Humans tend to think in terms of that for which they have a frame of reference. There is no frame of reference for severe pain unrelated to a flesh injury, for an injury induced chemical/genetic defect in the nerve itself. Therefore, central pain is unthinkable.
Certain ideas are so big that they require too much reflection, too much work even to form a frame of reference. For example, quantum physics. There is a pain of reflection if there ever was one, focused mainly on the interface between matter and waves, and the point at which one becomes the other. In the end, these things being nonintuitive, they are best discussed by mathematics. The average person could not care less. However, such considerations led to the atomic bomb and a reality that we must all deal with. You can pay me now or pay me later.
We are used to more concrete things and strongly prefer to think in those terms. This does not insulate us from the consequences of that which is almost indescribable and beyond our frame of reference. In this day and age, we all use things constantly which we do not understand. The computer on which this article is typed is one example. The recombinant DNA vaccines might be another. And then we come to pain. Central pain is too large an idea to be a popular topic of discussion. It is simply huge, and represents pain flowing outside its channels in a flood of chemical exciters which can only be discussed in terms of synapses, kinases, nerve growth factors, ion channels and the like.
By pointing this out, we have already established that the public is not interested, any more than we are interested in how the one key element works which Danish physicist Niels Bohr withheld from the Soviets during WWII in order to prevent them from making an atomic bomb. Pain has the same necessary balance of ingredients, but only the brightest neurochemist can grasp it. The bonding angle chemists can calculate as they may, but please don’t burden our brains with such high level stuff. The public cannot imagine pain on which morphine and other opiates have no effect and they are especially NOT interested in the chemical architecture of opiate receptors nor in NMDA.
This is the situation of nerve injury pain. The SENSATION of pain is clear enough for anyone, it is assumed. It is, in fact, the most clear sensation in the body. It requires no intellect. Animals are perfectly capable of feeling it and happen to possess all or nearly all of the same cascade of chemical pain exciters as mankind. It is not an intellectual sensation. It IS, however, powerful–an atomic bomb if the proliferation of ion channels explodes in the dorsal root ganglion and thalamus. It then becomes a pain Armageddon.
Asking the public to take this elemental, automatic sensation and understand it in terms of the complicated flow of ion channels in an action potential is just cruel. Since central pain can only be understood that way, bringing it up can be futile. Pain is simple. Central Pain is VERY complicated. There are at least five types of pain buried in burning dysesthesia, including burning, cold, wetness, creepiness, and a nerve directness reminiscent of how cold metal is uniquely sensed. It causes panic as well, but whether that is due to a unique component or to the degree of pain, we cannot say.
Of course it is much more cruel to ask us to endure central pain without any attempt to render help or encourage research. It is a public shame and condemnation not to fund research by those who do understand biochemistry well enough to find ways to stop nerve injury pain. We need a Manhattan project to STOP pain, employing the brightest of the bright, which must include funding the work to whatever degree necessary. It would be a peaceful, mankind friendly, commitment. It is not enough to say central pain is complicated and doubtful and walk away busily. This brands the indifferent observer’s charity as uninformed, inauthentic, and shallow. It takes a conscious desire to alleviate suffering to listen and to respond. Our demands must be made louder and more insistent or we will continue to be drowned out.
In the old days, surgeons worked by having four strong men hold the patient down. It was brutal to say the least. At the time that Morton, a dentist, discovered ether, approximately one in three people at Johns Hopkins committed suicide rather than undergo surgery. This should have said something, created some drive to stop surgical pain. Still, so linked was pain with “God’s will” in the misguided “religion” of the day, that the majority of surgeons in the Johns Hopkins Surgery Department angrily rejected ether.
Had it not been for one stubborn surgeon, brave enough to withstand the mockery and accusation, Morton’s discovery would have been for naught. Once ether was accepted, the lawyers went after Morton. Verbalizing anything they wanted into existence, they broke him on the astounding claim he had infringed on someone else’s idea; namely, his chemistry teacher. Morton died penniless, undernourished to the point of illness, virtually starved to death by legal fees in his own defense. We had all better be prepared to put in a good word for him on judgment day. He was a benefactor of all mankind.
If you think this description of Morton’s neglect is exaggerated, ask yourself who discovered local anesthestics, ketamine, or the epidural. HINT, the epidural was discovered in the 1930′s by one of the early contributors to painonline, but suppressed for nearly fifty years because women were “supposed to suffer” in childbirth. Sound familiar? Pain is “God’s will” (for any condition which science has not yet found a cure, and despite the fact that the mission of Jesus, the prophets, and ALL religious leaders has included much about HEALING).
As to any pain which HAS been cured, well, that pain is not God’s will, even if the ignorant, benighted churches of the Dark Ages and Medieval times claimed it was. Today we know better, or do we? Superstition and amateurish psychology are not the least of the worries of thoss with Central Pain because they deter funding of research which would relieve our misery.
How is it that God would be thrilled with hurling a hundred billion dollars into space to look for “extemophiles” or to take pictures of golf balls bounced on the surface of Mars but would object to a few hundred million at NIH to end needless pain once and for all? We have a hunch the pain cures would sell for more than the pictures of Mars (a lot more actually), thus helping the economy as well as those with pain. We could also quit paying warlords to grow opium in distant countries. What is a SECOND fisheye view of the moon worth, really? Even the National Science Foundation views much of that work as entertainment and consumptive, not scientific and productive. The EYE loves its delights, but the mind hates its hard exercises.
As to the lawyers who destroyed Morton, it would not be particularly surprising if they were all damned to hell. If only nerve injury pain medicine could be formulated as easily as lawyers can verbalize anything they want into existence. This only makes the truly moral and outstanding lawyers that much more admirable. If that profession were filled with men the caliber of Justice Traynor and the like, we should have no more problems with the courts.
Once it was shown plainly enough that ether worked, the Hopkins faculty largely came around. Their stubborness is buried today, as is Osler’s recommendation of leeches for peptic ulcers. The turnover required admitting that they had been routinely subjecting humans to the worst kind of tortures, in order to save them. The ego of surgeons, especially at the top institution of the day, had a hard time with that, but the specialty of anesthesiology was born kicking and screaming and has survived. The reason is, of course, that pain hurts.
Prior to this, for hundreds of years, certain countries, notably Holland, were so religious that they customarily put to death anyone making any effort to relieve a woman of the pain of childbirth. Their clerics had read Genesis to say a woman was saved in childbearing, and so of course anyone depriving a woman of her suffering, was destroying her soul. This is sufficient to demonstrate the absence of rational reflection when most people think about pain, especially if they view their ideas as validated by, or originating from, religion.
The problem at Hopkins, of course, was the lack of a frame of reference. Almost no one there had undergone surgery, especially the surgeons performing it. Had they done so, they would have been looking for little else than a way to stop surgical pain. We are only objective about other people’s pain. Our own matters.
Today, we see something of the same phenomenon. Very few people have had to experience central pain. Even among spinal cord injured subjects, central pain is the exception, rather than the rule. The paralyzed and the partially paralyzed have plenty to worry about without thinking about about those oddballs claiming to have constant, unbearable pain. A notable exception to this was Christopher Reeve. No doubt he wished as fervently to walk as any SCI patient ever has. Nevertheless, he donated fifty thousand dollars to the study of central pain, which he did NOT have. This is perhaps one of the greatest instances of generosity in medical history.
Mr. Reeve had to know that the fifty thousand could do something significant in the way of stem cell research and spine regrowth. Instead, he provided the money for pain research. Is there a greater instance of charity than this by an SCI person? The result was that Bryan Hains at Yale discovered that the Nav1.3 ion channel was responsible for nerve injury pain. This was an enormous breakthrough. We can never thank Christopher Reeve enough. May God rest his soul and that of his supportive spouse, who, it is said, talked him out of ending his own life. He must have had deep feelings and hope about a chance to walk, but instead he opened the door for a chance for others to escape the terrible onslaught of central pain. At judgment, when he faces his Maker, we should all rise to say a good word for him, for his great and charitable act.
Now we are engaged in a very similar struggle about central nerve injury pain that Morton encountered over ordinary pain. Since central pain is a nuclear explosion of pain sensations, it is simply outside the frame of reference of most people, who certainly cannot imagine that anything could be worse than their own pain. The great neurosurgeon, George Riddoch, who declared central pain to be a “pain beyond pain” was just talking words, surely, they might say. NOTHING could be beyond pain, could it? Because central pain is so big and so terrible, and mostly because WE don’t have it, it must be a mistake. We are justified in not inquiring after it. “Pain beyond pain” doesn’t make sense. Neither does the CP patient.
The behavioralists rush to explain it in terms of weakness, poor psychology, or whatever. However, the pain chemists have no problem with it whatsoever. They can create it with little effort in lab rats, cats, monkeys, or any animal they choose. All that is necessary is to use a mechanical drop weight on the cord, or to laser it. This relatively nonspecific injury will do the trick. From then on, the animal will writhe at light touch, at the stroking of the fur with a soft brush, or when seated on a hot plate at a temperature which causes no reaction in normals. If this is not enough, they can remove the dorsal root ganglion and measure the concentration of pain chemicals. The DRG is drenched in the acid chemicals of pain in CP. PhD’s doing this work would have to be stupid not to recognize what this means for humans, and so we have these men and women who believe us, if no one else does. The disbelievers include the majority of those with medical diplomas hanging on the wall, from institutions which considered pain to be be so insignificant that not a single day in medical school there was devoted to the chemistry of it.
But the situation is not really so bleak. The reason is that while the public and many clinicans cannot think in terms of the atomic blast–nuclear winter type of pain, they can conceive of pain in lesser doses, where it is PLENTY bad. The two examples of nerve injury pain which they do accept are:
1)herpes zoster (Shingles); and,
The curious thing about Herpes viruses is that once we have them, we never get rid of them. When our antibodies gain the upper hand over chicken pox and the like, these viruses retreat to the brain and spinal cord, where the blood brain barrier (use SEARCH at this site to read more about the blood brain barrier) prevents their complete destruction.
In this hiding place of the central nervous system, the Herpes viruses lay dormant, until some change in the immune system allows them to creep out again along the nerves. If they reach the cutaneous surface, blisters come out a few days after the burning pain (which is very similar to the dysesthesia of central pain) begins from nerve injury and there, the EYE can see that something is really going on along the nerve path. The rectangular distribution of a spinal nerve running beneath a rib which reddens the skin reminded someone of the shape of a shingle and hence, the popular name for Herpes Zoster. The important thing here is that there was some visual proof that some process was happening. Once a break in the skin was observed, the claim of pain did not seem too extreme.
In Bell’s palsy, the situtation is somewhat different. Several days before the unilateral drooping of facial muscles, there is a headache pain behind the ear, poorly localized. This headache is in all respects, similar to the headache experienced by those with Central pain who have involvement of the descending tract or nucleus of the Fifth Cranial nerve, so called facial central pain or trigeminal central pain. The viruses of Bell’s palsy are attacking a motor nerve for one side of the face. The lips,eyelids, and even skin around the nose droops. Typically, the patient is given some acyclovir, and if Herpes was indeed the dormant virus, the patient begins to get better in a couple of weeks. This treatment, followed by improvement, plus the drooping which can be seen by the EYE, legitimized Bell’s palsy and there has been little or no mocking or blaming the whole matter on behavioral factors.
Now what can be seen by the EYE in central pain? For the public, the answer is NOTHING. As to the PhDs who study rats, they can see that the little animals are chewing off their legs (autotomy), squealing and writhing at nothing more than the stroke of a brush on their fur, movement, or a warm surface. This visual confirmation, plus the chemical assay, makes CP unquestionable for the neurochemist. However, clinicians have no idea how to do neurochemistry, have forgotten what a kinase is, never got into ion channel currents, and so the whole matter is just too big to think about. Mormal pain is within the reach of the imagination. Constant unbearable pain over the whole body. That is just too much to swallow, even for many M.D.’s.
As it happens, we have these friends, the ones with Shingles and the ones with Bell’s palsy. They know perfectly well that they have had pain. And so, these victims of lesser variations on the theme of nerve injury become unknowing spokespeople for the Mother of all pain states, Central Pain, the end of the personality and soul. One must be a scientist to understand what is going on in CP. We cannot expect others to grasp it, to understand what is behind it, or to wish to be concerned about it. If you want someone to listen, you better find someone who has had Shingles or Bells’ palsy. THEY will accept that you suffer.
Still, it is the squeaky door which gets the grease. If we wait until the public is behind us before demanding that research money be allocated to stop central pain we will have a good long wait. Thank goodness there are minor variants of nerve injury pain (although not minor to the people who must endure it) or we would have no credibility among clinicians. There is of course also peripheral nerve injury pain such as in RSD (complex regional pain syndrome) or diabetic neuropathy to stimulate the drug companies to take interest since the market is there. About 100,000 people have some degree of central pain, but millions have diabetic neuropathy.
It is doubtful that there is any area of human life about which there is more superstition than PAIN. A book on how to end your own pain in some way doctors have not yet figured out will frequently be a bestseller although it has all the earmarks of quackery, and even if previous books of that nature failed to bring results. We WANT to believe pain is that way. The search for the Holy Grail continues and a number profit from claiming to have a map.
More is spent on pain relief than any other medical problem, but this is nearly always minor pain. The commonality of the shared human experience of manageable pain is why outlier pain which is life threatening by virtue of its severity seems unbelievable. The public does not fear pain because they know pain medicines are available. They do not fear surgery because anesthesia is available. Should pain become severe, just take more opiates. The medical profession is not talking about pain which they cannot touch, and is not likely to start talking about it. Why hang out your dirty linen?
Should anyone actually come face to face with central pain, the rest of the world becomes irrelevant. Everything else pales by comparison. This sounds irrational. There is so much that is important in life. Why ruin it by worrying about pain. Why indeed? We are either utterly indifferent to or completely preoccupied by central pain.
Yes, we have had a cord or brain injury. What that has to do with pain will not register with the public. It is somewhere beyond quantum physics. It is quite possibly an accusation against God even to claim to have such pain. And so, along with the humble lab rats, we thank those with Shingles, Bell’s palsy, and PNI, who speak out. They present small pieces of nerve injury pain for the public to hear about. WE sound beyond extreme, and in fact ARE beyond extreme. We have pain beyond pain. May God and the PhD’s help us and may the religious pain worshippers leave us alone. And no thank you, no thank you, we do NOT wish to read the book of Job again (at least not until YOU take advanced neurochemistry). We notice the book is particularly hard on those who attributed pain to some weakness in Job. You missed the point. You are irrational in your religion, just as you are not sufficiently educated to be irrational in your chemistry. Think of acid in the nerves, and eventually you will get the idea.