o propiedades como consecuencia del contenido de esta obra.
ELEDITOR
Colaboradores
A Vania Apkarian PhD
Associate Professor of Physiology Department of Physiology Northwestern University Feinberg School of Medicine Chicago, Illinois, USA
Mark Baccei PhD
Research Fellow Department of Anatomy and Developmental Biology University College London London, UK
Miroslav Backonja MD
Professor, Department of Neurology University of Wisconsin Medical School Madison, Wisconsin, USA
Panos Barlas BSc (Hons) DPhil MCSP LicAc
Research Fellow School of Health and Rehabilitation Keele University Staffordshire, UK
Ralf Baron MD
Professor of Neurology Chair, Department of Neurological Pain Research and Therapy Vice Chair, Neurological Clinic Christian-Albrechts-Universität Kiel Kiel, Germany
Allan I Basbaum PhD
Professor and Chair Department of Anatomy University of California San Francisco San Francisco, California, USA
Carlos Belmonte MD PhD Professor of Human Physiology and Medical School Director
Alicante Institute of Neuroscience University Miguel Hernández-CSIC San Juan de Alicante, Spain
David L H Bennett MB PhD
Specialist Registrar in Neurology Department of Neurology King’s College London London, UK
Charles B Berde MD PhD
Chief, Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine
Boston Children’s Hospital and Professor of Anesthesia and Pediatrics
Harvard Medical School Boston, Massachusetts, USA
Karen J Berkley PhD
McKenzie and Distinguished Research
Professor Program in Neuroscience Florida State University Tallahassee, Florida, USA
Stuart Bevan PhD
Novartis Institute for Medical Sciences London, UK
Christiane S Bieber MD University of Heidelberg Medical Hospital
Department of General Internal and Psychosomatic Medicine Heidelberg, Germany
Klaus Bielefeldt MD PhD
Visiting Associate Professor of Medicine Division of Gastroenterology, Hepatology and Nutrition University of Pittsburgh Pittsburgh, Pennsylvania, USA
Marcelo E Bigal MD PhD
Assistant Professor of Neurology Albert Einstein College of Medicine and Director of Research
The New England Center for Headache Stamford, Connecticut, USA
Jörgen Boivie MD PhD
Senior Consultant Department of Neurology University Hospital Linköping, Sweden
Michael R Bond MD PhD FRCS FRCP FRCPsych FRSE
Emeritus Professor of Psychological Medicine
University of Glasgow Glasgow, UK
Harald Breivik MD DMSc FRCA Professor of Medicine and Anaesthesiology
Department of Anaesthesiology
Rikshospitalet and Department Group of Clinical Medicine
University of Oslo Oslo, Norway
Kay Brune MD PhD
Doerenkamp Professor
Managing Director
Department of Experimental and Clinical Pharmacology and Toxicology
Erlangen Nürnberg University Erlangen, Germany
M Catherine Bushnell PhD
Harold Griffith Professor of Anesthesia Director, McGill Centre for Research on Pain
McGill University Montreal, Quebec, Canada
James N Campbell MD Professor of Neurosurgery and Director of the Blaustein Pain Treatment Center
John Hopkins Hospital Baltimore, Maryland, USA
Nathan I Cherny MBBS FRACP FRCP(Lon)
Director, Cancer Pain and Palliative Care
Department of Medical Oncology
Shaare Zedek Medical Center Jerusalem, Israel
Mary L Chipman MA Department of Public Health Sciences Faculty of Medicine University of Toronto Toronto, Ontario, Canada
John J Collins MBBS PhD FFPMANZCA FRACP
Head, Pain and Palliative Care Service
The Children’s Hospital at Westmead Westmead, New South Wales, Australia
A D (Bud) Craig PhD
Atkinson Research Scientist Divisions of Neurosurgery and Neurobiology
Barrow Neurological Institute Phoenix, Arizona, USA
Kenneth D Craig PhD
Professor, Department of Psychology University of British Columbia Vancouver, British Columbia, Canada
Jørgen B Dahl MD PhD
Head, Department of Anesthesiology Glostrup University Hospital Glostrup, Denmark
Marshall Devor PhD
Department of Cell and Animal Biology Institute of Life Sciences and Center for Research on Pain
Hebrew University of Jerusalem Jerusalem, Israel
Anthony Dickenson BSc PhD Professor of Neuropharmacology
Department of Pharmacology
University College London London, UK
Andrew Dickman MSc MRPharmS Specialist Principal Pharmacist
Marie Curie Centre Liverpool, UK
Raymond A Dionne DDS PhD Chief, Pain and Neurosensory Mechanisms Branch
National Institute of Dental and Craniofacial Research
National Institutes of Health Bethesda, Maryland, USA
Jonathan O Dostrovsky MSc PhD Department of Physiology University of Toronto Toronto, Ontario, Canada
David Dubuisson MD PhD
Clinical Associate Professor Department of Surgery
University of South Carolina School of Medicine
Columbia, South Carolina, USA
John Ellershaw MA FRCP Director
Marie Curie Palliative Care Institute Liverpool, UK
Bjorn E Eriksson MD PhD Department of Cardiology
Karolinska University Hospital Huddinge Karolinska Institute Stockholm, Sweden
Howard L Fields MD PhD Professor of Neurology and Physiology Department of Neurology University of California San Francisco San Francisco, California, USA
Maria Fitzgerald PhD Professor of Developmental Neurobiology Department of Anatomy and Developmental Biology
University College London London, UK
Herta Flor PhD
Professor of Clinical and Cognitive Neuroscience Central Institute of Mental Health Department of Neuropsychology University of Heidelberg Mannheim, Germany
Lucia Gagliese PhD CIHR New Investigator School of Kinesiology and Health Science
York University and Department of Anaesthesia and Pain Management University Health Network Toronto, Ontario, Canada
Neelima Gandham MBBS Mmed Senior Registrar Department of Anaesthesiology Royal Perth Hospital Perth, Western Australia, Australia
Gerald F Gebhart PhD Professor and Head Department of Pharmacology Carver College of Medicine
The University of Iowa Iowa City, Iowa, USA
Louis Gifford BSc MappSc FCSP Chartered Physiotherapist Falmouth Physiotherapy Clinic Falmouth, UK
Peter J Goadsby BMedSc MD PhD DSc FRACP FRCP
Professor of Clinical Neurology Institute of Neurology University College London The National Hospital for Neurology and Neurosurgery London, UK
Sharon M Gordon DDS MPH PhD Associate Professor, Department of Biomedical Sciences University of Maryland Baltimore College of Dental Surgery Baltimore, Maryland, USA
Richard H Gracely PhD Professor, Medicine, Rheumatology and Neurology Director of Mechanistic Studies Chronic Pain and Fatigue Research Program
University of Michigan Health System Veterans Affairs Medical Center Ann Arbor, Michigan, USA
Jan M Gybels MD PhD Professor Emeritus of Neurosurgery University of Leuven Oud Heverlee, Belgium
Hermann O Handwerker MD Institute for Physiology and Pathophysiology
University of Erlangen Erlangen, Germany
Karla S Hayes MD
Instructor, Psychiatry and Anesthesiology
MGH Pain Center
Massachusetts General Hospital Boston, Massachusetts, USA
Jennifer A Haythornthwaite PhD
Associate Professor of Psychiatry and Behavioral Science
Johns Hopkins University Behavioral Medicine Clinic Baltimore, Maryland, USA
Mary M Heinricher PhD Professor of Neurological Surgery and Physiology and Pharmacology Department of Neurological Surgery Oregon Health and Science University Portland, Oregon, USA
Raymond G Hill BPharm PhD DSC(Hon) FMedSci
Executive Director, Licensing and External Research, Europe
Merck, Sharp and Dohme Harlow, Essex and Visiting Industrial Professor of Pharmacology
University of Bristol Bristol, UK
Tomas G M Hökfelt PhD Professor of Histology and Cell Biology Department of Neuroscience Karolinska Institutet Stockholm, Sweden
Anita Holdcroft MBChB MD FRCA Reader in Anaesthesia and Honorary Consultant Anaesthetist Magill Department of Anaesthesia Imperial College London London, UK
Peter J Hoskin MD FRCP FRCR Professor in Clinical Oncology University College London
Mount Vernon Cancer Center
Mount Vernon Hospital Northwood, Middlesex, UK
Stephen P Hunt PhD FMedSci Professor of Molecular Neuroscience Department of Anatomy and Developmental Biology University College London London, UK
Wilfrid Jänig MD PhD Department of Physiology University of Kiel Kiel, Germany
Troels Staehelin Jensen MD PhD Professor of Experimental and Clinical Pain Research
Danish Pain Research Center Aarhus University Hospital Aarhurs, Denmark
Mark A Jones BS MAppSc Director, Postgraduate Coursework Masters Programs in Physiotherapy School of Health Sciences University of South Australia Adelaide, South Australia, Australia
Gareth T Jones BSc(Hons) MSc Econ PhD
Lecturer in Rheumatic Disease Epidemiology
Arthritis Research Campaign Epidemiology Unit University of Manchester Manchester, UK
David Julius PhD Professor and Vice-Chair Department of Cellular and Molecular Pharmacology
University of California, San Francisco San Francisco, California, USA
Joel Katz PhD
Professor and Canada Research Chair in Health Psychology
Department of Psychology and School of Kinesiology and Health Science York University Toronto, Ontario, Canada
Henrik Kehlet MD PhD
Section for Surgical Pathophysiology
The Juliane Marie Centre Rigshospitalet Copenhagen, Denmark
Brigitte L Kieffer PhD Department of Neurobiology IGBMC Illkirch, France
Hyungsuk Kim DDS PhD Clinical Pharmacology Unit Pain and Neurosensory Mechanisms Branch
National Institute of Dental and Craniofacial Research Bethesda, Maryland, USA
H Richard Koerber PhD
Associate Professor of Neurobiology Department of Neurobiology University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania, USA
Bart Koes PhD Professor of General Practice Erasmus Medical Centre Rotterdam, The Netherlands
Martin Koltzenburg MD FRCP Honorary Consultant Neurologist
The National Hospital for Neurology and Neurosurgery
Professor of Pain Research Institute of Child Health and Institute of Neurology University College London London, UK
Josephine Lai PhD
Professor, Department of Pharmacology University of ArizonaCollege of Medicine Tucson, Arizona, USA
Jon D Levine MD PhD
Professor, Division of Neuroscience Department of Medicine
University of California San Francisco San Francisco, California, USA
Bengt Linderoth MD PhD
Professor of Functional Neurosurgery Department of Clinical Neuroscience Section of Neurosurgery Karolinska University Hospital Stockholm, Sweden
Richard B Lipton MD
Professor and Vice Chair Department of Neurology Albert Einstein College of Medicine Bronx, New York, USA
Donlin M Long MD PhD Distinguished Professor of Neurosurgery
Johns Hopkins Medical Institute Baltimore, Maryland, USA
Benjamin G Lopez LMS FRCS (SN) Consultant Neurosurgeon Department of Neurosurgery
King’s College Hospital London, UK
Thomas Lundeberg MD PhD
Rehabilitation Medicine University Clinic & Spinalis
Danderyds Hospital
AB & Karolinska University Hospital Stockholm, Sweden
Bruce Lynn BSc PhD Professor of Physiology Department of Physiology University College London London, UK
Gary J Macfarlane
Professor of Epidemiology and Head of the Division of Epidemiology and Health Sciences School of Medicine University of Manchester and Professor of Epidemiology Department of Public Health University of Aberdeen Aberdeen, UK
Patrick W Mantyh PhD
Professor Departments of Preventative Sciences, Psychiatry and Neuroscience Director, Neurosystems Center University of Minnesota Minneapolis, Minnesota, USA
Mitchell B Max MD
Senior Investigator Pain and Neurosensory Mechanisms Branch
National Institute of Dental and Craniofacial Research, National Institutes of Health Bethesda, Maryland, USA
Emeran A Mayer MD
Professor Departments of Medicine, Physiology, Psychiatry and Biobehavioral Sciences Center for Neurovisceral Sciences and Women’s Health
David Geffen School of Medicine at UCLA Los Angeles, California, USA
John McBeth PhD
Lecturer in Rheumatic Disease Epidemiology
Arthritis Research Campaign Epidemiology Unit University of Manchester Manchester, UK
Edwin W McCleskey PhD Senior Scientist Vollum Institute Oregon Health and Science University Portland, Oregon, USA
John S McDonald MD Professor and Chairman Department of Anesthesia Professor of Obstetrics and Gynecology Harbor UCLA Medical Center Torrance, California, USA
Patrick J McGrath OC PhD FRSC Professor of Psychology, Pediatrics and Psychiatry
Canada Research Chair Psychologist IWK Health Centre Halifax, Nova Scotia, Canada
Stephen B McMahon FMedSci Sherrington Professor of Physiology Director, London Pain Consortium King’s College London London, UK
Henry J McQuay DM FRCA FRCP(Ed) Professor of Pain Relief Churchill Hospital Oxford, UK
Ronald Melzack OC OQ FRSC PhD Emeritus Professor Department of Psychology McGill University Montreal, Quebec, Canada
Richard A Meyer MD Professor of Neurosurgery and Biomedical Engineering Department of Neurosurgery
Johns Hopkins University School of Medicine Baltimore, Maryland, USA
Björn A Meyerson MD PhD
Emeritus Professor Department of Neurosurgery Karolinska University Hospital Stockholm, Sweden
Jeffrey S Mogil PhD
E.P. Taylor Professor of Pain Studies Department of Psychology & Centre for Research on Pain McGill University Montreal, Quebec, Canada
Richard C Monks MDCM FRCP(C)
Clinical Associate Professor Department of Psychiatry
University of British Columbia St Joseph, British Columbia, Canada
Andrew Moore DSc
Pain Relief Unit Churchill Hospital Oxford, UK
Timothy J Ness MD PhD
Simon Gelman Professor of Anesthesiology Department of Anesthesiology University of Alabama at Birmingham Birmingham, Alabama, USA
Lone Nikolajsen MD PhD Consultant in Anaesthesiology Department of Anaesthesiology Aarhus University Hospital Aarhus, Denmark
Michael H Ossipov PhD
Associate Professor Department of Pharmacology University of ArizonaCollege of Medicine Tucson, Arizona, USA
Parag G Patil MD PhD
Chief Resident Division of Neurosurgery Department of Neurobiology Duke University Medical Center Durham, North Carolina, USA
Frank Porreca PhD Professor of Pharmacology Department of Pharmacology College of Medicine University of Arizona Health Sciences Center Tucson, Arizona, USA
Donald D Price PhD
Professor of Neuroscience and Psychology Department of Oral and Maxillofacial Surgery
University of Florida Health Science Center
Gainesville, Florida, USA
Pierre Rainille PhD
Associate Professor Department of Stomatology
Faculty of Dental Medicine
University of Montreal Montreal, Quebec, Canada
Srinivasa N Raja MD
Director, Division of Pain Medicine Professor of Anesthesiology and Critical Care Medicine
Johns Hopkins University School of Medicine Baltimore, Maryland, USA
Andrew S C Rice MB BS MD FRCA Reader in Pain Research Department of Anaesthetics and Intensive Care
Imperial College London, UK
Matthias Ringkamp MD Assistant Professor Department of Neurosurgery
Johns Hopkins University School of Medicine Baltimore, Maryland, USA
Michael C Rowbotham MD Professor of Clinical Neurology and Anesthesia Pain Clinical Research Center
University of California at San Francisco San Francisco, California, USA
I Jon Russell MD
Associate Professor Department of Medicine Division of Rheumatology
The University of Texas Health Sciences Center
San Antonio, Texas, USA
Michael W Salter MD PhD Senior Scientist and Canada Research Chair (Tier I) in Neuroplasticity and Pain Programme in Brain and Behaviour Hospital for Sick Children Toronto, Ontario, Canada
Christine N Sang MD MPH Director, Translational Pain Research Department of Anesthesiology, Perioperative, and Pain Medicine
Brigham and Women’s Hospital Harvard Medical School Boston, Massachusetts, USA
John W Scadding MD FRCP Consultant Neurologist
The National Hospital for Neurology and Neurosurgery London, UK
Hans-Georg Schaible MD Director, Institute of Neurophysiology Friedrich-Schiller University Teichgraben Jena, Germany
Martin Schmelz MD Karl-Feuerstein Professor for Pain Research
Department of Anesthesiology
Faculty for Clinical Medicine
University of Heidelberg Mannheim, Germany
Jean Schoenen MD PhD
Professor of Neuroanatomy and Consultant Neurologist
Department of Neuroanatomy and Neurology
University of Liège
Liège, Belgium
Stephan A Schug MD FANZCA FFPMANZCA
Professor of Anaesthesia and Director of Pain Medicine
School of Medicine and Pharmacology
University of Western Australia and Department of Anaesthesia and Pain Medicine
Royal Perth Hospital
Perth, Western Australia, Australia
David L Scott BSc MD FRCP Professor of Clinical Rheumatology
Academic Department of Rheumatology
King’s College London London, UK
Philip J Siddall MBBS MM (Pain Mgt) PhD FFPMANZCA
Clinical Senior Lecturer
Pain Management Research Institute
Royal North Shore Hospital
Sydney, New South Wales, Australia
Brian A Simpson MA MBBChir MD FRCS
Consultant Neurosurgeon
Department of Neurosurgery
University Hospital of Wales Cardiff, UK
Christer Sylvén MD PhD FESC FACC FAHA
Professor of Cardiology
Department of Cardiology
Karolinska Institutet Stockholm, Sweden
Ron R Tasker MD MA FRCS(C) Professor Emeritus Division of Central Neurosurgery
University of Toronto Toronto, Ontario, Canada
Timo T Tervo MD PhD Professor of Applied Clinical Ophthalmology
Department of Ophthalmology
Helsinki University Eye Hospital Helsinki, Finland
Michael Thacker MSc MCSP GradDipPhys SRP MMACP Lecturer
Academic Department of Physiotherapy
King’s College London London, UK
Andrew J Todd MB BS PhD
Professor of Neuroscience
Institute of Biomedical and Life Sciences
University of Glasgow Glasgow, UK
Dennis C Turk PhD
John and Emma Bonica Professor of Anesthesiology and Pain Research Department of Anesthesiology University of Washington Seattle, Washington, USA
Anita M Unruh BSc(OT) MSW PhD Professor School of Health and Human Performance Dalhousie University Halifax, Nova Scotia, Canada
Catherine Urch MRCP PhD Honorary Senior Lecturer Department of Pharmacology University College London and Consultant in Palliative Care St Marys and Royal Brompton Hospitals London, UK
Maurits W Van Tulder PhD Associate Professor of Health Technology Assessment Institute for Research in Extramural Medicine (EMGO) VU Medical Centre and Institute for Health Sciences Faculty of Earth and Life Sciences Vrije Universiteit Amsterdam, The Netherlands
Charles J Vierck Jr PhD Professor of Neuroscience Department of Neuroscience and McKnight Brain Institute University of Florida College of Medicine Gainesville, Florida, USA
C Peter N Watson MD FRCPC
Assistant Professor Department of Medicine Division of Neurology University of Toronto Toronto, Ontario, Canada
Zsuzsanna Wiesenfeld-Hallin PhD Department of Clinical Neuroscience Karolinska Institute Karolinska University Hospital Huddinge Stockholm, Sweden
Heng Yu Wong MBBCh MRCP(UK) Visiting Scholar Center for Neurovisceral Sciences and Women’s Health Division of Digestive Diseases
David Geffen School of Medicine at UCLA Los Angeles, California, USA
Clifford J Woolf MBBCh PhD MRCP (UK)
Professor of Anesthesia Research Neural Plasticity Research Group Department of Anesthesia and Critical Care
Massachusetts General Hospital and Harvard Medical School Charlestown, Massachusetts, USA
Xiao-Jun Xu PhD
Associate Professor
Department of Clinical Neuroscience Section of Clinical Neurophysiology Karolinska Institute Karolinska University Hospital Huddinge, Stockholm, Sweden
Tony L Yaksh PhD
Distinguished Professor in Anesthesiology and Pharmacology Department of Anesthesiology University of California, San Diego La Jolla, California, USA
Joanna M Zakrzewska MD Professor of Pain in Relation to Oral Medicine
Clinical and Diagnostic Oral Sciences
Dental Institute
Barts and the London Queen Mary’s School of Medicine and Dentistry London, UK
Hanns Ulrich Zeilhofer MD
Professor of Molecular Neuropharmacology
Institute for Experimental and Clinical Pharmacology and Toxicology
Erlangen-Nürnberg University Erlangen, Germany
Xu Zhang MD PhD
Professor of Neurobiology Institute of Neuroscience
Shanghai Institutes for Biological Sciences
Chinese Academy of Sciences Shanghai, China
Prólogo
La teoría de la puerta de entrada del dolor, que Patrick Wall y yo publicamos en 1965, llevó a una explosión en la investigación sobre los mecanismos del dolor en la médula espinal y el cerebro, y proporcionó la justificación para realizar nuevos abordajes al tratamiento del dolor. En 1982, Pat y yo acabamos el libro —The Challenge of Pain — que puso de relieve los apasionantes y nuevos conceptos y descubrimientos, para un amplio público formado por profesionales, estudiantes y profanos en la materia. Sin embargo, seguía faltando un libro del que científicos y médicos pudieran aprovechar los nuevos conocimientos sobre el dolor. Decidimos publicar un libro con la última información, escrito por pioneros en un campo en rápido crecimiento, de forma que los médicos pudieran leer sobre el estado de la investigación clínica y de laboratorio, y los científicos pudieran conocer las consecuencias y la utilidad clínica de su trabajo. La primera impresión de la primera edición del Tratado del dolor de 1984 se agotó en un año. Se lanzó una segunda edición actualizada en 1989, y una tercera en 1994. Actualmente, se encuentra una de estas ediciones en las estanterías de prácticamente todos los que trabajan en el campo de la investigación y el tratamiento del dolor. Poco después de la publicación de la cuarta edición, en 1999, Pat se puso enfermo. Nuestras discusiones sobre el manual se centraron entonces en el futuro y, después de considerarlo con varias personas
importantes, nos decidimos por Steven McMahon y Martin Koltzenburg, que ya habían hecho importantes contribuciones en el campo de la investigación y el tratamiento del dolor. Pat y yo nos sentimos profundamente satisfechos cuando aceptaron nuestra invitación para ser los nuevos editores del Tratado del dolor. Su magnífica reorganización del texto y las destacadas colaboraciones de autores tanto antiguos como nuevos, hacen que esta edición sea la mejor de todas. Estoy encantado, y sé que Pat, fallecido el 8 de agosto de 2001, también lo estaría.
Pat y yo siempre pretendimos alcanzar la mayor cobertura posible en el campo del dolor, para potenciar la lucha contra el dolor y el sufrimiento desde todos los ángulos posibles. Steve McMahon y Martin Koltzenburg han mantenido este objetivo, produciendo esta extraordinaria nueva edición. Está actualizada e incluye un conjunto completo y unificado de conocimientos sobre todos los aspectos del dolor. Agradezco que el testigo haya pasado a las manos de una nueva generación de editores y colaboradores. El dolor, especialmente el dolor crónico, sigue destruyendo las vidas de millones de personas en todo el mundo. No existe objetivo más noble que aliviar el dolor y el sufrimiento. Esta nueva edición hará que ese día esté más cerca.
Ronal Melzack Professor Emeritus, McGill University Montreal, Canada
Prefacio
He subido a hombros de gigantes , frase escrita por Newton en una carta a Hooke en 1676 y lema acuñado en algunas monedas británicas, describe acertadamente nuestro papel en la creación de esta nueva edición del Tratado del dolor. Cuando se publicó la primera edición en 1984, ambos estábamos trabajando en el laboratorio de Patrick Wall en el University College London, como becario posdoctorado y estudiante de medicina. En las dos últimas décadas, este libro se ha publicado bajo la dirección de Pat Wall y Ron Melzack, y se ha consolidado como un texto básico en el campo. Su visión era que una obra que abarcara las ciencias básicas y clínicas del dolor desde la mesa de trabajo hasta la cabecera de la cama aportaría al campo un recurso muy necesitado. Fue su autoridad la que agrupó en un texto las colaboraciones de muchos de los principales líderes de opinión del campo. El deseo de unir estas dos, a veces antagonistas, ramas de la medicina puede verse desde el inicio de la carrera científica de Pat. Trabajando en Oxford, publicó sus dos primeros artículos científicos en Nature y Brain , antes y ahora importantes revistas de ciencia y neurología, respectivamente. Si bien Pat estaba comprometido con el estudio del dolor en el laboratorio, nunca perdió de vista los problemas clínicos. Su docencia regularmente incluía caminar con sus estudiantes por las salas del University College Hospital, y discutir con ellos los problemas de dolor de los pacientes. Por tanto, no sorprende que tantos científicos y médicos conozcan sus importantes colaboraciones que constituyen los pilares conceptuales básicos de su actividad habitual.
Cuando Pat se dio cuenta de que ya no podría seguir editando este libro, él y Ron dieron el atrevido paso de preguntarnos si continuaríamos su trabajo. Aceptamos no sin gran temor. La tarea fue más fácil para nosotros, porque podíamos discutir con ellos nuestros planes para la nueva edición. También damos las gracias a nuestros compañeros que nos aconsejaron sobre el contenido, y a los colaboradores de la nueva edición, especialmente los Drs. Basbaum, Campbell, Fields, Julius y Mayer, que actuaron como una importante caja de resonancia para nuestras ideas y nos aportaron muchas y muy útiles sugerencias. También queremos dar las gracias a Natasha Andjelkovic, Michael Houston, Tim Kimber y Rory MacDonald de Elsevier, que nos ayudaron
con sus conocimientos de las ediciones previas e incorporaron nuevas características, destacando, por primera vez, la inclusión de ilustraciones en color en el texto.
Hemos intentado por todos los medios seguir la exitosa visión de Pat y Ron en el manual y mantener el elevado nivel establecido. Igual que en ediciones previas, se han hecho algunos cambios. Se han añadido capítulos nuevos y se han reclutado nuevos colaboradores que reflejan los avances en este campo, como los descubrimientos que siguieron a la identificación crucial de la estructura molecular del receptor de la capsaicina TRPV1. Otro ejemplo en el otro lado del espectro son las sólidas pruebas derivadas de estudios epidemiológicos que han puesto de manifiesto la magnitud del problema clínico del dolor.
Por primera vez, esta nueva edición aparece publicada en papel y existe también una versión electrónica en inglés en Internet (e-dition) a través de la página webwww.textbookofpain.com. Esta última permitirá un acceso flexible al texto, que esperamos sea especialmente útil, sobre todo para quienes trabajan desde diferentes centros. También esperamos que las ilustraciones disponibles en la versión de Internet sean una herramienta útil y completa de enseñanza para todos los aspectos del dolor. Por encima de todo, la edición electrónica en inglés mostrará actualizacionesperiódicas que ayudarán a los lectores a estar al día sobre los nuevos avances y controversias, y les ayudarán en su evaluación. La retirada de varios inhibidores de la ciclooxigenasa 2 y la autorización de un nuevo inhibidor de la recaptación de serotonina y noradrenalina para el tratamiento de la polineuropatía diabética dolorosa son ejemplos de importantes cambios en la práctica clínica del tratamiento del dolor que se suceden a un ritmo más rápido que el que puede seguir la versión impresa. Por tanto, uno de los principales objetivos de la versión de Internet será mantener a los lectores actualizados e informados sobre todos los avances importantes que se produzcan en el campo clínico y de investigación.
Stephen McMahon
Martin Koltzenburg London 2005
A Patrick Wall, profesor, compañero y amigo.
Siglas y acrónimos
5-FU5-fluorouracilo
AAEaminoácido excitador
ACIP arteria cerebelosa inferior posterior
ACOGAmerican College of Obstetricians and Gynecologists
NADPH dinucleótido de nicotinamida y adenina fosfato
NAEneuritis alérgica experimental
NCDnúcleos de la columna dorsal
NDRnúcleo dorsal del rafe
NE [célula] nociceptiva-específica
NF200 neurofilamento 200
NFACS Neonatal Facial Action Coding System
NGF factor de crecimiento nervioso
NHANES National Health and Nutrition Examination Survey
NHC[canal iónico] dependiente de hiperpolarización de nucleótido cíclico
NHP Nottingham Health Profile
NHSAneuropatía hereditaria sensitiva y autonómica
NK1 neurocinina 1
NKA neurocinina A
NMDA N-metil-D-aspartato
NMOS neuropatía mieloóptica subaguda
NMR núcleo magno del rafe
NNH número necesario de pacientes para dañar
nNOS sintasa del óxido nítrico neuronal
NNT número necesario de pacientes para tratar
NO óxido nítrico
NOMnervio occipital mayor
NOS óxido nítrico sintasa
NP núcleo parabraquial [de la protuberancia dorsolateral]
NPY neuropéptido Y
NRS escala de clasificación numérica
NSS núcleo salival superior
NT neuralgia del trigémino
NTDCneurona transmisora de dolor central
NTG gliceril trinitrato
NTS núcleo del tracto solitario
OAPHosteoartropatía pulmonar hipertrófica
OFQ/N orfanina FQ/nociceptina
OMS Organización Mundial de la Salud
OTC [medicamento] de venta sin receta
OVL [corteza] orbitaria ventral lateral
PA potencial de acción
PACA [herramienta] evaluación de cuidados paliativos
PAF factor activador de las plaquetas
PAR receptor activado por proteasas
PASS Pain Anxiety Symptoms Scale
PBMC célula mononuclear de sangre periférica
PCA analgesia controlada por el paciente
PCQ Pain Coping Questionnaire
PDA asistente personal digital
PDI Pain Disability Index
PEBNpeso extremadamente bajo al nacer
PECpotencial relacionado con un evento cerebral
PES potencial evocado somatosensitivo
PET tomografía por emisión de positrones
Pf [núcleo] parafascicular
PFAGproteína fibrilar acídica de la glía
PG prostaglandina
PIP2 fosfatidilinositol 4,5-difosfato
PIPP Premature Infant Pain Profile
PISperíodo intersupresión
PIVA polipéptido intestinal vasoactivo
PKA proteína cinasa A
PKC proteína cinasa C
PKG proteína cinasa dependiente del GMP cíclico
PL punción lumbar
PLC fosfolipasa C
Po complejo posterior
POMS Profile of Mood States
PPDpospotencial despolarizante
PPS período postsupresión
PPSEpotencial postsináptico excitador
PPSIpotencial postsináptico inhibidor
PRI índice de clasificación del dolor
PSCCperfusión subcutánea continua
PTES prueba de tensión en la extremidad superior
QFR queratectomía fotorrefractiva
QIPquimioterapia intraperitoneal
QSART test del reflejo axonal sudomotor cuantitativo
QST test sensorial cuantitativo
RAreceptor adrenérgico
RM resonancia magnética
RMfresonancia magnética funcional
RNC respuesta no condicionada
RO receptor opioide
RT-PCR reacción en cadena de la polimerasa-transcriptasa inversa
RVM médula ventromedial rostral
S2/PV áreas segunda cortical somatosensitiva y parietal ventral
SC subnúcleo caudal
SCIsíndrome del colon irritable
SCL-90R Symptom Checklist-90 Revised
SDAFsíndrome de dolor abdominal funcional
SDRCsíndrome de dolor regional complejo
SF-36 36-item short-form of the Medical Outcomes Society
SFM síndrome de fibromialgia
SF-MPQ short-form McGill Pain Questionnaire
SG sustancia gelatinosa
SGBsíndrome de Guillain-Barré
SGPA sustancia gris periacueductal
SI, SII área primera y segunda somatosensitiva del córtex cerebral
SII síndrome del intestino irritable
SIP Sickness Impact Profile
Sm [núcleo] submedio
SMEsistema motor emocional
SMF sensaciones del miembro fantasma
SNCsistema nervioso central
SNP sistema nervioso periférico
SOICseudoobstrucción intestinal crónica
SP sustancia P
SPECT tomografía computarizada por emisión de fotón único
SPID suma de diferencias en la intensidad del dolor
SP-SAP sustancia P-saporina
SQUID dispositivo superconductor de inferencia cuántica
SRD subnúcleo reticular dorsal
SRIV simpaticólisis regional intravenosa
SSS seno sagital superior sst/SST somatostatina
STAI State-Trait Anxiety Inventory
STCsíndrome del túnel carpiano
STGV sistema trigémino-vascular
STPI Spielberger’s Trait Personality Inventory
SUNA cefalea neuralgiforme unilateral de corta duración
SUNCT cefalea neuralgiforme unilateral de corta duración con inyección conjuntival y lagrimeo
SVV síndrome de vestibulitis vulvar
TBS escala de conducta del dolor de Tübingen
TC tomografía computarizada
TCCterapia cognitivo-conductual
TDMtrastorno depresivo mayor
TDS teoría de decisión sensitiva
TE tracto espinotalámico
TEH tracto espinohipotalámico
TEM tracto espinomesencefálico
TER tracto espinorreticular
TET tronco encefálico del trigémino
TGIFtrastorno gastrointestinal funcional
THC tetrahidrocanabinol
TNF factor de necrosis tumoral
TNF factor de necrosis tumoral alfa
TOTPAR alivio total del dolor
TPDLtegmento protuberancial dorsolateral
TPI índice de puntos dolorosos con la palpación
Trk tirosina cinasa
TRP potencial receptor transitorio
TRPV1 potencial receptor transitorio vaniloide V1
TRPV2 potencial receptor transitorio vaniloide V2
TTM trastorno temporomandibular
TTP recuento total de puntos dolorosos con la palpación
TTS puntuación total de dolor con la palpación
TTX tetrodotoxina
TVPtrombosis venosa profunda
UDMumbral de dolor medio
UDP umbral del dolor por presión
Vc [nervio] caudal ventral
VCS vena cava superior
VDS escalas con descriptores verbales
VECT vía espinocervicotalámica
VGLUT transportador vesicular de glutamato
VIAAT transportador vesicular de aminoácidos inhibidores
VL [nervio] ventral lateral
VMb parte basal del [núcleo] ventral medial
VMpo parte posterior del [núcleo] ventral medial
VP [núcleo] ventral posterior
VPI [núcleo] ventral posterior inferior
VPL [núcleo] ventral posterior lateral
VPM [núcleo] ventral posterior medial
VPvsscara ventral del [núcleo] ventral posterior
VRP potencial de raíz ventral posterior
VSGvelocidad de sedimentación globular
WHYMPI West Haven-Yale Multidimensional Pain
Inventory
ZERPzona de entrada en la raíz posterior
CAPÍTULO 1
Mecanismos periféricos de la nocicepción cutánea
Richard A. Meyer, Matthias Ringkamp, James N. Campbell y Srinivasa N. Raja
Resumen
Los nociceptores son una clase especializada de aferentes primarios que responden a estímulos intensos, nocivos. Los nociceptores amielínicos transmiten el dolor urente por estímulos calóricos intensos aplicados sobre la piel lampiña de la mano y también el dolor por presión sostenida. Los nociceptores mielínicos transmiten el dolor agudo por estímulos calóricos aplicados sobre la piel hirsuta y por estímulos mecánicos intensos. Los nociceptores mielínicos y amielínicos transmiten el dolor por estímulos químicos. Después de una lesión cutánea, aumenta el dolor en respuesta a estímulos cutáneos, denominado hiperalgesia, en el lugar de la lesión (hiperalgesia primaria) y en la piel lesionada circundante (hiperalgesia secundaria). La lesión tisular aumenta la respuesta de los nociceptores, denominada sensibilización, que representa la hiperalgesia primaria. Esta sensibilización se debe a la liberación local de mediadores inflamatorios. La hiperalgesia secundaria se debe a la sensibilización de neuronas del sistema nervioso central. Cuando los nervios son seccionados, los nociceptores lesionados desarrollan una actividad espontánea y una sensibilidad mecánica, calórica y química ectópica. También cambian las propiedades de los nociceptores próximos, no afectados. Tanto los nociceptores lesionados como los no lesionados pueden desarrollar una respuesta a agentes adrenérgicos, que pueden explicar la afectación del sistema nervioso simpático en ciertas formas de dolor neuropático.
INTRODUCCIÓN
Una de las funciones vitales del sistema nervioso es informar sobre la existencia o amenaza de una lesión. La sensación de dolor, por su naturaleza aversiva inherente, contribuye a esta función. En este capítulo se considerará el sistema nervioso periférico, que responde a estímulos nocivos (perjudiciales o potencialmente perjudiciales) y, por tanto, transmite una señal para alertar al organismo de una lesión potencial. Los investigadores han estudiado la sensibilidad cutánea mediante el registro de fibras nerviosas individuales en diferentes especies, como en el ser humano. Se aplican estímulos al campo receptivo (es decir, al área de tejido que responde al estímulo aplicado) de fibras individuales, y se anotan las características de la respuesta neural. Nos centraremos en la piel por tres motivos. Primero, los receptores sensitivos de la piel se han estudiado de forma más extensa que los receptores de cualquier otro tejido. Segundo, la oportunidad de realizar estudios psicofísicos correlativos en humanos y animales permite extraer firmes conclusiones respecto a la función. Tercero, la sensibilidad dolorosa cutánea tiene una gran importancia clínica. Enfermedades como la neuralgia postherpética y otras patologías asociadas con neuropatías de fibras pequeñas tienen efectos importantes sobre la sensibilidad cutánea y, con frecuencia, producen un dolor intenso.
Las fibras sensitivas muy especializadas, solas o junto con otras fibras especializadas, informan al sistema nervioso central no sólo sobre el entorno sino también sobre el estado del propio organismo. En el caso de la capacidad sensitiva de la piel, los estímulos cutáneos pueden evocar sensaciones de frío, calor o tacto, entre otras. Existen fibras sensitivas
que son selectivamente sensibles a estos estímulos. Las fibras del calor, que predominantemente son fibras amielínicas, son extremadamente sensibles a un calentamiento suave por sus campos receptivos puntiformes. Se ha observado que estas fibras transmiten exclusivamente la calidad y la intensidad de la sensibilidad al calor (Johnson et al 1979). De forma similar, una subpoblación de fibras Aδ finamente mielínicas responde selectivamente a estímulos suaves por frío y codifican la sensibilidad al frío (Darian-Smith et al 1973). Para el sentido del tacto existen diferentes clases de fibras aferentes mecanorreceptivas que son extremadamente sensibles a las deformaciones de la piel. Estos mecanorreceptores de bajo umbral codifican características como la textura y la forma. Un umbral relativamente alto a un estímulo adecuado diferencia las otras clases de receptores cutáneos. Debido a que estos receptores con preferencia responden a estímulos nocivos, se denominan nociceptores (Sherrington 1906). Entre las diversas variedades de receptores de la sensibilidad, los nociceptores son exclusivos porque, normalmente, responden a las múltiples formas de energía que producen una lesión (estímulos calóricos, mecánicos y químicos) e informan al sistema nervioso central respecto a la localización e intensidad de los estímulos nocivos. Los nociceptores pueden subclasificarse según cuatro criterios:
1.Fibras C aferentes, amielínicas (velocidad de conducción < 2 m/s) frente a fibras A aferentes, mielínicas (velocidad de conducción > 2 m/s).
2.Modalidades de estimulación que evocan una respuesta.
3.Características de la respuesta.
4.Marcadores químicos característicos (p. ej., receptores expresados en la membrana).
Se considerarán las propiedades de los nociceptores cutáneos y luego se revisará cómo se relaciona su función con la sensibilidad al dolor. La lesión tisular puede desencadenar una cascada de acontecimientos que produce un aumento del dolor en respuesta a estímulos naturales, denominado hiperalgesia. Se produce el aumento correspondiente de la respuesta a los nociceptores, denominada sensibilización . Más adelante, se explicarán las características de la hiperalgesia y su equivalente neurofisiológico. Por último, consideraremos el papel que los nociceptores pueden desempeñar en el dolor intenso que, con frecuencia, acompaña a lesiones y enfermedades del sistema nervioso.
PROPIEDADES DE LOS NOCICEPTORES EN LA PIEL NO LESIONADA
La naturaleza puede haber diseñado los nociceptores de forma que cada uno tenga la capacidad de responder a todas las formas de energía debidas a estímulos (calóricos, mecánicos y químicos) que conllevan riesgos potenciales al organismo. En su lugar, la naturaleza ha adoptado una estrategia mixta por la que muchos nociceptores responden a múltiples tipos de estímulos (polimodales) y otros tienen propiedades de respuesta más especializadas. Estas propiedades de respuestas especia-
lizadas probablemente, al menos en parte, explican los diferentes aspectos de la sensibilidad nociceptiva (p. ej. Quemadura, dolor, punción y pinchazo). Como explicamos más adelante, los nociceptores también tienen distintas funciones efectoras, y la especialización aquí también puede desempeñar un papel. El resultado final es que los nociceptores tiene una compleja biología y unas propiedades heterogéneas. En estudios experimentales, el campo receptivo de un nociceptor con frecuencia se localiza primero mediante estímulos mecánicos. Luego se aplican otros tipos de estímulos a este campo receptivo. En los primeros estudios sobre nociceptores, sólo se utilizaron estímulos calóricos y mecánicos para estudiar los nociceptores. Por tanto, la nomenclatura CMC y AMC se utiliza con frecuencia para referirse a los nociceptores sensibles a estímulos calóricos y mecánicos de fibras C y a los nociceptores sensibles a estímulos calóricos y mecánicos de fibras A, respectivamente. Si una fibra responde a estímulos calóricos y mecánicos, la fibra también responderá a estímulos químicos en la mayoría de los casos (Davis et al 1993). Por tanto, los CMC y los AMC también se conocen como nociceptores polimodales .
La cuestión sobre si un nociceptor dado responde a un tipo concreto de estímulo es arriesgada, porque la supuesta falta de respuesta a una modalidad concreta podría deberse, de hecho, a la aplicación de un estímulo de intensidad insuficiente. El problema de la aplicación de estímulos muy intensos es que el estímulo puede alterar las propiedades del nociceptor de forma perdurable. Se produce un sesgo de selección: es más probable que se estudien los nociceptores con umbrales más bajos.
La forma más fácil de encontrar un nociceptor para un estudio electrofisiológico es aplicar estímulos constrictivos (mecánicos) a la piel y así identificar el campo receptivo. Este proceso de selección identifica las denominadas aferencias mecánicamente sensibles (AS). Con el tiempo, se evidenció que el sesgo de selección de este método había pasado por alto una clase importante de nociceptores: las aferencias mecánicamente insensibles (AI), conocidas a veces como nociceptores silentes. Debido a que estas fibras tienen, por definición, umbrales mecánicos altos (o no responden a estímulos mecánicos), es difícil hallar el campo receptivo mecánico de estas fibras.
Una técnica alternativa, descrita por Meyer y colaboradores, ha sido aplicar estímulos eléctricos en la piel para identificar el supuesto campo receptivo (Meyer et al 1991). Con esta técnica, resulta que, aproximadamente, la mitad de los nociceptores de fibras Aδ y el 30% de los nociceptores de fibras C son AI, mientras que las AI se definen como aferencias con umbrales mecánicos muy altos (> 6 bar = 600 kPa = 60 g/mm2) o no responden a estímulos mecánicos (Handwerker et al 1991, Meyer et al 1991). Además, se han descrito AI en la articulación de la rodilla (Schaible & Schmidt 1985), las vísceras (Häbler et al 1988) y la córnea (Tanelian 1991).
Como se verá, es importante distinguir las AI de las AS respecto a los distintos tipos de nociceptores. Desde la perspectiva de la nomenclatura, también debe destacarse que las AI no se definen como fibras que no responden a estímulos mecánicos, sino que más bien son fibras con un umbral muy alto (o sin sensibilidad), de forma que es difícil demostrar una respuesta a estímulos mecánicos en estudios electrofisiológicos.
Nociceptores
de las fibras C
El CMC es un aferente cutáneo habitualmente hallado, y se supone que la actividad de cierta magnitud de estas fibras evoca una sensación de dolor urente. El campo receptivo parece aumentar de tamaño con el tamaño del animal. Las cifras características del mono se sitúan entre 15 y 20 mm 2 (LaMotte & Campbell 1978) y son próximas a los 100 mm2 en el ser humano (Schmidt et al 1997). Con frecuencia, son áreas separadas de sensibilidad mecánica («puntos calientes») en el campo receptivo, pero en muchas fibras, las áreas de respuesta mecánica tienden a fusionarse sobre la región del campo receptivo. La mayoría de CMC responden a estímulos mecánicos, aunque no tan bien como
los nociceptores de fibras A (Davis et al 1993) y, por tanto, pueden considerarse polimodales.
Las respuestas a los estímulos calóricos se han estudiado con bastante detalle. En la Fig. 1.1 se muestra la respuesta de un CMC típico a una secuencia aleatoria de estímulos calóricos que oscilan entre 41 y 49 ºC. Puede verse que la respuesta aumenta de forma monotónica con la intensidad del estímulo respecto a este intervalo de temperatura, que engloba el umbral de dolor en el ser humano. De forma similar, la activación del receptor vaniloide 1 (TRPV1, conocido previamente como VR1) clonado, que hace de mediador en la sensibilidad al calor nocivo, la capsaicina y los protones, aumenta al aumentar la temperatura (Caterina et al 1997). El Capítulo 2 ofrece una descripción detallada de los canales iónicos que intervienen en la transducción de los estímulos.
Los estudios de modelación calórica combinados con los análisis electrofisiológicos han indicado lo siguiente.
• El umbral de calor de los CMC depende de la temperatura en la profundidad del receptor y no de la velocidad a la que aumenta la temperatura.
• La transducción de los estímulos calóricos (conversión de la energía calórica en potenciales de acción) se produce a diferentes profundidades cutáneas para diferentes CMC (Tillman et al 1995a).
• Las respuestas de los CMC por encima del umbral varían directamente con la velocidad de aumento de la temperatura (Tillman et al 1995a,b, Yarnitsky et al 1992).
La profundidad de los terminales de respuesta calórica de los CMC varía ampliamente, y oscila entre 20 y 570 m (Tillman et al 1995a). Cuando se aplica un estímulo de temperatura escalonada a la piel, la temperatura aumenta más lentamente en la subsuperficie, por la inercia calórica. La disparidad entre la temperatura de la superficie en comparación con la temperatura a nivel del receptor varía directamente con la profundidad e indirectamente con el tiempo. Dado que la profundidad de los terminales de los CMC varía ampliamente, los umbrales calóricos reales se obtienen cuando la temperatura aumenta muy gradualmente o cuando el estímulo es muy prolongado. Aunque la literatura refleja un amplio intervalo de umbrales calóricos para los CMC, cuando se estudian con estos tipos de estímulos calóricos, el umbral calórico de la mayoría de CMC se sitúa en un estrecho margen de 39-41 °C (Tillman et al 1995a). La respuesta de los CMC también está claramente influida por los estímulos previos. Se observa fatiga y sensibilización. Un ejemplo de fatiga es la observación de que la respuesta del segundo de dos estímulos calóricos idénticos es bastante inferior a la respuesta al primer estímulo (Fig. 1.2). Esta fatiga depende del tiempo transcurrido entre estímulos; la recuperación completa tarda más de 10 minutos. Se observa una reducción similar en la intensidad del dolor de estímulos calóricos repetidos en seres humanos (LaMotte & Campbell 1978). La fatiga también se evidencia en la Fig. 1.1B, en la que la respuesta a un estímulo dado varía de forma inversamente proporcional con la intensidad del estímulo previo.
También se observa un descenso de la respuesta calórica tras la apli cación de estímulos mecánicos al campo receptivo o estímulos eléctricos aplicados al tronco nervioso (Peng et al 2003). Ello indica que la fatiga a un tipo de estímulo determinado puede inducirse por estimulación heteróloga, es decir, por excitación con un estímulo de di ferente modalidad. Es interesante destacar que la recuperación de una fatiga cruzada o heteróloga es más rápida que la recuperación de la fatiga inducida por un estímulo de la misma modalidad. Supuestamente, se debe a que estos estímulos heterólogos no activan y, por tanto, no fatigan el sistema de transducción de estímulos de la misma forma. Asimismo, la fatiga puede producirse a partir de efectos independientes sobre el inicio (de una estimulación antidrómica) y la transducción de puntas (desde la estimulación natural en el campo receptivo). La fatiga a estímulos calóricos también puede obser-
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“No! Horrible!” said Kate. “But do get me a yellow taxi. That is quite safe.”
“Well, the man has gone for the automobile. You are English, yes?”
“Irish,” said Kate.
“Ah Irish!” he replied, with the flicker of a smile.
“You speak English awfully well,” she said.
“Yes! I was educated there. I was in England seven years.”
“Were you! My name is Mrs Leslie.”
“Ah Leslie! I knew James Leslie in Oxford. He was killed in the war.”
“Yes. That was my husband’s brother.”
“Oh really!”
“How small the world is!” said Kate.
“Yes indeed!” said the general.
There was a pause.
“And the gentlemen who are with you, they are—?”
“American,” said Kate.
“Ah Americans! Ah yes!”
“The older one is my cousin—Owen Rhys.”
“Owen Rhys! Ah yes! I think I saw in the newspaper you were here in town—visiting Mexico.”
He spoke in a peculiar quiet voice, rather suppressed, and his quick eyes glanced at her, and at his surroundings, like those of a man perpetually suspecting an ambush. But his face had a certain silent hostility, under his kindness. He was saving his nation’s reputation.
“They did put in a not very complimentary note,” said Kate. “I think they don’t like it that we stay in the Hotel San Remo. It is too poor
and foreign. But we are none of us rich, and we like it better than those other places.”
“The Hotel San Remo? Where is that?”
“In the Avenida del Peru. Won’t you come and see us there, and meet my cousin and Mr Thompson?”
“Thank you! Thank you! I hardly ever go out. But I will call if I may, and then perhaps you will all come to see me at the house of my friend, Señor Ramón Carrasco.”
“We should like to,” said Kate.
“Very well. And shall I call, then?”
She told him a time, and added:
“You mustn’t be surprised at the hotel. It is small, and nearly all Italians. But we tried some of the big ones, and there is such a feeling of lowness about them, awful! I can’t stand the feeling of prostitution. And then the cheap insolence of the servants. No, my little San Remo may be rough, but it’s kindly and human, and it’s not rotten. It is like Italy as I always knew it, decent, and with a bit of human generosity. I do think Mexico City is evil, underneath.”
“Well,” he said, “the hotels are bad. It is unfortunate, but the foreigners seem to make the Mexicans worse than they are, naturally. And Mexico, or something in it, certainly makes the foreigners worse than they are at home.”
He spoke with a certain bitterness.
“Perhaps we should all stay away,” she said.
“Perhaps!” he said, lifting his shoulders a little. “But I don’t think so.”
He relapsed into a slightly blank silence. Peculiar how his feelings flushed over him, anger, diffidence, wistfulness, assurance, and an anger again, all in little flushes, and somewhat naïve.
“It doesn’t rain so much,” said Kate. “When will the car come?”
“It is here now. It has been waiting some time,” he replied.
“Then I’ll go,” she said.
“Well,” he replied, looking at the sky. “It is still raining, and your dress is very thin. You must take my cloak.”
“Oh!” she said, shrinking. “It is only two yards.”
“It is still raining fairly fast. Better either wait, or let me lend you my cloak.”
He swung out of his cloak with a quick little movement, and held it up to her. Almost without realising, she turned her shoulders to him, and he put the cape on her. She caught it round her, and ran out to the gate, as if escaping. He followed, with a light yet military stride. The soldiers saluted rather slovenly, and he responded briefly.
A not very new Fiat stood at the gate, with a chauffeur in a short red-and-black check coat. The chauffeur opened the door. Kate slipped off the cloak as she got in, and handed it back. He stood with it over his arm.
“Goodbye!” she said. “Thank you ever so much. And we shall see you on Tuesday. Do put your cape on.”
“On Tuesday, yes. Hotel San Remo. Calle de Peru,” he added to the chauffeur. Then turning again to Kate: “The hotel, no?”
“Yes,” she said, and instantly changed. “No, take me to Sanborn’s, where I can sit in a corner and drink tea to comfort me.”
“To comfort you after the bull-fight?” he said, with another quick smile. “To Sanborn’s, Gonzalez.”
He saluted and bowed and closed the door. The car started.
Kate sat back, breathing relief. Relief to get away from that beastly place. Relief even to get away from that nice man. He was awfully nice. But he made her feel she wanted to get away from him too. There was that heavy, black Mexican fatality about him, that put a burden on her. His quietness, and his peculiar assurance, almost aggressive; and at the same time, a nervousness, an uncertainty. His heavy sort of gloom, and yet his quick, naïve, childish smile. Those
black eyes, like black jewels, that you couldn’t look into, and which were so watchful; yet which, perhaps, were waiting for some sign of recognition and of warmth! Perhaps!
She felt again, as she felt before, that Mexico lay in her destiny almost as a doom. Something so heavy, so oppressive, like the folds of some huge serpent that seemed as if it could hardly raise itself. She was glad to get to her corner in the tea-house, to feel herself in the cosmopolitan world once more, to drink her tea and eat strawberry shortcake and try to forget.
CHAP: II. TEA-PARTY IN TLACOLULA.
Owen came back to the hotel at about half-past six, tired, excited, a little guilty, and a good deal distressed at having let Kate go alone. And now the whole thing was over, rather dreary in spirit.
“Oh, how did you get on?” he cried, the moment he saw her, afraid almost like a boy of his own sin of omission.
“I got on perfectly. Went to Sanborn’s for tea, and had strawberry shortcake—so good!”
“Oh, good for you!” he laughed in relief. “Then you weren’t toomuch overcome! I’m so glad. I had such awful qualms after I’d let you go. Imagined all the things that are supposed to happen in Mexico— chauffeur driving away with you into some horrible remote region, and robbing you and all that—but then I knew really you’d be all right. Oh, the time I had—the rain!—and the people throwing things at my bald patch—and those horses—wasn’t that horrible?—I wonder I’m still alive.” And he laughed with tired excitement, putting his hand over his stomach and rolling his eyes.
“Aren’t you drenched?” she said.
“Drenched!” he replied. “Or at least I was. I’ve dried off quite a lot. My rain-coat is no good—I don’t know why I don’t buy another. Oh, but what a time! The rain streaming on my bald head, and the crowd behind throwing oranges at it. Then simply goredin my inside about letting you go alone. Yet it was the only bull-fight I shall ever see. I came then before it was over. Bud wouldn’t come. I suppose he’s still there.”
“Was it as awful as the beginning?” she asked.
“No! No! It wasn’t. The first was worst—that horse-shambles. Oh, they killed two more horses. And five bulls! Yes, a regular butchery. But some of it was very neat work; those toreadors did some very pretty feats. One stood on his cloak while a bull charged him.”
“I think,” interrupted Kate, “if I knew that some of those toreadors were going to be tossed by the bull, I’d go to see another bull-fight. Ugh, how I detest them! The longer I live the more loathesome the human species becomes to me. Howmuch nicer the bulls are!”
“Oh, quite!” said Owen vaguely. “Exactly. But still there was some very skilful work, very pretty. Really very plucky.”
“Yah!” snarled Kate. “Plucky! They with all their knives and their spears and cloaks and darts and they know just how a bull will behave. It’s just a performance of human beings torturing animals, with those common fellows showing off, how smart they are at hurting a bull. Dirty little boys maiming flies—that’s what they are. Only grown-up, they are bastards, not boys. Oh, Iwish I could be a bull, just for five minutes. Bastard, that’s what I call it!”
“Well!” laughed Owen uneasily. “It is rather.”
“Call that manliness!” cried Kate. “Then thank God a million times that I’m a woman, and know poltroonery and dirty-mindedness when I see it.”
Again Owen laughed uncomfortably.
“Go upstairs and change,” she said. “You’ll die.”
“I think I’d better. I feel I might die any minute, as a matter of fact. Well, till dinner then. I’ll tap at your door in half an hour.”
Kate sat trying to sew, but her hand trembled. She could not get the bull-ring out of her mind, and something felt damaged in her inside. She straightened herself, and sighed. She was really very angry, too, with Owen. He was naturally so sensitive, and so kind. But he had the insidious modern disease of tolerance. He must tolerate everything, even a thing that revolted him. He would call it Life! He
would feel he had lived this afternoon. Greedy even for the most sordid sensations.
Whereas she felt as if she had eaten something which was giving her ptomaine poisoning. If thatwas life!
Ah men, men! They all had this soft rottenness of the soul, a strange perversity which made even the squalid, repulsive things seem part of life to them. Life! And what is life? A louse lying on its back and kicking? Ugh!
At about seven o’clock Villiers came tapping. He looked wan, peaked, but like a bird that had successfully pecked a bellyful of garbage.
“Oh it was GREAT!” he said, lounging on one hip. “GREAT! They killed sevenBULLS.”
“No calves, unfortunately,” said Kate, suddenly furious again. He paused to consider the point, then laughed. Her anger was another slight sensational amusement to him.
“No, no calves,” he said. “The calves have come home to be fattened. But several more horses after you’d gone.”
“I don’t want to hear,” she said coldly.
He laughed, feeling rather heroic. After all, one must be able to look on blood and bursten bowels calmly: even with a certain thrill. The young hero! But there were dark rings round his eyes, like a debauch.
“Oh but!” he began, making a rather coy face. “Don’t you want to hear what I did after! I went to the hotel of the chief toreador, and saw him lying on his bed all dressed up, smoking a fat cigar. Rather like a male Venus who is never undressed. So funny!”
“Who took you there?” she said.
“That Pole, you remember?—and a Spaniard who talked English. The toreador was great, lying on his bed in all his get-up, except his
shoes, and quite a crowd of men going over it all again— wawawawawa!—you never heard such a row!”
“Aren’t you wet?” said Kate.
“No, not at all. I’m perfectly dry. You see I had my coat. Only my head, of course. My poor hair was all streaked down my face like streaks of dye.” He wiped his thin hair across his head with rather self-conscious humour. “Hasn’t Owen come in?” he asked.
“Yes, he’s changing.”
“Well I’ll go up. I suppose it’s nearly supper time. Oh yes, it’s after!” At which discovery he brightened as if he’d received a gift.
“Oh by the way, how did you get on? Rather mean of us to let you go all alone like that,” he said, as he hung poised in the open doorway.
“Not at all,” she said. “You wanted to stay. And I can look after myself, at my time of life.”
“We-ell!” he said, with an American drawl. “Maybe you can!” Then he gave a little laugh. “But you should have seen all those men rehearsing in that bedroom, throwing their arms about, and the toreador lying on the bed like Venus with a fat cigar, listening to her lovers.”
“I’m glad I didn’t,” said Kate. Villiers disappeared with a wicked little laugh.
And as she sat her hands trembled with outrage and passion. Amoral! How could one be a-moral, or non-moral, when one’s soul was revolted! How could one be like these Americans, picking over the garbage of sensations, and gobbling it up like carrion birds. At the moment, both Owen and Villiers seemed to her like carrion birds, repulsive.
She felt, moreover, that they both hated her first because she was a woman. It was all right so long as she fell in with them in every way. But the moment she stood out against them in the least, they hated
her mechanically for the very fact that she was a woman. They hated her womanness.
And in this Mexico, with its great under-drift of squalor and heavy reptile-like evil, it was hard for her to bear up.
She was really fond of Owen. But how could she respect him? So empty, and waiting for circumstance to fill him up. Swept with an American despair of having lived in vain, or of not having reallylived. Having missed something. Which fearful misgiving would make him rush like mechanical steel filings to a magnet, towards any crowd in the street. And then all his poetry and philosophy gone with the cigarette-end he threw away, he would stand craning his neck in one more frantic effort to see—just to see. Whatever it was, he must see it. Or he might miss something. And then, after he’d seen an old ragged woman run over by a motor-car and bleeding on the floor, he’d come back to Kate pale at the gills, sick, bewildered, daunted, and yet, yes, glad he’d seen it. It was Life!
“Well,” said Kate, “I always thank God I’m not Argus. Two eyes are often two too many for me, in all the horrors. I don’t feed myself on street-accidents.”
At dinner they tried to talk of pleasanter things than bull-fights. Villiers was neat and tidy and very nicely mannered, but she knew he was keeping a little mocking laugh up his sleeve, because she could not stomach the afternoon’s garbage. He himself had black rings under his eyes, but that was because he had “lived.”
The climax came with the dessert. In walked the Pole and that Spaniard who spoke American. The Pole was unhealthy and uncleanlooking. She heard him saying to Owen, who of course had risen with automatic cordiality:
“We thought we’d come here to dinner. Well, how are you.”
Kate’s skin was already goose-flesh. But the next instant she heard that dingy voice, that spoke so many languages dingily, assailing her with familiarity:
“Ah, Miss Leslie, you missed the best part of it. You missed all the fun! Oh, I say—”
Rage flew into her heart and fire into her eyes. She got up suddenly from her chair, and faced the fellow behind her.
“Thank you!” she said. “I don’t want to hear. I don’t want you to speak to me. I don’t want to know you.”
She looked at him once, then turned her back, sat down again, and took a pitahaya from the fruit plate.
The fellow went green, and stood a moment speechless.
“Oh, all right!” he said mechanically, turning away to the Spaniard who spoke American.
“Well—see you later!” said Owen rather hurriedly, and he went back to his seat at Kate’s table.
The two strange fellows sat at another table. Kate ate her cactus fruit in silence, and waited for her coffee. By this time she was not so angry, she was quite calm. And even Villiers hid his joy in a new sensation under a manner of complete quiet composure.
When coffee came she looked at the two men at the other table, and at the two men at her own table.
“I’ve had enough of canaille, of any sort,” she said.
“Oh, I understand, perfectly,” said Owen.
After dinner, she went to her room. And through the night she could not sleep, but lay listening to the noises of Mexico City, then to the silence and the strange, grisly fear that so often creeps out on to the darkness of a Mexican night. Away inside her, she loathed Mexico City. She even feared it. In the daytime it had a certain spell—but at night, the underneath grisliness and evil came forth.
In the morning Owen also announced that he had not slept at all.
“Oh, I never slept so well since I was in Mexico,” said Villiers, with a triumphant look of a bird that has just pecked a good morsel from
the garbage-heap.
“Look at the frail aesthetic youth!” said Owen, in a hollow voice.
“His frailty and his aestheticism are both bad signs, to me,” said Kate ominously.
“And the youth. Surely that’s another!” said Owen, with a dead laugh.
But Villiers only gave a little snort of cold, pleased amusement.
Someone was calling Miss Leslie on the telephone, said the Mexican chambermaid. It was the only person Kate knew in the capital—or in the Distrito Federal—a Mrs Norris, widow of an English embassador of thirty years ago. She had a big, ponderous old house out in the village of Tlacolula.
“Yes! Yes! This is Mrs Norris. How are you? That’s right, that’s right. Now, Mrs Leslie, won’t you come out to tea this afternoon and see the garden? I wish you would. Two friends are coming in to see me, two Mexicans: Don Ramón Carrasco and General Viedma. They are both charmingmen, and Don Ramón is a great scholar. I assure you, they are both entirely the exception among Mexicans. Oh, but entirelythe exception! So now, my dearMrs Leslie, won’t you come with your cousin? I wish you would.”
Kate remembered the little general; he was a good deal smaller than herself. She remembered his erect, alert little figure, something birdlike, and the face with eyes slanting under arched eyebrows, and the little black tuft of an imperial on the chin: a face with a peculiar Chinese suggestion, without being Chinese in the least, really. An odd, detached, yet cocky little man, a true little Indian, speaking Oxford English in a rapid, low, musical voice, with extraordinarily gentle intonation. Yet those black, inhuman eyes!
Till this minute she had not really been able to recall him to herself, to get any sharp impression. Now she had it. He was an Indian pure and simple. And in Mexico, she knew, there were more generals than soldiers. There had been three generals in the Pullman coming down
from El Paso, two, more or less educated, in the “drawing-room,” and the third, a real peasant Indian, travelling with a frizzy halfwhite woman who looked as if she had fallen into a flour-sack, her face was so deep in powder, and her frizzy hair and her brown silk dress so douched with the white dust of it. Neither this “general” nor this woman had ever been in a Pullman before. But the general was sharper than the woman. He was a tall wiry fellow with a reddened pock-marked face and sharp little black eyes. He followed Owen to the smoking room, and watched with sharp eyes, to see how everything was done. And soon he knew. And he would wipe his wash-bowl dry as neatly as anybody. There was something of a real man about him. But the poor, half-white woman, when she wanted the ladies’ toilet, got lost in the passage and wailed aloud: I don’t knowwhere togo!Noséadonde!Noséadonde!—until the general sent the Pullman boy to direct her.
But it had annoyed Kate to see this general and this woman eating chicken and asparagus and jelly in the Pullman, paying fifteen pesos for a rather poor dinner, when for a peso-and-a-half apiece they could have eaten a better meal, and real Mexican, at the meal-stop station. And all the poor, barefoot people clamouring on the platform, while the “general,” who was a man of their own sort, nobly swallowed his asparagus on the other side of the windowpane.
But this is how they save the people, in Mexico and elsewhere. Some tough individual scrambles up out of the squalor and proceeds to save himself. Who pays for the asparagus and jelly and face-powder, nobody asks, because everybody knows.
And so much for Mexican generals: as a rule, a class to be strictly avoided.
Kate was aware of all this. She wasn’t much interested in any sort of Mexican in office. There is so much in the world that one wants to avoid, as one wants to avoid the lice that creep on the unwashed crowd.
Being rather late, Owen and Kate bumped out to Tlacolula in a Ford taxi. It was a long way, a long way through the peculiar squalid endings of the town, then along the straight road between trees, into the valley. The sun of April was brilliant, there were piles of cloud about the sky, where the volcanoes would be. The valley stretched away to its sombre, atmospheric hills, in a flat dry bed, parched except where there was some crop being irrigated. The soil seemed strange, dry, blackish, artificially wetted, and old. The trees rose high, and hung bare boughs, or withered shade. The buildings were either new and alien, like the Country Club, or cracked and dilapidated, with all the plaster falling off. The falling of thick plaster from cracked buildings—one could almost hear it!
Yellow tram-cars rushed at express speed away down the fenced-in car-lines, rushing round towards Xochimilco or Tlalpam. The asphalt road ran outside these lines, and on the asphalt rushed incredibly dilapidated Ford omnibuses, crowded with blank dark natives in dirty cotton clothes and big straw hats. At the far edge of the road, on the dust-tracks under the trees, little donkeys under huge loads loitered towards the city, driven by men with blackened faces and bare, blackened legs. Three-fold went the traffic; the roar of the tramtrains, the clatter of the automobiles, the straggle of asses and of outside-seeming individuals.
Occasional flowers would splash out in colour from a ruin of falling plaster. Occasional women with strong, dark-brown arms would be washing rags in a drain. An occasional horseman would ride across to the herd of motionless black-and-white cattle on the field. Occasional maize fields were already coming green. And the pillars that mark the water conduits passed one by one.
They went through the tree-filled plaza of Tlacolula, where natives were squatting on the ground, selling fruits or sweets, then down a road between high walls. They pulled up at last at big gate-doors, beyond which was a heavy pink-and-yellow house, and beyond the house, high, dark cypress trees.
In the road two motor-cars were already standing. That meant other visitors. Owen knocked on the studded fortress doors: there was an imbecile barking of dogs. At last a little footman with a little black moustache opened silently.
The square, inner patio, dark, with sun lying on the heavy arches of one side, had pots of red and white flowers, but was ponderous, as if dead for centuries. A certain dead, heavy strength and beauty seemed there, unable to pass away, unable to liberate itself and decompose. There was a stone basin of clear but motionless water, and the heavy reddish-and-yellow arches went round the courtyard with warrior-like fatality, their bases in dark shadow. Dead, massive house of the Conquistadores, with a glimpse of tall-grown garden beyond, and further Aztec cypresses rising to strange dark heights. And dead silence, like the black, porous, absorptive lava rock. Save when the tram-cars battered past outside the solid wall.
Kate went up the jet-like stone staircase, through the leather doors. Mrs Norris came forward on the terrace of the upper patio to receive her guests.
“I’m so glad, my dear, that you came. I should have rung you up before, but I’ve had such trouble with my heart. And the doctor wanting to send me down to a lower altitude! I said to him, I’ve no patience! If you’re going to cure me, cure me at an altitude of seven thousand feet or else admit your incompetence at once. Ridiculous, this rushing up and down from one altitude to another. I’ve lived at this height all these years. I simply refuse to be bundled down to Cuernavaca or some other place where I don’t want to go. Well, my dear, and how are you?”
Mrs Norris was an elderly woman, rather like a conquistador herself in her black silk dress and her little black shoulder-shawl of fine cashmere, with a short silk fringe, and her ornaments of black enamel. Her face had gone slightly grey, her nose was sharp and dusky, and her voice hammered almost like metal, a slow, distinct, peculiar hard music of its own. She was an archaeologist, and she had studied the Aztec remains so long, that now some of the black-
grey look of the lava rock, and some of the experience of the Aztec idols, with sharp nose and slightly prominent eyes and an expression of tomb-like mockery, had passed into her face. A lonely daughter of culture, with a strong mind and a dense will, she had browsed all her life on the hard stones of archaeological remains, and at the same time she had retained a strong sense of humanity, and a slightly fantastic humorous vision of her fellow men.
From the first instant, Kate respected her for her isolation and her dauntlessness. The world is made up of a mass of people and a few individuals. Mrs Norris was one of the few individuals. True, she played her social game all the time. But she was an odd number; and all alone, she could give the even numbers a bad time.
“But come in. Do come in!” she said, after keeping her two guests out on the terrace that was lined with black idols and dusty native baskets and shields and arrows and tapa, like a museum.
In the dark sitting-room that opened on to the terrace were visitors: an old man in a black morning coat and white hair and beard, and a woman in black crêpe-de-chine, with the inevitable hat of her sort upon her grey hair: a stiff satin turned up on three sides and with black ospreys underneath. She had the baby face and the faded blue eyes and the middle-west accent inevitable.
“Judge and Mrs Burlap.”
The third visitor was a youngish man, very correct and not quite sure. He was Major Law, American military attaché at the moment.
The three people eyed the newcomers with cautious suspicion. They might be shady. There are indeed so many shady people in Mexico that it is taken for granted, if you arrive unannounced and unexpected in the capital, that you are probably under an assumed name, and have some dirty game up your sleeve.
“Been long in Mexico?” snapped the Judge; the police enquiry had begun.
“No!” said Owen, resonantly, his gorge rising. “About two weeks.”
“You are an American?”
“I,” said Owen, “am American. Mrs Leslie is English—or rather Irish.”
“Been in the club yet?”
“No,” said Owen, “I haven’t. American clubs aren’t much in my line. Though Garfield Spence gave me a letter of introduction.”
“Who? Garfield Spence?” The Judge started as if he had been stung. “Why the fellow’s nothing better than a bolshevist. Why he went to Russia!”
“I should rather like to go to Russia myself,” said Owen. “It is probably the most interesting country in the world to-day.”
“But weren’t you telling me,” put in Mrs Norris, in her clear, metalmusical voice, “that you loved China so much, Mr Rhys?”
“I didlike China verymuch,” said Owen.
“And I’m sure you made some wonderful collections. Tell me now, what was your particular fancy?”
“Perhaps, after all,” said Owen, “it was jade.”
“Ah jade! Yes! Jade! Jade is beautiful! Those wonderful little fairylands they carve in jade!”
“And the stone itself! It was the delicate stone that fascinated me,” said Owen. “The wonderful quality of it!”
“Ah wonderful, wonderful! Tell me now, dear Mrs Leslie, what you have been doing since I saw you?”
“We went to a bull-fight, and hated it,” said Kate. “At least I did. We sat in the Sun, near the ring, and it was all horrible.”
“Horrible, I am sure. I never went to a bull-fight in Mexico. Only in Spain, where there is wonderful colour. Did you ever try a bull-fight, Major?”
“Yes, I have been several times.”
“You have! Then you know all about it. And how are you liking Mexico, Mrs Leslie?”
“Not much,” said Kate. “It strikes me as evil.”
“It does! It does!” said Mrs Norris. “Ah, if you had known it before! Mexico before the revolution! It was different then. What is the latest news, Major?”
“About the same,” said the Major. “There is a rumour that the new President will be turned down by the army, a few days before he comes into office. But you never know.”
“I think it would be a great shame not to let him have a try,” put in Owen hotly. “He seems a sincere man, and just because he is honestly a Labour man, they want to shut him out.”
“Ah, my dear Mr Rhys, they alltalk so nobly beforehand. If only their deeds followed their words, Mexico would be heaven on earth.”
“Instead of hell on earth,” snapped the Judge.
A young man and his wife, also Americans, were introduced as Mr and Mrs Henry. The young man was fresh and lively.
“We were talking about the new President,” said Mrs Norris.
“Well, why not!” said Mr Henry breezily. “I’m just back from Orizaba. And do you know what they’ve got pasted up on the walls?— Hosanna! Hosanna! Hosanna! Viva el Jesús Cristo de Mexico, SocratesTomasMontes!”
“Why, did you ever hear of such a thing!” said Mrs Norris.
“Hosanna!Hosanna!Hosanna!To the new Labour President! I think it’s rich,” said Henry.
The Judge stamped his stick on the ground in a speechless access of irritability.
“They pasted on my luggage,” said the Major, “when I came through Vera Cruz: La degenerada media clasa, Será regenerada, por mi,
Montes. The degenerate middle class shall be regenerated by me, Montes.”
“Poor Montes!” said Kate. “He seems to have got his work cut out.”
“He has indeed!” said Mrs Norris. “Poor man, I wish he might come in peacefully and put a strong hand on the country. But there’s not much hope, I’m afraid.”
There was a silence, during which Kate felt that bitter hopelessness that comes over people who know Mexico well. A bitter barren hopelessness.
“How can a man who comes in on a Labour vote, even a doctored one, put a strong hand on a country!” snapped the Judge. “Why he came in on the very cry of Down withthestrong hand!” And again the old man stamped his stick in an access of extreme irritability.
This was another characteristic of the old residents of the city: A state of intense, though often suppressed irritation, an irritation amounting almost to rabies.
“Oh, but mayn’t it be possible that he will change his views a little on coming into power?” said Mrs Norris. “So many Presidents have done so.”
“I should say very probable, if ever he gets into power,” said young Henry. “He’ll have all his work cut out saving Socrates Tomas, he won’t have much time left for saving Mexico.”
“He’s a dangerous fellow, and will turn out a scoundrel,” said the Judge.
“Myself,” said Owen, “as far as I have followed him, I believe he is sincere, and I admire him.”
“I thought it was so nice,” said Kate, “that they received him in New York with loud music by the Street Sweepers’ Band. The Street Sweepers’ Band they sent to receive him from the ship!”
“You see,” said the Major, “no doubt the Labour people themselves wished to send that particular band.”
“But to be President Elect, and to be received by the Street Sweepers’ Band!” said Kate. “No, I can’t believe it!”
“Oh, it actually was so,” said the Major. “But that is Labour hailing Labour, surely.”
“The latest rumour,” said Henry, “is that the army will go over en bloc to General Angulo about the twenty-third, a week before the inauguration.”
“But how is it possible?” said Kate, “when Montes is so popular?”
“Montes popular!” they all cried at once. “Why!” snapped the Judge, “he’s the most unpopular man in Mexico.”
“Not with the Labour Party!” said Owen, almost at bay.
“The Labour Party!” the Judge fairly spat like a cat. “There is no such thing. What is the Labour Party in Mexico? A bunch of isolated factory hands here and there, mostly in the State of Vera Cruz. The Labour Party! They’ve done what they could already. We know them.”
“That’s true,” said Henry. “The Labourites have tried every little game possible. When I was in Orizaba they marched to the Hotel Francia to shoot all the gringos and the Gachupines. The hotel manager had pluck enough to harangue them, and they went off to the next hotel. When the man came out there to talk to them, they shot him before he got a word out. It’s funny, really! If you have to go to the Town Hall, and you’re dressed in decent clothes, they let you sit on a hard bench for hours. But if a street-sweeper comes in, or a fellow in dirty cotton drawers, it is Buenos Dios! Señor! Pase Usted! Quiere Usted algo? while you sit there waiting their pleasure. Oh, it’s quite funny.”
The Judge trembled with irritation like an access of gout. The party sat in gloomy silence, that sense of doom and despair overcoming them as it seems to overcome all people who talk seriously about Mexico. Even Owen was silent. He too had come through Vera Cruz, and had had his fright; the porters had charged him twenty pesos to
carry his trunk from the ship to the train. Twenty pesos is ten dollars, for ten minutes’ work. And when Owen had seen the man in front of him arrested and actually sent to jail, a Mexican jail at that, for refusing to pay the charge, “the legal charge,” he himself had stumped up without a word.
“I walked into the National Museum the other day,” said the Major quietly. “Just into that room on the patio where the stones are. It was rather a cold morning, with a Norte blowing. I’d been there about ten minutes when somebody suddenly poked me on the shoulder. I turned round, and it was a lout in tight boots. You spik English?I said yes!Then he motioned me to take my hat off: I’d got to take my hat off. Whatfor?said I, and I turned away and went on looking at their idols and things: ugliest set of stuff in the world, I believe. Then up came the fellow with the attendant—the attendant of course wearing his cap. They began gabbling that this was the National Museum, and I must take off my hat to their national monuments. Imagine it: those dirty stones! I laughed at them and jammed my hat on tighter and walked out. They are really only monkeys, when it comes to nationalism.”
“Exactly!” cried Henry. “When they forget all about the Patria and Mexico and all that stuff, they’re as nice a people as you’d find. But as soon as they get national, they’re just monkeys. A man up from Mixcoatl told me a nice story. Mixcoatl is a capital way in the South, and they’ve got a sort of Labour bureau there. Well, the Indians come in from the hills, as wild as rabbits. And they get them into that bureau, and the Laboristas, the agitator fellows, say to them: NowSeñores, haveyou anythingtoreportfromyour native village? Haven’t you anything for which you would like redress? Then of course the Indians start complaining about one another, and the Secretary says: Wait a minute, gentlemen! Let me ring up the Governor and report this. So he goes to the telephone and starts ringing: ringing: Ah!Is thatthePalace?Is theGovernor in?Tellhim Señor Fulano wants to speak to him! The Indians sit gaping with open mouths. To them it’s a miracle. Ah! Is that you. Governor! Good morning! How are you! Can I have your attention for a
moment? Many thanks! Well I’ve got some gentlemen here down fromApaxtle,inthehills:JoséGarcia,JesusQuerido, etc.—andthey wishtoreportso-and-so. Yes!Yes!That’sit!Yes!What?Youwillsee that justice is done and the thing is made right? Ah señor , many thanks! In the name of these gentlemen from the hills, from the villageofApaxtle,manythanks.
There sit the Indians staring as if heaven had opened and the Virgin of Guadalupe was standing tiptoe on their chins. And what do you expect? The telephone is a dummy. It isn’t connected with anywhere. Isn’t that rich? But it’s Mexico.”
The moment’s fatal pause followed this funny story.
“Oh but!” said Kate, “it’s wicked! It is wicked. I’m sure the Indians would be all right, if they were left alone.”
“Well,” said Mrs Norris. “Mexico isn’t like any other place in the world.”
But she spoke with fear and despair in her voice.
“They seem to wantto betray everything,” said Kate. “They seem to love criminals and ghastly things. They seem to want the ugly things. They seem to wantthe ugly things to come up to the top. All the foulness that lies at the bottom, they want to stir up to the top. They seem to enjoy it. To enjoy making everything fouler. Isn’t it curious!”
“It is curious,” said Mrs Norris.
“But that’s what it is,” said the Judge. “They want to turn the country into one big crime. They don’t like anything else. They don’t like honesty and decency and cleanliness. They want to foster lies and crime. What they call liberty here is just freedom to commit crime. That’s what Labour means, that’s what they all mean. Free crime, nothing else.”
“I wonder all the foreigners don’t go away,” said Kate.
“They have their occupations here,” snapped the Judge.
“And the good people are all going away. They have nearly all gone, those that have anything left to go to,” said Mrs Norris. “Some of us, who have our property here, and who have made our lives here, and who know the country, we stay out of a kind of tenacity. But we know it’s hopeless. The more it changes, the worse it is.—Ah, here is Don Ramón and Don Cipriano. So pleased to see you. Let me introduce you.”
Don Ramón Carrasco was a tall, big, handsome man who gave the effect of bigness. He was middle aged, with a large black moustache and large, rather haughty eyes under straight brows. The General was in civilian clothes, looking very small beside the other man, and very smartly built, almost cocky.
“Come,” said Mrs Norris. “Let us go across and have tea.”
The Major excused himself, and took his departure.
Mrs Norris gathered her little shawl round her shoulders and led through a sombre antechamber to a little terrace, where creepers and flowers bloomed thick on the low walls. There was a bell-flower, red and velvety, like blood that is drying: and clusters of white roses: and tufts of bougainvillea, papery magenta colour.
“How lovely it is here!” said Kate. “Having the great dark trees beyond.”
But she stood in a kind of dread.
“Yes it is beautiful,” said Mrs Norris, with the gratification of a possessor. “I have such a time trying to keep these apart.” And going across in her little black shawl, she pushed the bougainvillea away from the rust-scarlet bell-flowers, stroking the little white roses to make them intervene.
“I think the two reds together interesting,” said Owen.
“Do you really!” said Mrs Norris, automatically, paying no heed to such a remark.
The sky was blue overhead, but on the lower horizon was a thick, pearl haze. The clouds had gone.
“One never sees Popocatepetl nor Ixtaccihuatl,” said Kate, disappointed.
“No, not at this season. But look, through the trees there, you see Ajusco!”
Kate looked at the sombre-seeming mountain, between the huge dark trees.
On the low stone parapet were Aztec things, obsidian knives, grimacing squatting idols in black lava, and a queer thickish stone stick, or bâton. Owen was balancing the latter: it felt murderous even to touch.
Kate turned to the general, who was near her, his face expressionless, yet alert.
“Aztec things oppress me,” she said.
“They areoppressive,” he answered, in his beautiful cultured English, that was nevertheless a tiny bit like a parrot talking.
“There is no hope in them,” she said.
“Perhaps the Aztecs never asked for hope,” he said, somewhat automatically.
“Surely it is hope that keeps one going?” she said.
“You, maybe. But not the Aztec, nor the Indian to-day.”
He spoke like a man who has something in reserve, who is only half attending to what he hears, and even to his own answer.
“What do they have, if they don’t have hope?” she said.
“They have some other strength, perhaps,” he said evasively.
“I would like to give them hope,” she said. “If they had hope, they wouldn’t be so sad, and they would be cleaner, and not have vermin.”
“That of course would be good,” he said, with a little smile. “But I think they are not so very sad. They laugh a good deal and are gay.”
“No,” she said. “They oppress me, like a weight on my heart. They make me irritable, and I want to go away.”
“From Mexico?”
“Yes. I feel I want to go away from it and never, never see it again. It is so oppressive and gruesome.”
“Try it a little longer,” he said. “Perhaps you will feel differently. But perhaps not,” he ended vaguely, driftingly.
She could feel in him a sort of yearning towards her. As if a sort of appeal came to her from him, from his physical heart in his breast. As if the very heart gave out dark rays of seeking and yearning. She glimpsed this now for the first time, quite apart from the talking, and it made her shy.
“And does everything in Mexico oppress you?” he added, almost shyly, but with a touch of mockery, looking at her with a troubled naïve face that had its age heavy and resistant beneath the surface.
“Almost everything!” she said. “It always makes my heart sink. Like the eyes of the men in the big hats—I call them the peons. Their eyes have no middle to them. Those big handsome men, under their big hats, they aren’t really there. They have no centre, no real I. Their middle is a raging black hole, like the middle of a maelstrom.”
She looked with her troubled grey eyes into the black, slanting, watchful, calculating eyes of the small man opposite her. He had a pained expression, puzzled, like a child. And at the same time something obstinate and mature, a demonish maturity, opposing her in an animal way.
“You mean we aren’t real people, we have nothing of our own, except killing and death,” he said, quite matter of fact.
“I don’t know,” she said, startled by his interpretation. “I only say how it makes me feel.”
“You are very clever, Mrs Leslie,” came Don Ramón’s quiet, but heavy teasing voice behind her. “It is quite true. Whenever a Mexican cries Viva! he ends up with Muera! When he says Viva! he really means Deathfor SomebodyorOther!I think of all the Mexican revolutions, and I see a skeleton walking ahead of a great number of people, waving a black banner with Viva la Muerte! written in large white letters. Long live Death! Not Viva Cristo Rey! but Viva Muerte Rey! Vamos!Viva!”
Kate looked round. Don Ramón was flashing his knowing brown Spanish eyes, and a little sardonic smile lurked under his moustache. Instantly Kate and he, Europeans in essence, understood one another. He was waving his arm to the last Viva!
“But,” said Kate, “I don’t want to say VivalaMuerte!”
“But when you are real Mexican—” he said, teasing.
“I nevercould be,” she said hotly, and he laughed.
“I’m afraid VivalaMuerte!hits the nail on the head,” said Mrs Norris, rather stonily. “But won’t you come to tea! Do!”
She led the way in her black little shawl and neat grey hair, going ahead like a Conquistador herself, and turning to look with her Aztec eyes through her pince-nez, to see if the others were coming.
“We are following,” said Don Ramón in Spanish, teasing her. Stately in his black suit, he walked behind her on the narrow terrace, and Kate followed, with the small, strutting Don Cipriano, also in a black suit, lingering oddly near her.
“Do I call you General or Don Cipriano?” she asked, turning to him.
An amused little smile quickly lit his face, though his eyes did not smile. They looked at her with a black, sharp look.
“As you wish,” he said. “You know General is a term of disgrace in Mexico. Shall we say Don Cipriano?”
“Yes, I like that much the best,” she said.
And he seemed pleased.
It was a round tea-table, with shiny silver tea-service, and silver kettle with a little flame, and pink and white oleanders. The little neat young footman carried the tea-cups, in white cotton gloves. Mrs Norris poured tea and cut cakes with a heavy hand.
Don Ramón sat on her right hand, the Judge on her left. Kate was between the Judge and Mr Henry. Everybody except Don Ramón and the Judge was a little nervous. Mrs Norris always put her visitors uncomfortably at their ease, as if they were captives and she the chieftainess who had captured them. She rather enjoyed it, heavily, archaeologically queening at the head of the table. But it was evident that Don Ramón, by far the most impressive person present, liked her. Cipriano, on the other hand, remained mute and disciplined, perfectly familiar with the tea-table routine, superficially quite at ease, but underneath remote and unconnected. He glanced from time to time at Kate.
She was a beautiful woman, in her own unconventional way, and with a certain richness. She was going to be forty next week. Used to all kinds of society, she watched people as one reads the pages of a novel, with a certain disinterested amusement. She was never in any society: too Irish, too wise.
“But of course nobody lives without hope,” Mrs Norris was saying banteringly to Don Ramón. “If it’s only the hope of a real, to buy a litre of pulque.”
“Ah, Mrs Norris!” he replied in his quiet, yet curiously deep voice, like a violincello: “If pulque is the highest happiness!”
“Then we are fortunate, because a tostón will buy paradise,” she said.
“It is a bon mot, Señora mia,” said Don Ramón, laughing and drinking his tea.
“Now won’t you try these little native cakes with sesame seeds on them!” said Mrs Norris to the table at large. “My cook makes them,
and her national feeling is flattered when anybody likes them. Mrs Leslie, do take one.”
“I will,” said Kate. “Does one say OpenSesame!”
“If one wishes,” said Mrs Norris.
“Won’t you have one?” said Kate, handing the plate to Judge Burlap.
“Don’t want any,” he snapped, turning his face away as if he had been offered a plate of Mexicans, and leaving Kate with the dish suspended.
Mrs Norris quickly but definitely took the plate, saying:
“Judge Burlap is afraid of Sesame Seed, he prefers the cave shut.”
And she handed the dish quietly to Cipriano, who was watching the old man’s bad manners with black, snake-like eyes.
“Did you see that article by Willis Rice Hope, in the Excelsior?” suddenly snarled the Judge, to his hostess.
“I did. I thought it very sensible.”
“The only sensible thing that’s been said about these Agrarian Laws. Sensible! I should think so. Why Rice Hope came to me, and I put him up to a few things. But his article says everything, doesn’t miss an item of importance.”
“Quite!” said Mrs Norris, with rather stony attention. “If only saying would alter things, Judge Burlap.”
“Saying the wrong thing has done all the mischief!” snapped the Judge. “Fellows like Garfield Spence coming down here and talking a lot of criminal talk. Why the town’s full of Socialists and Sinvergüenzas from New York.”
Mrs Norris adjusted her pince-nez.
“Fortunately,” she said, “they don’t come out to Tlacolula, so we needn’t think about them. Mrs Henry, let me give you some more tea.”
“Do you read Spanish?” the Judge spat out, at Owen. Owen, in his big shell spectacles, was evidently a red rag to his irritable fellowcountryman.
“No!” said Owen, round as a cannon-shot.
Mrs Norris once more adjusted her eye-glasses.
“It’s such a relief to hear someone who is altogether innocent of Spanish, and altogether unashamed,” she said. “My father had us all speaking four languages by the time we were twelve, and we have none of us ever quite recovered. My stockings were all dyed blue for me before I put my hair up. By the way! How have you been for walking, Judge? You heard of the time I had with my ankle?”
“Of course we heard!” cried Mrs Burlap, seeing dry land at last. “I’ve been trying so hard to get out to see you, to ask about it. We were so grievedabout it.”
“What happened?” said Kate.
“Why I foolishly slipped on a piece of orange peel in town—just at the corner of San Juan de Latrán and Madero. And I fell right down. And of course, the first thing I did when I got up was to push the piece of orange peel into the gutter. And would you believe it, that lot of Mex—” she caught herself up—“that lot of fellows standing there at the corner laughed heartily at me, when they saw me doing it. They thought it an excellent joke.”
“Of course they would,” said the Judge. “They were waiting for the next person to come along and fall.”
“Did nobody help you?” asked Kate.
“Oh no! If anyone has an accident in this country, you must never, neverhelp. If you touch them even, you may be arrested for causing the accident.”
“That’s the law!” said the Judge. “If you touch them before the police arrive, you are arrested for complicity. Let them lie and bleed, is the motto.”
“Is that true?” said Kate to Don Ramón.
“Fairly true,” he replied. “Yes, it is true you must not touch the one who is hurt.”
“How disgusting!” said Kate.
“Disgusting!” cried the Judge. “A great deal is disgusting in this country, as you’ll learn if you stay here long. I nearly lost my life on a banana skin; lay in a darkened room for days, between life and death, and lame for life from it.”
“How awful!” said Kate. “What did you do when you fell?”
“What did I do? Just smashed my hip.”
It had truly been a terrible accident, and the man had suffered bitterly.
“You can hardly blame Mexico for a banana skin,” said Owen, elated. “I fell on one in Lexington Avenue; but fortunately I only bruised myself on a soft spot.”
“That wasn’t your head, was it?” said Mrs Henry.
“No,” laughed Owen. “The other extreme.”
“We’ve got to add banana skins to the list of public menaces,” said young Henry. “I’m an American, and I may any day turn bolshevist, to save my pesos, so I can repeat what I heard a man saying yesterday. He said there are only two great diseases in the world today—Bolshevism and Americanism; and Americanism is the worst of the two, because Bolshevism only smashes your house or your business or your skull, but Americanism smashes your soul.”
“Who was he?” snarled the Judge.
“I forget,” said Henry, wickedly.
“One wonders,” said Mrs Norris slowly, “what he meant by Americanism.”
“He didn’t define it,” said Henry. “Cult of the dollar, I suppose.”
“Well,” said Mrs Norris. “The cult of the dollar, in my experience, is far more intense in the countries that haven’t got the dollar, than in the United States.”
Kate felt that the table was like a steel disc to which they were all, as victims, magnetised and bound.
“Where isyour garden, Mrs Norris?” she asked.
They trooped out, gasping with relief, to the terrace. The Judge hobbled behind, and Kate had to linger sympathetically to keep him company.
They were on the little terrace.
“Isn’t this strange stuff!” said Kate, picking up one of the Aztec stone knives on the parapet. “Is it a sort of jade?”
“Jade!” snarled the Judge. “Jade’s green, not black. That’s obsidian.”
“Jade can be black,” said Kate. “I’ve got a lovely little black tortoise of jade from China.”
“You can’t have. Jade’s bright green.”
“But there’s white jade too. I know there is.”
The Judge was silent from exasperation for a few moments, then he snapped:
