Pain: The Fifth Vital Sign [Hardcover]

Why are we, the most medicated of societies, a culture in pain? That's the piercing question author Marni Jackson poses in Pain: The Fifth Vital Sign after a bee sting sends her on a four-year quest to explore this universal experience. Attitudes to treating pain are changing, Jackson discovers, and new approaches have begun to radically change the relationship between physician and patient. Still, suffering remains remarkably prevalent in a culture that manages to encourage addiction while withholding relief from people in discomfort. "It's slow business, educating doctors about pain and changing our attitudes toward it," Jackson writes. "If we knew more about pain treatment, would Robert Latimer, a Saskatchewan farmer, have felt he had no other recourse but to kill his severely disabled daughter, who suffered daily pain?"

The book is structured around Jackson's own divining-rod forays into the pain world. She zigzags between a minister injured in a high-speed police chase, a "pain warrior" treating cases in a Toronto clinic, her elderly mother's broken shoulder, the World Pain Congress in Vienna, self-mutilators, Florence Nightingale, a 15-year-old heroin addict, and the final days of a dying friend. Jackson's vivid storytelling makes this book a fascinating read. --Carolyn Leitch

Many patients and physicians have wished for a way to quantify pain as we do the other vital signs--blood pressure, temperature, heart beat, and respiration. Jackson explores the history, variety, acknowledgment, and treatment of pain, the fifth vital sign, accessibly and sympathetically, lending the subject personalism by citing her own experiences of pain, which range from a bee sting to her open mouth to anesthetic failure in the middle of a dental operation. She also mines the medical annals, citing such authorities as S. Weir Mitchell and William Livingston, and various literary works. Her interviews with pain experts make lively reading as she queries the likes of Angela Mailis of the Comprehensive Pain Program in Toronto, and Frank Adams, who was found guilty of "medical incompetence and unprofessional conduct" for humanely treating his patients' pain. Finally, her account of the Ninth World Congress on the Study of Pain, in Vienna, graphically depicts the complexity of a large meeting. A book for medical-school and hospital as well as public libraries. William Beatty
Copyright © American Library Association. All rights reserved

"An utterly engrossing, strangely uplifting journey into the dark but wondrous corners of human suffering. By giving language to a subject that seems to defy language, Marni Jackson performs a kind of miracle of insight and compassion." -- Barbara Gowdy

“Jackson is an ideal guide for this exploration. With her personal and personable perspective, she acts as a surrogate for the reader, simplifying complex issues (both philosophical and technical) and humanizing often abstract concepts. Jackson leavens this very serious subject matter with a wicked and subversive sense of humour.” -- Quill and Quire

“One might think there was nothing new to say about pain, but Pain: The Fifth Vital Sign is a work of real originality and freshness, full of insights which seem both startling and obvious.” -- Oliver Sacks, MD

“Jackson’s book is a timely and necessary contribution to this important dialogue.” -- The Globe and Mail

“Jackson’s compelling voice, in turns perfectly ironic, intrigued, and introspective, carries readers through no fewer than 33 chapters. Her vibrant curiosity and fearless theorizing makes this book far-reaching in scope, interest and, yes, profundity….Given that this medicalized, pain-ridden society is ours for a while, we had better keep this book beside the bed and absorb its comfort and compassion in large doses.” -- The Vancouver Sun

“[Pain will] impart a few invaluable lessons and allow a few opportunities to empathize with others, cringe in recognition and even lagh out loud….In brief and highly readable chapters, Jackson explores the history of pain and the various philosophies and studies that have attempted to understand and tame it.” -- Winnipeg Free Press

“Given that this medicalized, pain-ridden society is ourd for a while, we had better keep this book beside the bed and absorb its comfort and compassion in large doses.” -- The Kingston Whig-Standard, The Gazette (Montreal)

“…engrossing….Jackson, a skilled and sensitive writer, argues that science must learn learn to listen and respond and that doctors need to look beyond isolated symptoms to find the underling story.” -- The Edmonton Journal

"In Pain: The Fifth Vital Sign, Marni Jackson bravely tackles one of the most misunderstood and elusive subjects known to mankind. In so doing, she gives words to something that stubbornly defies language. This has to be one of the most difficult literary tasks imaginable….an important book.” -- NOW magazine

“…absorbing…If all her new book did was inform readers about this unexplored terrain, the Pain: The Fifth Vital Sign would be worth reading. But it does much more: it entertains, challenges and, ultimately, enlightens.” -- The Gazette (Montreal)

“[Pain]is a good read. It is comprehensive, intelligent and balanced. It puts a human face on pain, but clearly elucidates concepts as well. And it provides unexpected byways, never allowing the reader to become bored….The reader can never be sure what will be just around the corner on this journey.” -- The Hamilton Spectator

Praise for The Mother Zone:

"A witty and honest account of the strange isolation, the mingled joys and madness of motherhood... What holds all this together is a novelistic integrity that derives from the consistency of her voice -- funny, tough and relentless, pushing each thought as far as she can bear." -- The Toronto Star

"Funny, touching, reassuring, a revelation. The Mother Zone is a marvelous combination of personal experience tempered by intellectual observation." -- Books in Canada

"[The Mother Zone] reads like a novel and is as intimate as a poem... With a gift for metaphor, good humor and remarkable honesty, [Jackson] calls up the feelings and minutiae of motherhood... This wonderful self-portrait of emotional life in the mother zone provides solace and surprises from start to finish." -- Kirkus Reviews

"A fascinating insider's account... Jackson's frankly personal approach to her own passage through the Mother Zone avoids all the predictable expert postures... A remarkable first book." -- Maclean's

"Jackson gives readers back to themselves, the best thing a book can do." -- The Edmonton Journal

A compulsively readable explorer’s journal of the hidden territory of pain, as profound and insightful as the work of Oliver Sacks and Sherwin Nuland.

A bee sting on the lips was the tiny lance that set Marni Jackson off on a four-year exploration of the many ways in which we suffer. Exiled for an afternoon in the country called pain, she realized that no one had the words to describe her condition although it was as familiar as a headache. A fusion of emotion, nerve and memory, pain inspired only questions.

“Why do we still distinguish between mental pain and physical pain,” she asks, “when pain is always an emotional experience? Why is pain so poorly understood, especially in a century of self-scrutiny? Hasn’t anyone noticed the embarrassing fact that science is about to clone a human being but still can’t cure the pain of a bad back?” North Americans spend $24 billion a year on pain relief while chronic pain is on the rise. If pain is the reason why most people visit the doctor, why are most doctors so bad at addressing the problem of suffering?

Pain: The Fifth Vital Sign dives back into the history of pain and forward into the possibilities of pain genetics, bringing us stories of both people in pain and the pain pioneers: eccentrics and artists, wrestlers and writers, ministers and mothers, psychologists and philosophers, nurses and doctors. Marni Jackson has created a definitive, heartfelt, funny and beguiling portrait of a condition we can’t live with — and can’t live without.

"An utterly engrossing, strangely uplifting journey into the dark but wondrous corners of human suffering. By giving language to a subject that seems to defy language, Marni Jackson performs a kind of miracle of insight and compassion." -- Barbara Gowdy

“Jackson is an ideal guide for this exploration. With her personal and personable perspective, she acts as a surrogate for the reader, simplifying complex issues (both philosophical and technical) and humanizing often abstract concepts. Jackson leavens this very serious subject matter with a wicked and subversive sense of humour.” -- Quill and Quire

“One might think there was nothing new to say about pain, but Pain: The Fifth Vital Sign is a work of real originality and freshness, full of insights which seem both startling and obvious.” -- Oliver Sacks, MD

“Jackson’s book is a timely and necessary contribution to this important dialogue.” -- The Globe and Mail

“Jackson’s compelling voice, in turns perfectly ironic, intrigued, and introspective, carries readers through no fewer than 33 chapters. Her vibrant curiosity and fearless theorizing makes this book far-reaching in scope, interest and, yes, profundity….Given that this medicalized, pain-ridden society is ours for a while, we had better keep this book beside the bed and absorb its comfort and compassion in large doses.” -- The Vancouver Sun

“[Pain will] impart a few invaluable lessons and allow a few opportunities to empathize with others, cringe in recognition and even lagh out loud….In brief and highly readable chapters, Jackson explores the history of pain and the various philosophies and studies that have attempted to understand and tame it.” -- Winnipeg Free Press

“Given that this medicalized, pain-ridden society is ourd for a while, we had better keep this book beside the bed and absorb its comfort and compassion in large doses.” -- The Kingston Whig-Standard, The Gazette (Montreal)

“…engrossing….Jackson, a skilled and sensitive writer, argues that science must learn learn to listen and respond and that doctors need to look beyond isolated symptoms to find the underling story.” -- The Edmonton Journal

"In Pain: The Fifth Vital Sign, Marni Jackson bravely tackles one of the most misunderstood and elusive subjects known to mankind. In so doing, she gives words to something that stubbornly defies language. This has to be one of the most difficult literary tasks imaginable….an important book.” -- NOW magazine

“…absorbing…If all her new book did was inform readers about this unexplored terrain, the Pain: The Fifth Vital Sign would be worth reading. But it does much more: it entertains, challenges and, ultimately, enlightens.” -- The Gazette (Montreal)

“[Pain]is a good read. It is comprehensive, intelligent and balanced. It puts a human face on pain, but clearly elucidates concepts as well. And it provides unexpected byways, never allowing the reader to become bored….The reader can never be sure what will be just around the corner on this journey.” -- The Hamilton Spectator

Praise for The Mother Zone:

"A witty and honest account of the strange isolation, the mingled joys and madness of motherhood... What holds all this together is a novelistic integrity that derives from the consistency of her voice -- funny, tough and relentless, pushing each thought as far as she can bear." -- The Toronto Star

"Funny, touching, reassuring, a revelation. The Mother Zone is a marvelous combination of personal experience tempered by intellectual observation." -- Books in Canada

"[The Mother Zone] reads like a novel and is as intimate as a poem... With a gift for metaphor, good humor and remarkable honesty, [Jackson] calls up the feelings and minutiae of motherhood... This wonderful self-portrait of emotional life in the mother zone provides solace and surprises from start to finish." -- Kirkus Reviews

"A fascinating insider's account... Jackson's frankly personal approach to her own passage through the Mother Zone avoids all the predictable expert postures... A remarkable first book." -- Maclean's

"Jackson gives readers back to themselves, the best thing a book can do." -- The Edmonton Journal

Marni Jackson, one of Canada's most respected writers of non-fiction, has received numerous awards for reature-writing, columns and humour. She is the author of the highly acclaimed bestseller The Mother Zone (1992), which will be re-issued by Vintage Canada in April. Pain: The Fifth Vital Sign is also being published simultaneously in the United States by Crown. Marni Jackson lives in Toronto with her family.

A MICROHISTORY OF PAIN

I have given a name to my pain, and call it "dog."
Friedrich Nietzsche, The Gay Science

Pain is the Sasquatch of science, never witnessed, only endlessly speculated on. We can't even agree on the species. Man or beast? A sensation or an idea? It doesn't help that ideas about the meanings of pain are double-barreled abstractions that soon drift away from the experience itself into an epistemological fog.

Our efforts to describe pain soon confront us with another small problem: How do we define the self? What particular nexus of mind, body, and soul is this modern "I" who feels the strange brew of modern pain?

I've been ruthlessly selective in this chapter, skipping over many names and en-tire centuries, to avoid disappearing down philosophical cul-de-sacs. But as I began to investigate the earliest ideas of pain, what struck me was that philosophy, medicine, and drama were once much closer in the way they viewed pain. It wasn't until Descartes came along in the seventeenth century with "proof" of the mind-body split, followed by the age of Enlightenment, that pain began to shed its emotional and social dimensions. One of the earliest definitions of tragedy, for instance, was human pain-as our exile into something that can be witnessed and pitied, but never shared.

Philoctetes, a play written by Sophocles in 409 b.c., is a story that pivots around the physical pain of its main character, who suffers from a wound that began as a snake bite. "Terrible it is, beyond words' reach" is how Philoctetes describes his condition. This inviolate, unspeakable aspect of human pain is what the drama tries to voice. "Philoctetes makes us feel the power of pain to reduce a life to utter emptiness and misery," author David Morris writes in The Culture of Pain. "It unweaves the self until the self is nothing but pain. The body in tragedy is not just something we possess like an identifying birthmark or robe or kingdom," Morris argues, "but what we are. It both deWnes us, and, fatally, limits us."

Aristotle was another astute observer of human dramas, including pain, and his writings on the subject turn out to have a rather modern flair. He defined pain as an emotion rather than a mechanical sensation. He characterized both pain and pleasure as "appetites" that drive us toward the objects of our desires and away from the things that hurt us. For Aristotle, pain was not only a sensory event in the body, but a subjective state, like longing and fear. He saw the human cost of pain, how it "upsets and destroys the nature of the person who feels it." Aristotle may not have understood physiology, but he accepted the idea that pain is an expression of who we are.

Our uncertainty about the province of pain is conveyed by the roots of the words we use for it. Pain is probably derived from the Latin word poena, meaning punishment, and the English word tends to connote physical pain. But the French word douleur, from the Latin dolor, refers to both physical and mental pain. The French word peine suggests punishment, but it can mean sorrow as well. Oddly enough, the Italian language has no word for ache, despite the fact that studies of pain expression in different cultures report that Italian women in labor are louder than women from other countries.

The concept of pain as punishment turns up most vividly in the biblical story of Job, a wealthy, upright man whose faith in God is tested by Satan in a series of terrible afflictions. First he loses his wealth, then he becomes an outcast from his community. Finally Satan pulls out all the stops and inflicts a "plague of boils" on Job. "He slashes open my kidneys and does not spare," says Job, describing Satan's work. "He pours out my gall on the ground." William Blake's illustration of this scene shows the figure of Job writhing on the ground, his hands arched back in pain, as a naked, burly Satan stands over him like a TV wrestler in triumph. Job's test of faith is the first example of the theme of bloody martyrdom that runs throughout Christianity. Pain is inseparable from faith and "the central Christian mystery of a being who suffers pain in order to redeem others," as Morris writes. It was the pain that Jesus Christ suffered on the cross that proved to us that God's son was human, too. Suffering pain is how faith is forged; transcending pain is a mark of sainthood. The image of St. Sebastian pierced with arrows, with upturned eyes, carries the message that a belief in a life beyond the body has the power to undo pain. The idea of pain as spiritual punishment is still deeply entrenched in our attitude that physical pain arrives as a kind of moral test of character and should be toughed out. The price of admission for being human, the story of Job reminds us, is this: expect boils.

Fast-forward to the Middle Ages, a time when it was hell to have a toothache, even though laudanum laced with opium was readily dispensed. One of the opiophiles of the era was the enlightened sixteenth-century practitioner Paracelsus. He was the original patient-centered physician. "Every physician must be rich in knowledge," he wrote in Man and His Body, "and not only of that which is written in books; his patients should be his book, they will never mislead him . . . and by them he will never be deceived. But he who is content with mere letters is like a dead man; and he is like a dead physician." We may be overdue for a Paracelsus revival.

The man most responsible for our modern misconception of "mental pain" versus "physical pain," however, was the seventeenth-century philosopher and scientist Rene Descartes. Although he is often blamed for the mind-body split that came to characterize Western thinking, in other ways, Descartes's investigation into pain was farsighted. In the treatise De l'homme, his hypothesis about pain pathways and the "delicate threads" that conduct pain signals, for instance, turned out to be a crude but correct notion of nerve fibers and neurotransmitters. But it was his theory of the transmission of pain signals that led to what is known as the "specificity theory" of pain-the notion of pain as one fixed pathway or center. This idea dominated the study of pain until the last thirty or forty years.

Descartes's theory was accompanied by a famous illustration of a rather hunchbacked naked man, eyes a-bulge, who appears to be stepping into a campfire. His foot is in the flame. "If for example fire comes near the foot," he wrote in 1640, "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."

Descartes has helpfully labeled the diagram. The sensation of pain (A) is perceived in the foot and then travels up to the "common sense center" (F) in the pineal gland, which interprets the signal as pain. This same stimulus-response model still defines our popular understanding of pain: The coffee table hits your toe, a sensation in the nerves then tugs at the bell-rope of the brain, which interprets this event as pain. No coffee table, no pain. But even in his time, Descartes had to defend this theory against critics. When it was pointed out to him that some amputees still feel pain in their missing limbs-phantom limb pain-he nimbly responded that the brain was just being tricked by false signals. But he still characterized the mind as a passive central switchboard instead of as a coauthor of pain.

In Descartes's mechanistic view, pain is something that happens to the body, a sensation then promoted to the status of a concept in the brain. A worker-CEO arrangement, you could say, except that the goods flow only one way. Although the brain is the boss, it is a passive decoder, and pain only runs along one track, with its own special apparatus, impervious to emotions or environmental factors.

The race for pain's Northwest Passage-the path it takes in the body-was under way, and for the next three hundred years science pursued this mysterious trail. Pain began to lose its multiple meanings, as a visionary experience in religion, or as an expressive element of tragedy. Instead, pain became the property of science and medicine, even though they didn't quite know what to make of it. The focus shifted from exploring the questions of identity, consciousness, and grace that pain raises to describing its mechanisms in the body and brain. The pharmaceutical age began at the end of the nineteenth century. Cutting pain out of the body, cutting nerves, and killing pain became the new goals.

A time line of some of the landmarks of pain science and treatment over the past two centuries might look like this:

1803Morphine is synthesized from opium

1846The discovery of anesthesia

1853The invention of the hypodermic needle

1853Acetylsalicylic acid, predecessor to aspirin is developed

1914The Harrison Act in the United States sets restrictions on narcotic drugs

1943Pain Mechanisms published by William Livingston

1946Henry Beecher's work on the power of the placebo

1965The gate-control theory of pain published by Melzack and Wall in the journal Science

1966The first hospice, St. Christopher's, opens in the United Kingdom

1973International Association for the Study of Pain holds its first congress

1975The McGill Pain Questionnaire (first measurement of pain intensity)

1976Discovery of endorphins

1986The World Health Organization publishes The Analgesic Ladder: Guidelines to Cancer Pain Relief

2000The U.S...