'Where Doesn't It Hurt?': Human Pain Has Physiological Roots, but Also Spiritual, Cultural and Emotional Ones. the Author of 'How We Die' Muses on Its Nearly Poetic Complexity

Newsweek, May 19, 2003 | Go to article overview

'Where Doesn't It Hurt?': Human Pain Has Physiological Roots, but Also Spiritual, Cultural and Emotional Ones. the Author of 'How We Die' Muses on Its Nearly Poetic Complexity


Byline: Sherwin Nuland, M.D.

The first patient assigned to me as a medical student learning orthopedics half a century ago was an elderly immigrant woman, about whom the harried resident had told me simply that her chief complaint was "pain all the time." Uncertain how to proceed with the evaluation of such a global problem, and aware that I had to speak to her in straightforward terms she would understand, I stood hesitantly at the foot of the bed for a moment while framing the question that I hoped would bring some focus to my history-taking. "Mrs. R," I began, feigning an authority I did not feel, "where does it hurt you?" She looked up at me with a grimace that was part physical discomfort and part impatience, and said, "Ach, sonny, where doesn't it hurt me?"

Mrs. R was teaching me much more than she knew, and certainly much more than I realized at the time. Though the physical aspects of her hurting proved to have been caused by the gradual collapse of two severely osteoporotic vertebrae, its reverberations could be felt all over her body and within her spirit too. As long as humans have kept records, they have reflected the awareness that there is far more to pain than mere discomfort at the site of injury or disease. To the Babylonians and to the most modern of neuroscientists alike, the evaluation and treatment of pain have been understood to require methods that deal not only with the origin of the noxious stimulus, but with emotions as well. Nowadays, the International Association for the Study of Pain defines the subject of its research as "an unpleasant sensory and emotional experience associated with either actual or potential tissue damage," but Plato's description was not much different: he said that pain is physical while also an experience in the soul. Thus, both ancient and modern sources leave wide latitude not only for understanding the complex origins of pain but for seeking clues to help deal with them.

Still, even such generalized words as "physical" and "emotional" encompass far more than merely the site of origin, the neurological pathway to conscious awareness and the psychological accompaniments. Pain when sufficiently severe is capable of setting off a cascade of biochemical actions that affect hormone and enzyme production, circulation, voluntary and involuntary muscle, and reactive tissues in numerous organs of the body. The unpleasant consequences of all these responses are multiple and additive, whether they are expressed as directly as Mrs. R's hurting all over or in more literary terms as in Cervantes's, "When the head aches, all members partake of the pains. …

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