Book Review

The History of Pain

N Engl J Med 1996; 334:408-409February 8, 1996

Article

The History of Pain
By Roselyne Rey. 394 pp. Cambridge, Mass., Harvard University Press, 1995. $39.95. ISBN: 0-674-39967-6

This book offers interesting reading in the philosophy of science and social psychology. It provides a brief overview of concepts of pain throughout history without maintaining strict scientific criteria for what constitutes pain. The primary goal is “clarifying the pain mechanism by providing a history of all the scientific theories and hypotheses . . . on the physiology of sensation.” The author addresses the major scientific contributions and therapies for treating pain, as well as the scientific and institutional conditions under which these approaches were promulgated in France. The work of the French philosophical and medical giants is documented, including the contributions of Paré, Descartes, Barthez, Bichat, Velpeau, and Charcot, as well as minor players, such as Landré-Beauvais, Boerhaave, and Larrey.

Three chapters are outstanding and make up the bulk of the book: “Pain in the Age of Enlightenment,” “The 19th Century: The Great Discoveries,” and “Communication Strategies: The Approach to Pain during the First Half of the 20th Century.” The focus on the assessment and management of pain is clear, and it is easy to understand the relation between practices in earlier times and our current thinking. Landmark discoveries during these periods are of obvious importance to the present-day practice of medicine and neuroscience. There are scholarly considerations of the evolution of concepts of pain sensation and therapy and the worldwide scientific observations that have influenced current practices in the management of pain, including the isolation of morphine, the identification of gas anesthesias, the specificity of pain sensation, and the value of pain in diagnosis. Hypnosis and electrotherapy are also considered. The work of Jules-Joseph Déjerine on the role of the thalamus in sensation is reviewed, as is the dispute in France over the localization of function and pain centers in the brain. The experiments of Longet, Flourens, and Bernard that examined the actions of anesthetics in the central nervous system are detailed, and there is an interesting discussion of how anesthetics changed people's attitudes toward pain and the ethical issues raised by the legal consequences of the failure of gas anesthesia during the early days of surgery. Although not a common concern in modern science, the role of the French church in interpreting the social consequences of pain, such as the “virtues of pain,” is noted, as well as the Dolorist trend between the world wars, exalting the value of pain and pain as self-discovery.

Since it is not possible to interpret the mechanisms of pain only with reference to the French experience, much of the book is devoted to the discoveries of pain mechanisms throughout the world. The work of Galen, Hoffmann, Haller, Sydenham, Davy, Müller, Head and Holmes, and Sherrington is considered, as is the use of ether anesthesia by Long, Wells, Warren, and Simpson. Although these observations provide an important context for the French experience, the history of these investigators' work is more thoroughly analyzed in other accounts. The emphasis on French medicine is not always compelling, as, for example, in their response to ether anesthesia, which is more a matter of interest to French philosophers than to those interested in the broader history of pain. There are also many interesting historical notes that have little or no stated relevance to pain. The discussion of the revival of anatomy during the Renaissance contains interesting observations but no mention of how this revival altered views of the physiology of pain.

The author should probably have focused on critical events in French medicine to highlight this information, instead of beginning in ancient times. The early chapters are distracting, provide a slow start, and have a poor relation to the stated goals of the book. Seventeenth-century French poetry about wartime experiences, for example, provides no insight into pain, and the discussion of pain in the Renaissance is primarily an account of religious conviction, with allusions to the “pain of sin” and such statements as “penitence causes pain.”

The book appears to require a more compelling framework from the modern practices of pain management. The author expresses naive views of the mechanisms of pain, such as the undocumented observation, “We know that the threshold at which pain becomes unbearable varies . . . according to the culture from which the person comes.” the author views pain as independent of suffering and as a sensory event, yet she does not differentiate between the peripheral mechanisms of nociception and the conscious perception of pain. Issues of the physiologic basis of pain overlap with those related to “moral” pain and other folksy views of pain functions in the brain. The author maintains the unlikely expectation that the expression of suffering in a mythological context reveals ways of conceiving and managing pain. Many descriptions of pain throughout history involve cases without known cause and are therefore of little value. It is pointless to ask whether the threshold for the tolerance of pain was different in antiquity, since there is no way of answering such a question. Descriptions of schools in ancient times, such as that of Cos, and the writings of Celsus are limited and have an unclear relation to pain. The book states, “One of the most apparent functions of pain is to facilitate the physician's diagnosis.” This certainly is not a function of pain, although it may be a practical use of pain. The book also incorrectly states, “Overall, the classification of pain into four principal types still holds: tensive . . . gravative . . . pulsating . . . pungitive,” and fails to distinguish between the neurobiology of pain (i.e., brain mechanisms) and the diagnosis of disease.

The final chapter, “A Modern View: Pain Today,” was written by J. Cambier. Unfortunately, it is too short to be useful and highlights an important shortcoming of this book. One is always trying to decipher what the views of the author are, in addition to understanding an honest portrayal of historical facts. The book does not have a solid logical and scientific framework. Since this book is to be read by present-day practitioners and not ancient philosophers or barbers in the Middle Ages, a perspective is needed that brings all readers to the same starting point. Most people in the medical and scientific fields do not read from the perspective of a historian or philosopher. Although there are attempts throughout the book to bridge these differences, it is hard to distinguish between the author's quasiscientific views of pain and historical cultural perspectives on pain.

This book will be of interest to philosophers of science and persons with a broad interest in historical perspectives on pain. The book does not achieve its primary goal of elucidating the cause of pain and certainly will not have a substantial influence on current approaches to the management of pain. These goals require a more lucid interaction between historians and physicians that could evolve from the present work.

Brent Alan Vogt, Ph.D.
Bowman Gray School of Medicine, Winston-Salem, NC 27157