The Problem of Pain

What is pain? Everybody knows because everybody has suffered it, but nobody can tell anybody else. Dictionaries are hopeless.* The late Sir Charles Sherrington, who collected no fewer than 22 honorary doctorates for his brilliant researches in physiology, called pain "the psychical adjunct of an imperative protective reflex." That may be fine for another physiologist, but it is no help to a man with a nail through his foot. Although pain is what drives most patients to a doctor, it is the symptom to which, all too often, doctors pay least attention. One good reason: it is the subject about which they know least.

To beam a little light into this area of ignorance, the Journal of Chronic Diseases last week devoted its entire issue (110 editorial pages) to pain and its relief. The learned contributing experts are far from unanimous on how to define or measure pain, but they agree on one thing: something should be done about it.

Eskimos Too. The University of Oregon's Dr. Frederick P. Haugen reports that dogs raised from puppyhood in a solitary, restricted environment, so that they cannot hurt themselves or be hurt, do not act as though they feel pain when tested in early maturity. Even Sherrington's "imperative protective reflex" is missing--these animals have to learn to stay away from a hot stove, and it takes repeated burns to teach them. Dr. Haugen comments: "The influence of past experience and learning is evident in any group of patients as one observes the notable differences in their reactions to stress and pain."

Researchers have been busy with the distinction between pain itself and a sufferer's reaction to it. Why does a Szechwan coolie grit his teeth and stifle his cries when, with no anesthetic, his leg is sawed off, while a Madison Avenue account man leaps out of his grey flannel suit at the first brrr of the drill on a heavily novocained tooth? Does a Chinese feel pain less than an Occidental? Probably not, according to Dr. James D. Hardy, who (with Dr. Harold G. Wolff and Helen Goodell) pioneered in measuring pain on a "dolorimeter" at New York Hospital. Using a lens to focus the heat from an electric bulb onto a blackened area of skin, Dr. Hardy has compared the "pain thresholds" of whites, Alaskan Indians and Eskimos. The Eskimos' readings were a bit blurred because of language difficulties, but all three racial groups tested said "Ouch!" or its equivalent at the same amount of heat, i.e., when the skin temperature hit 113DEG F. Yet an Eskimo has been known to hack off his own gangrenous foot to save his leg. The conclusion: the differences between races and cultures must lie in the "psychical adjunct" part of Sherrington's definition--in the reaction to pain, not in the pain as such.

How much pain can a man bear? Nature, says Dr. Hardy, has provided him with a built-in ceiling. On the Hardy-Wolff-Goodell scale, pain is measured in ten degrees of one "dol" each. With their lamp heat, the researchers found that when the skin temperature got to 152DEG the pain reached its excruciating maximum. After that the pain stayed constant no matter how much heat was turned on.

By this reasoning, medieval torturers were wasting their time devising complicated machines to mangle their victims. They could have achieved the maximum of pain with the simplest means.

"An important implication." says Dr. Hardy, "is that high-intensity, intractable pain is a physiologic impossibility, and no pain, even at threshold level, can be sustained without remission for long periods of time. So-called intractable pain must therefore be of low intensity, periodic, or must not be truly pain at all, but rather a combination of nonpainful sensations which are interpreted by the individual as unpleasant and unacceptable."

Simple Salt. In the hospital the most frequent and most neglected pain is that of the patient fresh from the operating room, says Baylor University's Dr. Arthur S. Keats. But this pain is by no means universal. He and many other researchers have found that few patients complain of pain after a surprisingly long list of major operations--surgery on the head and neck (including thyroid), hand and wrist, genital organs, or after amputation, skin graft, removal of a breast, stripping of a vein, fracture reduction, nailing of a hip or dressing of a burn. The operations most consistently followed by pain are those in the chest and abdominal cavities.

No matter how real the pain, the reaction to it varies vastly with the individual and the circumstances. Boston's Dr. Henry K. Beecher noted in World War II that only one-fourth of the soldiers seriously wounded in battle complained of pain (their wounds meant the end of combat and return to safety); among civilians with comparable wounds produced by surgery, three-fourths complain. When Dr. Keats slipped such patients injections of simple salt solution instead of the narcotic they expected, 43% said that the pain went away. Other patients, told that they were to get "a new drug which was not very good,'' actually got a wallop of morphine; four out of 21 reported their pain no better, or actually worse, but when they got the salt solution an hour later, they suddenly felt fine.

For the very real pain that follows many operations, and for the kind that so often bedevils the cancer victim, the experts agree that the best drugs are those of the morphine and methadone families. And the necessary doses can often be reduced by combining them with chlorpromazine. But because of addiction problems, the ideal drug to kill pain remains as elusive as the definition of pain itself.

* Webster makes two painful tries: "(a) A form of consciousness characterized by desire of escape or avoidance, any varying from slight uneasiness to extreme distress or torture. (b) An affliction or feeling proceeding from a derangement of functions, disease, or bodily injury." Dorland's American Illustrated Medical Dictionary gives up without even a moan: "Distress or suffering."

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