November 24, 2015

Pain: The Forgotten Emotion

[Transcript of a paper given at the University of Melbourne, Australia, November 18, 2015]

Today I want simply to give you a brief insight into the work I’ve been doing over the past few years on the subject of pain, its history and its present, with a few suggestions for the potential practical relevance of the history of emotions for contemporary medical practice. This work began life in 2011 within the framework of the history of emotions, as part of a postdoc at the Languages of Emotion Excellence Cluster at Freie Universitaet Berlin, in conjunction with what has turned out to be a long stay at the Centre for the History of Emotions at the Max Planck Institute for Human Development. I was, ostensibly, working on the history of sympathy and compassion at the beginning of that project, having previously carried out research on the history of cruelty and pain in animals. But I was obliged to make some connections that weren’t immediately obvious to me when Joanna Bourke invited me to be a Pain Fellow at the Birkbeck Pain Project in London in 2012. The focus there was supposed to be bodily pain, but I quickly realised that a mind/body dualistic approach wasn’t going to work, and that the work I’d been doing on sympathy was in fact a close and informative bedfellow of pain.

What has followed has been a bit of an adventure, which has taken me out of my modern-historian comfort zone in a number of different directions. I’ve engaged many different disciplinary approaches to pain, gone back through the ages to examine the wealth of historical literature on pain, and scrutinised many more recent historical and contemporary medical journals than I’d ever thought likely. I’ve talked with anaesthetists, plastic surgeons, bioethicists, art practitioners, lawyers and anthropologists in a bid to try and join up the thinking on pain.

The first result of all this was an edited volume that came out last year, called Pain and Emotion in Modern History, which makes one titular compromise that I would now like to undo. I’d like to swap out the ‘and’ and replace it with ‘as’. As it stands the book attempts to collapse the distinction between physical and emotional and to reassess some well worn historiographical paths by taking seriously historical claims that feelings hurt. I think I’m right in saying that for modern historians at least, this was novel and unexpected, and came with a heavy burden of proof. But I was aware that for early modernists and medievalists these claims were perhaps already in the mainstream, and indeed for some within contemporary neuroscientific research the emotional nature of pain was driving experimentation. What I couldn’t see – at all – was any sense that any of these distinct fields were aware of each other, let alone talking to one another. I saw huge potential in reassessing the historical narrative in the light of some of the latest neuroscientific research, and indeed reassessing some of that neuro-research in the light of the historiography.

That led me to take on another project, which I’m finishing up in Melbourne, to write Pain: A Very Short Introduction, which rather terrifyingly is to cover the history of pain from antiquity to the present, and to include an analysis of contemporary medical and scientific understandings of pain, all in 35,000 words. What you’re getting today is sort of a precis of the argument in that book, and I hope to at least convey my main points: first, that pain is an emotion or, if that is too stark, that pain is meaningless without emotion; second, that if emotional experience is historical, contextually contingent, mutable, then so must be the experience of pain; third, if this is true, then pain necessarily resists a definition, and treatment and management must be carried out with an attention to any sufferer’s subjective appraisal of their own pain and the cultural context in which pain is expressed.

Why do I call pain a ‘forgotten’ emotion? Well, as I combed the historical record I found that, with remarkable consistency across time and place, people seemed instinctively to know that bodily pain and emotional pain were of the same order, and while historians have carefully pointed out this fact they have done so through the lens of modernity, which has been characterised by a dualistic approach that has mechanised pain in the body and made pain of the mind a distinct kind of disorder. The effect: historical actors’ own conceptualisations of pain have been treated as novel and re-constructible on the one hand, but exotic, unfamiliar and wrong, strictly speaking. At the same time, the neuroscientific research that is convincingly demonstrating how pain is contextually and emotionally experienced has no connection whatsoever to this long view. Ostensibly, neuroscientists are confirming what the colloquial expressions of ordinary people suggest was already known – in fact continues to be known in everyday experience – but which had been forgotten in scientific and academic bowers since the time of Descartes. Meanwhile, current medical approaches to pain in clinical settings are largely disconnected from both these strands of research, still underemphasise the substantive interrelationship of body, brain and society in the construction of meaningful experiences of pain, and therefore still tend to treat people in pain according to presentations of bodily lesion or mental disturbance. If medicine could be inspired to remember that pain is an emotion or made meaningful only through emotion, then pain management would radically change.

I begin the book with a conceptual analysis of pain in history, examining how the language of pain has tended to conflate body and soul, body and mind, and physical and emotional. These are common expressions of pain that betray a fundamental fuzziness of the category of pain. The ancient Greeks had a number of words for pain and suffering that tended to overlap. Chief among these terms was άλγος (algos), which denoted physical pain as well as woe, ill, or misery. The Greeks did have a way of isolating bodily pain, if necessary, although it was only ever a short elision to a more general concept of suffering. In the Iliad, talk of όδύνη (odune) is never far away from the general state of anguish that undergirds the epic, and the same is true of the famous Herculean scream in Sophocles’ Trachiniae. The poisoned robe that slowly kills the hero in a prolonged fit of agony puts Heracles interchangeably in bodily pain and woeful misery (όδύνη and άλγος). 

The Greek term πάθος (pathos) denotes suffering or experience and, in its original meaning, the adjective ‘pathetic’ was an appeal at an emotional level. In Aristotle’s rhetoric, pathos causes pleasure or pain in an audience, as well as in its producer, depending on which emotions are mobilised. The possibility of pain without injury is clear, and it is closely entangled with affective states. As a central element of the rhetorical triad that included ethos and logos, we can assume that through pathos the potential for the feeling of painful woe was built into rhetorical emotional appeals. Aristotle goes so far as to say that the person who is angry ‘suffers pain’ (λυπεῖται). Here we see the elision of grief or vexation with bodily pain in the word λύπη (lupé). If we pursue this further, finding the Latin derivation of pathos, through πάσχειν (pashein), in the word passio, we see the continued conflation of the emotional and the physical, of suffering and pain. If the Romans emphasised the emotional level of pain through passio, they also, like the Greeks, had a generally holistic approach to the concept of pain that included what we have tended to divide into mental and physical categories. The Latin dolor is preserved in the French douleur, the Spanish dolor, and the Italian dolore. Originally, it could stand for physical pain, as well as grief, anguish, sorrow and resentment. To some extent, this conflation has been preserved in the vernacular.

The categorical vernacular conflation of old is not limited to Western civilisation. In Late Imperial China, for example, there is a rich overlapping of physical, emotional, sensational and moral categories, with an interplay of characters such as (tong), (ku), and the portmanteau 痛苦 (tongku), denoting respectively ‘painful’, ‘suffering’ and together, something like ‘anguish’. In India, the Hindi word दर्द (dard) stands for a raft of different degrees of suffering, from uneasiness to torture and from mental distress to grief to anguish. A correlate would be the word दुःख (duḥkh), which often translates as sorrow or grief, but which can signify pain just the same. It has ancient roots in Sanskrit, connoting suffering on a spiritual level, but when deployed in compound terms can indicate the whole range of pain from a cut to a cramp to a calamity. I begin with this semantic journey to emphasise both an enduring conceptual continuity in the understanding of pain, and to highlight the seismic rupture in this understanding that radically altered what it meant to be in pain, to be treated for pain, and to treat for pain (medically) in modernity. That rupture indicates an historical separation of vernacular knowledge of pain from medical specialism about pain.

Before reaching that separation I will say a few words on pain in the religious and theological context of medieval and early modern Europe up to the time of the rupture. Ecce Homo – behold the man – are the words associated with Pontius Pilate upon presenting the bloodied, tortured and pained body of Christ to the assembled masses, prior to crucifixion (John 19:5). The images associated with this scene became emblematic of virtuous suffering, and of the theological importance for humans to endure bodily pain. The representation of Christ’s passion in this moment has been preserved by the art world in the figure of the vir dolorum, or the man of pains, which has reached us variously in Europe as the ‘man of sorrows’ or the Schmerzensmann, which depicts a hurt beyond the mere physical. The wounds, the blood, the instruments of torture are all figures that invite reflection on a suffering that goes beyond the mortification of flesh.

Pain was a central pillar in Christian religious practice from the Roman world to the Counter Reformation, and arguably beyond. As Javier Moscoso and others have pointed out, pain was foundational for medieval and early modern piety, as part of an ascetic quest to imitate the ultimate pain in Christ’s passion. It was a pain not merely to be endured, but to be sought after, enhanced in any way imaginable, and, sometimes literally, sanctified. The imitation of the passion was celebrated in the lives of the Christian martyrs, whose placid countenances in the face of horrible tortures served as proof of the intervention of the saints. Meanwhile, such tortures informed medieval and early modern systems of justice and punishment. Long before pain came to be considered useful from an evolutionary point of view, pain was considered useful from moral, spiritual and judicial points of view. Religious life was dominated by the meaningful fact of being and coming to be in pain. No human pain could reach the extent of Christ’s suffering on behalf of humanity, but to embrace pain after the fashion of Christ was to offset sin and therefore reduce the amount of suffering after death. In this sense, pain was considered by many to be a blessing, or an unmitigated good, since it promised a swifter route to redemption in the afterlife. It would have been heretical, given this view, to seek to desensitise oneself to pain. Instead, people were to steel themselves to live with and through pain. As Esther Cohen has pointed out, this theological stance was the only way to resolve a tangible and all too readily observable ubiquity of suffering with the notion of an omnipresent Providence.

Doubtless this narrative is familiar, but I hope you acknowledge that already we have an account of pain that differs markedly from the kind of mechanistic or utilitarian discourse that would have all pain be bad or unpleasant, and reducible to the nervous system. I contend that the experience of being in pain in this context must have been completely different to the experience of being in pain in a secular, modern, medical context. Neuroscience is providing us with extremely convincing evidence to suggest that what pain feels like – that is, the meaning ascribed to being in pain that defines how pain is experienced – is affectively constructed. We should seriously entertain the notion of pain as ecstasy, pain as piety or a feeling of closeness to God, and pain as pleasure. When such things crop up in the historical record they should be entertained at face value and not merely as rhetorical. I’ll say more about this in a couple of minutes.

The rupture in conceptual understandings of pain is usually ascribed to Descartes, but I want to do him some justice before condemning him. Descartes’ human was, in fact, not a separable entity of body and soul so long as the body was alive, but a union of body-mind or body-soul, which could not be reduced to its components. True, in his Meditations, Descartes insisted that the thinking thing (res cogitans) did not depend on a body, but when Descartes’ body was affected by pain, he felt it; that is, at the level of the rational soul – a thinking thing – there was a disturbance (of thought), caused by the disruption or injury of the body with which the soul was conjoined. He talked of an ‘admixture’ (permixtione) of mind and body when it came to the senses (e.g. hunger or pain). The human body in pain was not merely a reflex mechanism akin to a bell on the end of a rope, but a body-mind that only felt pain because the mind was inseparable from its corporeal seat. If it were otherwise, according to Descartes, the human thinking thing would look upon bodily injury (lesion) as the pilot of a vessel would look upon a damaged boat. This account is complex, rich, and useful.

But. This image, added to the Meditations later, in combination with what Descartes said about animals being like clocks or soulless automata, prevailed. A simplistic reading of the image, contrary to what Descartes actually wrote about pain, has been enormously influential in modern medical science, beginning the search for a mechanical pain pathway. It rests on the assumption that injury = pain and that reactionary movements away from the cause of pain are the results of nervous stimulation, like a bell on the end of a rope suddenly being pulled. As science became increasingly secular and as the soul retreated into the background, so the primacy of physical pain emerged. We have lived with this vision more or less ever since. Ironically, science’s loss of interest in the soul allowed animals into the realm of beings that feel pain, but when physiologists recognised that pain was an unpleasant experience in humans and animals alike, they nevertheless set out on Descartes’ path to find the ‘wheels and springs’ that made pain work.

Modern biomedical theories of pain were preoccupied with the ‘pain pathway’ – the specific mechanism by which pain is detected in the periphery and transmitted, via the spinal cord, to the brain. It was based on assumptions that intensity of injury directly correlated with intensity of pain, and that certain nerves were specifically involved in sending pain messages to the brain. There is a kind of comfortable intuitiveness about such assumptions, but they have been conclusively found to be completely incorrect. Essentially what we see in modern medicine is the parceling out of physical pain related to injury and mental pain, which really did not belong to biomedical concerns. Even though this began to change in the 1960s, we are essentially still living with this dualism in the way medicine is practiced. It has been to the detriment of countless millions of people suffering with chronic pain syndromes and, throughout the twentieth century, saw the moral fibre or character of the war wounded called into question as they continued to suffer from the traumatic effects of combat, whether physically injured or not. Pick up a standard medical text book on pain and you will still find, as a sort of rhetorical Cartesian hangover, a tendency to label nerves that detect injury as pain detectors, which send pain signals to the brain. Such rhetorical slippages have been unsupported since 1965, but they persist and they continue to affect medical practice.

What happened in 1965? Ronald Melzack and Patrick Wall published their new theory of the ‘gate control mechanism’, which in turn fostered neuroscientific research that revolutionised understandings of what pain is. Here is the circuit-board in the spinal cord. But the mechanism was coupled with a fuzzier idea that promised the reintroduction of something immaterial, or beyond the human, to make sense of the variability of pain experience. The gate control is essentially a processing centre in the spinal cord that processes signals coming from the periphery in conjunction with signals descending from the brain. It determines what signals make it to the brain to be interpreted as pain. Crucially, the receipt of injury signals from the periphery are only allowed through the gate in conjunction with evaluative cognitive and emotional involvement. The social context and an appraisal of threat determine how pain feels: what it meaningfully is. Pain is indistinguishable from the fear, anxiety, anger, or ecstasy that comes with it.
This has been confirmed by study of those people with rare cases of pain asymbolia, or congenital analgesia. This is a genetic condition that renders its ‘sufferer’ unable to ascribe any meaning to painful states. Injurious stimuli are perceived plainly as pressure, cutting, cramping, etc., but the person who perceives these things is indifferent to them. Research has shown that so-called ‘pain centres’ in the brain do, in fact, ‘fire’ in these people when given painful stimuli, but their ‘affective centres’ do not. It is precisely because there is no emotional context to the physical problem that the pain does not register as a problem. Far from being advantageous, people with congenital analgesia tend not to live very long, precisely because they are indifferent to the pain that comes after injury. If there is an evolutionary benefit for pain it is in restricting movement and in protecting those parts that need time to heal. A person with congenital analgesia does not limp when wounded in the leg, and would indifferently go on throwing a ball with a broken arm. This failure to conserve an injury – an affective failure – has the effect of wearing out bones, joints and muscles at a much greater rate than somebody who could feel pain in a ‘normal’ way. Pain, to put it in plain terms, keeps us alive. It depends, when ordinarily perceived, on what the neuroscientists call affect.

Neuroscientists have provided further evidence of this by demonstrating that specific brain activity typically observed when painfully injured roughly corresponds with brain activity when feeling ‘social pain’. Despite some worthy and necessary scepticism about what we are seeing when we look at an fMRI scan of a brain, there can be no question that parts of the brain strongly related to affective or emotional behaviour are involved in pain states, and that these parts of the brain are also involved under stimuli that replicate the affective conditions of pain, but which do not involve any physical harm. In other words, the thing that gives pain meaning – that makes pain painful – can be observed in situations where the body is completely uncompromised. In a now famous test Naomi Eisenberger tested the effect of social exclusion among a peer group. Using a computer game of ‘cyberball’, in which players passed a ball to each other while being scanned, Eisenberger was able to show that being excluded from the game caused brain activity similar to what one would expect to see in conditions of physical pain. Those who felt excluded went through an emotional ordeal that looked, for all intents and purposes, the same as physical pain. The meaning-making processes that are part and parcel of experiencing physical pain are the same when experiencing such things as exclusion, bullying, grief. A broken heart – the archetypical cliché of emotional pain – turns out to be painful in the same sense as a broken leg (although with different consequences, of course). If hurt feelings have been, since time immemorial, a colloquial commonplace, contemporary medicine has started down the road of providing neuroscientific verification of this fact. Ronald Melzack has, much more recently, pushed the implications of his research even further, and coined the neuromatrix theory of pain. Key to this theory is the insistence that experience is not present anywhere, but is created in the brain.

Pain is output of the brain, not input from the periphery. Melzack forcefully states that injury is not pain. Pain is a quality produced in the brain, and is not reconcilable with, or reducible to, injury per se. The neuromatrix theory posits the production of a neurosignature of the whole body – an internal neuro ‘image’ or ‘pattern’ of the body understood as the self – which is ever-present. While the particulars of an individual’s neuromatrix may be genetically programmed, it is nevertheless plastic, being formed and informed by a number of factors that together produce a sense of the self: sensory inputs, including aural and visual, are components; affective and emotional states, which are themselves forged in the crucible of culture, play a part; the meanings and values attached to body parts, proportions, postures, and movements – some of it instinctive, some of it culturally prescribed – are factored in. All these inputs are processed and, in Melzack’s analogy, ‘arranged’ into a symphonic output that equates to the body-self. A cut in the leg may or may not be painful, but I know it is a cut in my leg because of the neurosignature imprint of my neuromatrix. The neuromatrix promises the collapse of both Cartesian dualism and the distance between biomedicine and phenomenology. The brain is not merely a machine, an automaton, or a computer. The brain is plastic, subject to change, and influenced by the world in which it is situated.

This research, I think, casts the history of pain – replete with seemingly inaccessible allusions to religious ecstasy, sexual pleasure and agonies of the soul – into a new light. What might seem like metaphor or rhetoric on face value might actually be a faithful recording of the experience of pain from distinct historical and subjective perspectives. The history of pain is so rich – I’ve barely skimmed the surface of a tiny fraction of it here, that I think it bears re-visiting with a commitment to embrace the unfamiliar as, for want of a better word, authentic. Moreover, that rich history should be sufficient for biomedicine to give up its quest for a definition of pain. It is emotional, historical, contextual. This observation thrusts the emphasis back on to the subjective experience of pain. Doctors’ most reliable source for what their patients are going through is not an fMRI scanner, a prescribed pain questionnaire, or a premeditated search for a lesion, but lies in who the patient is and in what they say and do, combined with an appreciation of their circumstances and the societal prescriptions for what can and should be expressed and what cannot. In short, doctors need to become literate in the pain practices – which is to say the emotional practices – of the people around them. Maybe historians of emotion can help with that.

Pictures: Bernard Picart, The Death of Hercules, 1733; Lucas Cranach the Elder, Christ as Man of Sorrows [Schmerzensmann], before 1537; The pain pathway, from René Descartes, Traite de l’homme, 1664; Gate Control Mechanism, Melzack and Wall, Science, 1965; ‘Social and Physical Pain Produce Similar Brain Responses’, Eisenberger, Lieberman and Williams, Science, 2003; ‘Pain and the Neuromatrix’, Melzack, Journal of Dental Education, 2001.

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