The Pain Chronicles

by Melanie Thernstrom

  Yet, Dr. Mackey points out, there is no evidence that greater brain activity necessarily indicates greater pain. The difference could reflect the man squeezing the ball harder with one hand (or feeling more anxious while using the injured hand, or any number of other factors). As a physician, Dr. Mackey believed in the worker’s pain, but he felt it was important to refute what he believed was specious methodology, which could as easily be used in other cases to falsely discredit patients’ pain.

  “What was remarkable is that the expert who was arguing for it is an internationally acclaimed researcher in cognitive systems,” he recalls. “It showed me that even a really smart person can be naive in regard to pain and approach it as if it were this Cartesian experience”—as if increased brain activity was the bell in the brain that simply rang louder when there was more pain.

  “The holy grail” of functional imaging, he says, “would be to be able to distinguish different patterns for different types of pain and to use that information to tailor specific treatments for a particular person. As you know, when I treat a person with pain, I go through a process of trial and error of different medications that is very laborious and frustrating for both the patient and me. I hope that one day we could use scanning, along with other information, as a predictive tool in which we could tell someone, You have this genetic profile, this type of injury, and based on this imaging information, we believe you are going to respond to this particular therapy.”

  When asked if he thinks there will be a breakthrough in the treatment of chronic pain that is similar to that of anesthesia, he points out that a century and a half later, we don’t know how anesthesia works, and although anesthesia allows us “to conquer pain, the person can’t be conscious!” Moreover, turning off an entire system, the way anesthesia does, is going to be much simpler than trying to turn off only the pain system, because pain is so intricately woven throughout the brain, with so many networks available to reroute it if one is disabled.

  At the moment, the pictures offered by the current technology are too primitive—the resolution of the images too coarse—to fathom pain. But “ultimately,” he says, “if we believe that our experiences and beliefs and perceptions are made up of firing of neurons and flow of information in neural circuits, then each experience has to be characterized by a different pattern. The limitation in understanding those patterns is only technological, and technology continuously improves.” By contrast, he says, “some people believe that consciousness is uniquely human and God-given: that it is inherently nondeterministic and cannot be defined or distilled down to the firing of neurons. I believe that it can, and I’m of the opinion that we’re inching closer and closer.”

  It’s easy to think of obstacles. Perhaps we need to see how the neurons are wired together to recognize pain, which the scans cannot show. Perhaps—even though the technology is improving—the gap between the coarse current technology and what we would really need will always be too great. Or perhaps each individual’s pain is simply too individual. Even if perceptions are all composed of neurons firing in particular patterns in particular networks, it may be that these patterns differ sufficiently from person to person in ways that will make it perpetually difficult for us to interpret them, even when we have functional imaging scans with far higher resolutions than today’s.

  The neural networking patterns of pain might turn out to be like fingerprints—something that everyone has and that, in essence, serve the same purpose for everyone, but differ too much in random detail from person to person to be able to meaningfully categorize them. After all, one could say that just as thoughts all spring from neuronal patterns, all the wondrous qualities of a painting depend on arrangements of paint on canvas. But we cannot now and probably never will be able to teach a computer to be able to analyze a new painting and say whether it has any merit—whether it is interesting, pleasing, or stirring—by showing it examples of thousands of famous paintings and hoping it can discern an underlying, predictive pattern.

  “I’m not saying that we’re going to be able to see the ghost in the machine—the experience of pain itself,” Dr. Mackey responds. “My hope is that we can get to the point where imaging can become a clinically useful tool, in the same way that we can use a cholesterol test as a biomarker for heart disease to guide us to choose an effective therapy. I don’t think functional imaging will allow us to ‘see’ pain or suffering or love in the foreseeable future. But in the same way that pattern-classifying software might enable us to identify a painting as being from the Impressionist period, or possibly even as a Monet, I think it will be able to identify different types of pain. In regard to using functional imaging as a diagnostic tool, I believe the question is now a when, not an if.”

  “The idea of functional imaging as a pain meter is unrealistic,” counters Scott Fishman, the head of pain services at UC Davis. “Humans are variable enough in our physiologies that doctors can’t even agree on reading an EKG or on what a stroke means, which are much more clear-cut things. How are scans going to prove or disprove someone else’s pain and suffering—or even illuminate its nature?”

  Pain and suffering are properties of the mind, he points out, and he doesn’t believe that “functional imaging is actually looking at the mind. The mind is like a virtual organ—it doesn’t have a physical address that we know of. Right now, imaging is just looking at the brain.” Imaging shows the level of activation of different parts of the brain, from which we can extrapolate something about the mind, but to understand pain, “what we really need to see is how the parts talk to each other—and the complex nuances of their language.”

  Functional imaging is able to show that, of the brain’s hundred billion neurons, a few hundred million of them, in various areas, become more active during the time at which the subjects report an experience of pain. What it does not do is explain the connection between that experience and the activity of those neurons. Imagine watching a silent film of a concert. You would be able to discern patterns in which the players in the bass section become active at one moment, vigorously gesturing, and then the rest of the orchestra joins in, but you wouldn’t hear the notes themselves or deduce how they form strands of melody and harmony and meld together to create the ethereal experience of listening to music.

  “Pain is an aspect of consciousness, and consciousness is not neurons firing,” agrees Daniel Carr, the physician in whose clinic I first began to understand pain as a disease. “The gears of a watch rotate and keep time, but the turning of the gears is not time. Functional imaging is a picture of a mechanism associated with the experience of consciousness, but it is not consciousness. Consciousness is a transcendent emergent epiphenomenon that depends on the firing of neurons in some distributed way that we don’t understand and perhaps can’t understand.”

  Do we need to understand consciousness itself in order to understand pain? What are the limits of that understanding? Could we ever become fully transparent to ourselves? “If a higher being told us how consciousness works,” he muses, “could we understand the explanation?”

  RIGHT NEXT DOOR

  The eminent neurobiologist Allan Basbaum told me a story about a pain researcher and a vision expert. “You still don’t know how pain works?” the vision guy asks the pain guy.

  “You may know something about how vision works,” the pain man replies, “how the retina’s rods and cones receive light stimuli, how its nerve cells transmit them via the optic nerve to the brain, and so on. But tell me—in what part of the brain does beauty lie?”

  The vision guy falls silent.

  “Let me know when you find it,” the pain man says, “because pain is right next door.”

  NOTES

  INTRODUCTION: THE TELEGRAM

  warned colleagues against visiting patients who had advanced consumption: See “History of Tuberculosis,” Respiration 65 (1998): 5.

  German physician identified Mycobacterium tuberculosis: Robert Koch presented his finding on March 24,
1882.

  diseases are understood metaphorically: See Susan Sontag, Illness as Metaphor and AIDS and Its Metaphors (New York: Picador, 2001), 34.

  “Where does it hurt?”: See Michel Foucault, The Birth of the Clinic (New York: Routledge, 2003), xxi.

  articulated but not popularized: See “Infectious Disease During the Civil War: The Triumph of the Third Army,” Clinical Infectious Diseases 16 (1993): 580–84.

  decades before anyone thought to employ them: Nitrous oxide was discovered in 1772 but was not used as an anesthetic until 1844. Sulphuric ether was known to resemble nitrous oxide by the 1820s but was not used as an anesthetic until 1846.

  serious, widespread: Estimates of Americans experiencing chronic pain vary considerably, from 19 million to as high as 130 million. The International Association for the Study of Pain, along with the European Federation of IASP Chapters, released the results of a comprehensive survey in 2004 that found that one in five adults claimed chronic pain, which was defined as pain that persists or recurs for more than three months. More than a third of households in Europe included a chronic pain sufferer, compared with almost half (46 percent) of homes in the United States.

  a 2009 report by the Mayday Fund: See A Call to Revolutionize Chronic Pain Care in America: An Opportunity in Health Care Reform, the Mayday Fund, November 4, 2009.

  Another study in the United States: See “Broad Experience with Pain Sparks a Search for Relief,” ABC News/USA Today/Stanford University Medical Center Poll, May 9, 2005.

  most chronic pain patients: 2000 survey commissioned by Partners Against Pain, an educational program sponsored by Purdue Pharma.

  “history of man is the history of pain”: See Vladimir Nabokov, Pnin (New York: Random House, 2004), 126.

  “place of pain”: See Bhagavadgita, Edwin Arnold, trans. (Mineola, N.Y.: Courier Dover, 1993), 41.

  “Thorns also and thistles”: See Genesis 3:18 (King James Version).

  “against these satanic agencies”: See American Dental Association, Transactions of the American Dental Association 11–12 (1872): 105.

  origin of toothache: See also Benjamin R. Foster, Before the Muses: An Anthology of Akkadian Literature (Bethesda, Md.: CDL Press, 2005), 995.

  I. THE VALE OF PAIN, THE VEIL OF PAIN: PAIN AS METAPHOR

  I gratefully acknowledge the assistance of Sara Brumfield, a doctoral student at UCLA, for her expertise on ancient Mesopotamia as well as her translations of biblical, Babylonian, and Sumerian texts.

  “pain remains veiled”: Martin Heidegger, Poetry, Language, Thought, Albert Hofstadter, trans. (New York: Harper Perennial, 2001), 94.

  “uncanny strangeness”: David B. Morris, The Culture of Pain (Berkeley: University of California Press, 1993), 25.

  “most truthful way of regarding illness”: Sontag, Illness as Metaphor, 3–4.

  bowing before the whirlwind: God appears to Job out of the whirlwind in Job 38:1.

  “love is love of x”: See Elaine Scarry, The Body in Pain (New York: Oxford University Press, 1985), 5.

  Dickinson tries to describe this great blank: See The Poems of Emily Dickinson (Cambridge: Harvard University Press, 1998), 501–502.

  “Head pain has surged up upon me”: Foster, Before the Muses, 400.

  dolor dictat: See Alphonse Daudet, In the Land of Pain, Julian Barnes, trans. (New York: Knopf, 2003), 27. Daudet sources the phrase to Ovid, but I was unable to confirm that. He also writes of a similar phrase by Sithus Itlaius, dolor verba aspera dictat (pain dictates the words I now write).

  “fine explorer in Central Africa”: Ibid., 8–9.

  two different types of nerve fibers: See Ursula Wesselmann, “Chronic Nonmalignant Nociceptive Pain Syndromes,” in Surgical Management of Pain (New York: Thieme, 2002), 365 ff.

  forces the creature to tend to its wound: See, for example, Patrick David Wall, Pain: The Science of Suffering (New York: Columbia University Press, 2000), 2–3.

  not thought to cause the invertebrate pain: See a summary of evidence presented by The Senate [of Canada] Standing Committee on Legal and Constitutional Affairs, “Do Invertebrates Feel Pain?” www.parl.gc.ca/37/2/parlbus/commbus/senate/Com-e/lega-e/witn-e/shelly-e.htm, accessed December 31, 2009. “Although it is impossible to know the subjective experience of another animal with certainty, the balance of the evidence suggests that most invertebrates do not feel pain. The evidence is most robust for insects, and, for these animals, the consensus is that they do not feel pain.”

  reduced by opiate pain medication: See, for example, Janicke Nordgreen et al., “Thermonociception in Fish: Effects of Two Different Doses of Morphine on Thermal Threshold and Post-test Behaviour in Goldfish (Carassius auratus)” Applied Animal Behavior Science 119 (June 2009): 101–107.

  lacks the complexity that is necessary for consciousness: See James D. Rose, “The Neurobehavioral Nature of Fishes and the Question of Awareness and Pain,” Fisheries Science 10 (2002): 1–38.

  interoceptive cortex: See A. D. (Bud) Craig, “Interoception: the Sense of the Physiological Condition of the Body,” Current Opinion in Neurobiology 13 (2003): 500–505.

  ‘etsev: Help with the Hebrew etymology was provided by Sara Brumfield of UCLA.

  malevolent and beneficent demons and deities: See Walter Addison Jayne, The Healing Gods of Ancient Civilizations (New Hyde Park, N.Y.: University Books, 1962), 89–128.

  eyes, mouth, nostrils, and ears: Ibid., 104.

  trepanation: See Robert Arnott et al., Trepanation: History, Discovery, Theory (Netherlands: Swets & Zeitlinger, 2003) and Symeon Misseos, “Hippocrates, Galen, and Uses of Trepanation in the Ancient Classical World: Galen and the Teaching of Trepanation,” Neurosurgical Focus 23 (November 11, 2007).

  “free me from all possible evil”: See the Ebers Papyrus, “Prayer to Isis,” cited in Pacific Medical Journal 59 (1916): 459.

  Arrows thrown by Rudra: See The Rig Veda: An Anthology (New York: Penguin, 1981), 222.

  “Apollo-” or “sun-struck”: Jayne, Healing Gods, 308.

  “Artemis-” or “moon-struck”: Ibid., 311.

  “Oh Father, Headache”: Translation provided by Sara Brumfield of UCLA.

  Asclepius: See Gerald David Hart, Asclepius, the God of Medicine (London: Royal Society of Medicine Press, 2000).

  “first taught pain the writhing wretch”: See Pindar, The Odes of Pindar: Literally Translated into English Prose (London: Bell & Daldy, 1872), 272.

  “What are a ripe fig and an apple to me?”: See Foster, Before the Muses, 995.

  “Magic is effective”: Cited in Wolfgang H. Vogel and Andreas Berke, Brief History of Vision and Ocular Medicine (Amsterdam: Kugler Publications/Wayenborgh Publishers), 46.

  Poem of the Righteous Sufferer: Ibid., 392 ff.

  “willingly or unwillingly”: Morris, The Culture of Pain, 24–25.

  “I have given a name to my pain”: Friedrich Wilhelm Nietzsche, Basic Writings of Nietzsche (New York: Random House, 2000), 174.

  “Pain, while always new to you”: Daudet, In the Land of Pain, xi.

  Bethany Hamilton: See Bill Hemmer, “Brave Surfer, Heart of a Champion,” CNN American Morning, November 5, 2003.

  A 1981 study of Boston runners: See D. B. Carr et al., “Physical Conditioning Facilitates the Exercise-induced Secretion of Beta-Endorphin and Beta-Lipotropin in Women,” New England Journal of Medicine 305 (September 3, 1981): 560–62. However, there has been some recent disagreement with the idea of a “runner’s high” among scientists, some of whom say that it is not clear that the endorphins reach the brain.

  an action that needs to be taken: See Wall, Pain, 146.

  soldiers who had lost limbs: Wall, Pain, 5–7.

  between half and two-thirds of amputees: See M. T. Schley et al., “Painful and Nonpainful Phantom and Stump Sensations in Acute Traumatic Amputees,” Journal of Trauma 65 (October 2008): 858–64. This offers a figure of 44.6 percent. The higher figure of 62 percent comes from S. W. Wartan et al., “Phantom Pain and Sensa
tion Among British Veteran Amputees,” British Journal of Anesthesiology 78 (1997): 652–59.

  three ages: The Rig Veda (New York: Penguin, 1981), 285.

  lulled pain and brought forgetfulness: Padraic Colum, The Adventures of Odysseus and the Tale of Troy (Rockville, Md.: Arc Manor, 2007), 38.

  “the wounded Scythians”: Cited in Thomas Dormandy, The Worst of Evils: The Fight Against Pain (New Haven: Yale University Press, 2006), 27.

  “induces deep slumber”: Ibid., 21.

  “I possess a secret remedy”: Martin Booth, Opium: A History (New York: St. Martin’s Press, 1999), 24.

  “How divine this repose is”: Cited in Jean Dubos, The White Plague (Piscataway, N.J.: Rutgers University Press, 1987), 64.

  “Illness is as much a failure as poverty”: Cited in Daudet, In the Land of Pain, 33–34.

  “Pain upsets”: Aristotle, The Nicomachean Ethics, William David Ross, trans. (New York: Oxford University Press, 1998), 76.

  ‘itstsabown: Help with the Hebrew etymology was provided by Sara Brumfield of UCLA.

  “the eyes of them both were opened”: See Genesis 3:7 (King James Version).

  “The Lord gave”: See Genesis 1:21 (King James Version).

  “Where were you?”: See Job 38:4 (King James Version).

  “was silent as one who experiences no pain”: The Gospel of St. Peter: Synoptical Tables, with Translation and Critical Apparatus, trans. John Macpherson (T. & T. Clark, 1893), Book 3, Verse 11.

  human palm is not substantial enough: See Frank T. Vertosick, Jr., Why We Hurt: The Natural History of Pain (Orlando: Harvest Books, 2001), 156.

  extant skeleton of a man crucified in that period: See Gary R. Habermas, The Historical Jesus (Joplin, Mo.: College Press, 1996), 174.