The Pain Chronicles

by Melanie Thernstrom

  And yet . . . what?

  I knew, of course, that I should see a doctor. I didn’t like the idea that I was not seeing a doctor, since that would be weird: a normal urban American with health insurance always sees a doctor when she has a medical problem. And there were many bodily complaints for which I had done exactly that—and benefited. But those were cases, I realized now, in which I already knew what was wrong. I was prone to coughs; I loved watching my primary care physician write prescriptions, knowing that in forty-eight hours I’d feel better. Always. It offered a kind of ritual satisfaction. As he recited the instructions with which I was so familiar, I’d take the first easy breath. In an important sense, it seemed to me, the cough actually ended when he handed me the prescription, as if the prescription were a telegram announcing that the enemy was retreating; the fighting might drag on for a few days, but the war was effectively over.

  Beneath this satisfying exchange, however, there was always the threat of another possibility. Perhaps one day there’d be no prescription to give. The doctor wouldn’t know what was wrong—or he would, and I wouldn’t want to know, because there would be no remedy.

  It wasn’t that I thought the diagnosis created the illness. My father’s parents had been Christian Scientists who thought disease was an illusion—that you are only as sick as you think you are—but I had never been persuaded. Perhaps, nevertheless, there was some way in which you weren’t fully sick—sick sick—without the pronouncement that you were. After all, observation changes its object. Perhaps an undiagnosed illness might be a tree falling in the forest without making a sound, a matter of at least debatable ontological status. If I wasn’t listening to my pain, how real could it be? If I went to the doctor, I’d be not only listening but soliciting a witness—a professional witness—to listen, too.

  Of course, I didn’t really believe any of this. It was inconsistent with the basic way I understood the world. But who knows? Reality can surprise. As long as I didn’t make an appointment, it was possible—or rather it was not impossible—that a devastating diagnosis was being adeptly avoided.

  On the subway one day, I sat in a free handicapped seat. Holding the pulley hurt my arm now, like trying to hold on to the leash of an angry animal. At the next stop, however, a pregnant woman lumbered toward me. I looked at my lap for a minute before standing up, tears of resentment springing to my eyes. She’s not handicapped—she’s healthy. She’s so healthy, she’s conjuring new life. I am—what?

  A doctor would fix the problem, I told myself. She would fix it or reassure me that it was nothing, and then it would actually be nothing.

  I asked a friend who was a doctor whom I should see, and he suggested that I consult a neurologist. I thought the specialty had an ominous ring, but I began to feel better in the neurologist’s waiting room. Flipping through a women’s magazine, I discovered an article about the body’s miraculous healing powers: “90% of pain resolves itself in six to twelve weeks, regardless of the method of treatment used,” the article stated. Though the primordial jungles had been a dangerous place—roots to trip on, thorns to pierce—our ancestors healed themselves without any help from neurologists. I began to feel I had simply been impatient; surely my body would reveal its healing powers.

  “No injury?” the neurologist asked. She moved my limbs as if they belonged to an antique doll whose face looked young but whose parts no longer moved well. She smiled at me, a frank “at your service” smile.

  “I’d call it cervical strain,” she declared. On her desk, a picture of a little girl with straight brown bangs stared out, seriously. I averted my eyes.

  “Cervical?”

  “The cervical spine is the neck. As opposed to the lumbar spine.”

  “Ah.” I returned the girl’s stare. “So you think it’ll get better?”

  “Sure.”

  “Why does my arm hurt, too?

  “You know that children’s song: ‘the neck bone’s connected to the shoulder bone; the shoulder bone’s connected to the . . .’ ” Her voice turned into a lullaby.

  “So, it’ll get better, right?”

  Could I have asked any more anxiously? I reproached myself. What if the doctor was of the mind-set that where there is smoke, there is fire?

  In fact, my anxiety had the opposite effect, and she became reassuring. “I wouldn’t worry about it,” she said.

  I beamed at her.

  “Sometimes we carry tension in our neck and shoulders. How are things going, personally, for you?” she asked. “Are you under stress? As you know, there’s a connection between the body and the psyche.”

  “Oh, absolutely. I am under stress.”

  On my way out of the room I pinched the magazine with the healing article. I thought of this article frequently as the six to twelve weeks I gave my pain to improve turned into six to twelve months without improvement. In fact, though I told myself it couldn’t be, I suspected at times that the pain was growing.

  ACUTE AND CHRONIC PAIN

  The article I read was correct, but it neglected to explain that its description of natural healing applies only to acute pain, not to chronic pain—a distinction with which I was not familiar at that time.

  Acute pain is a healthy reaction to tissue damage, steering us away from threats, alerting us to injury, and resolving when the injury does, often without any treatment at all. Acute pain is often referred to as protective pain because its messages are helpful and should be heeded. It’s the body’s warning that you are beginning to bend your knee in the wrong direction, or a louder distress message telling you that you have done so. The protection of pain is one of the most important survival tools, its value eerily illustrated by patients who suffer from some form of the rare genetic disease called congenital insensitivity to pain (or congenital analgesia)—an indifference to physical pain of any kind. People suffering from this condition—suffering, one might say, from a lack of physical suffering—often die young, having destroyed their bodies by inadvertently walking on broken ankles, scratching their eyes, and chewing their tongues.

  An oft-used metaphor for chronic and acute pain is that of a fire alarm. Acute pain is like a well-functioning alarm signaling danger; it ends when the fire does. Chronic pain is not protective; its intensity bears no relation to the amount of tissue damage and may, in fact, arise without any apparent damage at all. It is like a broken alarm that rings continuously, signaling only its own brokenness. There may be no fire; the original injury may be long healed. Or there may not have been an injury in the first place; the problem lies in the alarm system itself. It is as if a wire has been cut and the whole system begins to malfunction.

  Imagine a home-security alarm that is first triggered by a cat, then a breeze, and then, for no reason, begins to ring randomly or continuously. As it continues to ring, it triggers other noises in the house: the radio and television start to blare; the oven timer dings; the doorbell buzzes repeatedly; and the phone rings maniacally even though no one has placed a call. It’s as if a demon has entered the house. This is neuropathic pain—a pathology of the central nervous system and the basis of much chronic pain.

  My own conception of pain was primarily as something to overcome. It was a challenge to which I fancied myself fully equal—which my life provided ample opportunities to demonstrate. The phrase accident-prone has a passive ring; my style had involved a more vigorous courting of disaster. Mine was a willful blitheness, a loose-limbed, gangly clumsiness married to an adolescent impetuousness I had never chosen to outgrow. I consistently overestimated my physical abilities. The black diamond ski trail looked good to me, though the green circle matched my skill. There was no time to walk down the stairs when I was late, though leaping sometimes landed me in a pile at the bottom. If you’re not afraid of ladders, why bother with the safety latch—the function of which I recalled only when, standing at the top, I felt the ladder folding up beneath me.

  But I was not traumatized. These incidents did not keep me, for exam
ple, from buying a wild horse and assuring its previous owners that I was an expert rider, though my last lessons had occurred during fifth-grade sleepover camp, and when I got home from camp, my mother—who has a fear of horses—discontinued them. In my twenties, I broke a bone each year for three years in a row and sported a variety of bruises, sprains, and burns. But I recovered splendidly from everything. How had I lost the knack?

  “Perhaps you could be a little more careful,” Cynthia had suggested sweetly as she carted me around in my casts. But I didn’t want to be. Carelessness felt like carefreeness; carefulness, like an acknowledgment of aging, fragility, and mortality. And breaks hurt less than one might imagine. At first, I found, you can stave off the pain by concentrating on how you’re going to get help, when, for example, the horse has ditched you an unknown number of miles in the woods and is trotting back solo for its dinner. By the time the pain catches up with you again, you’re safe in a cozy cast, coddling the fractured limb like a baby bird in its shell.

  My greatest triumph over pain occurred on a warm March day. I was in graduate school, living in a country cottage ten miles outside Ithaca, New York. For no good reason I began to leap down the thawing driveway. My foot landed on a patch of ice. I tumbled forward, flinging out my right arm to break the fall, and felt a jarring pain.

  I drove myself into town, steering with my left arm and whimpering. I had a psychoanalysis session, and since my analyst’s office was near the student health services center, I decided to stop and explain the situation.

  “Do you want to sit down?” my analyst asked, and the sound of her calm voice seemed so restful. I realized that I was tired from the effort of getting there. I lay down on the couch for a minute, explaining that I wouldn’t be able to stay long because of the pain. Yet, as I began to talk, I was amazed to find that when I concentrated on the session, the pain became less urgent. It was as if Pain and I had been alone, and then when another person entered, Pain tactfully disappeared into a back room in my mind. I knew Pain was still in the house, but my analyst and I had been left to ourselves to have a private conversation.

  As soon as I went back out to the street, Pain met me again. Still, I thought I’d stop off for a milk shake, as I was in the habit of doing after therapy. But as I stared at the menu on the wall, I realized there was no time.

  At the student health center, the doctor noticed that the tissue of my arm had swollen and asked what time the accident had occurred. Although I nodded, chastened, as he lectured me on the importance of seeking immediate medical attention lest an infection such as gangrene set in, I felt triumphant inside. So, I thought, emotional pain is greater than physical pain; psychotherapy trumps orthopedics; the mind transcends the body.

  This template for understanding pain stayed with me for many years and seemed borne out by other mishaps in the years that followed. Then, toward the end of my twenties, I got tired of accidents. My New Year’s resolution the year I was twenty-eight was to have a break-, sprain-, and burn-free year. So it seemed unfair to me that, having more or less kept the resolution, I had now acquired a different affliction—an illogical, unhealing harm.

  There is a certain pleasure in ordinary, acute pain: the pleasure of seeing the body work. You think your body is like china—as if you have dropped your favorite teacup and it’s ruined forever. But it’s not. The bones knit, the cast is cut open, and you feel the forgiveness of healing, the erasure of mistakes, again and again.

  The experience of chronic pain, on the other hand, is one of defeat. The memory of transcending prior pains reproached me, as did stories of football players finishing a play despite broken legs and soldiers soldiering on despite grievous injuries. Whatever was wrong with my neck and arm now, I kept telling myself, they weren’t as bad off as if they had been broken. So why couldn’t I anesthetize them?

  What I (like most people) didn’t know is that there is a simple physiological answer to this question. It has nothing to do with the triumph of the will, but with a quirky aspect of acute pain. Although the intensity of acute pain generally reflects the degree of injury, there’s a neat trick by which grave injuries can temporarily not hurt at all. After an injury, the brain can sometimes stave off pain by temporarily switching on powerful pain-inhibiting mechanisms and releasing its own painkillers, such as endorphins, into the spinal cord, in a process known as descending analgesia. This phenomenon conferred a survival advantage upon our ancestors and thus became an evolutionarily selected trait, allowing them to leap away after being bitten by a saber-toothed tiger on a pain-free high of adrenaline and endorphins instead of bursting into tears.

  Such stress-induced descending analgesia was necessarily temporary, however, or its pain-blocking powers would have turned into a survival disadvantage by keeping us from tending to our wounds back in the cave (or allowing us to go out for a milk shake with a broken arm instead of seeking medical attention). And sometimes stress-induced descending analgesia proves harmful: even temporary ignorance of an injury may lead to further damage (as in a sport, in which the player finishes the match unaware of a broken limb and ends his or her career).

  What is all this blood? shark attack victims wonder as they paddle toward shore. Is my leg still there? Unintentionally expressing nature’s rationale, teenage surfer Bethany Hamilton, whose arm was bitten off by a shark, recalled, “I didn’t feel any pain—I’m really lucky, because if I felt pain, things might not have gone as well.” Undistracted by pain, she was able to focus on paddling to shore. A flood of nervous impulses from the damaged tissue would have interfered with her brain’s ability to formulate and execute a plan for survival.

  Some stress-induced descending analgesia can be activated by simple aerobic exercise. A 1981 study of Boston runners showed that beta-endorphins (the brain’s internal opiate-like neurotransmitters) are released along with adrenaline, creating the “runner’s high” that allows them not to feel blisters and muscle aches until they cross the finish line.

  Acute pain—as Dr. Patrick David Wall, a preeminent British pain researcher, theorized—is not a general perception by the brain: it is a perception about an action that needs to be taken. The brain can process the sensory information necessary for only one decision at a time. When you are swimming from a shark, fighting a battle, running a race, or even preoccupied with an important psychotherapy session, your brain is preoccupied with that goal; thus it fails to heed sensory inputs from injuries and generate an experience of pain. Indeed, many of those impulses never even reach the brain: the “gate-control” theory that Wall and his colleague Ronald Melzack developed in 1965 states that there are a series of neurochemical “gates” in the spinal cord that close off unwanted information.

  During the Yom Kippur War of 1973, Wall’s research team interviewed Israeli soldiers who had lost limbs. The team found that the soldiers’ initial wounds had not hurt most of them. But the descending analgesia proved limited to the area of injury: the same soldiers who didn’t feel pain from their wounds also teared up when pierced by an IV needle. A day later all of the men were in pain. A majority of them went on to develop phantom limb pain—pain that is experienced as coming from the missing limb (which afflicts between half and two-thirds of amputees). Fifteen years later, those cramping and burning sensations had not eased with time. The descending analgesia that had erased their pain on that first day never reappeared. Rather, their pain had become chronic, and chronic pain is, by definition, pain that the brain fails to modulate.

  DESTROYER OF GRIEF

  I wanted a holiday from pain—an hour or two, smooth and round as my old hours. I did not want aspirin, Motrin, or Aleve. I wanted the ancient medicinal herbs that date back, the Rig Veda explains, three ages before the gods were born, or the wine potion that Helen of Troy gave grieving visitors—what was it called?—that lulled pain and brought forgetfulness of every sorrow.

  Those ancient medicinal herbs . . . Cannabis, the vapors of which, writes Herodotus, caused “the wounded Scythi
ans to howl with relief and joy” in healing huts where the seeds were thrown on hot red stones. Black henbane, the “killer of hens,” whose yellow-veined flowers crowned the dead in Hades and which was used in witches’ brews to induce visions and convulsions and to confuse memory of pain. Mandrake, whose twisted human-shaped root was said to grow under scaffolds from the ejaculation of hanged men’s final death spasms. When uprooted, it shrieked in pain, killing those that heard its cry, yet it could be made into a potion that eased the pain of the living. According to a medieval heresy, it was mandrake mixed into vinegar that caused Jesus to fall into sleep for three days, after which he awakened in the tomb, as if resurrected.

  But the “key to paradise” has always been opium, the ancient Sumerians’ hul gil (“plant of joy”) that “induces deep slumber and steeps the vanquished suffering eyes in Lethean night,” as Ovid wrote. Opium was said to console the goddess Demeter herself when she wandered the earth to search for Persephone, for when she suckled its milk, she momentarily forgot her grief and fell into the twilight sleep that is halfway to Hades. How did mortals figure out the secret of how to extract the drug from the white opium-rich Papaver somniferum (“the poppy that brings sleep”)? Only in the brief interval in which the petals begin to drop can the fat, round capsules containing the unripe seeds be tapped, through an incision out of which the “Milk of Paradise,” the cloudy fluid also known as “poppy tears,” seeps. But it is not until it dries and oxidizes that it turns into a sticky, black opium-containing gum.