shooting the messenger

1

CHAPTER-1

Shooting the Messenger

Figure-1. Athena. DeviantArt.com ©2010-2012 Juraj Nevolnik

KNEE DEEP IN PAIN Shooting The Messenger

Next Chapter: Hastening The Inevitable

he gods were running out of amusing things to indulge

themselves with. Poseidon was getting tired of slapping

mermaid tails and Zeus had run out of targets after

destroying much of the forest with his bolts of lightning fired

from the top of Mt. Olympus. Feeling a bit mean spirited the

brothers plotted to have some serious fun.

They decided to hold a special give away. They announced they

would hand out gifts, offering four; Beauty, Brains, Drama and

the fourth was a mystery item labeled ‘P’. The only rule was,

while anyone could pick one of the four and walk away with it,

if someone went on to take two they must accept the mystery

gift as well.

Narcissus happened to glance up from the edge of the still pond

where he was sitting admiring his looks, and mumbled:

“I am already beautiful, who needs brains; they are boring, I

have no interest in mystery,

but…hhhmm… I could surely use

some drama…”.

He took that one.

Big surprise there!

Aphrodite came along and knowing that brains were so

overrated snapped up Beauty, and quickly departed fully aware

of the trouble the brothers were capable of.

Athena was passing by and decided she was definitely

interested. She selected Beauty and of course without wasting a

breath also immediately picked up Brains.

Bamm! Zeus roared:

“Athena, you and your sisters will forever live with Pain”.

Unwittingly she had been awarded the mystery gift ‘P’. Athena

complained loudly but no one heard.

T

Summary Pain is not welcome but it

serves a purpose. This chapter outlines a brief history and general discussion of pain.

3

She tried to console herself by assuming the two gods were

talking about sharing life with a man, which can bring

unbounded misery all on its own. Finished with their

particularly mean prank, one brother went back to chasing

mermaids, while the other flew back up to the throne on the

mountain amidst smoldering remains of previously zapped tree

tops. Both brothers completely oblivious of the damage their

prank was about to do.

Narcissus was too busy with “Mmwahh… Mmwahh” kissing

his own reflection in the pond. It is said he stars in several soaps

on daytime American TV. Judging by how long some of the

soaps have been airing, there might be some truth to that rumor.

One thing is certain. Women’s pain is real. Even though it

has taken society a very long time to acknowledge it, primarily

because women were expected to suffer in silence, and they did.

Historically what carried more weight was pain in a ‘man’.

Something else has changed. We will see that later toward the

end of the chapter in a conversation about some special

receptors.

Claudius Galen (129-199 A.D.) would know pain when he

saw it. He was the Roman physician officially appointed to

taking care of gladiators.1 Given the cuts, bruises, bludgeoning,

hammering, stabbing and piercing these combatants endured in

the arena there would be no dearth of material for Galen’s study

on treating pain. A picture of a real life gladiator can be painted

from findings of two pathologists at the Medical University of

Vienna 2 working on an archaeological dig in Turkey.

They examined 67 bodies with painstaking detail in what

appeared to be a cemetery where gladiators were buried. Marks

and scars on the bones of skeletons indicate healed wounds on



these professional fighters who were expensive to maintain for

their nourishment, training, and medical treatment. Most of

them were young, in their 20s and 30s and since this was a

profession, perhaps adequately lucrative, they repeatedly

returned to combat until they were either killed by another

combatant, or were so badly wounded someone had to finish

them off, possibly an associate, fulfilling a mutual pact of mercy.

Do individuals experience, and express pain differently?

Apparently pain expression does have predictable religious,

cultural and ethnic elements to it. If you grew up in a first

generation immigrant family in North America you would have

been exposed to some confusing signals about how varying

degrees of pain are expressed. For instance in some cultures,

middle aged and sometimes even younger people will groan

when sitting down or getting up.

Figure-2. Pain everywhere. Pollice Verso. (Thumbs Down). Jean-Léon

Gérôme. Phoenix Art Museum 3

For many of us it would sound like the person is in pain but

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that may not be the case at all. For instance, in a study published

in 1991, female Mexican patients moan when uncomfortable but

it may not mean they are suffering from pain. Nevertheless,

nursing staff view them as whiners who have a low tolerance for

pain.4 Such lack of awareness of cultural differences can create

peculiar situations in the delivery of healthcare.

In 1993 authors of the same study looked at two populations

of women patients, one Anglo American and the other Mexican

American, and asked them to use the McGill Pain Questionnaire

to evaluate pain they were experiencing after a cholecystectomy.

Multivariate analysis of variance (MANOVA) was employed to

see if there were any significant differences in the two groups on

any measures of pain. There weren’t any. Nursing staff were then

asked to rate pain experienced by patients based on the two

groups of women’s responses. As it turned out nurses assigned

more pain to Anglo Americans and judged the Mexican

American women’s pain to be less.5

In the paper ‘Culture and Pain’, 6 Gary Rollman quotes an

article from the 1985 issue of Clinical Journal of Pain

“..Scandinavians are tough and stoic with a high tolerance to

pain; the British are more sensitive but, in view of their

ingrained ‘stiff, upper lip’ do not complain when in pain; Italians

and other Mediterranean people are emotional and overreact to

pain; and Jews both overreact to pain and are preoccupied with

pain and suffering as well as physical health.”7 Quoting another

study Rollman writes about how some Christians, in an attempt

to identify with Christ’s own pain and suffering, embrace pain

either when it is accompanied by disease or inducing it by “self-

chastisement” as in stigmata.8

According to the Institute of Medicine, well over a 100

million American adults—more than the total affected by heart



disease, cancer, and diabetes combined, suffer from chronic pain

at a cost of up to $635 billion each year in medical treatment and

loss of productivity.9 In his testimony, Dr. Philip A Pizzo, Dean

of the Stanford University School of Medicine as well as

Professor of Pediatrics and of Immunology and Microbiology,

called the magnitude of pain in the United States ‘astounding’,

with more than 116 million Americans suffering from pain that

persists for weeks to years. This data does not include children,

individuals in nursing homes or chronic care facilities, prisons or

the military, making the impact even more significant. Authors

of the study, released in 2011, argue for ‘relieving pain’ to be

given a national priority given the toll it takes on human lives

and social consequences, not to mention the hard dollar costs.

Figure-3 "Kaibo Zonshinzu Anatomy Scrolls (1819) 11

There is also a gender element in sensitivity to pain.10

Women are more frequent sufferers, but seek help more readily,

and as a result recover more quickly from pain. They are also less

likely to allow pain to control their lives. Unfortunately, biology

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and skeletal differences make women more prone to pain, and

they also feel it more acutely than men. A constant and

unavoidable irritant in women’s anatomy is the Q-Angle,

covered in the chapter Care to have a joint? Other causes of pain

may be explained by hormonal differences. When researchers

injected male mice with estrogen, a female hormone, the result

was a lower tolerance for pain. However, female mice when

injected with testosterone, a male hormone, resulted in the

female mice exhibiting a higher threshold for pain.

So, what is pain?

Galen of Pergamom, the gladiator physician, who was a

famous anatomist and also served as personal physician to the

Roman emperor Marcus Aerilius, distinguished three types of

nerve: "soft" nerves, "hard" nerves, and pain nerves, and believed

the brain was central to sensing pain. His contributions to

medicine are memorialized with naming of the ‘vena Galeni’ or

‘vein of Galen’; one of the larger vessels responsible for draining

the anterior and central regions of the brain.12

Up until Galen most of existing medical knowledge and

philosophy did not connect pain to the brain and dominant

thinking continued to identify pain as an emotional state. Plato

(c. 427 BC – c. 347 BC), the prominent classical Greek

philosopher, and founder of the Academy in Athens, thought

that the heart and liver were where the sensation of pain was felt

and it arose not only from peripheral sensation but could also be

an emotional response in the soul in the heart. 13 Plato’s student,

Aristotle, did not believe the brain had much to do with the

sensation of pain either. He was of the opinion that pain was the

result of evil spirits entering the body through injuries.

Hippocrates, known as the father of medicine, was of the



view that pain resulted from imbalances in the vital fluids.14 Ibn-

Sina of Persia [980-1037], a great Muslim physician known in the

western world as Avicenna, wrote extensively about the brain as

a center for pain sensation. He expanded Galen’s four pain

classification types to fifteen.15 Many of the terms used by Ibn-

Sina in his classification are strikingly similar to those used in

the 1975 McGill Pain Questionnaire16 developed by Ronald

Melzack in Canada. Earlier, in 1965 Dr. Melzack had introduced

the Gate Control Theory at MIT.

It was not until the mid 17th century when the brain became

center stage for pain sensation. René Descartes (1596–1650), a

philosopher, broke from established religious thought about

pain being punishment from God, and theorized that it had

nothing to do with the soul but instead there was a direct

mechanical pathway from the site of the injury on the human

body to the brain.17

Defining pain is not easy and explaining it is not that simple.

Scientists and researchers still struggle with identifying what it

is. What makes this topic a moving target for definition is the

variability of individual experiences in the severity and duration

of pain. The International Association of Pain describes it as an

“unpleasant experience”, both sensory and emotional.18 But

some people can feel pain when there is no apparent injury while

others do not feel it even when they are hurt. And still others

who have had a limb amputation continue to feel pain in the

limb that is missing. 19 Apparently, after the amputation, nerve

cells rewire themselves to continue to receive pain messages.

If the brain is part of the pathway for pain sensation does it

mean it could be mobilized to combat pain? The Gate Control

Theory 20 put forth in 1965 by Ronald Melzack who specialized

in phantom pain at McGill University in Montreal, and Patrick

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David Wall, a leading British neuroscientist, provided further

insight into the pain-brain connection. According to this theory,

pain messages reach neurons in the ‘substantia gelatinosa’, the

gelatinous caps in the rear dorsal horn of the spinal cord, and

from there the messages are sent to the brain (Figure-4, left

panel) through a gate mechanism which is held open for rapid

transfer of information.

Under normal conditions substantia gelatinosa also receives

messages from the brain. Further, according to the theory,

messages from the brain may “…make it possible for central

nervous system (brain) activities subserving attention, emotion,

and memories of prior experience to exert control over the

sensory input.” After the first sensations of pain are registered at

the brain, it is possible to

modulate the severity by

sending impulses to the gate

in order to close it (Figure-4,

right panel).

Thus messages from the brain could serve to offset or limit

the severity of pain at the spinal cord before pain sensation is

transmitted to the brain. Not only the brain, but sensory inputs

like rubbing or scratching the vicinity of the pain source can

help close the ‘gate’ to prevent or attenuate pain messages from

reaching the brain. What makes this theory particularly

interesting is that it is based on the differences in the types of

nerve fibers. Ones that carry ‘pain’ impulses are being blocked by

those that carry ‘touch’ sensations. Scientists know about this

difference in nerve structure and function.

Neurons are self sufficient nerve cells that conduct electrical impulses back and forth in the body. A vast majority of them are found in the brain. They die with age and disease.



Figure-4. Model of Gate Control Theory. © 2012 Nouvelle Sante. Knee Deep in Pain.

Pain happens to be relayed by very narrow diameter nerves and

travels at a slower speed, about half a meter per second.21

Known as ‘C’ fiber nerves they also take longer to recover in

between firing of impulses; this keeps the maximum to 250

impulses per second. In comparison, the ‘touch’ nerve, called the

‘A’ fiber, is wider in diameter, travels at up to 130 meters per

second and shoots at the rate of 2,500 impulses per second. There is one other difference; ‘C’ fibers are uncoated while

‘A’ fibers are sheathed within a ‘myelin’ hose structure, helping

in delivering noiseless messages that travel along highly focused

paths. The speed and protection of transmission make the ‘A’

fiber a very important ally against pain.

So, if you were a pain researcher who would you pick as your

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‘best friend forever’? Paris Hilton, of course. 22

When you accidentally touch

the hot surface of a toaster in

trying to get your bread out in

a hurry, it is the ‘A’ fiber over

which this information travels

to the spinal cord from where

a motor neuron shoots a

stimulus to the muscles in

your arm and hand to

withdraw instantly.

If it were not for the ‘A’ fiber

your fingers would be toast.

Just so they are not left

behind from the ‘pain inflicting party’, prostaglandins,

membrane associated lipids that activate whenever, and

wherever there is a problem, can cause pain by direct action

upon nerve endings. Even at low concentrations, they markedly

lower the pain threshold thereby increasing sensitivity. Lowering

of the threshold can cause even normally painless stimuli to

become exaggerated. When produced within the central nervous

system, they sensitize perception to painful substances. Pain is

thus induced both at the site and at the central nervous system,

where signals are processed.23 Prostaglandins are covered in

more detail in the chapter 10: Veni, Vidi, Vici.

When the Huns invaded China, the dreaded Shan Yu of

Hollywood, and leader of the ruthless warriors, claimed he will

kick a certain ruler’s behind before long. Little did he know that

it would be somewhat difficult since that certain part of the

emperor’s anatomy was a bit preoccupied. Being that he was

sitting on pins and needles, not worrying himself sick, but in fact

Dorsal Horn The dorsal horn is found towards the back of the spine through all levels of the spinal cord; cervical, thoracic, lumbar, and sacral. This area receives information from the rest of the body in ‘substantia gelatinosa’ cells at the cap of

the horn. These sensations include touch, vibration, temperature and pain. These sensory messages are then relayed to the brain. Please see Appendix for more information on substantia gelatinosa.



relaxing his mind to think clearly and to devise new strategies,

such as bringing Fa Mulan from Disney on board to fight the

invaders.

Not surprisingly the people who built the Great Wall also

knew a thing or two about gates. The pain relief practice that has

been used, and has thrived, in China for over 2,500 years, some

say 8,000 years, is acupuncture. It remains an an unfathomable

mystery, how, several thousand

years ago, without advanced

diagnostic and analytical

Equipment and billion dollar labs,

some geniuses in China figured out

a connection between nerves, pain

and relief.

The proposed mechanism used by

the gate control theory, validates

‘zhen jiu’ in a fascinating manner. 25

Inserting needles in the skin in

selected areas and then twirling

them stimulates the two sets of

nerves, containing ‘A’ and ‘C’ fibers.

Some of the initial pain sensation

gets through to the brain through

the spinal cord possibly because the ‘A’ fiber nerves have not

been poked yet. Once they get stimulated they start reaching the

spinal cord much faster and with higher frequency than the pain

carrying impulses, in effect closing the gate. At this stage pain

messages are unable to get through to the brain, in a sense,

bumping up against the closed door. This is like a “who’s your

daddy now” moment for the touch sensing ‘A’ fiber nerves

standing at the gate looking down at the pain sensing ‘C’ fibers.

The gate control theory does not explain how, pain remains

A name for Gate Control Theory does not exist in

Chinese, but if it did it would be called “chowmen kumchi luwen”

閘門控制理論.24

The Chinese name for acupuncture happens to

be 针刺 (pronounced chen

su, written zhen jiu). It translates as ‘needle thorn’ on Google. Pain Receptors are found at the receiving end of the neuron’s pathway for communications at the tips of dendrites; tentacle like nerves. They are found throughout all tissues of the body, including skin, muscles, joints, and organs.

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absent for several hours after acupuncture. And for itself,

acupuncture has not done well in studies 26 showing some

benefits of statistical significance but not enough for clinical

relevance and pain reduction “independently of the

psychological impact of the treatment ritual is unclear.”27

A 2005 study in JAMA concluded, “Acupuncture Treatment

No More Effective Than Sham Treatment In Reducing

Migraine”.28 Even if acupuncture was as effective as supporters

say, it still remains one of the pain remedies and another

weapon against the ‘messenger’. But we are still far from a cure.

Here we will return to the gender-pain connection and see if

men and women respond differently to medications. Well, at

least one remedy appears to be more effective for women than

for men. It has been discovered that pain killers that bind to

kappa-opioids receptors work better in women than men.

Researchers are not sure if it is a woman's estrogen that makes

them more effective, or is it a man's testosterone which

obstructs the mechanism for ‘kappa-opioids’ pain relief in men.

But any discussion really becomes strictly academic as the

person feeling the pain is less concerned about its definition and

more about how to seek relief. There is probably no mortal out

there who has gone through life without experiencing pain. In

fact, in the U.S., chronic pain is responsible for more disabilities

than heart disease, stroke, cancer, and AIDS combined.29

Regardless of where pain originates, prevailing scientific

thought tells us the sensation is communicated to the spinal

cord, from where it is transmitted to the brain to be registered in

memory.30 From there, as a response, signals are sent to facial

muscles where a visible reaction is conveyed and to other

muscles that may help in taking corrective action where the



original stimulus that triggered the pain occurred. At the same

time messages may be sent to muscles that control the vocal

chords to complain about the pain. It would be safe to assume

unless our brain tells us we have pain we will never know about

it.

Above all, pain is a crucial feedback mechanism. Without

registering pain we would not be able to stop and remedy

whatever we are doing that triggered the stimulus in the first

place, possibly causing irreparable harm to the body. Arguments

against the value of pain as a signaling and messaging

mechanism 31 will continue to place emphasis on finding new

and novel ways of ‘shooting the messenger’ while ignoring root

causes.

In this, modern medical treatment has diverged from

ancient practices. Where pain was, in many cases, supposed to

be a necessary part of sickness and salvation, the actual cause of

the affliction was given priority, and any cure, medical,

therapeutic, or magical focused on the problem and not the

pain. After all, Attila the Hun, in his lecture to prospective MBA

students, advocated shooting the person who did ‘not’ deliver

bad news.32 But it may have been tyrants like Attila the Hun, the

real one, who can be credited for the priority shifting from

curing the disease to the treatment of pain.

Imagine being a personal physician for a ruler. Every time

you stepped out to purchase herbs and ingredients to treat some

royal illness, people in the market place bowed out of respect

and gave you preferential treatment. After all you were

responsible for the king’s continued health. You were clearly

distinguishable because of the tall pointy hat you always wore in

public.

When the chemist would try to advise you the ingredients

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you are shopping for are not related to the malady you were

supposed to be treating, you would mutter under your breath

you don’t know my life. They don’t know how hard you get

whacked ‘upside your head’ when the king squirms in pain. And

the throbbing lumps make your head look like a potato with a

personality which you don’t want others to see.

Hence the tall pointy hat!

Now you need pain medication both for yourself and for

your liege.

For your own welfare and self preservation; ‘better to treat

the pain than the problem’; and in your defense, we understand.

Finding an actual cure for many of the diseases is just not that

simple, if at all possible.

Taking care of pain is only one aspect of treatment. If the

root cause is not addressed, pain will return. The longer it takes

to treat the source, the higher the chances the person will

eventually become a chronic pain patient.

For citations please see pages 253 through 257 in Bibliography.



Appendix

Spinal chord – gray matter Wikipedia User: Polarlys. CCA 2.5 Generic license.

Pain and other noxious information is transmitted through

myelinated delta-‘A’ and unmyelinated ‘C’ afferents to the

substantia gelatinosa in the dorsal horn, mostly to lamina II. SG

neurons exhibit a variety of excitatory and inhibitory synaptic

responses that range in duration from milliseconds to minutes.

The sensory received at the SG is modified and integrated

regulating the outputs of projection neurons located in lamina I,

IV–V. 33

shooting the messenger

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