History of Pain: A Brief Overview of the 17th and 18th Centuries
You might be asking yourself, why is the history of pain important to me? How can history help me provide more effective pain treatment for my patients?
Pain can be scary and it triggers superstitious thinking that leads to fear. Fearful pain patients are often their own worst enemies because they feel like they have no control over their bodies, which only adds to their fear. Knowledge is a powerful tool and my initial goal with every pain patient is to share creditable information about pain. I want to temper that fear with knowledge and guide the patient in becoming his or her own best friend and advocate.
A history of pain will help you understand the nature of pain and how providers and researchers arrived at the current range of treatment options. Part 1 of this series will review pain management practices from the 17th and 18th centuries.
René Descartes and the Dualistic Nature of Pain
We begin our journey of discovery in the 17th century with René Descartes (1596-1650), whose research and influence initiated new thinking about pain that has transcended three centuries. Not only did he impact how we think about pain, but his contributions to science and medicine were so influential that they are still evident in Western medical practice today.
In 1644, Descartes’ Principles of Philosophy was published, in which he discussed pain in phantom limbs. From his observations, he deduced that pain was felt in the brain, not the phantom limb. He introduced his concept of the soul: that the soul of pain was located in the pineal gland. He argued that persistent agitation of the nerves from the phantom limb produced sensations as if the phantom limb was still intact. However, Church thinking at that time considered pain closely linked to original sin, and had a very strong power over scientific thought.1 Descartes was aware of the Church’s influence and, therefore, placated the Church by introducing the soul into his thinking.
Descartes believed the pain from the phantom limb was real and not imaginary. Pain was a perception of the soul. Further, he felt that pain was somehow limited to touch and that pain was not a specific sensation, but a more general mode of animal spirits. It is generally believed that Descartes incorporated the notion of the soul to avoid trouble with the Church, being well aware of what had happened to Galileo!
The influence of the Church persisted and was evident up to the 19th century. Traditional Catholic religion maintained that pain was rooted in the passion and death of Christ; that suffering individuals were closer to Christ and that their anguish could be offered up in penance for earthly sins.
In Descartes’ L’Homme (1644), which was published 14 years after his death, Descartes presented a model of pain in the form of a boy sticking his foot in a fire. This well-known model has had profound influence on subsequent pain research.2 Descartes believed that as the fire came close to the foot, the painful stimulus resulted in the pulling of a delicate thread that ran up the boy’s leg to the brain by the shortest route.
Descartes expanded William Harvey’s (1628) model of circulation, which embodied the movement of spirits via valves. Harvey’s main contribution to medicine was his study of the heart and the movement of blood around the body. According to his theories, these valves acted as little doors opening to let the spirits through and, thus, prevented reflux.3
Descartes’ model of the dualistic nature of pain suggests that pain is primarily a sensory phenomenon that is separated from higher order (neocortical) influences. It is the either/or school of thinking: either pain is physical or it is of psychic origin; they are mutually exclusive of one another.
About 20 years ago, I had the opportunity to listen to a lecture in Portland, Oregon, by Antonio Damasio, MD, the M.W. Van Allen Professor of Neurology and Chairman of the Department of Neurology at the University of Iowa, College of Medicine. He had just published Descartes’ Error: Emotion, Reason, and the Human Brain, in which he stated, “The error is the abysmal separation between body and mind. The suffering that comes from physical pain or emotional upheaval might exist separately from the body.”4 Damasio stated quite emphatically that medical schools in the United States largely ignore human dimensions and instead concentrate on the physiology and pathology of the body proper. Further, Damasio felt that this neglect stems from a Cartesian dualistic view of humanity that has persisted for 3 centuries.
The true value of Descartes’ research and thinking is that he opened the way to subsequent research on the localization of cerebral functions. He tried to dispel the confusion between pain and sadness. He felt that sadness always followed pain because the soul recognized the weakness of the body and its inability to resist the injuries that afflicted it.1
Descartes’ work marked a major milestone in pain research and application. He created controversy in the world of pain research, which contributed to more debate and, ultimately, progress. His research at that time was revolutionary, especially when you consider the level of technology available. His theories were very different and far-reaching as represented by the example of the boy who stuck his foot in the fire.
Damasio’s critique of Cartesian dualism is relevant today, especially since there are still many pain providers who feel that pain is only a sensory event. Damasio’s observations were very important, especially considering that the British school of research was influenced by Francis Bacon—considered to be the creator of empiricism and the scientific method—to advance science through inductive reasoning, and France was influenced by Descartes’ reductive mechanistic philosophy. These differences carried on throughout the 18th century.
Progress in the 18th Century: Shifts in Medical Philosophies
The 18th century is often referred to as the Age of Enlightenment. A shift in thinking, associated with the decrease of Church influence, was taking place in the secularization of thought and the separation between science and metaphysics. Additionally, thoughts and sentiments were shifting regarding the perception and definition of pain.1 In The History of Pain, Roselyne Rey observed that there were three different medical philosophies in the 18th century: