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The source of “boot nail guy,” a popular medical anecdote about pain without injury/nociception

PainSci » bibliography » Fisher et al 1995
updated
Tags: mind, pain, fun, case, odd, nocebo, harms, pain problems

Four articles on PainSci cite Fisher 1995: 1. The Complete Guide to Patellofemoral Pain Syndrome2. Complete Guide to Plantar Fasciitis3. Pain is Weird4. Mind Over Pain

PainSci commentary on Fisher 1995: ?This page is one of thousands in the PainScience.com bibliography. It is not a general article: it is focused on a single scientific paper, and it may provide only just enough context for the summary to make sense. Links to other papers and more general information are provided wherever possible.

This small item in the “Minerva” column of the British Medical Journal from 1995 is the source of a widely cited medical anecdote. The gist of it is that a man came to the hospital in terrible pain from a nail through his foot… except that the nail had actually gone between his toes. The anecdote is popular because it seems to support a very popular idea: that pain can occur without injury or nociception (danger signalling from injured tissues). If true, it means that people can "hallucinate" pain based on perception alone. By extension, that would also strongly suggest that pure psychosomatic pain is also possible. So a lot hinges on this little story.

But is the boot-nail-guy story for real? There is at least a somewhat credible source. If you are determined, you can verify the citation with a free trial membership for BMJ.com. But there is not much to verify: barely more than a photo with a caption, in the full text of the “Minerva” column. It is not a formal case study.

There is not much reason to doubt the overall veracity of the story, but there certainly are reasons to doubt that it is exactly what it seems to be, or that it actually constitutes compelling evidence of pain-without-nociception. Most notably, even though Boot Nail Guy probably did have an unpleasant trip to the hospital, it’s also possible (even likely) that the incident did not play out just exactly as described, and it seems very plausible to me that the whole thing was not so much perfectly uninjured person experiences terrible pain and more like slightly injured person is really freaked out until proven safe.

This slightly formal anecdote is not compelling “evidence” of pain without nociception at all, but it can be a credible example of a pain experience that may have been exaggerated by the mind. For a more detailed discussion of this odd source and its significance, see The legend of Boot Nail Guy reconsidered, or Pain is Weird (where it is put into a broader context).

~ Paul Ingraham

original abstract Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

A builder aged 29 came to the accident and emergency department having jumped down on to a 15 cm nail. As the smallest movement of the nail was painful he was sedated with fentanyl and midazolam. The nail was then pulled out from below. When his boot was removed a miraculous cure appeared to have taken place. Despite entering proximal to the steel toecap the nail had penetrated between the toes: the foot was entirely uninjured.

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