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“On a Scale from Zero to 10” – Pain Across History


In his 2006 book The Worst of Evils: The Fight Against Pain, physician and historian Thomas Dormandy described this as "probably the greatest sculpted image of the fight against physical pain."  It is the Laocoon, a Greek work of the first century that depicts a scene from the Trojan War and that is in the Vatican Museum


This is the first of three posts that look at different elements of pain’s history. My goal is to convey something of the scope, complexity, and drama of this history within medicine and beyond. Clinical and social psychologists, physiologists, anthropologists, literary scholars, anatomists, journalists, neuroscientists, clinicians, and fiction writers have created an inexhaustible pain literature. In the last 100 years historians have added their voices. In studying pain’s history we connect, if indirectly, to an experience shared by virtually everyone who ever lived. In bringing pain’s history to life, we engage with a human condition that provokes basic questions, from birth to death, about our bodies, minds, spirits, and selves.


What follows here is a very selective overview of pain’s history. It includes two themes that run through the series: a shift in the clinical and social status of pain after 1945, and the centrality of the brain to expanding our understanding of why pain hurts the way it does.

 

In 1944, Lt. Col. Henry Beecher, an anesthesiologist, was field medic in charge of pain control in Benzio, an Italian beach town. As wounded men arrived at his post, Beecher would offer something for the pain. To his astonishment, many soldiers, including a third of the most badly wounded, declined. When Beecher asked injured soldiers if they had any pain, more than 70 percent said no. This did not jibe with Beecher’s training, in which pain was understood as proportional to an injury’s severity.


Beecher began to track soldiers’ responses to offers of pain relief, and in 1946 he published his findings. Among seriously wounded soldiers he had asked within 12 hours of being wounded, 25 percent reported only slight pain and 32 percent reported no pain. Beecher described the men as “not in shock and mentally coherent.” How could this be? Beecher proposed that the soldiers’ sudden removal from combat, a site of constant danger, to a place where they would be safe and cared for, helped ease their pain.


Beecher’s study was a landmark in a new chapter of pain’s history. In asking how individual circumstances might affect pain’s physical impact, Beecher began to develop a concept of pain not as a simple stimulus-response event but as complex, personal, subjective, and variable. What was heresy in 1944 – dissent from a narrow, mechanical model of pain – has become the prevailing view.


To see how this post-1945 shift in the clinical and social understanding of pain was significant, let’s start at the top.


The Scope of Our Topic


Think about how much human territory “pain” covers -- everything from a paper cut to high school heartbreak. Pain is eternal and universal. Virtually everyone who ever lived has felt pain. It has been a defining issue in the history of medicine and today is a formidable, global health challenge. Pain is a central metaphor of major religions – think of Jesus on the cross, the trials of Job, and the Buddha on pain and suffering. It has been a focus of painting, sculpture, and photography; a workhorse theme in literature; a staple of popular culture; and central to studies of perception, consciousness, and the full slate of mind/body issues.


In 2024 in America, chronic pain is a complex, quiet epidemic.


Pain didn’t become all that overnight. Its history is as old as humanity’s.


History of Pain 101


In the ancient world, pain signified one of two events: the invasion of a person’s body by malign spirits, or the displeasure of a god, or gods, over what a person had done, said, or thought. “Pain was a cosmic power and the key to God’s presence within us. Pain was the road to redemption, as much for the saint as for the sinner.” Although a notion of pain as divinely driven had had its skeptics, in the nineteenth century scientific approaches to pain began to take shape. Expanding knowledge of anatomy and physiology, helped by the gradual end of taboos on dissection as well as advances in surgery and microscopy, brought our innards into view.


More broadly, in the 1800s, “pain took on a leading role within the social, political, and scientific arenas as never before. Physical anguish and psychological suffering became progressively more central both in private life and the public sphere.”

Medical science and technology helped expand pain’s footprint; examples include surgical anesthesia after 1846, syringes after about 1870, and the germ theory of disease in the late 1800s. All contributed to changes in clinical medicine and to pushback on the problem of pain. So by the time Henry Beecher arrived at a medical tent in Italy, the groundwork was in place for pain’s new clinical and social prominence.


Two other clinicians, also affected by their wartime experiences, would make major contributions.


John Bonica was born in Italy in 1917. His family came to America when he was seven. After his father died, Bonica took numerous jobs to finance medical school, including a stint as a pro wrestler. His name in the ring was Johnny “Bull” Walker. Johnny was light-heavyweight champion in Canada in 1939. Years later, Bonica would undergo nerve blocks and other procedures to help address wrestling injuries that had morphed into chronic pain. Like Beecher, Bonica was trained in anesthesiology. At a 7,700-bed wartime hospital at Fort Lewis, Washington, he was called to the operating room several dozen times a day. As staff doctor in charge of pain control, he consulted colleagues in many specialties on a staggering array of wounds.


After the war, no one was more crucial to the refashioning of pain among clinicians than John Bonica. In 1953 he published The Management of Pain, a 1,500-page work that covered current surgical treatments as well as cognitive-behavioral methods, hypnosis, and physical medicine. In the 1970s Bonica led the creation of the International Association for the Study of Pain (IASP), the group that catalyzed global scientific exchanges on pain in a journal and conferences that attracted clinicians from diverse specialties.


On his 50th birthday in October 1942, University of Oregon surgery professor William K. Livingston received two fateful telegrams. One was from book publisher Macmillan with good news: the company wanted to publish Livingston’s manuscript. The other was from the US Surgeon General, with orders to report for duty at Oakland (CA) Naval Hospital, where Livingston spent the entire war and worked with hundreds of wounded soldiers. Like Beecher, he slowly realized that patients with nerve injury did not fit how he understood pain. He kept careful records as Oakland Naval grew to 12,000 beds.


Livingston’s manuscript was published in 1943 and titled Pain Mechanisms. It was a substantial critique of a prevailing understanding of pain. Livingston spelled out the weaknesses of current pain models in which the transmission of pain signals from the body to the brain was thought to be hard-wired. The book explored new concepts, including a broad role for the central nervous system in the pain experience and the importance of specific spinal-cord neuron groups for modulating painful sensory input.


Renegades at the Gates


Among the scientists drawn to Livingston’s book were psychologist Ronald Melzack and neuroanatomist Patrick D. Wall. When Melzack arrived at the Massachusetts Institute of Technology in 1962, he was given Wall’s name as a possible source of laboratory space. Their meeting began a collaboration between two vastly different personalities. What they shared was profound dissatisfaction with how clinicians understood pain and abhorrence at the suffering pain caused.


Still, “we argued about nearly everything it was possible to disagree on,” Melzack recounted in an interview decades later. In 1965 they published their gate control theory (GCT) of pain. The “gate” was located in the dorsal horns of the spinal column, which they said opened and closed to modulate the content, movement, and perceptual outcome of painful stimuli. Wall and Melzack said that the gate operated by balancing the excitation of two types of nerve cells: large-diameter fibers open the gate, whereas small ones close it.


Melzack and Wall thus rejected a prevailing specificity theory of pain, which said that hurtful stimuli sent uniform, unmediated signals to a spot in the brain that registered pain. The GCT emphasized complex spine and brain processes that mediated the body’s responses and affected the pain experience. 


The Brain: The Final Frontier


Almost six decades on, the GCT has had an enduring impact. The brain is the focus of evolving understanding of why people feel pain as they do.


In The Brain and Pain: Breakthroughs in Neuroscience, Richard Ambron spells out this understanding. He says about 30 million Americans suffer from chronic pain. He describes how our central nervous systems – brains and spines – “link the control of pain to centers in the brain that regulate mood, anxiety, and attention.” Here is a start on understanding why pain seems, and is, subjective.


Specialized nerve cells and complex chemicals have roles in transmitting and modifying painful inputs. Our brains have about a trillion neuronal circuits operating in and across diverse brain sectors. Ambron shows how pain is produced by a matrix of proteins, electrochemical interactions, brain structures, and cellular functions that shape feelings, beliefs, attitudes, and how we understand our own pain.


In 2021, cardiologist (and chronic pain patient) Haider Warraich summarized today’s prevailing view of pain. “It is informed in its every variance by personal histories, cultural idiosyncrasies, racial and gender imbalances, and genetic and epigenetic predispositions.” But wait – there’s more. Ambron says “studies of the masochists and religious subjects show how context can engage different regions of the brain to attenuate pain.” He thus includes within today’s pain model people who enjoy significant pain.


Ambron is forthcoming about the many unanswered questions about pain and the brain. A good number of these center on how genes affect pain. Genes are our era’s choice for what historian Nicolas Rasmussen calls “master molecules” – biochemical kingmakers in crafting what we are as people. We are on track to learn more about the role of genes in pain and in our responses to it. Some new knowledge will apply to many people. It’s unclear how or how deeply, or how, our quirks, attitudes, and makeup might be electrochemically encoded.


Eight decades after Henry Beecher wondered about wounded soldiers’ pain, medicine and society have made real strides in addressing pain. We are far from a complete understanding; pain’s capacity for surprise is immense. But a view of pain as enmeshed with personal attributes and experiences moves us closer to pain’s elusive heart.


In the 19th century, biophysical explanations of pain began to emerge and to challenge religious interpretations. In my next post, I’ll put efforts to develop a clinically useful pain measurement system under an historical microscope.


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