Pain is a Fool

Pain is hard-wired into the deepest layers of our ancient sub-limbic brain, buried beneath swaddling layers of warm, mammal cortex. Pain is a foundation function -- a primordial alarm underlying the nervous system of every beast you know, from the stately sea cucumber to the majestic certified accountant.

Unlike, say, the body's artfully orchestrated endocrine ballet, pain is not metered or managed by any particular system. Rather, it is a decentralized, local phenomenon in which individual clumps of tissue get a chance to holler if they feel there is cause for alarm. If enough such clumps holler together it generally gets the attention of the large-scale organism (you), who is then expected to take some sort of rectifying action (withdrawing a limb from harm, for instance, or applying pressure to a wound).

Sometimes mistakes are made. Wires get crossed. Signals fire louder, chronically. Pain can strike without meaning, without new injury, confused and reactionary like a cornered animal -- primed for damage and anticipating the hurt.

It can strike anywhere, but those who believe that humanity's greatest achievement is bipedal locomotion would argue that the smartest indignity comes from chronic pain in the back -- for it robs them of their basic freedom to move. And who can blame them?

But those who prefer the world of the mind swear there is nothing worse than a headache -- for it robs them of their basic freedom to think. As Cervantes said, "When the head aches, all the members partake of the pain."


In the Beginning...

Ten thousand years ago, when civilization was young and impressionable, the seat of the human spirit and intellect was often considered to be the heart. The head was seen as a secondary lobe of meat in which the mind was apprehended and interpreted but from which it did not originate. Thus it seemed only proper to release untoward spirits not by creating a vent in the all important chest, but rather by cutting a hole in the skull.

Primitive human beings did not call this act trepanation, but we do.

While it may strike the modern reader as counter-intuitive to treat a headache with a painful -- and often septic -- head wound, archaeological research suggests that as many as half of ancient trepanees may have lived long enough to heal before being gored by an animal or clubbed down by one of their fellow men. In the terms of the day this made the operation a raging success.

The surgical implement of choice would likely have been a shard of sharpened flint. Anaesthetic came in the form of passing out from bloodloss. Practitioners who lost too many patients often forfeited their lives in payment, as the concept of malpractice insurance remained to be invented.


In Imhotep We Trust

The world's earliest known physician was Imhotep, prime minister under the reign of Djoser during Egypt's Third Dynasty (2686-2613 BC). Besides architecture and engineering, the multi-talented Imhotep was a systematic cataloguer of symptoms, diseases and treatments. Some of this wisdom still reaches us through the so-called Surgical Papyri (called respectively the Smith Papyrus and the Ebers Papyrus), purchased at a Luxor auction in 1862 by an American named Edwin Smith. Consider, for instance, Prescription No.201 from the scrolls:

Soak some castor roots in water until they dissolve, and then apply the solution to the head of a patient who has a headache and he will immediately recover.

So pervasive was the awe for Imhotep's methodical application of remedies that he was eventually deified by both the Egyptians and the Greeks (who called him Imouthes and identified him with the god formerly known as Asklepios).

The influence of Imhotep's systematic approach can also be found in the famous Codex Hammurabi of ancient Babylon, dating from around 1700 BC. The codex compiled millennia of Semitic tribal customs into a uniform body of law covering all aspects of ancient life, from penalties for crimes to fees for medical services, guided by the hand of chronic workaholic and enlightened Mesopotamian dilettante King Hammurabi (reigned c.1792-1750 BC).

The headaches, however, went on.


The Humours of Hippocrates

The more pragmatic approach to medicine come unto its own in ancient Greece, where the philosophical underpinnings of the scientific method were maturing -- aiming to pare away uncertainty by reaching conclusions through rigorous and reproducible experimentation. A strong proponent of this new way of thinking was the bumbling mathematician and absent-minded philosopher Hippocrates (470-410 BC), who worked tirelessly against superstitious interpretations of medical woes.

For example, Hippocrates was of the mind that sacrificing a goat would have little if any beneficial impact on a particular patient's case of pneumonia.

His solution, however, suffered the classic Hellenic fault of idolizing the form of the answering philosophy rather than its content -- in other words, Hippocrates' replacement theory had the admirable characteristics of inner harmony and pleasing symmetry, but at the same time suffered from being largely incorrect.

Drawing on a tradition of ballyhooed quads of influences such as the four seasons of the year or the four elements of the world, Hippocrates popularized the concept of the four humours -- or liquids -- of the body, whose changing proportions were supposed to lie at the root of all issues of physical and mental health.

Hippocrates identified the four humours as blood, phlegm, yellow bile and black bile, and identified each with a season (spring, summer, autumn, winter), an element (air, fire, earth, water), a quality of moistness and/or temperature (warm-moist, cold-moist, warm-dry, cold-dry), and a dominant personality characteristic (sanguine, phlegmatic, choleric, melancholic).

Any imbalance of these four qualities (dyscrasia) would lead to illness, expressing itself differently depending on the mutual play of the humours. For example, a patient experiencing bouts of irritability might be suffering from an excess of yellow bile, thus impairing their moral faculties; the appropriate treatment would be to encourage the patient to take in substances considered disharmonious with yellow bile but harmonious with phlegm (the antithesis of yellow bile in terms of associated qualities), in hopes of restoring a healthy balance (eucrasia).

In this context epilepsy was understood to be a disease whereby an overproduction of phlegm blocked the airways, thus necessitating that the body jerk and convulse in order to forcibly clear the obstruction. And, since it was well understood that the lungs and brain were a common system responsible for respiration, the remedy was obvious: again, trepanation.

Hippocrates is reputed to be the first physician to describe the symptoms of the migraine headache, including apparitions of light bursts and the typical spreading pattern of the pain across the head.



Rome Wasn't Bled in a Day

The mantle of Hippocrates was taken up by the Roman physician Claudius Galenus, better known as Galen (131-201 AD), the strength of whose multi-millennial influence was outshone only by his own radiant ego:

I have done as much for medicine as Trajan did for the Roman Empire. It is I, and I alone, who revealed the true path of medicine. It must be admitted that Hippocrates already staked out this path...he prepared the way, but I have made it passable.

Galen's prize pig was his obsession with the pulse, which he believed spoke volumes about the health of a patient despite his abject ignorance of the heart and circulatory system. To this end, Galen favoured bloodletting as a remedy to a host of illnesses, including the headache, though he also saw prudence in purging the body of excess yellow bile:

How constantly do we see the head attacked with pain when yellow bile is contained in the stomach: as also the pain forthwith ceasing when the bile has been vomited.

As a philosopher Galen argued that the brain, not the heart, was the seat of the mind, thus elevating the head and the headache to new importance.

He also emphasized that the harmony of the human body arose from its intelligent design by a single creator, a perspective which would make his teachings palatable through the Dark Ages in Europe. Indeed, so revered were his writings that for centuries physicians across Christiandom took his advice on faith and did little if any experimentation of their own, leading to an interregnum in the advance of Western medical science that would last until the sixteenth century.

Progress continued outside of Europe in the hands of medical pioneers like Abu Ali Husain ebn Abdallah Ebn-e Sina (980-1037 AD), known by most of his friends as Ibn Sina and by strangers as Avicenna in an effort to spare their tongues the unenviable task of elocuting his interminable proper name. Ibn Sina favoured treating headaches by bloodletting from the scalp.


Paracelsus was a Punk

Equally unfamiliar with the art of making your name a household word was Auroleus Phillipus Theostratus Bombastus von Hohenheim (1493-1541), whom history has dubbed Paracelsus for the sake of brevity.

Paracelsus was widely reputed to be extraordinarily gifted, driven, and obnoxious. As a prodigious adolescent he already had a masterful knowledge of alchemy. As a young man he was thrown or chased out of dozens of university towns across mediaeval Europe after flamboyant displays of disrespect for established teachings -- including not but limited to burning the works of Galen and Avicenna, suggesting that comets were fundamentally unrelated to leprosy, and expanding his knowledge by collecting cures from "low people" like midwives and veterinarians.

He may also have called Aristotle an "ass."

His greatest contribution in the war against the headache is considered to be the so-called Elixir Ad Longam Vitam, also popularly known as Swedish Bitters, a fanciful concoction of herbs and roots designed to quell the yellow bile in the gut and thereby release vaporous pressure on the head. When this failed Paracelsus recommended massage, or the ingestion of an opium-based tincture known as laudanum (which left patients not only free of pain but also free of coherent thought or the impetus to move).

Paracelsus was but one pioneer in a century of intellectual rebirth. Inspired by the artful butchery of Belgian anatomist Andreas Vesalius (1514-1564), in 1628 Englishman William Harvey figured out what the heart was for by operating on executed criminals, finally overturning the last of Galen's poppycock concerning the circulation of the blood. This was the beginning of understanding the body on a mechanical level.


I Think, Therefore My Head Hurts

Eschewing the notion of action at a distance, gentleman philosopher, transcontinental layabout and Frenchman Rene Descartes (1596-1650) sought to find a solid, mathematical basis for each of the sciences, from geometry to biology. To that end he established modern algebra and theorized that conductive filaments like miniature aqueducts ferried sensation-inducing particles around the body. Quoth Descartes in his work De l'homme (1640):

If for example fire comes near the foot, minute particles of this fire, which you know move at great velocity, have the power to set in motion the spot of skin on the foot which they touch, and by this means pulling on the delicate thread which is attached to the spot of the skin, they open up at the same instant the pore against which the delicate thread ends, just as by pulling on one end of a rope one makes to strike at the same instant a bell which hangs at the end.

Today we call these filaments nerves.

Descartes' understanding was rarified and simplistic, however, and the study of the nervous system would not gain significant new insight until the arrival on the scene of Scottish-American Silas Weir Mitchell (1829-1914), whose pioneering work earned him the epithet "the father of neurology."

Mitchell took pain out of the clockwork realm of mechanism and into the light of subjective experience, cataloguing the idiosyncratic nature of pain in different individuals and circumstances. As a field surgeon during the American Civil War and later in his own Philadelphia-based practice, Mitchell studied the distribution of nerves beneath the skin, the phenomenon of sensation experienced in amputated limbs, the physiology of the brain and the pain of chronic headaches, including migraine and cluster variants.

Resisting the tenacious Aristotlean conjecture that pain was a moral faculty whose expression revealed the true character of a patient, Mitchell wrote:

Under such torments the temper changes, the most amiable grow irritable, the soldier becomes a coward, and the strongest man is scarcely less nervous than the most hysterical girl.

Mitchell also wrote reams of pretentious poetry, indicating that he may have caused as many headaches as he cured.


Things Go Better With Coke

Armed with an evolving but still immature concept of pain and the cause of headaches, physicians in the nineteenth and early twentieth centuries focused on diminishing pain by attempting to block the pathway along which its signals seemed to travel, and the profession of anaethesiology was born. Opiates replaced ether, which were in turn supplanted by cocaine -- each an unregulated "wonder drug" in their time -- and the science of surgery advanced by leaps and bounds once freed of the distracting influence of thrashing, screaming patients.

In 1853 Bayer began marketing acetylsalicylic acid under the name aspirin, giving scientific blessing to the extract of willow that had been used to soothe inflammation since Galen's time. Codeine, another analgesic derived from opium, arrived on the scene as well. Drugs like these gave the public their first taste of over-the-counter pain relief relatively free of quackery.

Until the 1914 Harrison Act restricting narcotic use in the United States, Coca-Cola and other soft drinks containing caffeine and cocaine were sold as headache cures.

While researchers like Blix Goldscheider, William Livingston and Willem Noordenbos began to tap the real complexity of the pain response, as late as the 1960s the Cartesian concept of the brain as a passive receptor of pain persisted, frequently leading to the conclusion that patients with headaches or other chronic afflictions without any apparent source of injury were simply emotionally disturbed, and in need of psychiatric counselling. Or perhaps a bottle of Coke.


The State of the Art

The modern era of pain research began with the introduction of Gate-Control Theory by Canadian Ronald Melzack and Briton Patrick Wall in 1965. In essence, they described a more heuristic, non-linear, feedback-based system creating various modalities of pain rather than a one-to-one bell-pulls-rope reaction, and laid the basis for our present understanding of chronic hurt in all its sneaky, enigmatic glory.

As summarized by Marni Jackson in her 2002 book Pain, The Fifth Vital Sign:

"Pain is in the brain" is how Melzack puts it. There is no fixed pain pathway that we can magically yank out of the body, like a varicose vein -- there are only various transactions between peripheral signals, the central nervous system, different regions of the brain, and our individual response to the world.

Today all kinds of chronic pain are treated with a variety of techniques including patient self-regulation through biofeedback, acu-pressure and -puncture, physiotheraputic message, and a new panoply of targeted pharmaceuticals such as triptans and ergot alkaloids for addressing vascular headache pain.

Despite this, consumers around the world spend billions of dollars each year on over-the-counter drugs like aspirin, acetaminophen, and ibuprofen, as well as trillions of dollars on experimental prescription medications like Cox-2 inhibitors (some of which were withdrawn from many markets in 2004 due to concerns about side effects). Alternative analgesics derived from natural sources comprise an rapidly expanding segment of the market, with choices such as cayenne, passion flower and kudzu treatments.

Statistic vary, but it seems that at least one in ten people globally suffer from migraine headaches, while one in a hundred suffer the debilitating bane of cluster headaches.

Modern sufferers can at least take heart in the fact that they are unlikely to be prescribed bloodletting by leeches, or be induced to vomit. Most of all, they can rest assured that it is unlikely that anyone will attempt to relieve their pain by drilling a hole in their head.