In an editorial in the British medical journal the Lancet in 1940, the editor observed what every parent has heard at least once. "When the little girl said tearfully to her sister, 'My toothache is worse than your toothache' she put her finger on the crux of the matter; for who shall say her nay?" He goes on to comment that "pain is one of the phenomena that defy measurement, so many are the variables. Some will maintain that a wealth of diagnostic information is contained in terms commonly applied to pain: gnawing, aching, pricking, stabbing, boring, tingling, cutting, shooting, starting, cramping, agonising, oppressive, bearing down, and many others; and the practitioner may never get the help from his scientific colleagues which will enable him to be more precise."
While this is certainly true, Joanna Bourke’s brilliant study of pain shows us exactly why pain is both so very personal to each of us and so elusive to scientific description, even in the 21st century.
Bourke confronts the central question: how do we understand our own pain and, as with the two sisters, how do we know someone else’s pain? Our bodies are constantly expressing meaning. Our faces reflect those meanings. But are these meanings preprogrammed in our body and psyche or do we imagine that our own sense of our interior life, which we learn as we develop in a specific time and place, is identical to that of other people – sisters included?
Pain tests the limits of the question of how we become human or whether we are all human in the same way. Is pain written on our faces because of what we are experiencing or is that experience, as well as our understanding and expression of it, determined by other factors?
Charles Darwin (and many since) claimed that pain is merely the neurological processing of sensory experience. It is part of our primitive inheritance from our prehuman ancestors. Our brain feels pain because the multiple sensors in the largest of our sensory organs, the skin (and below it), send “pain signals”. Bourke relates a joke in which a neurologist suffering a stomachache responds to his doctor when asked where it hurts: “In my brain, of course”.
But as she shows in meticulous and often startling ways, exploring the meanings of pain in the modern world, it is not only the “brain” that feels pain but also the “mind”. And the mind is something we build and alter (as is the brain) over our entire lives. Our mind changes with each of the moments in our lives and is shaped by our beliefs about them as much as by our experiences.
But, you think, pain is pain is pain is pain. When I stub my toe my pain is the same whether I am living in ancient Athens or modern Dublin. Isn’t it? Well, sometimes it is and sometimes it isn’t. There is a study that asked American soldiers who were wounded in battle during the second World War and who had been shot in their civilian lives about their pain. Virtually all of them recounted that the pain of being shot in battle was much less than the remembered pain of being shot at home. If you are a young man among other young men, perhaps, the question of pain also takes on other meanings: being brave or stoic or even manly. So your experience of pain, as well as your memory of it (not necessarily the same thing), is shaped by the context in which you felt it.
Bourke confronts in this book, as she has in many earlier ones, the question of how we as human beings are both material beings, made of flesh, with a genetic inheritance, a preprogrammed course of development from birth to death, and a body with a mind that processes these experiences in ways that are constantly changing over time. We are what we were and we become what we never planned to be. And the most recent work on what has come to be called “brain” and “genetic” plasticity shows that, as well as our mind responding to our experiences of the world, our seemingly unchanging bodies respond to it also.
Pain is therefore a pretty good indicator of how we experience the world through the filters our mind applies, as both a living thing protecting us against the travails of our experiences and the repository of our cultural inheritance and beliefs about those experiences. We are of flesh, and flesh senses the world about us. But how do we transform that into what we feel as pain?
Ether and chloroform
The early 19th century was the age of the first real miracles in pain management. Both ether, in 1846, and chloroform, the next year, were discovered to be pain “killing” agents and were soon used during surgery and childbirth. Their effects had been known before, as were those of nitrous oxide, but they were previously used only in “parlour games” – a nice way of saying that people got high for pleasure.
But that first generation to be spared pain was not always so certain about the value of this. Bourke recounts tales of patients refusing anaesthesia because they were terrified, for example, that a limb would be amputated while they were unconscious or, as in the case of childbirth, because they (and their physicians) were of the religious belief that pain was part of the process. As one nursing sister told a woman in labour in 1941, “You’ve had the sweet. Now you must have the sour!”
When my firstborn arrived, in the 1980s, such a view was stated in quite another language, but with the same moral tone. “Natural childbirth” avoided painkillers, which falsified the mother’s pure experience. The claim was that modern medicine had turned childbirth into a “disease” and that freeing the mother-to-be from anesthesia was the first step to reclaiming our real nature. Luckily, my wife was smart enough to make up her own mind about pain control. But we, even in the 21st century, ask such moral questions as whether a newborn baby boy “feels” pain when circumcised or whether a terminally ill patient might become addicted to opiates.
Bourke shows us the complicated web of meanings associated with pain and what, in the end, defines us at any given moment as human beings. It is an often painful recognition that the natural aspects of our experiences are shaped by who we are and how we live. It is so much easier to imagine that we function as a “natural” being in an organic, green world unshaped by our hopes, fears, and beliefs.
