Oh, My Aching Back

From the Church Fathers, through St Ignatius Loyola and Pascal to the Marquis de Sade, the problem of pain was agonisingly debated, not least because mortification was holiness and judicial torture the authorised engine of truth. But nowadays, pain, in either its medical or its metaphysical aspects, is oddly little discussed given the ubiquitous misery it causes.

Hoping to learn about medical views on pain down the centuries, I recently consulted the pick of the reference books, Roderick McGrew’s Encyclopaedia of Medical History (1985): no entry was to be found. Even weighty Roman Catholic works of reference no longer tangle with the topic. In the Dictionnaire de théologie, published in 33 volumes between 1935 and 1972 under the editorship of Vacant, Mangenot and Amann, there are, astonishingly, no entries on pain or suffering; and it says much that modern Catholic scholars such as François Varone, author of Le Dieu censé aimer la souffrance (1984), deny that suffering has any special purpose in the divine scheme, thereby seemingly reducing the crux of Christian theology to vacousness. Pain appears to have become an embarrassment.

Yet even if we don’t philosophise about it these days and have outgrown decadent Fin de Siècle glamorisation, in our daily dealings it remains as important as ever. It’s pain that tells us we’re ill; a conspicuous show of it commands the sympathy of others; and, explicitly or not, pain management remains the bread and butter of medical practice. However, in a book rendered appallingly poignant by her premature death this year, the brilliant young French medical historian Roselyne Rey observes that pain always was and still remains a poor relation in the medical mansion. Suffering, the Church had ruled, was the lot of sinners; so like the poor, pain would always be with us – which made it easy for doctors to consider it best left to the sufferers themselves, or to priests or nurses, while the heroic surgeon sawed on.

Half a century ago, John Alfred Ryle, the founder of social medicine, declared that one of the mistakes of scientific medicine was to have shelved the problem of pain. With both clinical and humane ends in mind, he called for fresh study. Since then things have indeed improved, but saving lives remains sexier than managing pain; from arthritis to cancer, pain relief is far from perfect; and protocols get in the way (heroin, for example, is medically unavailable in the US). Reflecting on his loathing of doctors, Jeffrey Barnard, smitten with pancreatitis, recently observed that ‘most of all I hate them for their meanness and narrow-mindedness about dispensing pain relief.’

Even when pain is specifically addressed by medical scientists, their mental programming, Rey shows, is not always conducive to understanding. In The Basis of Sensation (1928), Lord Adrian rightly stated that ‘whatever our views about the relation of mind and body, we cannot escape the fact that there is an unsatisfactory gap between such events as the sticking of a pin into my finger and the appearance of a sensation of pain in my consciousness. Part of the gap is obviously made up of events in my sensory nerves and brain.’ No doubt; but by then insisting that ‘the psychological method by itself can tell us nothing at all,’ the Nobel Prize-winning neurophysiologist was led to conclude that it was the laboratory bench that would provide the answers. In other words, all true pain was physical pain, to be explained by scientific investigation; psychological pain was flimflam.

Clinicians, too, have striven to distinguish authentic pain from distress whose basis was emotional or psychological – ‘all in the mind’, as they say. ‘Real pain, especially severe pain,’ insisted the American physician, Walter Alvarez, ‘points to the presence of organic rather than functional disease. On the other hand, a burning, or a quivering, or a picking, pricking, pulling, pumping, crawling, boiling, gurgling, thumping, throbbing, gassy or itching sensation, or a constant ache, or soreness, strongly suggests a neurosis.’ It is with strategies such as these that scientific medicine has sought to rescue ‘real pain’ or ‘healthy pain’ from (mere) ‘suffering’ – the former legitimated by falling within the domain of medicine.

Pain, Rey observes, remains poorly understood because it ‘has no clearly defined status’; all divisions between ‘real’ and ‘subjective’ pain, having been founded on archaic metaphysical body/mind dualisms, are plainly problematic, not to say question-begging. No physician can pop a thermometer into the brain or X-ray the heart. Whatever its nature or function, pain is felt. As Rey observes, it is best conceived of not as a raw physical sensation but as an experience (feeling filtered through culture). Not least, the dubious desire among nonsense medics to distinguish ‘physical’ and ‘mental’ pain invariably discounts ‘psychosomatic disorders’ and sows suspicions about malingering. Rey’s point is that we will fathom the paradoxes of today’s often offhand or dismissive attitudes only when we understand their history.

Yet figuring pain in the past is problematic, both personally and philosophically. Pain always comes mediated through distinctive models of mind-body relations and particular theories of disease. Moreover, it is harder to convey than most emotions and experiences. When Funny Burney describes her mastectomy without anaesthetic as ‘the most terrifying pain ... when the dreadful steel was plunged into the breast – cutting through veins – arteries – flesh – nerves’, we can vicariously share that horror. But what of that dauntless early Victorian intellectual, Harriet Martineau? She took to her bed for five years, complaining of unbearable abdominal agonies whose roots were quite obscure. Can we even guess what she was going through? ‘Language has not yet been adjusted,’ reflected the physician, Thomas Beddoes, ‘with any degree of exactness, to our inward feelings.’ Miss Martineau’s tender womb certainly entered the public domain, and she was no slouch at what Post-Modernists now call ‘writing the body’; but for all that, the historian is left a bewildered bystander. Sometimes words simply fail, or at best achieve a lapidary eloquence. Here’s William Tildesley, a 17th-century diarist: ‘June 15, In great payne; June 16, In paines alover; June 17, In great payne.’ And such mute ness may help to explain why many codes of conduct – Stoicism is the obvious example – have prescribed dignified silence as an assertion of brain over pain. Post-Holocaust conventional wisdom deemed that the most hideous pain – that caused by rape, torture, genocide – is necessarily unspeakable, and all verbalisation profane.

As well as these humanistic dilemmas, theoretical difficulties abound. The standard assumption that pain as physiological tracer and pain as inner agony are distinct entities may be quite anachronistic. The dominant medical teachings from Hippocrates onwards regarded maladies holistically, viewing the ‘physical’ and the ‘spiritual’ as a continuum mediated through such concepts as humours and temperaments. Cartesianism and the new pathology that dominated hospital medicine from around 1800 were meant to put paid to such ‘confusions’, but the reverse seems to have happened: for all their trumpeted path-lab proficiency, physicians found themselves encountering pain clusters which were impossible to match against bedside or post-mortem lesions. Those who were not inclined to dismiss such symptoms as (merely) psychosomatic or as telltale marks of the fake pioneered the concept of the ‘syndrome’ and formulated intermediate explanatory categories like neuralgia, functional disorder or chronic pain without lesion.

Rey structures her inquiry around the exchanges between biomedical scientists and clinicians (sometimes a dialogue of the deaf), the former affirming the purpose of pain within the biological order, the latter charged with alleviating it. Every culture, group and individual has distinctive pain thresholds beneath which it is normal to grin and bear it. But unexpected pain – strange, erratic, searing, intense or protracted modes of discomfort – has led sufferers to pursue primary care, convinced that pain reveals some deeper malady and desperate for relief. Within old-style medicine, the physician used to ‘take the history’ while the patient recited the pain: its nature, location, onset, duration, intensity, periodicity, quality. Clinicians had always felt the pulse and gauged eye and skin colour, but hands-on physical examinations became standard practice only belatedly – as late as mid-Victorian times a physician could still take the view that ‘not only degrees of pain, but its existence, in any degree, must be taken upon the testimony of the patient.’

Things changed, thanks to the emergence of what Michel Foucault dubbed the new ‘clinical gaze’. The traditional bedside question – ‘What is the matter?’ – gave way to the modern: ‘Show me where it hurts.’ Diagnosis switched from subjective symptoms to objective signs – and power shifted from patient to physician. With the help of new diagnostic aids – stethoscopes, ophthalmoscopes and (exactly a century ago) X-rays – it became possible to allocate pain to specific bodily sites and pathological events.

Rey retraces the conceptual underpinnings for what Max von Frey called the ‘doctrine of specificity’ to the rise of neuroanatomy in the Scientific Revolution. In the 18th century the great Swiss-born physiologist, Albrecht von Haller, clarified the distinction between muscles (endowed with irritability, the property of contracting under stimulus) and nerves (which alone possessed sensitivity, the power to communicate feeling). Early in the 19th century, François Magendie in France and Charles Bell in Britain established the sensory/motor division of the spinal roots as fundamental to nervous organisation.

Experimenters sliced and snipped, but they also looked to philosophy, their theory of the ‘reflex arc’ being suggested by the Cartesian model of the body machine. Affirming the mechanistic nature of organisation, Descartes had pointed to the instinctive withdrawal of a foot from a flame. Heat impacted on the skin, causing signals to speed to the brain like a tug on a bell-rope. Pain was the bell, a literal fire-alarm for self-preservation. This physiological representation of pain as a beneficial reflex mechanism, a warning system, appealed to anatomists, reinforcing their ‘all is for the best’ vision of the perfection of the organism. Neurology confirmed that human behaviour was not random but governed by well-designed natural laws of ‘motivation’. By way of a practical spinoff, the Enlightenment educationalist, Helvét-ius, and the utilitarian Bentham, deemed that mankind innately reacted to the stimulus of pleasure and the sanction of pain (‘the only evil’, according to Bentham). Not only was an applied science of motives therefore feasible: Enlightenment sensationalism paved the way for the audacious cruelties of modern behaviourist and conditioning psychologies.

The triumph of the sensory-motor model of nervous organisation rendered it conceptually easy – albeit experimentally tricky – for 19th-century physiologists to study the pathways between pain and the central nervous system. There was growing awareness, indirectly inspired by phrenology, of paintracks and the localisation of functions in the brain. Rey recounts how, through exquisite vivisection experiments (sometimes performed on themselves) which involved severing nerve fibres, a string of ingenious investigators from Pierre Flourens to Henry Head and Charles Sherrington laid bare the central nervous system’s intricate mechanisms. By 1900, the sensory-motor alterations which, it had long been known, could be effected by severing spinal nerve roots, were being produced by slicing segments off the brain. Pain was the most reliable demonstration of the body’s nervous circuitry: no pain, no physiological research.

The differential sensitivity to pain of various bodily parts had long puzzled observers: why were fingertips or lips so much more responsive than the skin on the back? Why was pain not felt directly in diseased internal organs like the liver? Neurologists like Frey showed that these unequal reactions were products of the differential distribution of nerve endings. And pain was also discovered to possess a labile quality, defying crude bell-pull reflex models. Bodily surfaces could become unresponsive or supersensitive (hyperaesthesic, as in tickling, for example); indeed, one standard test for witches had been insensitivity to pain, discovered by applying a candle flame to the subject or sticking pins in them. The new neurophysiology proved that such bizarre occurrences were authentic – not as the Devil’s doings but as products of cerebral abnormalities. The great Parisian nuroanatomist Jean-Martin Charcot experimented on hysterics’ reactions to pain stimuli, using hypnosis to induce anaesthesias and hyperaesthesias. Others explored the ‘phantom organ’ and, conversely, the loss of sensation in an intact part – occurrences given an autobiographical twist in Oliver Sacks’s A Leg to Stand On.

Every new understanding of the protective role of pain has led to fresh conceptual problems. If pain was integral to the reflex response, could it (asked Enlightenment materialists like La Mettrie and successors like Thomas Laycock) be said to be the cause of activity? Or was it only noises off, a scream in the machine? Some, implicitly harking back to the old Cartesian denial that animals felt pain at all, argued that pain was not the motivation for retracting one’s foot from the fire, but the psychological voice-over to stimulus and response reflexes.

Philosophical questions have similarly been raised by modern investigations showing how the pain substrate lies in cerebral biochemistry. A research tradition sparked by Henry Dale’s investigations into the brain-modifying properties of ergot revealed the role of chemical neurotransmitters in pain inhibition. Endorphins are released to override the normal protective mechanisms of pain, notably at times of great excitement or danger – which explains why soldiers are often oblivious to appalling wounds in the heat of battle. Such discoveries have proved suggestive for the molecular modelling of drugs like antihistamines. On the other hand, if consciousness is finally being shown to be just a trick of chemistry, wouldn’t it be wise to make destiny a matter of our choice and join the Prozac generation?

Not all therapeutic persuasions have embraced these biochemical or neurophysiological accounts of pain. For some, pain is still viewed as immediate proof of the sovereignty of the psychological. The 19th century brought to light pain-inducing or inhibiting conditions (such as hypnosis, trance, hysteria, voodoo and brain-washing) which parapsychologists still claim defy reductionist explanation, while Freud explained both ‘hysterical’ anaesthetisations and diseaseless symptoms (like persistent coughs) as somatic conversions, consequent on the repression of primary psychological disturbance. The cunning of the unconscious dis places emotional conflict or insupportable anguish by translating them into more manageable organic modes. Georg Groddeck, Freud’s erstwhile follower, argued that all physical pain was, at bottom, psychological, to be glossed as non-verbal language. Similarly, in Pain and Pleasure: A Study of Bodily Feelings (1957), Thomas Szasz suggested that pain should be read as a communication system well-adapted for attracting attention in a highly medicalised society. Biomedical critics may counter that such psychological explanations are trivialising and false, but the enduring value of psychological theories is that they reach out to the richer domains of philosophy, language and subjectivity which personalise the barbs of pain.

Within biomedicine, however, it has been axiomatic that ‘real’ pain has a purpose: if in some pie-in-the-sky utopia, dog-bites and frostbite, toxins and infections provoked no pangs, survival would be jeopardised. For Darwinian doctors, pain is a healthily adaptive response to danger. But why then is it so often chronic or insupportable? Are these not disproportionate to its functions, a monstrous form of overkill?

Rey leads us through medical controversies on this subject via analysis of the leading (but in the English-speaking world neglected) interwar French biophilosopher, René Leriche. In his view, pain serves little purpose either diagnostically or prognostically; indeed ‘in certain chronic cases it seems to be the entire disorder which, without it, would not exist.’ Leriche mocked the medical pieties about ‘good pain’: ‘Defence mechanism? Welcome warning? ... When the pain does arrive, it is already too late ... The pain has only made the whole battle, lost early on in the game, sadder and more unbearable.’ In challenging orthodox views of ‘healthy pain’, Leriche did for medicine what the Enlightenment did for theodicies at large: he questioned the tenets that vindicated pain.

Broadly speaking, there were two ways to rationalise pain: it could be read as absolutely evil or as deprivation (as in hunger pangs). Manichaeism interpreted it as the devil’s work: Platonists and Thomists have seen it as privation. Conventional Christians denied that pain was an original design feature of Creation, having entered the world through Original Sin; this divine penalty theory was etymologically reinforced, ‘pain’ coming from poena (‘punishment’). Preachers asserted that the Lord plagued sinful mankind with pain, while individuals were to bear affliction as a cross. Martyrdom to disease was no less glorious than martyrdom to the infidel. Especially for Catholics, mortification was an induction into holiness, stunning the flesh to liberate the spirit.

Yet caution was always urged, lest pain were fetishised, making a proud cult out of homo dolorosus. Christian charity in any case required the relief of pain – Luke had been a physician, Christ had performed healing miracles and the promise of Heaven was not agony but bliss. Hence apologetics required nuanced positions. Suffering was a gift of Providence, a blessing; yet it was also to be alleviated by medical aid and pious offices.

Medieval churchmen adopted unflinching attitudes towards physical pain, but with the age of reason, even theodicies had to be refined. According to William Paley’s Natural Theology (1802), pain was a ‘lesser evil’ designed to prevent a ‘greater’. Today’s twinge in the toes is a providential hazard-sign, directing us to cut back alcohol consumption lest tomorrow we get gout. Ingenious apologists even speculated that God might have brought distress into the world out of sheer creative superfecundity. The blind and deaf, freaks and cripples, averred Soame Jenyns, enriched creation through multiplying the dazzling heterogeneity of types. Almost anticipating Leriche, Samuel Johnson gave Jenyns’s special pleading for pain the drubbing it deserved – such apologiae were tantamount to suggesting that the Almighty took sadistic ‘delight in the operations of an asthma, as a human philosopher in the effects of the air pump’. The sting in Johnson‘s tale was that, unlike God, animal experimenters were cruel.

By Victorian times, pain was becoming a scandal and its empire a gift for sceptics. Darwin regarded Scripture as no less vicious than Nature: he could not stomach the ‘cruel’ Christian doctrine that unbelievers would be condemned to eternal hellfire. And faced by the murderous struggle for survival, he and other sensitive souls could no longer accept that the wise man automatically looked, as Pope had recommended, ‘from Nature up to Nature’s God’. Christian evolutionists, of course, had their riposte: God had programmed suffering into the evolutionary economy to weed out the weak. Similarly, through all her sufferings, Harriet Martineau deplored the moral repugnance of Christian teachings on pain. In Life in the Sick-Room, she claimed that pieties about the beauties of suffering glamorised morbid self-pity and sapped the will to be well. Christianity was locked into a culture of cruelty and woe.

The Enlightenment made its philosophical keynote not the uses of adversity but the minimisation of suffering, notably via the principle of utility. Bentham, that great atheistic cat-lover, urged an end to wanton cruelty towards animals, because they suffered too. This left the medical profession on the horns of a dilemma. Many doctors were distinguished humanitarians, campaigning against the slave trade and other abominations. Yet medical progress seemed to hinge on experimental physiology, and Victorian experimentalists increasingly came under fire for their alleged indifference to the pain they inflicted on dumb animals – charges still in the anti-vivisectionist arsenal. British experimenters responded with the ‘greater good’ defence; certain Continental physiologists, by contrast, upheld the Cartesian ‘automaton’ position on the brute creation, flaunting a lofty indifference in the name of science.

This Enlightenment upheaval in attitudes to pain leads Rey to re-open an old question: has the endurance of pain changed over time? Do moderns deplore pain because they have become too soft to bear it? Again, different societies respond dissimilarly to ‘painful’ sensations – some ‘psychologise’ more while others ‘somatise’. Some cultures encourage operatic wailing and stylised screaming rituals, others the stiff upper lip: either may prove an effective coping strategy. Body events will be experienced more or less painfully, depending on wider frameworks of meaning. In the West, women commonly experience menopause as painful because it signals status deterioration (ageing). In other communities, so anthropologists say, deliverance from menstruation and uncontrolled fertility may lead to social upgrading and hence be unattended by distressing symptoms.

Has the civilising process brought increased sensitivity to pain, as has often been claimed: ‘the savage does not feel pain as we do,’ judged the celebrated American physician Silas Weir Mitchell. This alleged phenomenon might be read positively (as indicative of truer or more honest humanity) or negatively (as a lamentable weakening of moral fibre). ‘That anybody should be in pain and not be immediately relieved – that sharp pain should ever be inflicted upon anyone,’ bemoaned the eminent Victorian jurist, James Fitzjames Stephen, ‘shocks and scandalises people in these days.’

Assessment, as Rey recognises, is tricky. Does the founding of Amnesty International testify to the intensified moral conscience of our century or to the fact that torture is now more brazen than ever? Does the use of epidurals in labour mark the end of a punitive streak among gynaecologists or show that Western women are no longer prepared to experience their natural functions? All that is clear is that the organism has plastic powers of adjustment to meet the challenges demanded of it.

Equally clear is the fact that the medical profession has become more responsive to the clamour for pain relief. Though sedatives and narcotics had long been used to quell pain – mandragora, henbane (hyosciamine) and sedative sponges were well known in antiquity – painkilling was not central to the classical physician. That analgesics gradually became more important in prescribing practice was partly due to increased access to effective drugs. From the 17th century, opium was easily available, while the rise of the pharmaceutical industry led to major synthetic compounds: morphine (1806), codeine (1836) and, precisely a century ago, acetylsalicylic acid, the humble aspirin.

Attitudes altered accordingly. There is little sign that the Renaissance physician conceived of pain-control as his priority. Growing customer assertiveness changed that, as did competition from quacks promising gentle remedies. Pain management developed. Eighteenthcentury physicians began to calm the dying with generous doses of laudanum, and the 19th century brought the anaesthetics revolution. That idea, or its uptake, came slowly, however – it seems remarkable that, as late as the 1790s, Humphry Davy could be involved in autoexperimentation with nitrous oxide (laughing gas) as a putative remedy for respiratory disorders, without capitalising on its remarkable anaesthetic properties. By the 1840s, however, ether was being used for dental extractions and chloroform for surgery and for painless childbirth; Queen Victoria’s fourth son, Prince Leopold, was delivered under chloroform in 1853. The hypodermic syringe, invented in the same year, allowed the injection of narcotics, and cocaine came into use in the 1880s, popularised not least by Freud. Hypnosis enjoyed a vogue, rather like acupuncture today – needling has a physiological effect, stimulating endorphin release.

A major breakthrough in recent years has been the ‘gate’ theory of pain developed in the Sixties by Ronald Melzack and Patrick Wall. Discarding the old mechanical ‘fire-alarm’ theory as simplistic, they argued that controls operate all the way from the nerve endings to the brain. When messages from the nerve ends reach the spinal cord, a fine-tuning takes place regulating the degree of pain suffered, and pain can be enhanced or inhibited by signals from the brain. By emphasising the symbiosis of physiological and psychological factors, ‘gate theorists’ have shown how the intensity of the pain felt depends on circumstances: when we are depressed, we may become supersensitive to pain. This proof that behaviour affects pain, suggests J. Cambier in his Postscript to The History of Pain, may finally put paid to the old physiological/psychological polarity. In recent years healthcare systems have been investing in specialist pain managers, pain clinics and pain-management courses. Further signs of a new sensitivity are the flowering of the hospice movement, the founding in 1973 of the International Association for the Study of Pain with its journal Pain (1975), and the establishment in this country of the Pain Society.

Ivan Illich and other critics of ‘medical imperialism’ have deplored the retreat from gladiatorial confrontations with pain. Such aversion from reality, they allege, undermines integrity and autonomy: those who cannot face pain will not be able to face death. Maybe so, but effective pain control can at least materially enhance the quality of life in the terminally and chronically sick, as the liberal policy with morphine dosages followed in British hospices indicates. In times when fears are growing that healthcare costs will spiral insupportably, attention to pain and its reduction may help us to order our priorities.