Professional Documents
Culture Documents
Michael L. Whitworth, MD
What Is Pain?
The word pain derives from the middle English word (circa 12501300 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.
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.
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.
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.
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.
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 patients 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 deLiucci 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
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.
Ren 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 bodys 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 its 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
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 pains 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)
concert to help control pain. The advances in neurophysiology over the past several years
are profound and will be discussed elsewhere
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.