[RADIOLAB INTRO]

JAD ABUMRAD: All right! Three, two, one. Hey, I'm Jad Abumrad

ROBERT KRULWICH: Okay, I'm Robert Krulwich.

JAD: [laughs] You're cheery today.

ROBERT: I was chery.

JAD: This is Radiolab.

ROBERT: And this is our podcast version.

JAD: Yes. And today on the podcast, stay in that cheery frame of mind.

ROBERT: Okay.

JAD: Because we're gonna talk about pain today.

ROBERT: [laughs]

JAD: So here's the quandary: it is really hard to put words to pain.

ROBERT: Mm-hmm.

JAD: Like, to describe to somebody, "I have this pain in my back and it feels like a—ah! Like, ow, it really hurts!" I mena, it's like it's really difficult to describe to someone in a way that would let them feel it too. It's like one of these classic empathy barriers, right?

ROBERT: That's true.

JAD: But if you could quantify it, measure it, if I could know exactly numerically what you're going through?

ROBERT: Mm-hmm?

JAD: Maybe that would help. Maybe we could be better friends.

ROBERT: If you could. Do you think you could? Is that what this is?

JAD: I don't know. Well, we're gonna try. See, our producer Tim Howard over the last few months has encountered three different people who in different ways are trying to measure pain, share it.

ROBERT: So we're going to do three episodes of pain ...

JAD: Calibration.

ROBERT: Calibration.

JAD: A triptych of pain calibration.

ROBERT: Okay. Bring it on!

JAD: Here's Tim.

TIM HOWARD: Hi.

JUSTIN SCHMIDT: Hey, come on in.

TIM: I got started with all this when I met this guy.

JUSTIN SCHMIDT: Yeah, I'm Justin Schmidt. I'm a research biologist.

TIM: But he's really a bug guy.

JUSTIN SCHMIDT: I like to try to get into the head of the stinging insect.

TIM: He lives in Tucson Arizona, and works in this one-story building on a residential street.

JUSTIN SCHMIDT: Right now we're in—in my laboratory at Southwestern Biological Institute.

TIM: Could we—could we just take a quick, like, glance around?

JUSTIN SCHMIDT: Yeah.

TIM HOWARD: I'd love to just, like, know what it is we're looking at.

JUSTIN SCHMIDT: Underneath those cabinets are 48 drawers of insect specimens so these are ...

TIM: Oh, wow.

TIM: He's got wasps.

JUSTIN SCHMIDT: That's Apoica, and it's a nocturnal wasp.

TIM: That is terrifying, this one here.

TIM: Different kinds of weird.

TIM: What is this guy?

TIM: Hornets.

JUSTIN SCHMIDT: That's actually a flightless grasshopper.

TIM: He's got a lot of ants.

TIM: Wow, there's some little furry ...

JUSTIN SCHMIDT: Yeah those are velvet ants.

TIM: They're huge!

JUSTIN SCHMIDT: If you pick up one of these things and get stung by it, it's going to feel like, "Oh my goodness, that could kill a cow!"

TIM: Okay, so this all started for Justin back in the ‘70s when he was a grad student.

JUSTIN SCHMIDT: And I just thought, for a lark, I took a seminar course in etymology. We—we had one entomologist in the whole university.

JAD: This is a course in bug science?

TIM: Yeah. This was in Georgia, and he was outside one day in the field and he was trying to get a sample of ...

JUSTIN SCHMIDT: A harvester ant.

TIM: A harvester ant. What does that look like?

JUSTIN SCHMIDT: They're about a third of an inch long and they're bright red, pretty good-sized ants actually.

TIM: And he was trying to get one into a jar and ...

JUSTIN SCHMIDT: I got stung by one and I—I kind of went, "Oh, that's odd."

TIM: It didn't really hurt at first.

JUSTIN SCHMIDT: Okay, it sort of felt like somebody was using a dental syringe, a really fine needle, slowly injecting a little bit of water. It had this kind of crystalline feeling. It wasn't an immediate pain, this was a delayed thing. And so then I thought, "Oh, okay." But after about a minute it started really hurting. I said, "Oh, this really hurts!" This really deep, sort of, visceral pain, something was going in and tearing out your nerves, and your muscles and your tendons. What struck me was how dramatically different this was from anything that I'd experienced from bumblebee, honeybee, sweat bee, yellowjacket, paper wasp.

TIM: And once the pain subsided he thought, "Man, I need to study that!"

JUSTIN SCHMIDT: Yeah.

TIM: You know, he had all these, kind of, higher level science questions about, you know, evolution of pain and insects and how different stinging insects developed.

JUSTIN SCHMIDT: But the problem was oh, okay, pain. What do we do about measuring pain?

TIM: If he was really gonna get to the bottom of why one insect was more or less painful than another he couldn't do that with just words like, "More," or "Less."

JUSTIN SCHMIDT: I need numbers.

TIM: With numbers, he could do all kinds of research. Not to mention it would make working with other bug scientists just a lot easier.

JUSTIN SCHMIDT: And I started looking into this and found out oh, this wasn't anything new. Nobody really knows how to measure pain.

TIM: Because, you know, no two people feel pain the same way.

JUSTIN SCHMIDT: Some people have higher pain tolerance than others.

TIM: On the other hand, that harvester ant was objectively way more painful than anything he'd ever been stung by.

JUSTIN SCHMIDT: Oh yeah.

TIM: So Justin realized, "What I need is a universal insect sting pain scale." So Justin starts traveling all around the world and he's—you know, every time he hears about a bug, especially a stinging bug, he goes looking for it. And ...

JAD: In order to be stung by it?

JUSTIN SCHMIDT: Well I don't like pain.

TIM: Right.

TIM: So he says he's not trying to get stung, but it usually happens. And as far as he's concerned, that's a good thing. For example ...

JUSTIN SCHMIDT: I was petrified of this—this synoeca, which I call the Warrior Wasp.

TIM: A synoeca is this black wasp with this metallic sheen.

JUSTIN SCHMIDT: Down in Central America.

TIM: And they're known for this warning sound that they make with their nests…

JUSTIN SCHMIDT: They have this big carton nest, carton being kind of paper, kind of goes [mouths sound].

TIM: Justin was there with another scientist, and they're tromping through the jungle and then they find a nest.

JUSTIN SCHMIDT: Here we are at this nest.

TIM: And it starts to make that sound.

JUSTIN SCHMIDT: Well, sure enough, we eventually got a kamikaze that came out and nailed me.

TIM: Where—where did it sting you?

JUSTIN SCHMIDT: Kind of on my forehead. And I just sort of sat on a stump and said, "Oh, this really hurts!" It—it hurt like a yellowjacket or a hornet, but it was just a whole lot more.

TIM: And it kept hurting for an hour.

JUSTIN SCHMIDT: And so, I, you know, recorded what the feeling was for this hour.

TIM: So—but you're sitting there on a stump or something, and your forehead is throbbing and you're taking notes?

JUSTIN SCHMIDT: Well, what else can you do?

TIM: He—he talks about getting stung by something that makes him hurt so much that he just starts ...

JUSTIN SCHMIDT: Screaming in pain.

TIM: For like an hour and lying on the ground because that'll make the pain less, I guess.

JUSTIN SCHMIDT: And my left hand is sitting here shaking, it's trembling, you know, it's going up and down. And I said, "Darn hand, stop that!"

TIM: Now with his other hand he's taking notes about exactly how it feels.

JUSTIN SCHMIDT: This left one is here flapping away and, in any case...

JAD: How many times has he been stung?

TIM: He told me he's been stung by like 150 species, and probably about 1,000 times.

JAD: What?

TIM: And he's used all those experiences to build up a scale.

JUSTIN SCHMIDT: Which you could say is—is a five-point scale. Zero, one, two, three and four. Zero being that's essentially trivial.

TIM: And four being ...

JUSTIN SCHMIDT: It really hurts!

JAD: But wait, how does he deal with the whole subjectivity thing? Because, like, your four is going to be different than my four.

TIM: He did something pretty clever, which is that he took that one sting that we pretty much all know, and decided, "I'm gonna use that as ..."

JUSTIN SCHMIDT: A reference.

TIM: So ...

JUSTIN SCHMIDT: I anchored it with the honeybee.

TIM: Which is ...

JUSTIN SCHMIDT: Ouch!

TIM: Which I could—you can talk about with anybody, anybody's been stung by a honeybee...

JAD: Yeah.

TIM: It also doesn't hurt too much and it doesn't hurt too little...

JAD: So it's like a midpoint...

JUSTIN SCHMIDT: Exactly, and—and a middle point, in this case, was easier than a top or a bottom, because I didn't know what the top or bottom was. There's no way to know what the top and the bottom is, so a honeybee was—was that, and so you give that a two.

TIM: A two out of four. The prime meridian of pain. And every time he gets stung by new bugs he'll ask himself ...

JUSTIN SCHMIDT: Is it more than a honeybee, less than a honeybee, about the same as a honeybee? A whole lot more, a whole lot less.

TIM: Then he gives that sting its own number. Dig this: 1.0: Sweat Bee. Light. Ephemeral. Almost fruity. 1.8: the bullhorn, a rare, piercing, elevated sort of bee, someone has fired a staple into your cheek. 2.0: A Bald-Faced Hornet, rich, hearty, slightly crunchy, similar to getting your hand mashed in a revolving door. 3: Red Harvester Ant, bold and unrelenting. Somebody's using a drill to excavate your ingrown toenail.

JAD: Ahh! This is his pain scale?

TIM: Justin calls this his tongue-in-cheek version.

JUSTIN SCHMIDT: That was more fun.

TIM: But yeah, these are some of the things that he's measured.

JAD: And what's the—what's the worst, what's the top of the scale?

TIM: The Bullet Ant.

JUSTIN SCHMIDT: It sends excruciating waves of burning pain that are undiminished for 12 hours. And you get these pulsations, you get this—this pain crescendo that goes to you just about wanting to scream, and then it backs off a little bit so you say "Ah," kind of give you a little bit of a sigh of relief and then it ascends back up and it keeps doing this. These hills and valleys of—of ascending pain and then decreasing—even the decreasing to the lowest still hurts.

JAD: So this scale works for him? Like, he uses it to communicate with bug scientists?

TIM: Yeah, yeah.

JAD: Well, all right, that's kind of cool, but I gotta be honest, this is—I'm wanting more right now because I—I like the scale but I'm thinking actually beyond bugs to like—let me just put my cards on the table, like childbirth, okay? Like, we talk about, like, the gap ...

TIM: Oh!

JAD: Okay, I know, but we talk about the gap between, like, two people feeling pain and being able to share pain, that's where the rubber meets the road.

ROBERT: Well it's used in a lot of marriages as a constant. "You don't know! You don't know what..."

JAD: Exactly! Thank you, Robert. Does Tamar use it the way Karla uses it?

ROBERT: I can't say that on a recording. [laughs] No, not at all, really. Never, I don't know, well that didn't cross my mind.

TIM: Karla, who's a very sort of understating lady when it comes to this subject she'll be like "You have no idea. You don't even begin to know what you don't know about what we just went through."

TIM: Well, that brings me to my second story.

PAULA MICHAELS: Can I—can I take it from the top?

TIM: For this one we go back a few years.

PAULA MICHAELS: So we're in 1948 ...

JAD: Who is this lady?

TIM: This is Paula Michaels, she's a professor of the history of medicine.

PAULA MICHAELS: I teach at the University of Iowa.

TIM: And she told me this story that takes place in New York at New York Hospital in 1948.

PAULA MICHAELS: Right, so there's James T. Hardy, there's Carl T. Javert ...

TIM: Hardy and Javert are doctors.

PAULA MICHAELS: And they're trying to test drugs, you know, what drugs are going to be useful to alleviate the pain of childbirth. And in this period there's a whole range of things that are being used.

TIM: What are some of the ones that they're using?

PAULA MICHAELS: Well, like, morphine and scopolamine. Demerol is a big thing.

JAD: Nice.

PAULA MICHAELS: And heroin, which to me sounds completely crazy.

JAD: They play around with crack too?

TIM: They would have if they knew about it. The problem is they want to be able to test all of these drugs so that they can use them in a standard way, but they weren't actually sure how much pain women were really in, and ...

JAD: I guess you kind of have to know that in order to know how much drugs to give them.

TIM: Yeah. They had no idea and it was a source of a lot of debate.

PAULA MICHAELS: Yes. One man, Grantly Dick-Read, a British physician basically said straight out, "It's in women's minds, not their bodies."

TIM: What?

PAULA MICHAELS: Childbirth is a completely painless experience, entirely psychological in origin.

TIM: Wow, that is an incredibly bold thing for a man to say.

PAULA MICHAELS: Yes that's chutzpah.

TIM: Now, Hardy and Javert didn't take it that far but they wanted to get past the whole messy psychological part of childbirth.

PAULA MICHAELS: And eliminate that woman's subjective experience of pain from the calculation of whether these drugs are effective or not.

TIM: And—and how are they gonna do this?

PAULA MICHAELS: Well, their method is pretty crazy. They had this apparatus called a dolorimeter.

TIM: It was this little wood box that had dials and knobs plugged into the wall, and then was connected by a wire to another part.

PAULA MICHAELS: What they called The Exposure Unit.

TIM: That was like a heat gun with an aperture that can shoot out heat. Then they got some volunteers.

PAULA MICHAELS: Some of them were nurses. Some of them were the wives of obstetricians or other physicians.

TIM: All very pregnant. And they told these women, "This might not be very pleasant, but by participating you're gonna be making childbirth just so much better for every woman to follow."

PAULA MICHAELS: That's right.

TIM: And the women were excited to help.

PAULA MICHAELS: And then when the woman went into labor ...

TIM: Hardy and Javert would show up bedside with the dolorimeter, and they'd wait for the contraction to finish.

PAULA MICHAELS: And then between contractions ...

TIM: During that pause they'd take the heat gun and they'd put it against the back of the woman's hand and they'd say to her, "All right, we want to know about that contraction, the one you just had. Yeah, we want to know how much it hurt."

PAULA MICHAELS: They'd say, "Is it more like A or more like B?" And then the woman would respond...

TIM: "Guess B is closer."

PAULA MICHAELS: And then they would say is it more like B, or more like C?

TIM: C, maybe?

PAULA MICHAELS: That was a way of then saying, "Ok, well that was a contraction of three dols.

JAD: Dol, what's a dol?

TIM: The dol is their unit of pain, their—their standard unit they use for everybody.

JAD: Hmm.

TIM: And so over the course of labor after every contraction they would repeat this process. Same drill.

PAULA MICHAELS: Is it more like A or more like B?

TIM: Again ...

PAULA MICHAELS: A, B?

TIM: ... and again ...

PAULA MICHAELS: B or more like C?

TIM: ... and again.

PAULA MICHAELS: Over the course of her whole labor...

JAD: So wait, on top of all the labor pains they're just cranking this heat up and up?

TIM: Yeah.

JAD: Wow!

TIM: In the case of one patient who insisted on going the distance ...

PAULA MICHAELS: A pain intensity of 10 1/2 dols was measured.

TIM: Hardy and Javert called this, "The Ceiling."

PAULA MICHAELS: This is the most intense pain which can be experienced. Second-degree burns were inflicted upon the hands of this patient by the four tests made at levels higher than nine dols.

JAD: Second-degree burns?

TIM: Yeah.

JAD: I mean I like what these guys are trying to do but, wow, that is sadistic.

PAULA MICHAELS: It seems totally twisted, but it's in the name of science. It's for a greater good.

JAD: [laughs] Okay.

TIM: All right, so then the doctors, they took all of the data from all of the women, and they start going through it looking for patterns, looking for things in common. And then the most incredible part to me is that they converted all that information into a mathematical formula.

PAULA MICHAELS: Dols of pain equals 10.5-1.5 times contraction intervals in minutes.

JAD: What?

TIM: Well, so they're saying if you tell us the amount of time between the contractions at any point in her labor, we can tell you exactly how much pain the woman is in. No more mystery, there's no more wondering.

JAD: [laughs] Problem solved.

TIM: The code is cracked.

JAD: And—and what happens? Does this breakthrough sweep the medical establishment? I'm guessing it doesn't.

TIM: Well, no.

PAULA MICHAELS: Other people could not achieve the same results that they achieved using the dolom—[laughs] don't know why I can't—dolom. Dolorimeter. Using the dolorimeter. They were not able to achieve the same results.

TIM: When other doctors tried to do it that formula didn't seem to apply to the women that they looked at.

JAD: Shocker.

TIM: Obviously, there's a lot of problems with the entire approach these guys had.

JAD: No!

TIM: [laughs] Yeah, I mean for starters they were trying to compare pain in the abdomen to, you know, like a burning sensation on the arm.

JAD: Yeah, I mean that's a—that's like a translation problem.

TIM: Yeah, well—I mean, in my opinion there's kind of a bigger translation issue happening.

JAD: Which is?

TIM: In order to talk about a pain you're feeling, you need to be able to observe it, and—and kind of stand apart from it in your own head, if that makes sense.

JAD: Sure.

TIM: And when you hear women talk about the pain of childbirth ...

SARAH: Hello, my name is Sarah, I'm in Sacramento, California.

TIM: We asked people to submit theirs through the Radiolab app, and when you listen to these different accounts ...

SARAH: My experience with childbirth pain was ...

TIM: ... it sounds like there's a certain point where everything shifts, and one woman said it was at about, like, seven centimeters dilated.

SARAH: And that's when you lose your mind, and you can't think, you can't talk.

TIM: Suddenly the pain becomes so great...

SARAH: So, so bad.

TIM: ... that there's no more reference point.

SARAH: I just remember ...

TIM: There's no more objective distance.

SARAH: ...making these noises that were just unearthly.

TIM: And in these submissions, it's usually at this point in the story where the woman either draws a blank...

SARAH: Wow!

TIM: Or resorts to some crazy analogy.

[ARCHIVE CLIP, Woman: I felt like there was a freight train bearing down on my vagina, from inside my body. And then I could almost hear it building, like [imitates train sound]]

[ARCHIVE CLIP, Woman 2: I felt like I was being dragged out to sea.]

TIM: That's one I actually heard a couple times.

[ARCHIVE CLIP, Woman 3: Waves, waves of pain.]

TIM: And it was kind of like that for—for Paula too.

PAULA MICHAELS: I turned very much inward, in a way that—that made time feel like it stopped. I was drowning. Drowning.

EULA BISS: In this lake of pain, and there was a horizon, and when the contractions were intense, I would swim towards the horizon.

TIM: This is Eula.

EULA BISS: I'm Eula Biss, I'm a non-fiction writer.

TIM: And she's our third pain calibrator. And for me, Eula kind of gets it closest at finding a way to communicate pain.

TIM: If—if I could say you have a relationship with pain, when did that—when did that start for you?

EULA BISS: Let's see about almost 10 years ago, I think I was about 26.

TIM: At the time Eula was a grad student in Iowa.

EULA BISS: And I just woke up one morning in the fall, and I had a terrible pain in the side of my neck, upper back, side of my face.

TIM: She had no idea what it was.

EULA BISS: It was a burning pain.

TIM: With his nauseating, tingling sensation.

EULA BISS: I've really never felt anything else like it in months past. And it didn't go away, and it was making it very difficult for me to sleep. It started to interfere with my thinking too, I couldn't concentrate.

TIM: So one day she went to the hospital, and by this point she was a total mess.

EULA BISS: So I was kind of teary, and shaking and I said, "You—you need to give me something to help me with this."

TIM: And so the doc said, "All right, well, take a look at this thing up here on the wall. This is called the pain scale."

EULA BISS: It had the numbers zero to ten, at one end it said No Pain at the other end it said the Worst Pain Imaginable.

TIM: And the doctor says to her, "Okay, what number is your pain?" Eula starts to think about it.

EULA BISS: The worst pain imaginable is kind of vague, is this the worst pain you yourself can imagine? Or is it the worst pain imaginable on Earth?

TIM: Hmm.

EULA BISS: You know, this was around the time that I think a man had died being dragged behind a truck in Texas, and I remember sitting in the exam room thinking about that. And then I was trying to do some rudimentary mathematics. If being dragged behind a truck to your death is the worst pain imaginable, what—what proportion of that do I feel? And I thought, you know, a third of that seemed pretty significant to me.

TIM: So she says "Three, I guess?" And the doc's like, "All right." And he does some tests, he tries to figure out exactly what's going on, can't really, but since she said three anyway he's like, "All right, well, you know, have some Aspirin. Go home." And this happened a few times. She wasn't getting any better, so at a certain point she calls up her dad, who's also a doctor, and she starts complaining.

EULA BISS: I was telling him how frustrated I was that—that the doctors didn't seem to be taking this very seriously, and he said, "Well, when they ask you to rate your pain what—what do you tell them?" And I said, "I usually say three." And he said, "Well there's your problem."

TIM: Her dad tells her you should say eight. Even if you're not feeling it, that's what you gotta say. And Eula thinks, you know, this is ridiculous, why do we even have a pain scale if I'm not supposed to take the number seriously?

EULA BISS: And he said in part it's a tool that's meant to protect practitioners, because it's emotionally difficult to have someone say to you, "It feels like someone's jamming a red hot poker through my eyeball," rather than "I've got a nine."

TIM: But then he made a suggestion, which I think is really clever.

EULA BISS: He suggested one scale where it would measure what you're willing to do to get rid of your pain. What would you trade for pain relief? Would you give up your sense of sight for five years? Would you relinquish your ability to walk?

TIM: Did you come up with any answers at that point?

EULA BISS: I did. They were disturbing answers, you know? When my father asked, "Would you accept a shorter lifespan?" At that point in time I thought, yeah I would.

TIM: How many years?

EULA BISS: I was thinking I'd take 10 years off my life.

TIM: Wow!

TIM: For me, that was basically the first time I felt like I understood her pain.

EULA BISS: But, you know, I was 26, and life seems really long when you're 26. Now I'm in a much different space. My pain is not nearly as bad as it was then, so now I'm not really in the bargaining mood anymore.

TIM: I bet like how about a bad haircut? Would you take a really bad haircut? A mohawk?

EULA BISS: Huh. Okay. Yeah, actually I would.

TIM: [laughs]

TIM: And these days, Eula is kind of pessimistic about the idea that we're ever gonna really have a useful pain scale.

EULA BISS: At the end of the day, I'm not sure pain is a quantity that is measurable.

TIM: Thinking that kind of bums her out.

EULA BISS: Because part of me wanted to believe in the project of quantification.

TIM: Why?

EULA BISS: I—I'm not sure. I think because not believing in it is a little bit lonelier. The idea that we cannot feel, cannot understand, and cannot imagine each other's pain is a really isolating thought.

JAD: By the way, what was her pain from? Did she get a diagnosis?

TIM: Well, her doctor tried a lot of stuff, actually. They did a brain scan, they checked for a spinal infection, and ultimately ...

EULA BISS: He said, "You know, unfortunately, we—we don't know what causes this. We don't know how to treat it. We don't know if it will ever get better, But we do know it's real." [laughs] And that was my final conversation with him, and he said, "Good luck out there."

JAD: Thanks to producer Tim Howard, Justin Schmidt, Paula Michaels and Eula Biss.

ROBERT: I'm Robert Krulwich.

JAD: I'm Jad Abumrad. Thanks for listening.

[LISTENER: Hi guys, I just called, and I think I messed up, so I want to try it again. Okay? Okay. Hi, this is Clarice, I am a Radiolab listener in Jamaica Plain, Massachusetts, and here are the credits: Radiolab is supported, in part, by the National Science Foundation, and the Alfred P. Sloan Foundation, enhancing public understanding of science and technology in the modern world. More information about Sloan at www.sloan.org. I think that one was better. Thanks y'all. Bye.]

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