History Is a Distillation of Rumor

Pain and Religion

The early concept of pain as a form of punishment from supreme spiritual beings for sin and evil activity is as old as the human race. In the book of Genesis , God told Eve that following her fall from grace, she would endure pain during childbirth: “I will greatly multiply your pain in childbearing; in pain you shall bring forth children, yet your desire shall be for your husband, and he shall rule over you” (Genesis 3:16). This condemnation led early Christians to accept pain as a normal consequence of Eve’s action and to view this consequence as being directly transferred to them. Thus any attempt to decrease the pain associated with labor and delivery was treated by early Christians with disapproval and disapproval. It was not until 1847, when Queen Victoria was administered chloroform by James Simpson for the delivery of her eighth child, Prince Leopold, that contemporary Christians and, in particular, Protestants accepted the notion that it was not heretical to promote painless childbirth as part of the obstetric process.

From the Old Testament, Job has been praised for his endurance of pain and suffering. While Job’s friends wondered whether these tribulations were an indication that he had committed some great sin for which God was punishing him (Job x:17), Job was considered a faithful servant by God, not guilty of any wrongdoing. He was described as a man who was “blameless and upright” and one who feared God and turned away from evil.

In the 5th century, St. Augustine wrote that “all diseases of Christians are to be ascribed to demons; chiefly do they torment the fresh baptized, yea, even the guiltless newborn infant,” thus implying that not even innocent infants escape the work of demons. In the 1st century, many Christians were rebuked and suffered ruthless persecution, including death, because of their belief in Jesus as the Messiah. Some who were subsequently described as martyrs endured their suffering in the belief that they did it for the love of Christ, and they felt that their suffering identified them with Christ’s suffering on the cross during his crucifixion. This may be the earliest example of the value of psychotherapy as an important modality in managing pain. Thus some present-day cancer patients with strong religious beliefs view their pain and suffering as part of their journey toward eternal salvation. This concept has led to several scientifically conducted and government-sponsored studies evaluating intercessory prayer as an effective modality for controlling cancer pain.

To fully appreciate the historical concept of pain, it is important to reflect on the origins of the term “pain patient.” The word pain comes from the Latin word poena , which means that “punishment.” The word patient is derived from the Latin word patior , meaning “to endure suffering or pain.” Thus it is not too outrageous to appreciate that in ancient days persons who experienced pain were interpreted to have received punishment in the form of suffering that was either dispensed by the gods or offered up to appease the gods for transgressions. ^,

In some cultures, the tribal concept of pain came from the belief that it resulted from an “intrusion” from outside the body. These “intruders” were thought to be evil spirits sent by the gods as a form of punishment. In this setting, the role of medicine men and shamans flourished because these were the persons assigned to treat the pain syndromes associated with internal disease. Since it was thought that spirits entered the body by different avenues, the rational approach to therapy was aimed at blocking the particular pathway chosen by the spirit.

In Egypt, the left nostril was considered to be the specific site where the disease entered. This belief was confirmed by Papyri and Berlin, who stated that the treatment of headache involved expulsion of the offending spirit by sneezing, sweating, vomiting, urination, and even trephination. ^, In New Guinea, it was believed that evil spirits entered via a spear or an arrow, which then produced spontaneous pain. Thus it was common for the shaman to occasionally purge the evil spirit from a painful offending wound and neutralize it with his special powers or special medicines. Egyptians treat some forms of pain by placing an electric fish from the Nile over the wounds to control pain. ^, The resulting electrical stimulation that produced relief of pain actually works by a mechanism similar to transcutaneous electrical nerve stimulation (TENS), which is frequently used today to treat pain. The Papyrus of Ebers, an ancient Egyptian manuscript, contains a wide variety of pharmacologic information and describes many techniques and recipes, some of which still have validity. ^,

Early Native Americans believed that pain was experienced in the heart, whereas the Chinese and India identified multiple points in the body where pain might originate or might be self-perpetuating. Consequently, attempts were made to drain the body of these “pain points” by inserting needles, a concept that may have given birth to the principles of acupuncture therapy, which is well over 2000 years old.

The ancient Greeks were the first to consider pain to be a sensory function that might be derived from peripheral stimulation. In particular, Aristotle believed that pain was a central sensation arising from some form of stimulation of the flesh, whereas Plato hypothesized that the brain was the destination of all peripheral stimulation. Aristotle advanced the notion that the heart was the origin or processing center for pain. He based his hypothesis on the concept that an excess of vital heat was conducted by the blood to the heart, where pain was modulated and perceived. Because of his great reputation, many Greek philosophers followed Aristotle and embraced the notion that the heart was the center for pain processing. In contrast, another Greek philosopher, Stratton, and other distinguished Egyptians, including Herophilus and Eistratus, disagreed with Aristotle and proposed the concept that the brain was the site of pain perception, as suggested by Plato. Their theories were reinforced by actual anatomic studies showing the connections between the peripheral and central nervous systems.

Nevertheless, controversies between the opposing theories of the brain and the heart as the center for pain continued. It was not until 400 years later that the Roman philosopher Galen rejuvenated the works of the Egyptians Herophilus and Eistratus and greatly re-emphasized the model of the central nervous system. Although Galen’s work was compelling, he received little recognition until the 20th century.

Toward the period of the Roman Empire, steady progress was made in understanding pain as a sensation similar to other sensations in the body. Developments in anatomy and, to a lesser extent, in physiology helped establish that the brain, not the heart, was the center for the processing of pain. While these advances were taking place, simultaneous advances were occurring in the development of therapeutic modalities, including the use of drugs (e.g. opium), as well as heat, cold, massage, trephination, and exercise, to treat painful illnesses. These developments led to the establishment of the principles of surgery for treating diseases. Electricity was first used by the Greeks of that era, as they exploited the power of the electrogenic torpedo fish ( Scribonius longus ) to treat the pain of arthritis and headache. Electrostatic generators, such as the Leyden jar, were used in the late Middle Ages, resulting in the re-emergence of electrotherapy as a modality for managing medical problems, including pain. However, there was a relative standstill in the development of electrotherapy as a medical modality until the electric battery was invented in the 19th century. Several attempts have been made to revive its use as an effective medical modality, but these concepts did not catch on and were largely used only by charlatans and obscure scientists and practitioners.

Over the centuries, many modes of anesthesia/analgesia have been developed and refined so that their mortality and morbidity have become negligible. General anesthesia was formally discovered by William Morton in 1846. In 1847, while even the concept of analgesia for the relief of labor pain was considered heretical and unchristian, Simpson used chloroform to provide anesthesia for the labor pains of Queen Victoria during the delivery of her eighth child, Prince Leopold. This action helped legitimize the practice of pain relief during childbirth. Around the same time, a hollow needle and syringe were invented. Many local anesthetic agents have been discovered in this era. In 1888, Corning described using a local anesthetic, cocaine, to treat nerve pain. Techniques for local and regional anesthesia for both surgery and pain disorders have proliferated rapidly.

The history of anesthesia is full of instances wherein attempts to relieve pain were initially met with resistance and sometimes violence. In the mid-19th century, Crawford Long from the state of Georgia in the United States attempted to develop and provide anesthesia, but contemporary Christians of that state considered him a heretic for his scholarly activity. As a result, he had to flee for his life from Georgia to Texas. Although surgical anesthesia was well-developed in the late 19th century, religious controversy over its use required Pope Pius XII to give his approval before anesthesia could be used extensively for surgical procedures. Pope Pius XII wrote, “The patient, desirous of avoiding or relieving pain, may without any disquietude of conscience, use the means discovered by science which in themselves are not immoral.” More recently, the Church endorsed palliative care, including pain management using high-dose opioids or sedatives at the end of life (even if life-shortening) as long as the palliative therapies were proportionate and used to treat refractory symptoms in a terminally ill patient. Pope John Paul II stated: “Moreover, while patients in need of pain killers should not be made to forego the relief that they can bring, the dose should be effectively proportionate to the intensity of their pain and its treatment.” ( http://www.ldysinger.stjohnsem.edu/@magist/1978_JP2/Addresses/04_11_pal-care.htm ).

Pain and Pain Theories

Throughout the Middle Ages and the Renaissance, the debate on the origin and processing center of pain raged. Fortunes fluctuated between proponents of the brain theory and proponents of the heart theory, depending on which theory was favored.

Heart theory proponents appeared to prosper when William Harvey, recognized for his discovery of the circulation, supported the heart as the focus for pain sensation. However, Descartes disagreed vehemently with the Harvey hypothesis, and his description of pain conducted from peripheral damage through nerves to the brain led to the first plausible pain theory, that is, the specificity theory . In his 1664 Treatise of Man, René Descartes traced a pain pathway and described pain as “a specific sensation, with its own sensory apparatus independent of touch and other senses.”

In the 1850s, by examining the effect of incisions in the spinal cord, Schiff demonstrated that touch and pain were sensations independent of each other. He postulated that pain had its own specific nervous system pathways from the spinal cord that traveled to the brain. Further work along the same lines by Bliz, Goldscheider, and von Frey contributed to the concept that separate and distinct receptors exist for the modalities of pain, touch, warmth, and cold.

During the 18th and 19th centuries, new inventions, new theories, and new thinking emerged. This period was known as the Scientific Revolution, and several important inventions took place, including the discovery of the analgesic properties of nitrous oxide, followed by the discovery of local anesthetic agents (e.g. cocaine). Anatomy has also developed rapidly as an important branch of science and medicine; most notably, the discovery of the anatomic division of the spinal cord into sensory (dorsal) and motor (ventral) divisions. In 1840 Mueller proposed that based on anatomic studies, there was a straight-through system of specific nerve energies in which specific energy from a given sensation was transmitted along sensory nerves to the brain. Mueller’s theories led Darwin to propose the intensive theory of pain, which maintained that the sensation of pain was not a separate modality but instead resulted from a sensory overload of sufficient intensity for any modality. This theory was modified by Erb and then expanded by Goldscheider to encompass the roles of both stimulus intensity and central summation of stimuli. Although the intensive theory was persuasive, the controversy continued, with the result that by the mid-20th century, the specificity theory was universally accepted as the more plausible theory of pain.

With this official, though not unanimous blessing of the contemporary scientific community, strategies for pain therapy began to focus on identifying and interrupting pain pathways. This tendency was both a blessing and a curse. It was a blessing in that it led many researchers to explore surgical techniques that might interrupt pain pathways and consequently relieve pain, but it was a curse in that it biased the medical community for more than half a century into believing that pain pathways and their interruption were the total answer to the pain puzzle. This trend began in the late 19th century by Letievant, who first described specific neurectomy techniques for treating neuralgic pain. Afterward various surgical interventions for chronic pain were developed and used, including rhizotomy, cordotomy, leukotomy, tractotomy, myelotomy, and several other operative procedures designed to interrupt the central nervous system and consequently reduce pain. Most of these techniques were abysmal failures that did not relieve pain and occasionally resulted in more pain than previously present.

Pain as a Disease

The cardinal features of disease as recognized by early philosophers included calor, rubor, tumor, and dolor. The English translation is heat, redness, swelling, and pain. One of the important highlights in the history of pain medicine was the realization that even though heat, redness, and swelling may disappear, pain can continue and be unresponsive on occasion to different therapeutic modalities. When pain persists long after the natural pathogenic course of disease has ended, a chronic pain syndrome develops with characteristic clinical features, including depression, disability, disuse, and decreased mobility, causing other medical conditions such as obesity and arthritis to worsen. The risk of another comorbidity of chronic pain increases with chronic opioid exposure that, in some instances, can be complicated by dependency and opioid use disorder, formally known as addiction. John Dryden once wrote, “For all the happiness mankind can gain is not in pleasure, but in rest from pain.” Thus many fatal nonpainful diseases are not as feared as relatively trivial, painful ones.

Physicians and healers have focused their attention on managing pain. Thus in managing cancer, an important measure of successful treatment is the success with which any associated pain is managed. Although many technological advances have been made in medicine, it is only within the past 10 to 20 years that significant strides have been made in dealing with chronic pain as a disease entity per se—one requiring specialized assessment, workup, diagnosis, and specialized therapeutic interventions targeting the cause of pain and pain itself.

Pain in the 20th Century

In 1907, Schlosser reported significant relief of neuropathic pain for long periods with the injection of alcohol into damaged and painful nerves. Reports of similar treatment came from the management of pain resulting from tuberculous and neoplastic invasion. In 1926 and 1928, Swetlow and White, respectively, reported on the use of alcohol injections into thoracic sympathetic ganglia to treat chronic angina. In 1931, Dogliotti described the injection of alcohol into the cervical subarachnoid space to treat pain associated with cancer.

One consequence of war has been the development of new techniques and procedures to manage injuries. During World War I (1914-1918), numerous injuries were associated with trauma (e.g. dismemberment, peripheral vascular insufficiency, and frostbite). In World War II (1939-1946), peripheral vascular injuries as well as phantom limb phenomena, causalgia, and many sympathetically mediated pain syndromes occurred. Leriche developed the technique of sympathetic neural blockade with procaine to treat the causalgic injuries of war. John Bonica, himself an army surgeon during World War II, recognized the gross inadequacy of managing war injuries and other painful states of veterans with the existing uni-disciplinary approaches. This led him to propose the concept of multi-disciplinary, multimodal management of chronic pain, including behavioral evaluation and treatment. Bonica also highlighted the fact that all kinds of pain were being undertreated; his work has borne fruit in that he is universally considered the “father of pain,” and he was the catalyst for the formation of many established national and international pain organizations. Bonica’s lasting legacy is his historic volume The Management of Pain , first published in 1953. The clinic that he developed at the University of Washington in Seattle remains a model for the multi-disciplinary management of chronic pain. As a result of his work, the American Pain Society (APS) and the International Association for the Study of Pain (IASP) were formed. Anesthesiology was developed as a division of surgery and did not reach full autonomy until after World War II. With the discovery of new local anesthetics, regional anesthesia began to flourish in the United States. Bonica’s wife had a very difficult delivery, alerting Dr. Bonica to the gap in childbirth analgesia. He played a major role in advancing the safe use of epidural anesthesia to manage the pain associated with labor and delivery in the 20th century. Regional anesthesia suffered a significant setback in the United Kingdom with negative publicity surrounding the 1954 cases of Wooley and Roe, in whom serious and irreversible neurological damage occurred after spinal anesthesia. It took three more decades to fully overcome this setback and to see regional anesthesia widely accepted as safe and effective in the United Kingdom. Several persons contributed significantly to the development of regional anesthesia, including Corning, Quincke-August Bier, Pitkin, Etherington-Wilson, Barker, and Adriani.

An outstanding contribution in the field of research was the development and publication of the gate control theory by Melzack and Wall in 1965. This theory, which was built on the preexisting and prevalent specificity and intensive theories of pain, provided a sound scientific basis for understanding pain mechanisms and for developing other concepts on which sound hypotheses could be developed. The gate control theory emphasizes the importance of both ascending and descending modulation systems and provides a solid framework for the management of different pain syndromes. The gate control theory almost single-handedly legitimized pain as a scientific discipline and led not only to many other research endeavors building on the theory but also to the maturity of pain medicine as a science. As a consequence, the American Academy of Pain Medicine (AAPM), the American Society of Regional Anesthesia and Pain Medicine, the IASP, and the World Institute of Pain (WIP) have become serious and responsible organizations that deal with various aspects of pain medicine, including education, science, certification, and credentialing of members of the specialty of pain medicine.

Dr. Jan Sternsward, Chief of the Cancer Unit at the World Health Organization (WHO), collaborated with IASP to focus on cancer pain and palliative care for cancer patients worldwide. In 1982, representatives from IASP, including Drs. Mark Swerdlow, John Bonica, Robert Twycross, Kathleen Foley, and Fumi Takeda met in Italy and developed what eventually became the 1986 report entitled cancer pain relief. With IASP, WHO made a historic statement declaring pain relief a human right issue and called on member states to make pain-relieving drugs available, including oral morphine, which was on the WHO essential drug list.

Memorial Sloan Kettering’s James Ewing Hospital (MSK) was a focal point for the main site to evaluate new analgesics in patients with cancer pain. A young internist, Dr. Raymond Houde, with the assistance of a research nurse, Ada Rogers, and a psychologist, Stanley Wallenstein, began work on opioid pharmacology, including equianalgesic opioid doses in 1951. From Henry Beecher at Harvard and from his own experiments with student volunteers at Michigan, he learned that the perception of pain was modified by multiple variables—emotional state, expectations or fears for the future, previous medications or treatments, and the course of the disease itself. Houde’s meticulous and patient-sensitive methods were recognized in the late 1950s as the standard for analgesic trials. A neurologist, Kathleen Foley, brought together various programs to form the first designated pain service in a cancer setting in the United States. In addition to Dr. Houde and Ada Rogers, it included Charles Inturrisi, professor of pharmacology at Weill Cornell Medical College, and Gavril Pasternak, professor of neurology, who was developing a laboratory to study opiate receptors in the brain. This program combined basic and clinical research, along with a training program as well as a supportive care program for patients with complicated pain started by a PhD nurse practitioner, Nessa Coyle. Dr. Kathleen Foley published the first taxonomy of cancer pain syndromes.

Pain and the Impact of Psychology

The history of pain medicine is incomplete without acknowledging the noteworthy contributions of psychologists. Their influential research and clinical activities have been an integral part of a revolution in the conceptualization of the pain experience. For example, in the early 20th century, the role of the cerebral cortex in the perception of pain was controversial because of a lack of understanding of the neuroanatomic pathways and the neurophysiologic mechanisms involved in pain perception. ^, This controversy largely ended with the introduction of the gate control theory by Wall and Melzack in 1965. The gate control theory has stood the test of time in subsequent research using modern brain-imaging techniques such as positron emission tomography, functional magnetic resonance imaging, and single-photon emission computed tomography have also described the activation of multiple cortical and subcortical sites of activity in the brain during pain perception. Further elaboration of the psychological aspects of the pain experience includes the three psychological dimensions of pain: sensory-discriminative, motivational-affective, and cognitive-evaluative.

Psychological researchers have greatly advanced the field of pain medicine by reconceptualizing both the etiology of pain experience and treatment strategy. Early pain researchers conceptualized pain experience as a product of either somatic pathology or psychological factors. However, psychological researchers have convincingly challenged this misconception by presenting research that illustrates the complex interaction between biomedical and psychosocial factors.

This biopsychosocial approach to pain encourages the realization that pain is a complex perceptual experience modulated by a wide range of biopsychosocial factors, including emotions, social and environmental contexts, and cultural background, as well as beliefs, attitudes, and expectations. As the acutely painful experience transitions into a chronic phenomenon, these biopsychosocial abnormalities develop permanency. Thus chronic pain affects all facets of a person’s functional universe at great expense to the individual and society. Consequently, logic dictates that this multimodal etiology of pain requires a multimodal therapeutic strategy for optimal cost-effective treatment outcomes. ^,

Additional contributions from the field of psychology include therapeutic behavioral modification techniques for pain management. Techniques such as cognitive behavioral intervention, guided imagery, biofeedback, and autogenic training are the direct results of using the concepts presented in the gate control theory. In addition, neuromodulatory therapeutic modalities such as TENS, peripheral nerve stimulation, spinal cord stimulation, and deep brain stimulation are also logical offspring of the concepts presented in the gate control theory.

The evaluation of candidates for interventional medical procedures is another valuable historical contribution from the field of psychology. Not only is the psychologist’s expertise in the identification of appropriate patients valuable for the success of therapeutic procedural interventions for the management of pain, but the psychologist’s expertise is also helpful in identifying patients who are not appropriate candidates for procedural interventions. Thus psychologists have contributed positively to the cost effectiveness and utility of diagnostic and therapeutic pain medicine. Psychologists’ contribution to the care of patients with cancer pain is invaluable. Psychological research in cancer led by Dr. Jimmie Holland et al., MSK led to the development of a new field of psycho-oncology that is essential in addressing the pain and suffering of patients with cancer pain.

Pain and Pain Organizations