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11 Articles in Volume 13, Issue #6
Ask the Expert: Cash Patient on High-Dose Oxycodone With Negative Urine Screens
Cluster Headache: Providing Relief for a Debilitating Disorder
Editor's Memo: Keeping the Trust in Difficult Times
Gout: New Guidelines for Managing An Ancient Disease
History of Pain: A Brief Overview of the 17th and 18th Centuries
Letters to The Editor: Guidelines for Opioid Prescribing, Drug Legislation
Long-term Opioids, Sickle Cell Disease, and Pain Patches
Lumbar Spinal Stenosis: A Review of the Treatment Options and Modalities
Malabsorption of Opioid Medications
Non-Opioid Pharmaceutical Treatment of Cancer Pain
Treatment of Postherpetic Neuralgia With Low Level Laser Therapy

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.

Descartes’ Error

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:

  • First, there was the mechanical school of thought—those who wanted to return to the notion that the human body functions as a simple machine—which was popular up until the middle of the 18th century.
  • Second, there was the vitalist school of thinking, which was more dominant toward the end of the century. Those thought leaders adopted the concept of sensitivity, which included the simultaneous concepts of physiology and psychology.
  • Third, the minority school of thought (animism) felt that nature was more passive. Those believers accepted mechanical explanations and considered the soul to be directly responsible for all organic functions. Further, they believed it made pain an important sign in illness as a result of internal strife.1

Albrecht von Haller

The first major contributor to this shift in thinking was Albrecht von Haller (1708-1777). He was interested in the reactions of fibers and how to distinguish between the irritability of muscle fiber (which he called the contractibility) and the excitability of nerve fibers (which he called sensitivity). (In today’s vernacular, this would be considered “hyperesthesia” in extreme forms.) In von Haller’s work, only the nerves are sensitive, while muscle fibers are irritable. Von Haller felt strongly about a strict dichotomy between sensitivity, which was associated with consciousness, and irritability, which was independent of consciousness. Von Haller was the first person to discover that only nerves produce sensation and only those parts of the body connected to the nervous system can undergo a sensation.

As knowledge and research progressed in the 18th century, a major trend started to develop where research focused on more specific aspects of pain. The specific aspects of pain for von Haller were the roles of muscle fibers and nerves. This is still an area of interest in today’s pain research. I would suggest that von Haller’s work was the beginning of what we now consider “myofascial” pain.

Pierre Jean George Cabanis

Toward the second half of the 18th century, there was a reaction against von Haller’s theory of pain, which was lead by Pierre Jean George Cabanis (1757-1808). Cabanis’ work incorporated a psychophysiological approach to pain, which included the emotional component. For Cabanis, sensitivity could not be defined outside the realm of pleasure and pain, since what affects us can never be indifferent to us.1 In Cabanis’ view, pain was useful; it instilled stability, balance, and equilibrium to the nerves and muscular systems. The idea of the usefulness of pain led to the therapeutic techniques of electrical shock and stimulation.

Cabanis also felt that sensations (pain) could be generated spontaneously in the brain and provoke pains that were real. This notion is where Cabanis introduced the concept of hypochondria and pain: pain is not a pure physiological reaction to a stimulus, but requires the mental activity of the patient. It seems to me that Cabanis was either extending Cartesian dualism—pain separate from the physiological perception (dualism)—or was inferring that pain was somehow a combination of physiology and psychology. According to Rey,1 the work of Cabanis focused on sensitivity as the cornerstone for life, and pain provided the ideal experience to study the relationship between the physical and mental.

Cabanis’ questions about the psychophysiological conditions necessary for pain to reach consciousness led him to view the perception of pain as being a complex, chronologically staged process. During this process, any given sensation at any given time could be absorbed by another sensation. He proposed a competitive model between external and internal feelings, where the weakest sensations were absorbed by the strongest.1

Cabanis’ research and ideas were a major step forward in how the pain patient was treated. His work led to new techniques, such as using electrical stimulation for the treatment of pain. He introduced the concepts of psychophysiology and the emotional components of pain. These concepts continued to grow well into the 19th century, even though his thinking contradicted von Haller’s theories.

Xavier Bichat

The next major contributor to consider is Xavier Bichat (1771-1802). Bichat’s work represented a passage from organic sensitivity to animal sensitivity and the “threshold concept.” His work on the two nervous systems and their relationship to the understanding of pain was an important contribution. He separately studied the sympathetic and parasympathetic systems, which, in the 18th century, was highly significant. He believed the two systems were very distinct, each having two principal centers: one in the brain and the other in the ganglions. Pain coming from the ganglions was very different than pain coming from the spinal nerves. This distinction agreed with the vitalists—those who believed living organisms are fundamentally different from non-living entities because they contain some non-physical element or are governed by different principles—but differed from von Haller’s thinking. This debate between Bichat and von Haller persisted for more than a half century and had major consequences for physiology and the treatment of pain. Bichat’s contribution to pain medicine was his discovery of the importance of the sympathetic nervous system.

Bichat’s work complemented the work of Cabanis, which led to a more global psychophysiological approach to pain treatment. This approach also led to the increasing use of opium as a treatment option, which was not present in the 17th century.1 The work of Cabanis and Bichat represented the beginning of an important trend in pain treatment: the holistic and multidisciplinary approach.

Conclusion

This article was a brief overview of the history of pain in the 17th and 18th centuries. Part 2 will cover pain management in the 19th and 20th centuries. In this article, I have imposed arbitrary parameters and left out many contributors who have played an important role in adding to our understanding of the pain experience. I attempted to include the major contributors who appeared to build on one another’s work. The framework for this article came largely from Roselyne Rey’s book titled, The History of Pain

Note: All of the major contributors covered in this article are available online. For those who are interested in more information about the history of pain, I would recommend you visit The John C. Liebeskind History of Pain Collection at the Louise M. Darling Biomedical Library at the University of California, Los Angeles.

Last updated on: June 12, 2015
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