Pushing back into chaos
Salt Lake City, Utah, United States
The pathway of pain according to René Descartes: “Particles of heat” (A) close to the foot (B) contact the skin and pull threads (C) up the body, that “open the pores” (D, E) and allows “animal spirits to flow from a cavity (F) into the muscles,” causing the muscles to flinch away, the eyes to turn to the fire, and the hand to extend while turning the body away protectively.
Pain is perhaps the most useful yet most feared human experience. It has been crucial to our evolutionary development, but the modern era has sought to expunge it. The New York Times has reported that scientists may be able to use the genes from a woman who feels no pain to create a novel pharmaceutical.1 Society cannot escape the media discourse that extols the elimination of pain. Yet it seems that perhaps we do not know what we are attempting to eradicate. What is real pain? When, for example, are narcotics used because a patient’s pain is “real?”
The history of pain is as old as humanity itself. We seek to alleviate it, avoid it, and cause it. Yet the concept plagues human thought as a complex amalgam of intangible theories. Its essence continues to elude the human mind despite its omnipresence within the mind. It seems that pain may be the greatest escape artist of all time.
Pain first arose as a concept in Western society in the eighth century BCE when Homer wrote detailed descriptions of pain in The Iliad and The Odyssey, but evidence of pain discourse has been found in traditional Chinese medicine texts from nearly 3,000 years ago. However, it was not until the Renaissance, from the fourteenth to seventeenth centuries, that the brain became linked to pain sensations.2 It was around this time that René Descartes popularized the functionality of the brain in interpreting pain transmissions.
Descartes characterized pain as a manifestation of the soul. In his Principles of Philosophy, Descartes described phantom limb pain, which localized pain to the pineal gland and the soul.3 Whether this was to appease the dominancy of Church thinking, which linked pain to Original Sin, or whether Descartes actually believed that the soul was the true perceiver of pain, this mentality was a powerful force in molding the understandings of pain that permeate Western medicine today. Moreover, in 1664, Descartes’ L’Homme planted the seed for a mechanical perspective of natural human biology, his vision for pain pathways becoming compulsory to modern pain theories.4 With secularization and the eighteenth century Age of Enlightenment, such mechanical notions were often isolated biologically or intertwined psychologically with the soul based on varying schools of thought (mechanical, vitalist, and animist).5
From the nineteenth century on, pain has embodied a number of different theories, including the specificity theory, which drew on the notion of specific sensory nerves, and the intensity theory, which focused on stronger nerve activation to generate pain. The subsequent pattern theory was based on electrophysiology and myelination of nerve fibers, closely followed by the gate control theory based on dynamic modulation with central nervous system control with descending modulatory fibers and interneurons.6 Both have had their places at the forefront of pain medicine, which initially emerged in the 1960s.7 But with more recent advances in the understanding of nociception, the specificity theory seems to be the most prevalent today.
Regardless, there is a pervasive desperation to understand the true mechanism of pain. The emergence of chronic pain as a medical ailment has further obfuscated this thinking. Its elusive subjectivity8 underscores the fact that while pain signals travel down specific pathways in the body, emotional and cognitive pathways are simultaneously enmeshed,9 resulting in a messy bowl of cognitive, psychological, and somatic spaghetti noodles. I argue that pain exists outside the realm of language and description. But as humans, we find we must singularly identify and discuss this complex web of emotion and physicality that strings through our lives. Within modernity, the desire to understand pain, while intrinsic to human nature, also collides with a growing (and perplexing) cultural awareness of quality of life, in which pain supposedly has no place.
Amidst the anatomic chaos of human sensory pathways, it is nearly impossible to redirect cognition away from pain, exposing the fallibility of Descartes’ notion of pain due to “the abysmal separation between body and mind.”10 By managing pain and emotion, even if just with medication, we indelibly address the human condition within each patient (in spite of potential inadvertent intention).
So, as physicians, we are obligated to find some semblance of a soul within our patients. But does that mean we appease that soul when it shrieks in pain? Is that not at the heart of our current opioid epidemic? What is the source of the complaint? Why is a patient truly in pain? More importantly, what is their pain? I am not talking about sharp, searing, stabbing, dull, diffuse, radiating descriptors of pain, but literally and figuratively, what is the composition of their pain? In essence, pain is such an individual manifestation of emotions and physical sensations, that I wonder if we can ever truly say that “pain is controlled.” Perhaps “manage” approaches a more realistic perspective of pain, but perhaps more prudent would be “listen.” Maybe it is not that we need to immediately eliminate the pain, but rather investigate it, try to see from which obscure realm of the body and mind it stems, identify possible exogenous influences, and then respond to why the result of these interactions is pain. This may in fact not involve removing the pain. Rather, it may involve addressing the primary source of the pain, while also recognizing that it is a sign of unrest in the body, a warning flag.
However, we are confronted with a society that now views drugs not only as alleviation for pain, but as answers to improving life overall. Whether or not this stemmed from the accelerating rhetoric around chronic pain management in the 1960s is debatable. What is clear is that there is a cultural blurring of the lines between quality of life and interpretations of pain. In short, we no longer wish to see the red flag that pain may be waving in our face.
Pain has a reason. Given our current narcotic predicament, it seems that the pendulum for pain management has swung too far simply for comfort of living. Herein lies another possible etiology for pain, beyond traditionally prescribed neuropathic, somatic, and visceral types of pain: psychological. Can fear of pain de facto manifest pain?
Pain is riddled with mystique. And as human beings, such obscurity is unnerving; it is not amenable to our categorical labels. Nevertheless, just because we have something does not mean we have to use it. I have sprinklers for my lawn, but that does not mean I water all day long. Rather, I schedule the sprinklers to run just enough to keep the grass from dying in 100-degree heat, but not so much that it becomes neon green and water is streaming down the sidewalk, being wasted. Likewise, we have access to pain killers, but perhaps that pain should not always be killed; perhaps there is a robustly essential component to it that plays a role in developing our evolutionarily self-protective and self-awareness mechanisms. An intangible manifestation of brain, body, and soul, pain reflects the gruesome battle raging within the human body, between potassium ions and cardiac myocytes, limbic neurons and emotions, leukocytes and cytokines, in addition to the thunderous tsunami of the outside world that crashes against the shores of the soul on a regular basis. But who determines how much is too much? How far do we push back into the chaos? Who decides where to draw the line between patient human dignity and necessary distress?
- Traite de L’Homme. Descartes R. Paris, France: Angot; 1664.
- Murphy H. At 71, She’s Never Felt Pain or Anxiety. Now Scientists Know Why. The New York Times. March 28, 2019:A7.
- Chen J. History of Pain Theories. Neuroscience Bulletin. 2011;27(5):343-350. doi:10.1007/s12264-011-0139-0.
- Olson KA. History of Pain: A Brief Overview of the 17th and 18th Centuries. Practical Pain Management. 2015;13(6). https://www.practicalpainmanagement.com/pain/history-pain-brief-overview-17th-18th-centuries?page=0,1. Published June 12, 2015. Accessed March 26, 2019.
- Descartes R. Traite de L’Homme. Paris, France: Angot; 1664.
- Weiner DB. Dr Roselyne Rey. History of Psychiatry. 1995;6(23):409-410. doi:10.1177/0957154×9500602310.
- Chen J. History of Pain Theories.
- Collier R. A Short History of Pain Management. Canadian Medical Association Journal. 2018;190(1). doi:10.1503/cmaj.109-5523.
- Bourke J. The History of Medicine as the History of Pain. History Today. 2011;61(4). https://www.historytoday.com/joanna-bourke/history-medicine-history-pain. Accessed March 26, 2019.
- Collier R. A Short History of Pain Management.
- Damasio A. Descartes’ Error: Emotion, Reason, and the Human Brain. Journal of Psychosomatic Research. 1996;41(4):386. doi:10.1016/s0022-3999(96)00093-1.
KYRA MCCOMAS is a third-year medical student at the University of Utah School of Medicine who has a passion for historical literature and writing, in addition to her zeal for medicine, humanism, and patient care. She studied history and biochemistry as an undergraduate at Santa Clara University. If she has a day off, she can be found venturing into the mountains, either hiking, snowshoeing, or skiing with her dogs.