To be in physical pain is to find yourself in a different realm -- a state of being unlike any other, a magic mountain as far removed from the familiar world as a dreamscape. Usually, pain subsides; one wakes from it as from a nightmare, trying to forget it as quickly as possible. But what of pain that persists? The longer it endures, the more excruciating the exile becomes. Will you ever go home? you begin to wonder, home to your normal body, thoughts, life?
Ordinarily, pain is protective -- a finely wired system warning the body of tissue damage or disease and enforcing rest for the bone to knit or the fever to run its course. This is known as acute pain; when the tissue heals, the pain disappears. When pain persists long after it has served its function, however, it transforms into the pathology of chronic pain. Chronic pain is the fraction of pain that nature cannot heal, that does not resolve over time, but worsens. It can begin in many ways -- as trivial as a minor injury or as grave as cancer or gangrene. Eventually, the tissue heals, the diseased limb is amputated, or the cancer goes into remission, and yet the pain continues and begins to assume a life of its own. The doctor assures the patient she is fine, but the pain worsens, the body sensitizes, and other parts begin to hurt, too. She has trouble sleeping; she stumbles through her days. Her sense of her body as a source of pleasure changes to a sense of it as a source of pain. She feels haunted, persecuted by an unseen tormentor. Depression sets in. It feels wrong ... maddening ... delusional. She tries to describe her torment, but others respond with skepticism or contempt. She consults doctors, to no avail. Her original affliction -- whatever it may have been -- has been superseded by the new disease of pain.
Chronic pain is a specter in our time: a serious, widespread, misunderstood, misdiagnosed, and undertreated disease. Estimates vary widely, but a 2009 report by the Mayday Fund, a nonprofit group, found that chronic pain afflicts more than 70 million Americans and costs the economy more than $100 billion per year. Another study in the United States indicates that as much as 44 percent of the population experiences pain on a regular basis, and nearly one in five people describes himself or herself as having had pain for three months or more. Much of the degraded quality of life from diseases such as cancer, diabetes, multiple sclerosis, and arthritis stems from persistent pain. In one survey, most chronic pain patients said that their pain was "a normal part of their medical condition and something with which they must live." One-third of the patients said that their pain's severity was "sometimes so bad [they] want to die." Almost one-half said they would spend all they have on treatment if they could be assured it would banish their pain.
Yet treatment for chronic pain is often inadequate. In part, this is because it is only in recent years that chronic pain has been understood to be a condition with a distinct neuropathology -- untreated pain can eventually rewrite the central nervous system, causing pathological changes to the brain and spinal cord that in turn cause greater pain -- though this new understanding is not widely known. Chronic pain is sometimes defined as continuous pain that lasts longer than six months, yet chronic is not ordinary pain that endures, but a different condition, in the same way an alcoholic's drinking differs from that of a social drinker. It is not the duration of pain that characterizes chronic pain, but the inability of the body to restore normal functioning.
"The history of man is the history of pain," declares Pnin, a character in a Nabokov novel of the same name (a name that is itself just one letter removed from the word pain). The longing to understand physical pain and to alleviate it has threaded through all of human history, from the earliest records of thought. No single discipline seems adequate to address or represent pain, because every lens through which one tries to examine it -- personal, cultural, historical, scientific, medical, religious, philosophical, artistic, literary -- fractures pain into a different light. In the Sanskrit Hindu scripture, the Bhagavad Gita, the god Krishna speaks of "life, which is the place of pain ... " What is pain whose place in life is so central? To unravel its riddles, we must look at the ways in which pain has been understood and interpreted. These understandings seem to fall into three basic paradigms. First, there is what we might call the premodern view, in which pain is never simply a bodily experience, but reflects a spiritual realm suffused with meanings and metaphors, from the pain-causing demons of ancient Mesopotamia who spread their wings wide, to the Judeo- Christian tradition in which pain begins with the expulsion from Eden. "Thorns also and thistles shall [the ground] bring forth to thee," God condemns Adam -- a curse that is transformed, in Christianity, into a means of redemption.
Pain was also seen as a force that could be used for positive spiritual transformation. Pilgrims and ascetics in many different traditions elected to draw closer to God by undergoing painful rites, and martyrs embraced painful death. Belief in pain's spiritual properties made pain the critical instrument of jurisprudence in the premodern world -- not only as the appropriate punishment for crimes but also for determining guilt, both through torture and through the curious precursor to the jury trial known as "trial by ordeal," in which the suspects were subjected to painful rituals (such as holding a hot iron, walking on hot coals, or plunging a hand into boiling water). If God failed to protect them from pain, they were deemed guilty.
The premodern paradigm is not entirely obsolete; although it has been supplanted, it has not been expunged. To understand our attitudes toward pain today, we must understand the legacy we inherit from five thousand years' worth of struggle to make sense of this mortal condition. Suffering was -- and still is -- regarded by many as something that can, must, or ought to be endured. Although it is difficult to believe, the invention of surgical anesthesia (through the inhalation of ether gas) by an American dentist in the mid-nineteenth century was controversial at the time. Many agreed with the president of the American Dental Association, who declared, "I am against these satanic agencies which prevent men from going through what God intended them to go through." The use of anesthesia during childbirth was especially controversial, as it was believed to circumvent the divine injunction to bring forth children in pain. Even after the invention of anesthesia, many surgeons continued to perform surgery without it, including experimental surgeries on slave women who were said not to suffer the same pain as their mistresses. The premodern understanding of pain was replaced in the mid-nineteenth century by a new biological view of pain as simple, mechanistic sensation: a function of nerve endings that send predictable pain signals to the brain, which responds passively in turn with a proportionate amount of pain. Influenced by Darwin, the biological view of pain saw all pain as protective -- serving, usefully, as a warning of tissue damage. The remedy for pain seemed plain: treat the disease or injury, and the pain should take care of itself.
Excerpted from The Pain Chronicles by Melanie Thernstrom. Published in August 2010 by Farrar, Straus and Giroux, LLC. Copyright 2010 by Melanie Thernstrom. All rights reserved.
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