The History of Pain
Michael L. Whitworth, MD
What Is Pain?
The word pain derives from the middle English word (circa 1250–1300 AD)
peine meaning punishment, torture, pain. This word was derived from old French which
was derived from the Latin poena meaning penalty, pain. This word was derived from
the ancient Greek word poin meaning penalty . The English word pain was used in
1297 as "punishment," especially for a crime; also (c.1300) "condition one feels when
hurt, opposite of pleasure," The earliest sense in English survives in phrase “on pain of
death”. The verb meaning "to inflict pain" is first recorded c.1300. The methods used for
punishment in order to produce death were also quite painful in the middle ages, and the
word came to mean the same for the
punishment and the physical effect of
the punishment. But punishment,
including torture, was commonly used
as a remedy to many societal ills,
transgressions against Christianity, and
both civil and criminal behavior. The
methods of torture used were
gruesome and profoundly painful,
therefore medieval torture and pain
were synonymous. The church used
torture during the Inquisition in order
to extract confessions of sins and to
ensure the non-believer became a Christian. The torture itself was not supposed to
produce immediate death, unless a confession was acquired just before death. Each
method of torture could be used only once, then another form of torture had to be
employed, therefore there were an entire array of devices of torture created for this sacred
purpose. Some of these methods are detailed in appendix A. The long unbroken history
of this etymology of the word “pain” reflects a continuous uninterrupted understanding
and usage reflecting the fact that all cultures throughout time have had to deal with pain.
In the modern English language, its usage is commonly employed to designate both
physical and emotional suffering, is used as a verb and a noun, and for the symptom of
acute pain and the disease of chronic pain. Only through use in sentence context can one
determine the appropriate meaning.
Aristotle (384-322 B.C.) thought of pain as an emotion, like joy and Thomas More
(1478-1535) stated pain is "the direct opposite of pleasure." Rene Descartes (1596-1650)
perceived it as a sensation, like hot or cold and because of his perception of man as a
machine (revolutionary for the time), also noted pain was a signal of physical pathology
(Specificity Theory). Descarte defined pain as "Fast moving particles of fire ..the
disturbance passes along the nerve filament until it reaches the brain..." Descartes (1664).
Later, Dunglison (1846) defined pain as "a disagreeable sensation, which scarcely admits
of definition" (this happens to be true today). Harris (1849) defined pain as the
diminutive word "dolor." Mathison (1958) called pain "an emotion as vague as love, and
as hard to define." The International Association for the Study of Pain (IASP) in 1975
defined it as "an unpleasant sensory and emotional experience associated with actual or
potential tissue damage, or described in terms of such damage." This definition is a
rather radical departure from the prevailing theory over the past 300 years: the Descarte
Specificity Theory which viewed pain as stimulus-response. The IASP definition now
invoked the use of emotion and also noted pain may not correlate with tissue damage.
The departure from Descarte has become increasingly important with the recognition that
whereas acute pain may be a symptom, chronic pain is actually a disease in itself. Pain
may be acute (less than two weeks), subacute (less than 3 months but longer than 2
weeks), or chronic (longer than 3 months). The length of time pain lasts is not only
important from the standpoint of different treatments being needed, but as pain becomes
chronic there are actual changes that occur in the spinal cord independent of any tissue
injury. Most acute pain is a symptom of tissue injury. Chronic pain however, may
persists long after the tissue injury has resolved. But chronic pain may also be a mixture
of tissue injury that is ongoing in addition to spinal cord neurological changes. Chronic
pain is more closely related to that of a disease rather than a symptom. Acute pain is a
symptom of tissue injury that involves some destruction of tissue, inflammation of the
tissue, and the bodies attempt to repair the inflammation and tissue destruction. Chronic
pain on the other hand, is more related to any of the chronic disease conditions including
diabetes or hypothyroidism. Just as chronic disease states cannot be cured, usually
chronic pain cannot be cured. However just as these other chronic conditions lend
themselves to treatment, chronic pain may also be effectively treated but rarely is it
eradicated. The gate theory of Wall and Melzack (1965) offers insight into the
mechanisms of modification of pain by other incoming neurons and was the first break
from Descarte in centuries. Emotion, especially anxiety and depression, prior history of
response to pain, factors such as how your parents dealt with pain, cultural factors, sleep
disturbance, etc. are but a few of the many factors that modify pain and amplify it as it
moves along the spinal cord and brain. Chronic pain, the disease, consists of changes in
the spinal cord itself that persists long after the inflammation of the acute pain is gone, or
may open gates to amplify the remaining inflammatory response.
Pain in the Literature
Plato(428-348 B.C.) compared pain to pleasure in that when a person was
suffering from acute pain, "...there is nothing pleasanter than to get rid of their pain."
Aristotle (384-322 B.C.) on the other hand said, "Pain upsets and destroys the nature of
the person who feels it." His concept of pain as a passion of the soul
felt in the heart prevailed for almost twenty-three centuries. Not only
was Aristotle’s view of pain influential on medicine for such a long
period but so were his concepts of the humors of the body that were
used as a basis for treatment into the mid 1800s. Lucretius (90-53 B.C.)
said that "...atoms cannot ache with any pain or grief" and "...pain exists
when violence attacks." Galen (A.D.129-199) was the first to recognize
"referred pain" (pain felt in areas other than the affected part). He noted
five different forms of sympathetic pain in his writings. Milton (1608-74) said "But pain
is perfect miserie, the worst of evils..." (Paradise Lost), and Cervantes (1547-1616) noted
in Don Quixote, "When the head aches, all the members partake of the pains." Thomas
Jefferson (1743-1826), observed "The art of life is the avoiding of pain”. He suffered
from chronic migraine headaches. Ralph Waldo Emerson (1803-82) stated in his Natural
History of Intellect, "He has seen but half the universe who never has been shown the
house of Pain.". Music is full of expression of pain, both in words and in notes. Gustav
Mahler exemplifies this in his second symphony, but Beethovan, Mozart, and virtually
every great composer confronted and explored pain in their works.
Some notable quotations about pain:
“The pain of the mind is worse than the pain of the body” Publilius Syrus
(Roman author, 1st century B.C.)
“Pain is inevitable. Suffering is optional.”
Pain and death are part of life. To reject them is to reject life itself.” Havelock Ellis
(British psychologist and author 1859-1939)
“Your pain is the breaking of the shell that encloses your understanding.” Kahlil Gibran
(Lebanese born American philosophical Essayist, Novelist and Poet. 1883-1931)
“Given the choice between the experience of pain and nothing, I would choose pain”
William Faulkner
“Pain is deeper than all thought; laughter is higher than all pain” Elbert Hubbard quotes
(American editor, publisher and writer, 1856-1915)
“If you are distressed by anything external, the pain is not due to the thing itself but to
your own estimate of it; and this you have the power to revoke at any moment.”
Marcus Aurelius (Roman emperor, best known for his Meditations on Stoic philosophy,
AD 121-180)
Pain is such an uncomfortable feeling that even a tiny amount of it is enough to ruin
every enjoyment.” Will Rogers (American entertainer, famous for his pithy and
homespun humour, 1879-1935)
“We must embrace pain and burn it as fuel for our journey.” Kenji Miyazawa
“Pain is temporary. It may last a minute, or an hour, or a day, or a year, but eventually it
will subside and something else will take its place. If I quit, however, it lasts forever.”
Lance Armstrong
"We all must die. But if I can save someone from days of torture, that is what I
feel is my great and ever new privilege. Pain is a more terrible lord of mankind
than even death itself." ~ Albert Schweitzer, humanitarian, physician, theologian
and composer
Early History of Pain
Primitive cultures and concepts
Primitive humans, in spite of the lack of understanding of anatomy or physiology, had
little difficulty in comprehending pain associated with injuries but were perplexed by pain
caused by internal diseases or disorders. Externally visible cuts, contusions, or abrasions
were readily understood causes of pain, whereas internal pain was thought to be due to
demons. Early means to treatment of visible sources of pain or known injury were relegated
to massage and the injured part, placing it in the cold water of a stream or lake, with
placement of the injured area in the heat of the sun, and later using fire. Pressure was
applied over the affected part and to diminish pain and over time primitive cultures learned
to place pressure over specific regions that had a more pronounced effect although they did
not know why. The cause of a painful disease or pain inflicted by a foreign object was
thought to be due to evil spirits, pain demons, or magic fluids going into the body.
Treatment consisted of eradicating the intriguing object or making efforts to appease or
frighten away the pain demons. This was done with rings worn in the ears and nose
talismans amulets Tiger claws and other charms. In some primitive societies the treatment
was filled with activities in order to keep these evil spirits away from the body and therefore
without pain. Spells and words of might were used by the injured man enabling him to cause
the pain demons to flee from him. Pain, in early cultures, was thought to be the “sting of an
evil spirit” that was initially treated by a sorceress-healer
who is a representation of an incarnation of the Great
Mother, while men began to assume the role of protector
of the family. However even in patriarchal states the
woman retained the preeminent role as healers. The
sibyls and pythonesses of the ancients played formidable
roles in the process of healing which included the power
of exercising demons of illness and pain. The first sibyls
(prophetess) was recorded in Greece in the 5th century
BC with the most famous being the sibyl at Delphi. But
later it was the medicine man that conjured up a changing
of shape by dressing as an anti-demon, creating a special
medicine hut house where he muttered incantations, and
wrestled with pain demons. It is interesting that the
power afforded the medicine man and special location of
healing thousands of years later gave rise to the positions of power that doctors and hospitals
hold in today's society. Some medicine man or shaman made small wounds for bloodletting
and allowed that fluids or spirits or demons to escape in other societies the shaman
physically sucked the spirit directly from the created wound, taking the evil spirit within
himself and subsequently neutralizing it with magic. This is a therapy that continues to be
used today in some countries. In some cultures, the medicine man was replaced by a priest,
who was deemed a servant of the gods. Because human pain was thought to placate the
deities, human sacrifices were made, and priests offered prayers in constructed shrines to
appease the offended deities. These structures were known by different names throughout
the ages such as ziggurats in the Babylonian and Assyrian cultures, pyramids in Egypt,
temples in Greece, and teocallis in the Aztec cultures. Clay replicas of the painful body part
were left in these temples for relief, and after a sacrifice was made to the gods, it was thought
relief would be granted to the person suffering in pain. Prayers, exorcisms, and incantations
are found on Babylonian clay tablets, in Egyptian papyri, and in Persian leathern documents,
in carvings from Mycenae, and on parchment rolls from Troy.
hhhhhh Ancient civilizations
Ancient Egyptians believed pain other than that caused by wounds, was caused by
religious influences of their gods or spirits of the dead. The spirits arrived at night and
entered the body through the nostril or the ear. There were several demons and gods that
were thought to inflict pain. The demon could depart through vomiting, urine, sneezing, or
sweating of the limbs. It was believed there was a widely distributed network of vessels
called “metu” that carried the breath of life and sensations to the heart. This was the
beginning of the concept that the heart was a center of sensation, an idea that lasted more
than 2000 years. In Babylonian medicine intrusion into the body by an object, whether by
demons or natural means, was the cause of pain. The pain of dental caries was thought to be
due to worms burrowing into the teeth.
Pain and other medical knowledge was attributed in India to the god Indra. Budda in
500 B.C. believed the universality of pain in life was due to frustration of desires. It was
noted, birth is attended with pain decay is painful, disease is painful, death is painful. Union
with unpleasant is painful, painful and separation from the pleasant in any creating that is
unsatisfied, that too is painful. Even though pain was recognized as a sensation, the
Buddhist and Hindu focus on the emotional aspect of pain. The Hindus believe that pain was
experienced in the heart which was considered to be the seat of consciousness.
The practice of medicine in ancient China was codified in Huang Ti Nei Ching Su Wen,
the Chinese canon of medicine written between the eighth and fifth centuries B.C. tracing its
origin back to the time of the yellow Emperor who lived in 2600
B.C. The Chinese concept includes two opposing unifying forces,
the Yin or the negative passive force, and the Yang a positive active
force which are in balance and assist the energy call that Chi to
circulate to all parts of the body via 14 channels or meridians, each
connected to an internal organ. Pain exists due to an obstruction or
deficiency or excess outpouring of the circulation of the Chi causing
an imbalance in the yen and the yang. Acupuncture is thought to
correct the imbalance through focusing on one of 365 points along the meridians.
The Greek goddess of revenge, Poine, was sent to punish mortal men who dared anger
the gods. The word pain may derive partially from the Poine. The culture of the Greeks
seamlessly integrated belief in the gods and their interaction with man and exploration of the
nature of man. The ancient Greeks were intensely interested in the nature of sensation in the
sense organs of the body. Pythagoras traveled widely from Egypt to Babylon and to India,
stimulated his disciple Alcmaeon, to study the senses. It was Alcmaeon that produce the idea
that the brain, not the heart, was a center for sensation and reason. This view did not gain
widespread acceptance in ancient Greek culture partially due to opposition from Aristotle for
whom the heart reigns supreme. Anaxagoras who died in 428 B.C., believed all sensations
were associated with pain, and the more the subject and object are unlike, the more intense
the pain which was perceived in the brain. In contrast his contemporary Empedocles
believes the capacity for all sensation especially pain and pleasure, was located in the heart's
blood. Hippocrates believed pain was due to one of the four basic vital humors (blood,
phlegm, yellow bile, and black bile) being deficient or in excess and wrote of trepanation as
a means of releasing the pain. He also used willow bark (contains salicylate) as an analgesic.
Plato who died in 347 B.C. believed that sensation resulted from the movement of atoms
communicating through the veins to the heart and liver which were the centers for
appreciation of all sensation. The brain was thought of as an accessory organ in interpreting
these sensations. Plato noted pain and pleasure were opposites, with the production of
pleasure occurring on the elimination of pain. Aristotle who died in 322 B.C. elaborated
further on Plato's concepts. He distinguished the five senses. For Aristotle the brain had no
direct function in sensory processes for the heart was the center of all sensory perception.
Aristotle believed the brains function was to produce cool secretions which cooled the hot air
and blood arising from the heart. Pain was an increase in one of the 5 senses, especially
touch. Pain was caused by excess of vital heat. Like touch, pain arose in the end organs of
the flesh and was conveyed by blood to the heart. Aristotle's subsequent successors cast
serious doubts on their masters views. However anatomical evidence that the brain was part
of the nervous system was not demonstrated until 50 to 75 years later by Herophilus (335280 BC) and Erasistratus (310-250 BC). These philosophers noted that nerves attach to the
spinal cord were two kinds: those for movement and those for feeling.
The advances made that the Egyptians and Greeks were lost to Roman culture for four
centuries until rescued by Galen (131-200 AD). Galen was educated in Greece and in
Alexandria then subsequently came to Rome where he
became the court physician to Marcus Aurelius. He studied
the central and peripheral nervous systems, established the
anatomy of the cranial and spinal nerves and a sympathetic
systems. He defines three classes of nerves: soft nerves which
had sensory functions, hard nerves which were concerned
with motor function, and a third type related to the
transmission of pain. Soft nerves were thought to contain
invisible tubular structures in which a “psychic pneuma”
flowed. Center in sensibility was the brain and received all
kinds of sensations. Unfortunately the advances made by
Galen were all but ignored until 1000 years later, and the concept promoted by Aristotle of
the heart being the center of the sensorium prevailed for the next 1500 years.
Herbal Medicine and Other Ancient Remedies
For thousands of years, herbal medicine has been used throughout the world as a
treatment for pain. Whereas the vast majority of treatments in ancient times were bogus or
based on belief systems rather than effectiveness, some plants were effective in the treatment
of pain. Plants such as hemp, henbane, poppy, and mandragora were all effective analgesics.
A Babylonian clay tablet from 2250 B.C., describes a treatment for the relief of a toothache
with powdered henbane seeds mixed with gum mastic. The Egyptian Ebers Papyrus
mentions opium as a painkiller and the Hindu Charaka and Susruta, written about 1000 B.C.,
mention the use of wine and hemp fumes to produce "insensibility to pain." Socrates (470399 B.C.) took hemlock to relieve his pain and Hippocrates (460-379 B.C.) discusses
belladonna, opium, mandragora, and jusquiam. Pliny (A.D. 23-79) described a mysterious
"Stone of Memphis," which makes one "quite benumbed and insensible to pain." Theriac
was a concoction of up to 64 substances, originally developed in the 1st century AD as an
antidote to venomous snake bites and other poisonous animals. Ultimately its use spread
throughout the world and was used for 1800 years in medical treatments for over 100 uses. It
contained opium, myrrh, saffron, ginger, cinnamon, castor, hemp, as well as many other
substances. Galen (A.D. 129-199) wrote on the use of the mandrake root as a painkiller and
his writings with respect to both surgical and medical therapies, were esteemed for 1500
years virtually unchallenged.
Pain control during surgery was difficult throughout the ages. Early Egyptians produced
unconsciousness (and sometimes death) by progressively tapping with mallets on a wooden
cap worn by the patient. Egyptian and Assyrian physicians performed surgical operations
after compressing the carotid artery to induce unconsciousness. Egyptians used electric eel
from the Nile and from the Mediterranean (the black torpedo fish) to produce analgesia by
placing a live fish over the affected painful part. While effective, the treatment was also
dangerous since selection of too large a fish
could produce fatal electrocution. Similarly, the
Greeks used the Mediterranean torpedo fish to
deliver electrical treatments, especially as a
treatment for headaches. The Chinese used
mandrake wine to produce pain relief. In 1170,
Roger of Salerno (Ruggiero Frugardi),
mentions monks using sponges soaked in opium
and held over the patient's nose for surgical
procedures. A century later, Theodoric de Lucca
(1205-96), referring to the same solution stated,
"The patient may be cut and will feel nothing as if he were dead.”, however of course some
actually did die. Alcohol has been used as a painkiller for many centuries. In Mexico, the
agave plant was utilized as an anesthetic and Amazonians used caapi vine roots to deaden
pain. The Australian Bushmen use duboisia tree leaves and in India the fruit of the java plum
tree are used as painkillers. The East Indian pangiun tree is used as a narcotic and native
Indians in North America used Dogwood (C. canadensis) bark to relieve pain; Hops
(Humulus Lupulus) blossoms for earache or toothache; Speckled Alder (Alnus incana) twigs
for headache and backache; Burdock (Arctium minus) leaves for rheumatic pains. Coca
leaves are chewed by the South American Indians partially as a pain reducing agent.
AmeriIndianas used “pain pipes” held against the skull, and mouth suction was applied to
pull out the pain or illness. Moxibustion, as practiced by the Chinese, used a small cone of
combustible plant material (usually wormwood) was laid on a prescribed point (as in
acupuncture) and set afire. The pain of the blister acted as a counterirritant and the patient
soon forgot the original ailment's pain. Moxibustion continues to exist today, but is used
through heating of acupuncture needles rather than physically burning the skin.
The Early Christian Period
Because of the example of healing through laying on of hands by Jesus, the
elimination of pain was thought possible in the early years of Christianity, and continuing on
today the same reenactment of laying on of hands and by prayer by individuals and by the
clergy exists. Faith and prayer in the early Church could turn every action into a remedy.
Physicians have long held this type of intercession with high regard. One of the tasks that
Jesus was to heal the sick and to banish pain and suffering. Consequently the Catholic
Church place great stress upon the alleviation of pain by its clergy through prayer. Later,
pain was considered a disciplinary measure for sinners, "good for the soul," and not to be the
object of scientific scrutiny. It was perceived as a divine punishment and a continuous act of
penance or contrition. Therefore, pain could be rationalized as a preview of what it meant to
be damned. This view of pain was especially pervasive in certain arenas. Pain during
childbirth was felt to be an accepted punishment and a duty for Original Sin until the mideighteen hundreds when Queen Victoria of England prevailed against church doctrine and
accepted an anesthetic for childbirth. An unfortunate consequence of church dogma and
doctrine was the belief that the deceased human body need remain intact, thereby preventing
dissection of human bodies postmortem, and blocking advancement of the fields of an
anatomy and physiology for 1500 years.
The Dark Ages
With the political destruction of Rome in 476 AD and the establishment of the Holy
Roman empire, came a time where there were few advances in technology, literature,
medicine, art, or in virtually any other realm. Europe disintegrated into a series of feudal
states with very little commerce, travel, or cross-pollination with other cultures. There were
multiple invasions, initially from the Goths, the Vikings, then the Muslims that kept Europe
in chaos. Without strong state governments, the peoples of Europe found refuge in feudal
barons and within the Church. The Church of the dark ages was frequently locally powerful
but the Pope held little influence. The rise in feudal state power prevented consolidation
with other feudal states, and the land barons preferred their independence. Money became
much less important in a serf society, and education took on a decidedly back seat role. All
secular learning was in preparation of studying the Bible. Great monasteries were
constructed to provide a refuge for those that preferred to escape into a religious order.
Recorded history, as had been so prominent in Rome and Greece, essentially ceased to exist
for 800 years. Hand reproduction of copies of the Bible under the watchful eye of the
monastic guides eclipsed, then finally supplanted history documentation or secular writings.
The one bright spot in medicine in the Dark Ages, was at the very end of that period
when Avicenna, the latin name for Ibn Sina, a Persian physician (980-1037 AD) , wrote a
series of extraordinarily insightful treatises. The centerpiece of his works is the “Canon of
Medicine” in which he combined his own insight with that of the writings of Galen, Indiana,
and contemporary Moslem to formulate many modern medical philosophies including The
Canon is a 1,000,000 word book that is considered the first pharmacopoeia and among other
things, the book is known for the introduction of systematic experimentation and
quantification into the study of physiology, the discovery of the contagious nature of
infectious diseases, the introduction of quarantine to limit
the spread of contagious diseases, and the introduction of
evidence-based medicine, experimental medicine, clinical
trials, randomized controlled trials, efficacy tests, clinical
pharmacology, neuropsychiatry, physiological psychology,
risk factor analysis, and the idea of a syndrome. in the
diagnosis of specific diseases. The importance of this
man’s work cannot be underestimated as it guided medical
schools and European medicine for the next 600 years. His
influence is so profound he is known as the “Prince of
Physicians”. He distinguished five external senses and five
internal senses, and localized the internal senses to the
cerebral ventricles. He describes 15 different types of pain
due to different types of humoral changes and suggested
methods of relief such as exercise, heat, and massage, in
addition to the use of opium and other natural drugs.
Avincenna was first to recognize pain as a discrete and separate sense. Avicenna wrote in the
early eleventh century that "Nerves are one of the 'simple members' -- homogeneous,
indivisible, the 'elementary tissues' (others include the bone, cartilage, tendons, ligaments,
arteries, veins, membranes, and flesh)." He rendered an accurate physical description of
them: "white, soft, pliant, difficult to tear." He and his contemporaries began to describe the
complex and varied arrangements of nerves throughout the body, attempting to differentiate
further their functions. In the Canon of Medicine, he observed: "Dryness in the nerves is the
state which follows anger" suggesting he believed the nerves to be entangled with and
responsive to the emotions, yet another sign of their strong connections to the brain.
The Middle Ages
Contrary to the rather stagnant European middle ages, the Islamic middle ages fluorished
in research, continuing the advances of Avicenna. Muslim physicians contributed
significantly to the field of medicine including anatomy, pharmacology, pharmacy,
physiology, and surgery. The Arabs were influenced by and subsequently expanded on
works of Galen, Hippocrates, Sushruta, and Charaka. They adopted as a template for
medical practice the systemic approach of medicine, that rapidly spread throughout the Arab
Empire. In 1242 Ibn al-Nafis gave the first description of pulmonary and coronary
circulation, develped the concept of metabolism, and developed new systems of physiology
to replace Galenic systems while discrediting many erroneous theories based on the four
humours. Mansur ibn Ilyas in 1390 wrote “Anatomy of the Body” that contained
comrehensive diagrams of the body’s nervous system. There were over 2,000 drugs and
medicines cited by the end of the 12th century. However, the Arab Empire was culturally
and politically isolated from Europe during the middle ages, so advances in medicine
happened much slower in Europe.
The European middle ages were a time of consolidation of church power and expansion of
influence into virtually every aspect of daily life. There were plentiful reminders of pain in
the art embedded in the church depicting the suffering of Christ. The daily lives of the
people was difficult with manual labor in an agrarian based society causing significant daily
discomfort. The church was not always monolithic in its message about pain with a
divergence developing in the self flagillation and
suffering of the Franciscans in order to achieve a
mystical path to knowledge compared to the more
practical Dominicans that eschewed suffering and
pain as it interfered with the intellectual pathway to
knowledge and the ability to study. However, folk
medicine largely replaced the advances of ancient
medicine for most of the population, yet medical
knowledge was preserved and practiced in monastic
institutions where the books of learning were
housed. Organized professional medicine did not
begin to re-emerge until the Schola Medica Salemitana in Salerno Italy was established in
the 11th century. This institution along with Monte Cassino translated many Byzantine and
Arabic works. Later, the great universities of the 13th century, Paris, Montpellier, and
Bologna, had accepted medicine
as one of the four pillars of
learning, therefore became very
influential in European medical
treatment. The centrality of pain
in the Christian definition of
what it meant to be human,
notably Adam's suffering after
the Fall and Christ's humanity as
defined by his physical suffering,
was also accepted by the 1300
AD European universities of the
time. The textbooks used in
these universities were newly
translated Latin works of
Aristotle, Galen, and Avicenna
used to teach the students of the arts that pain was at the very core of the definition of
humankind as a living animal. Works from a medical tradition, such as the Hippocratic “On
the Nature of Man”, were also used to show that pain was a defining human characteristic.
However, pain, then as now, also presented practical issues- namely how to treat pain. The
legitimacy of the university system hinged upon the search of the medical schools to provide
a theoretical and practical response to the pain complaints of the patients. The Universities
were rich with books by Aristotle on logic and philosophy, and also added new works by
Galen on pathology and pain. Academic discussions about the causation of pain led to the
conclusion that it could be caused by an “imbalance of the normal complexion of the
individual”, ie. An imbalance in the four humours (blood, phlegm, bile, and black bile).
These humours were thought to be carriers of the four qualities, heat, cold, dryness,
humidity, that characterized the four elements that made up the human body, earth, water,
air, and fire. Pain was reasoned to appear if the humours were in imbalance, even in one
body part. The character of the pain depended both on the affected part and on the specific
imbalance. A “weighty” pain was always due to the internal organs whereas a gnawing pain
represented an abundance of a “biting substance” Within this medical model, pain could
also be caused by a break in the continuity of the body, internal or external. The middle ages
Universities gave substantial deference to the writings of the ancients more than the
experience of the practitioner in making a diagnosis, determining prognosis, or the delivery
of therapeutic advice. However, the patient’s reflections on their pain were recorded and
compendiums of pain patterns from these reflections was integrated into the medical lexicon
of the time. Taddeo Alderotti (1223-c.1295), medical master at Bologna, studied written
medical testimonies to ask why mentally ill people did not always perceive pain and whether
a large pain could conceal a smaller one. The experience of pain in childbirth was given
more weight than a biblical curse by Bartholomew of Varignana (c.1260-p.1321) and Dino
del Garbo (d.1327), both who practiced and taught medicine in Italy. Arnald of
Vilanova (d.1311) who taught at Montpellier, advised in his Mirror of Medicine that the
patient's account of pain was relevant in making a good diagnosis. For most medical authors,
the main reason to study pain was to develop a tool for a better diagnosis of internal diseases.
This was, for example, the aim of the complex classification of pain into 15 different types
developed by the master Pietro d'Abano (c.1250-c.1316) from the University of Padua.
According to Pietro, a pain could be throbbing, dull, stabbing, distending, pressing, vibrating
or shaking, piercing, gnawing, nailing, crushing, grappling, freezing, itching, harsh or loose.
In the treatment of pain, opium was well known to university
trained and non-university trained healers alike. Physicians and
apothecaries fought to control the market of narcotics. The use
of ice as a local painkiller was also advocated, and was thought to
work in the same way as opiates. However, they were not
considered first-choice painkillers on theoretical grounds because
they did not attempt to eliminate the cause of pain: they only
masked its perception. The extent of narcotics use during this
time period is difficult to establish. Common therapeutic devices
that aimed to eliminate the cause of pain by restoring the humoral
balance were more likely to have been used. In this respect, pain
was just another ailment that would benefit from bloodletting,
laxatives, purgatives and the monitoring of food, drink and sleep.
Other remedies, such as astrological seals, were thought of as
being useful as painkillers because they conveyed some specific properties explained by a
magical rationality.
In extreme juxtapositioning to the University healers studying pain, the Inquisition or
“Holy Office” began on the road to sanctioned torture under Pope Innocent III (1198-1216)
when he ordered members of his church to prosecute heretics. Previously heretics had their
property confiscated, however under the Inquisition, heretics were tortured, burned to death,
or submitted to combinations of torment resulting in death. Torture was used as a way to
submit the heretics to a taste of hell, and at the last minute they would repent, although
sometimes too late to save their physical bodies. Inventiveness rose to new heights during
the Inquisition with a multitude of methods devised to inflict the maximum amount of pain.
Appendix A. lists some of these gruesome methods. The last victim of Inquisition was put to
death in 1826, thereby closing the door on a horrible ethnic of Christian history.
Unfortunately, torture became so commonly employed in society that it was used to settle
differences and punish criminals in addition to being used as a method to save the souls of
those that were lost. The only other significant advance occurring in pain management in the
Middle Ages was a gradual shift in understanding of the location of the center of sensory
perception from heart to the brain. Albertus Magnus localized the sensory source to the
anterior cerebral ventricle of the brain in 1254 AD and made extensive study and
commentary of the works of both Aristotle and Avicenna. Mondino de’Liucci presented a
bizarre overlapping of Aristotle and Galenic thought in his year 1316 unillustrated anatomy
book Anathomia Mondini that served as a textbook for over 200 years in many European
medical schools. During the middle ages the population was occupied in for centuries with
the recurring Black Death, which further cause contraction of travel for fear of contagion. 25
million people died of the plague is about one third of Europe's population. Also during the
middle ages, the painful disease syphilis became quite prominent. It was known the French
disease, and cause pain is so severe that the sufferers felt they had been beaten with sticks.
The Renaissance
Prior to the Renaissance, it was thought pain existed outside the body as a punishment
from god. The torture inflicted during the most egregious aspects of the Inquisition did
nothing to change that view and in fact encourged it. The only relief from pain was to be
through prayer and through confession (frequently just before death mercifully removed the
pain from the tortured). The treatments available during the Renaissance included electrical
therapy developed from electrostatic generators (batteries and other electrical generation had
not yet been invented). Massage, exercise, use of natural herbs including opium (not
commonly available) were used to treat pain. This was a period of great scientific interest
with advances being made in physics, physiology, anatomy, and chemistry. Plato's and
Aristotle's works were studied in particular from the Greek originals, and not translations as
had been done throughout the middle ages. The fall of Constantinople in 1453 opened up
massive libraries of ancient works that bridged continents and cultures. One of the most
famous academies of learning was the Academia Platonica founded in Florence Italy by
Lorenzo the Magnificent (1449-1492). Leonardo da Vinci (1452-1519) was one of the
greatest scientists and artists of the era. His early drawings were inaccurate based on
descriptions of dissections from the middle ages, but later he
began performing dissections himself when the ban against
human dissection was lifted by Pope Sixtus IV in the 1470s.
Subsequently the accuracy of depiction of the human body
(especially the muscles) improved markedly. These drawings also
were a prelude to the further study of physiology of muscles. He
considered nerves as tubular structures and pain sensibility was
strictly related to touch. The sensorium source was located in the
third ventricle of the brain and the spinal cord was thought of as a
conductor that transmitted signals to the brain. Da Vinci made
wax castings of the ventricles of the br ain as part of his work.
Bartolemeo Eustachi (1520-1574) was an anatomist that was one
of the first in the Renaissance era to illustrate the entire nervous
system intact as seen in the drawing on the next page.
The anatomist Vesalius in 1543 further expanded on Leonardo da Vinci's concepts and his
works, the brain was considered the center of sensation. This period saw an explosion of the
understanding of anatomy of the human body, but studies
on physiology would have to await scientific advances in
the 17th century with electricity and magnetism and
pneumatics that were necessary to further define concepts
of pain and nerve transmission.
In the Renaissance, there were only a few effective
drugs employed: opium and quinine.
Seventeenth Century
Aristotle's concept of the heart as the source of pain was alive and well in the 1700s.
William Harvey in the year 1628 discovered the circulation of blood believed the heart was
where pain is experienced.
René Decarte (1596-1650) did extensive anatomical studies including sensory physiology.
He believed that nerves contained a large number of fine threads that for the marrow of the
nerves and connect the brain with the nerve endings in skin and
tissues. Descarte was the first to separate the body from the soul
by reducing a human being to a mechanical apparatus. This
concept led to the modern view that pain is not inevitable and as
a result of original sin, but
rather is a result of the
dysfunction in a mechanical
apparatus. His famous
drawing in the year 1664 demonstrated clearly the
precursor to specificity theory that was not published
until 1835. Descartes proposed his theory by presenting
an image of a man's hand being struck by a hammer. In
between the hand and the brain, Descartes described a
hollow tube with a cord beginning at the hand and ending
at a bell located in the brain. The blow of the hammer
would induce pain in the hand, which would pull the cord
in the hand and cause the bell located in the brain to ring,
indicating that the brain had received the painful
message. Based on this theory, researchers began to pursue physical treatments such as
cutting specific pain fibers to prevent the painful signal from cascading to the brain. Also in
1664, Thomas Willis, a physician and professor at Oxford University, coined the term
“neurology” in his textbook Cerebri anatome which is considered the foundation of
neuroanatomy.
Eighteenth Century
The 18th century was a time of continued scientific exploration in Europe. With the societal
infrastructure still in development in America in a very agrarian society, there was not much
scientific advancement (with a few notable exceptions), and virtually no medical
advancement in the New World. Theories of pain were slow to move throughout the
scientific community and even slower throughout the very fragmented medical community
internationally. In the first volume of his 1794 Zoonomia; or the Laws of Organic
Life, Erasmus Darwin supported the idea advanced in Plato's Timaeus, that pain is not a
unique sensory modality, but an emotional state produced by stronger than normal stimuli
such as intense light, pressure or temperature. Yet, there continued to be a lack of availability
of tools to understand human neurophysiology and disease causation. European medical
doctors adhered to the dogmas of vitalists, iatrochemists, and iatrophysicists. Each of these
“brands” of medical practice had followers and none were able to explain the ills of the
human body. The practitioners and university centers alike thought the ills of the human
bodies were due to maladjustment of the body’s system. Diagnosis of illness was based on
the four humours of Aristotle, bodily “tension”, or other even cruder doctrines. The Aristotle
doctrine acceptance led to “bleeding” of the body or use of leeches to cure illness was
common in the 18th century. Combining this with use of the drugs used in Europe (most of
which were quite toxic or were patent medicines), and the lack of sterility, there was a
healthy fear of being treated by a doctor. In America, herbal medicine was frequently used
including witch-hazel, ginseng, snakeroot, etc and many people grew their own herbal
gardens for medicinal purposes. Most doctors were self trained in America or trained as an
apprentice with only relatively few doctors having been trained in the European institutions
since the first US medical school was not established until 1765 at the University of
Pennsylvania. Patent medicines began arriving from Europe into North America, carried
over by settlers. These included Daffy's Elixir Salutis for "colic and griping," Dr. Bateman's
Pectoral Drops, and John Hooper's Female Pills representing some of the first English patent
medicines to arrive in North America. The medicines were sold by postmasters, goldsmiths,
grocers, tailors and other local merchants.
The development of electricity and magnetism moved slowly throughout the century but
provided the foundation for both the understanding of neural transmission and pain
perception. Stephen Gray in 1729 described static electricity conduction over metal
filaments and classified materials as insulators or conductors; DuFay described positive and
negative electricity in 1733, and the Leyden jar (the first capacitor to store electricity) was
created in 1745. In 1744, Christian Gottlieb Kratzenstein made the first experiment to
determine the effects of electricity upon the human body. He found “the action of the heart
was accelerated, the circulation was increased, and that muscles were made to contract by the
discharge.” Subsequently he began to administer electricity for the treatment of certain
diseases, finding it to be particularly useful in rheumatic
diseases and palsies. From 1756 to 1791, John Wesley, an
itinerate preacher in England, acquired his own friction
electricity generators and leyden jars, and became an expert in
the treatment of many diseases with electricity. Of note is that
he kept copious notes on the results of treatments, both the
successes and failures, that laid the foundation for
electrotherapy treatment of pain and other conditions for
centuries into the future. John Wesley also purchased scores of
the static electricity generators and donated them to clinics for medical treatment he had
established. From 1760-1780, static electricity was becoming better accepted as a treatment
and was incorporated into European hospital treatments. However by 1800, the public had
become skeptical of many of the offered treatments since they were being rendered by flim
flam artists and charlatans claiming cures for a variety of conditions including pain. In the
US, a Yale trained and degreed medical doctor, Elisha Perkins, invented electric metallic
tractors which he claimed would cure many diseases by simply rubbing these across the skin.
These became wildly popular in Europe and the US. In 1800 he was demonstrated to be a
fraud by John Haygarth who did a parallel control test with painted wooden otherwise
identical tractors and found no difference in the results, thus ushering in the beginnings of
controlled studies. Other significant advancements of the
century include the discovery of oxygen and nitrous oxide by
Josph Priestly in 1774 and in 1799 Humphry Davy discovered
the anesthetic properties of nitrous oxide.
Nineteenth Century
The concept of pain in the 19th century was in flux throughout the century, primarily due to
changing views of society on religion, hell, and the purpose of pain. Early in the century, the
predominate view of pain as a punishment still prevailed in the public eye. However by mid
century, Darwin published “The Origin of Species” that was in itself controversial, but was
extremely provocative, calling into question some of the fundamental principles of church
dogma. There were a series of letters and responses in the journal Lancet in mid century to
late century questioning the function of pain but also calling into question the religious
presupposition for the need of pain. The concept of hell among the public was changing
from a literal place with eternal damnation requiring everlasting pain to a figurative hell or
that there is no need for further punishment once a person is already in hell. This change in
view caused fewer people to believe in an external God driven pain as punishment and rather
that there must be some other (medical) explanation for pain. Therefore, a medical
explanation for pain was more widely accepted than a religious one by the end of the century
than at it’s beginning, especially in England.
The medical community in America was not held in high esteem during the 19th century,
and in fact was frequently overtly
deleterious to patient health early
in the century. The continued
application of the four humours to
patients with subsequent
treatments such as bleeding of a
patient, use of purgatives in those
already having diarrhea, or giving
morphine for those in shock, made
the profession of medicine so
dangerous by the end of the 1830s
that several states began delicensing physicians and the
medical profession. People needing medical attention would not necessarily turn to an actual
physician, of which few were available in rural areas. They may have preferred to be treated
by a local or Amish healer, a patent medicine-maker, or a midwife. Doctors were simply
tradesmen competing for clients against other tradesmen. Many doctors considered it part of
their jobs to keep up a sophisticated social calendar and attract the kind of patients who could
pay good money for their services. There was a proliferation of medical schools in America
in the 1800s, but these were very unlike the University systems in Europe. These were
effectively trade schools, frequently offering one year of education. By 1850 there were 52
medical schools in America compared to 3 in all of France. The quality of physician and
inconsistencies in medical philosophies continued to cause erratic results at best, and a public
highly suspicious of the training and expected outcomes of physician treatment. The
American Medical Association was established in 1847 as an attempt to bring some
standardization into medical training and practice, however it took more than a decade for
these to be implemented. It was not until the 1880s that medicine was able to establish its
credibility and convince legislatures of states that licensure of the profession was again
warranted.
The application of medical treatments made increasingly available throughout the century
outstripped the scientific underpinnings of medical therapies, that had yet to be developed.
Up to the 18th century all main textbooks of medicine contained the work of Hippocrates
and Aristotle in which the heart was depicted as the sensory center. In the 19th century, the
text books began to reflect an updated view of neurology, a field in its infancy. The anatomy
texts continued to develop along with the primitive understanding of neurophysiology, and
the textbooks before the 1870s often reflected bizarre anatomical constructs such as the
assumption that blood would carry administered local anesthetics along the spine instead of
spinal fluid. Those relying on these textbooks would institute treatments that had no merit
but were actually dangerous. Corning, a neurologist in New York, performed the first
epidural injection of local anesthetic in 1885 on this basis, believing that he needed to place
the needle directly into the spinal cord in order for it to be effective. He aimed at the
thoracic spinal cord but fortunately missed, and did not penetrate dura, since the 120mg
cocaine he injected would have caused instant paralysis and probably death if injected either
into the cord or into the spinal fluid. Instead, the patient developed a sensory block only
from the waist down and Corning erroneously reported this as a spinal injection in the
medical literature based on assumptions made by consulting an outdated anatomy textbook
before the procedure.
With the development of the battery (voltaic pile) by Faraday in 1800, new worlds of
exploration of electricity, magnetism, and ultimately physiology were
opened. The 19th century was an era of very rapid developments in these
realms. An electrochemical telegraph (very slow) was developed by
Campillo in 1809, Orsted discovered electric current produces a magnetic
field, and the first galvanometer was invented in 1821. The electromagnet
was invented in 1825 by Sturgeon and improved by Joseph Henry in 1828 by
using several coils of wire. Electromagnetic induction was discovered in
1831, the first electromagnetic telegraph created in 1832 in Russia by Baron
Schilling, and in 1835 the electrical relay was developed by Joseph Henry.
The first practical battery was built in 1836 by Daniels and Cooke and
Wheatstone in the UK and Samuael Morse in the US in 1838 independently
developed the telegraph and codes. The lead acid battery (rechargeable) was
created by Plante in France in 1859, the first dry cell battery by Gassner in
1887 (Zinc-carbon), and the first alkaline battery (NiCd) in 1899.
Paralleling these scientific discoveries in electrophysics were medical advances. Charles
Bell described the motor function of the ventral root and sensory function of the dorsal root
in 1811, later confirmed by Magendie in 1822. In 1823 Sarlandiere in France introduced
electroacupuncture and Magendie in 1826 used platinum needles inserted into muscles,
nerves, and through the eye to the optic nerve for electrostimulation therapy in humans.
Duchenne invented cutaneous electrical stimulation pads for electrical treatment in 1833,
thereby bypassing the need to place needles into the tissue. This was a precurser of the
TENS units of the mid 20th century. He found using a chopped DC current produced a more
comfortable and warming sensation to patients. He also developed motor stimulation points
for activation of specific muscles. A portable hand cranked electromagneto was invented in
1854 delivering mild shocks for the treatment of virtually anything. Julius Altheus, a British
physician, became a champion of electroanalgesia in 1855 and wrote many books on the use
of interrupted current on peripheral nerves (TENS) and more importantly developed
scientific method as applied to clinical medicine (prior to this anecdotes by physician were
given supreme weight in determining effectiveness). During the 1800s Winslow and others
(Charles Bell described the motor function of the ventral root and sensory function of the
dorsal root in 1811, later confirmed by Magendie in 1822), defined the anatomy and some of
the physiology of the sympathetic nervous system.
The age of exploration of microscopic structures was also found in the 19th century.
Purkinje (Purkinje cell), Schwann (myelin sheath), Remak (unmyelinated nerve), Ranvier
(nodes) all made important discoveries during that time. Staining methods advanced through
the work of Joseph Gerlach in 1858 who was the founder of staining techniques….he used
carmine as a stain. Weigert, Nissl, and Bielschowsky were major contributors to staining
techniques in the 19th century. Neuroanatomy techniques were developed by Augustus
Waller (1816-1870) Wallerian degeneration, Wilhelm His (1831-1904) histogenesis of the
nervous system, Paul Fleschig (1847-1929) myelogenetic study of the nervous system.
Mechanical sensors were discovered by Meissner, Paccini, Merkle, and Golgi during this
time.
SPECIFICITY THEORY
The prelude to the specificity theory was a drawing of Descarte in the 17th century, however
was not published in the current form until Muller. The law of specific nerve energies
(specificity theory) was developed by Johannes Muller in 1835 and was expressed: ". . .
(T)he same cause, such as electricity, can simultaneously affect all
sensory organs, since they are all sensitive to it; and yet, every
sensory nerve reacts to it differently; one nerve perceives it as
light, another hears its sound, another one smells it; another tastes
the electricity, and another one feels it as pain and shock. One
nerve perceives a luminous picture through mechanical irritation,
another one hears it as buzzing, another one senses it as pain. . .
He who feels compelled to consider the consequences of these facts
cannot but realize that the specific sensibility of nerves for certain
impressions is not enough, since all nerves are sensitive to the
same cause but react to the same cause in different ways. . .
(S)ensation is not the conduction of a quality or state of external bodies to consciousness,
but the conduction of a quality or state of our nerves to consciousness, excited by an external
cause." Effectively, the theory stated pain is a specific sensation with his own sensory
apparatus independent of touch and other senses. It had been suggested by Galen, Avicenna,
and Descarte, and in 1853 by Loetze. In 1858, the theory was proven by Schiff after
analgesic experiments on animals. After creating a series of lesions through the spinal cord
he noticed that touch and pain were independent. Sectioning of the gray matter of the spinal
cord eliminated the pain but not touch whereas a cut through other sections of the white
matter of the spinal cord caused touch to be lost but not pain.
INTENSIVE THEORY
The prelude to intensive therapy was in Plato and E. Darwin in that pain not uniquely
sensory (as per the specificity theory) but was an emotional state activated by light, pressure,
or temperature. Wilhelm Erb, in 1874, also argued that pain can be generated by any sensory
stimulus, provided it is intense enough, and his formulation of the hypothesis became known
as the intensive theory
The concept of nociception was developed in 1898 by the British physiologist, Sir Charles
Scott Sherrington (1857-1952), who proposed the key concept of nociception: pain as the
evolved response to a potentially harmful, "noxious" stimulus, but through competition and
integration using the same neural pathways. The nociceptive part was readily grasped by
scientists, but the integration and competition aspect required another half century to be
accepted. The concept of pain as nociception represents a significant departure from the
concept of the purpose of pain up to this point in time. Previously pain’s function was to
heal, to punish, or to ennoble. Sherrington demonstrated pain was to serve as a warning sign.
Treatment advances made during this time period included the isolation of morphine from
opium. In 1806, after centuries of use of opium as a
painkiller, Friederich Wilhelm Sertuerner (17841841), an apothecary's assistant in Westphalia, isolated
the alkaloid of opium. He called it "morphium" after
the Greek god of dreams, Morpheus. Later it was
changed to morphia or morphine. In general, its use as
painkiller would have to wait for the invention of the
hypodermic syringe and hollow needle in the 1850s. It
would remain the principal pain drug well into the
twentieth century. For treatment of headaches
(particularly those due to alcohol induced hangovers)
the bromates were introduced in the 1860s. These
drugs were frequently part of a mixture of nostrums or
patent medications, and were also used to treat stress.
Effectively this class of drug was the first minor
tranquilizer (sedative-hypnotic). The primary drug
used was sodium bromide which had a very long
lasting effect, but also a very narrow therapeutic index.
It caused severe gastritis, but in chronic use could be
quite addicting with some consuming 5-6 bottles of the
drug per day. The bromides were determined later to
be carcinogens and were outlawed in 1975 with a few exceptions. The bitter tasting
bromides were largely replaced with the introduction of the barbiturates in 1903, with the
exception of Bromo-seltzer that remained popular for many decades. The xray was
discovered in 1895, with almost immediate universal acceptance of xrays films for
diagnostic purposes.
SURGICAL ANESTHESIA
The need for an adequate surgical anesthetic was wanting for many thousands of years
with tapping on wooden bowls over the head until unconsciousness occurred, bilateral
carotid artery compression to the point of unconsciousness, and holding children over natural
gas until they became unconscious the preferred means of anesthesia. Later from the 9th to
the 16th centuries, the soporific sponge was described in textbooks and other compilations as
a means to attain surgical anesthesia but not without significant risk of death. The following
is a recipe for the soporific sponge from Theodoric of Cervia from the
work, Cyrurgia (Venice, 1498):
"The composition of a savour for conducting surgery, according to Master Hugo, is as
follows: take opium, and the juice of unripe mulberry (probably a textural mistake for black
nightshade),hyoscyamus (henbane), the juice of hemlock, the juice of leaves of mandragora,
juice of climbing ivy, of lettuce seed, and of the seed of the lapathum (dock) which has hard,
round berries, and of the water hemlock, one ounce of each. Mix all these together in a
brazen vessel, and then put into it a new sponge. Boil all together out under the sun during
the dog days, until all is consumed and cooked down into the sponge. As often as there is
need, you may put this sponge into hot water for an hour, and apply it to the nostrils until the
subject for the operation falls asleep (he who must go under the knife,--llit. be cut into). Then
the surgery may be performed and when it is completed, in order to wake him up, soak
another sponge in vinegar and pass it frequently under his nostrils. For the same purpose,
place the juice of fennel root in his nostrils; soon he will awaken."
Chloroform was introduced in 1847 in England and was used extensively, whereas shortly
thereafter diethyl ether was introduced in the United States. Because of the toxicity of
chloroform ultimately diethyl ether replaced chloroform in the United States. Chloroform
and diethyl ether were used in the late 1800s for production of general anesthesia for surgery
and childbirth. Charles Gabriel Pravaz (1791-1853) of France, who invented the hypodermic
syringe in 1851; and Alexander Wood (1817-84) of Scotland, who invented the hollow
hypodermic needle in 1853. In 1869, Claude Bernard (1813-78), a French physiologist,
injected morphine prior to the administration of chloroform or ether for general anesthesia.
In 1884, the breakthrough came when Carl Koller (1857-1944), a Viennese ophthalmologist,
discovered the anesthetic properties of cocaine. William S. Halsted (1852-1922), a Bellevue
Hospital surgeon, blocked the inferior alveolar nerve with a four percent cocaine solution in
November 1884 - the first mandibular nerve block. However, cocaine was found to be an
addictive and dangerous drug. Coca cola was originally developed by Pemberton, a
pharmacist, and was initially sold as a cure all for everything given that it contained
relatively high concentrations of cocaine. Coca Cola contained relatively high amounts of
cocaine, a very potent local anesthetic, from 1886 until 1891, when the amount of cocaine
was lowered by 90%, then essentially eliminated after 1903. Heroin was originally
synthesized in 1874 by Wright, and experiments on rabbits were not encouraging, therefore
no further development of the drug occurred until Hoffman at Bayer Co. synthesized the
drug in 1897. The creation of heroin was actually a chemist error since he was tasked with
creating synthetic codeine to be used as a less addictive substitute for morphine. Instead
heroin was nearly 3 times as potent as morphine yet was marketed by Bayer as a nonaddictive cough syrup from 1898 until 1910. It was also used to eradicate morphine
addiction until it became apparent it was far more addictive than morphine given its passage
across the blood brain barrier before deacetylation to morphine, thereby developing very
high brain levels of morphine. The drug was universally removed from the world markets
after 1925, but is still used in Britain in epidurals for labor pain and as a pain medication in
the oral tablet form. Other 19th century advances in pain included the observations of Weir
on causalgia pain produced by US Civil War wounds, the development of aspirin in 1898 as
a substitute for the severely gastric irritating willow bark (contained salicylic acid) , and the
application of hot mustard plasters used in 19th and early 20th century America as a
treatment for pain based on the principle of counterirritation.
Twentieth Century
In 1916 Rene Leriche discovered causalgia pain in soldiers from the Great War could be
partially alleviated through periarterial sympathectomy initially performed surgically. Later
he blocked the sympathetic chain with procaine and found some of the patients had long
lasting pain relief. This linked the sympathetic nervous system and causalgia.
William K Livingston (1892-1966) studied the visceral neurological system and causalgia,
noting similarities between the diffuseness of the pain and argued against absolute
specificity. Livingston wrote in his Pain Mechanisms (1943): "I believe that the concept of
'specificity' in the narrow sense in which it is sometimes used. . . has led away from a true
perspective. . . Pain is a sensory experience that is subjective and individual; it frequently
exceeds its protective function and becomes destructive. The impulses which subserve it are
not pain, but merely a part of its underlying and alterable physical mechanisms. . . The
specificity of function of neuron units cannot be safely transposed into terms of sensory
experience.
"A chronic irritation of sensory nerves may initiate
clinical states that are characterized by pain and a
spreading disturbance of function in both somatic and
visceral structures. If such disturbances are permitted to
continue, profound and perhaps unalterable organic
changes may result in the affected part. . . A vicious
circle is thus created."
By the 1950s, the specificity theory had been strongly
supported by the work of Joseph Erlanger, Herbert Gasser,
and Ainsley Iggo, who had recorded pain impulses from
Livingston's Case Notes from
single nerve fibers. But several investigators proposed
a WWII Peripheral Nerve
alternative physiological models to replace the specific
Injury Patient, 1945
one-to-one pain pathway of perception and response,
which might better explain the clinical observations
ofBeecher, Leriche, Livingston, and others. These included the pattern theory of Graham
Weddell and D.C. Sinclair, which suggested that pain perception was the interpretation of the
spatial and temporal patterns of stimuli, and the multisynaptic modification system proposed
by the Dutch surgeon Willem Noordenbos. However, these theories lacked strong
experimental support. Henry Beecher further advanced the perception of pain by using
experimental pain production and noted the differences between the experimental
hospitalized and home groups. He concluded: "Thus emotion can block pain; that is
common experience. It is difficult to understand how emotion can affect the basic pain
apparatus than by affecting the reaction to the original sensation." Certainly psychological
effects have great influence on subjective responses, not only pain but other responses as
well. Every small boy has learned, knows, even though he does not consciously recognize
the fact, that emotion can block the pain of a wound received during fighting but not
perceived until the fight and the emotion have subsided." (From: Henry K.
Beecher.Measurement of Subjective Responses: Quantitative Effects of Drugs. New York:
Oxford University Press, 1959)
In 1965, a collaboration between two self-described iconoclasts, Canadian
psychologist Ronald Melzack and British physiologist Patrick Wall, produced the gate
control theory. Their paper, "Pain Mechanisms: A New Theory," (Science: 150, 171-179,
1965) has been described as "the most influential ever written in the field of pain." Melzack
and Wall suggested a gating mechanism within the spinal cord that closed in response to
normal stimulation of the fast conducting "touch" nerve fibers; but opened when the slow
conducting "pain" fibers transmitted a high volume and intensity of sensory signals. The gate
could be closed again if these signals were countered by renewed stimulation of the large
fibers. Ironically, the paper published came out of simply batting ideas back and forth and
was subsequently proven with electrode stimulation of the forehead. The two had published
a virtually identical paper 3 years earlier in a less well known journal, and it went completely
unnoticed by the scientific and medical communities.
The multidisciplinary pain clinic began when the young anesthesiologist John J.
Bonica (1917-1994), was assigned to take charge of pain control at Madigan Army
Hospital in Washington State in 1944, and
found himself seeing "cases that baffled
me." He sent the patients for consultations
with colleagues: an orthopedist, a
neurosurgeon, a psychiatrist, but "they
knew less than I did." He proposed that
the four meet twice a week at lunch for
conversation and exchange of information
on difficult pain problems. The success of
this informal collaboration prompted him
to establish a multidisciplinary pain clinic
at Tacoma General Hospital in 1947,
which he brought to the University of
Washington in 1960.
Bonica saw the idea of interdisciplinary collaboration as the key to the
John Bonica understanding of pain. He described his clinic as "a totally different thing,
much more fruitful and efficient. . . The basis of my program is patient care; the frosting is
the research." (Quotations from the Oral History of John Bonica, 1993)
In 1973, encouraged by the response to the gate
control theory, John Bonica (shown here at another
conference in 1972) organized a highly productive
scientific meeting of some 300 pain researchers in
Issaquah, (Seattle) Washington, where he won their
unanimous endorsement of a new International
Association for the Study of Pain based on the
concept of interdisciplinary collaboration.
Treatments of the 20th Century
Brochure announcing the Issaquah
conference, 1973
The synthesis of Novocain (procaine) by Alfred Einhorn (1856-1917) of Germany in 1905
finally provided a local anesthetic without the dangerous side effects of cocaine. It was
introduced into the United States in 1907, and became the most popular anesthetic for dental
procedures. Epidural blocks with cocaine were performed in the early 1900s with excellent
pain relief results. Unfortunately the results are short acting and it wasn't until the
administration of steroids epidurally in the 1950s and 1960s was it apparent that there were
other receptors and structures that needed to be targeted for long-term relief. The facet was
thought to be the source of much spinal pain (Ghormley ) until Mixter and Barr in 1934
demonstrated clinical confirmation that disc herniations previously described in the extensive
pathology spine sections dissected by Schmorl, are a source of pathology. Almost
immediately attention turned to the disc as a source of pain, and surgical discectomy was
born. Later, Nik Bogduk defined the anatomy of the medial branch of the posterior primary
ramus innervating the facet joints. Much later the sacroiliac joint anatomy was defined with
dissections by Frank Willard and Way Yin. Procedures were developed to treat pain
associated with each anatomical structure. Spinal cord stimulation was invented in 1967 first
performed by Shealy and subsequently intrathecal infusion pumps were developed.
During the 20th century there continue to be advances in not only the theories of pain. The
most significant advance in the series included gate control theory (Melzack/Wall 1965)
which explains why there are many influences on perception of pain and also why there does
not seem to be a direct relationship with pain intensity and stimulus intensity. This becomes
very important chronic pain which is no longer seen as merely an extension of acute pain. In
the 20th century there were many advances made in analgesics, the use of anticonvulsants to
slow pain pathways, anti-inflammatory agents, and the synthesis of many new opioids. Pain
clinics were developed in the 1980s as a means of handling chronic pain, frequently in a
multidisciplinary approach. The use of psychological counseling, physical and functional
rehabilitation, medication management, peripheral nerve blocks, central nerve blocks, neural
destructive techniques, and neuromodulation techniques were all packaged in a single clinic
setting. Because of the expense of maintaining such a cadre of individuals providing such
care, the full multidisciplinary clinic is not nearly as popular as it once was. Currently it is
more popular to utilize an interdisciplinary clinic in which selected disciplines are brought in
to meet the patient’s specific needs or the patient is sent to other specialist clinics working in
concert to help control pain. The advances in neurophysiology over the past several years
are profound and will be discussed elsewhere
Appendix A Methods of Torture to Produce Pain
If you have a weak heart, it is suggested you skip this section due to the
graphic nature of the content. The Crusades were winding down around
1250-1300 AD and methods of securing confessions from the heathen
became commonplace. Eventually, methods of torture became so common,
they were used to quell civil disobedience, inflict pain due to crimes, and to
settle arguments in addition to their continued original use. Much of
Europe adopted the methods of torture used as punishment to inflict pain.
Wooden wedges were forced underneath the toenails to invoke confession
from the criminal or the heretic. The toenails
often became infected and other tortures were
applied if this was not enough for confession.
A scissor like tool was used to slice
the tongue up after the victims
mouth was forcibly opened. The
copper boot was inserted onto the
foot of the criminal and filled with
molten lead causing significant
burns. The sprinkler was a device
filled with molten metal and
dripped on the stomach, back, and
other body parts of the victim.
During the water torture, the
victims nostrils were pinched shut
and fluid was poured down his
throat. Instead of water, sometimes
vinegar, urine, or urine and a combination of diarrhea were forced down the
throat. The thumbscrew was a sharp tipped device that was tightened on the
thumb until it was crushed. The tool was also used on toes. Toothed bars
were used to squeeze the victim's testicles til they
were destroyed. Another method of torture was
the application of heavy weights to the legs of a
person sitting on a Spanish donkey until the force
was so great that it destroyed the perineal area,
penis, and testicles. The Foot Press slowly
squeezed the naked foot between the iron plates
lined with sharp spikes to crush the bones of the
foot. The Scottish Boot was placed around the
ankle of the victim and then wedges were forced
into the ankle. The name breast ripper was a
device with 4 sharp prongs that were impaled into
the breast and back, and while the person was
held down, the device was forcibly moved
upwards thereby removing the breasts and
muscle. The pear, shown at the right, was a
metal object that is shoved inside the mouth anal
cavity and vagina. Once in place the screw at the
end was turned and the pear opened up inside the cavity. This caused much
damage and lead to death. The victim was bound on an oblong wooden frame
with a roller at each end. If the victim refused to answer questions, the rollers
were turned until the victim's joints were pulled out of their sockets. The branks
were a mask that had a metal piece that goes in your mouth. The mouth piece
has spikes on it, which unables you to talk. The Juda Cradle is a horrible
torture. The victim is hung above a cone pyramid type object and then is
lowered upon it. the sharp tip of the cone or pyramid is forced into the area
between the legs. The headcrusher simply
crushed your head. The whirligig was not that
bad of a torture. It just span the victim til they
puked. The cat's paw was a short pole with a
pitch fork at one end. It was used to tear the
the flesh of the victim. The heretic fork, shown
to the left, was a two sided prong that went
between your chin and your chest. You could
not talk with instrument in place and it was
very painful. The chair of spikes was a chair of
spikes. The victim would sit in the chair and
weights would be applied onto the victim
forcing his body into the metal spikes. And of
course we are all familiar with drawing and
quartering in which ropes were attached to the
legs and arms, each one hooked to one of
four houses made to run in opposite
directions. Hanging was used as a death penalty but with the person only
partially hung, they were subsequently disemboweled.