Pain Like Love

Pain most resembles love in its resistance to language and to thought.  “Hurts so good,” as rocker John Mellancamp sings about love in a refrain that simply thickens the resistances.  Love and pain are classic enigmatic terms—encompassing an “unknowable x” at their heart—but love is far more garrulous.  “The merest schoolgirl, when she falls in love,” as Virginia Woolf writes in On Being Ill (1926), “has Shakespeare or Keats to speak her mind for her; but let a sufferer try to describe a pain in his head to a doctor and language at once runs dry.”1  Emily Dickinson gestured toward such native absences when she described pain as containing “an element of blank.”2  Pain enfolds what we might call a negative semantics, akin to negative theology in which to name the attributes of deity is inescapably to falsify or diminish God.  It is only at the peril of misrepresentation that we fill in or cover up with language the native blankness of pain.    
            Medicine, of course, cannot afford a negative semantics.  It might be described from afar as a major industry for the proliferation of new terms.  Medicine’s power to help patients generates and may depend upon a steady linguistic innovation (statins, immune system, code blue, zocor) that maps new language on to an ever-expanding knowledge of human neurobiology and of its health-care coordinates.  In a medical effort to map a patient’s pain, the famous Melzack–McGill Pain Questionnaire constructs an ingenious grid of linguistic descriptors—stabbing, throbbing, crushing, dull, sharp—corresponding to real differences in affect, intensity, sensation, and organic mode of operation.  Pain questionnaires, however, despite their value, discover only what they are pre-instructed to find, just as Geiger counters detect radiation.  They mirror back—inflected for a specific patient—the state of knowledge that their statistic-driven, science-trained, psych-wise questionnaire creators built into them.

The resistances native to pain survive, so far, even the latest high-tech instruments that peer into the genome, mostly the genome of manipulated knock-out mice.  A genetics of pain tends so far to report a single repeated finding: interrelated and ever-increasing layers of complexity resistant to simple, clean therapies.3  Chronic pain, as distinct from acute pain familiar in simple tissue damage, remains especially challenging to what sociologist Nikolas Rose calls the “molecular gaze” of biomedicine.  New biomedical technologies, Rose argues, no longer merely seek to cure organic damage or to enhance health.  They change what it is to be a biological organism by making it possible “to refigure—or hope to refigure—vital processes.”4  The American Pain Society has recently led a successful campaign to have pain charted, in regular clinical observation, as the so-called fifth vital sign.  Such progress is a welcome response to the documented medical undertreatment for pain and does not necessarily seek to refigure a vital process.  The medical drive to manage pain, however, can conceal a refiguring drive to eradicate it that brushes dangerously close to Dr. Strangelove science.  What socio-military engineer wouldn’t like to possess the secret of how to conquer pain?   Chronic pain, while hugely frustrating to doctors and to patients, at least exposes dreams of conquest to humiliation.  Chronic pain emphasizes the power of all pain, like love, to draw us away from clarities, toward the unspoken and unsayable, the non-thought and unthinkable, toward realms of wordless feeling and mute presence.  It propels us—as if returning to a dank, primal, and secretive native element as inaccessible as a Jurassic swamp rimmed by giant fronds and megaton reptiles—into error.

The myth of two pains, as I once called it, is a foundational error that seems deeply resistant to correction: indeed, it supports a baroque superstructure of proliferating errors.5  Today radio interviews still open with the invariable question: is pain mental or physical?  Would anyone ask whether love is mental or physical.  We accept, instinctively, that love is a mind/body state that defies Cartesian splitting.  Even spiritualized or sublimated love anchors its Platonic upward climb in the body.  If the error of splitting love seems clear, English speakers nonetheless feel compelled to know (perhaps so they can conduct their lives with error-free rigor) whether pain is either mental or physical.  They want to hear that pain is solidly physical—unlike bogus pain that is only mental.  A headache is real (so they myth goes), our temples throb, the body hurts; mental pain, by contrast, is unreal, disembodied, not really pain, all in your head.  Too many patients today still hear this myth repeated by otherwise well-educated doctors, not unfortunately well-educated about pain.

Medicine is not doomed to perpetuate the myth of two pains, despite its deep roots in popular culture.  Neurosurgeon John D. Loeser (former president of both the American Pain Society and the International Society for the Study of Pain) describes the basic breakthrough in pain medicine this way:  “The brain is the organ responsible for all pain.”6  The phantom limb pain experienced by amputees proves that you don’t need an attached material leg to feel pain in your leg:  an attached brain is enough.  Turn off the brain, via anesthesia, and you turn off pain.  Pain is always in your head because it couldn’t possibly be anywhere else.  Your rub your arm when you hurt it because the brain interprets certain electrochemical signals (originating in the arm) as pain.  The brain also interprets as pain in the arm, however, certain other electrochemical signals from an injured heart.  Heart and arm are meat and bone: they don’t feel, they don’t think, they just continue doing whatever non-conscious work that sound limbs and organs do.  The organ responsible for pain—pain in arm, heart, head, any body part or any pain—is as Loeser says the brain. 

The myth of two pains looks weaker the more you look at the brain. The brain is not only a neuromatrix that interprets nociceptive signals from within the body but also the organ that receives and interprets signals from the outside environment. “Chronic pain is a transdermal phenomenon,” as Loeser puts it, “and the environment is always a player in the chronic pain patient’s predicament.”7  Chronic pain, as transdermal, crosses the social space between individuals.  Our biological life as social animals—not existential isolated solitary beings, as Modernist myths depict us—is clear from the distinctive inflections that different cultures give to pain, from rituals of childbirth to disability insurance.  Japanese low back pain patients, for example, compared to a control group of American low back pain patients, proved significantly less impaired in vocational, avocational, psychological, and social function.8  Signals from the outside socio-cultural environment can be imitated by the suggestions of experimenters.  In another study, one hundred volunteers were told that an electrical stimulus might possibly produce pain, but they were not told that the stimulator could produce no more than a harmless hum.  The result: fifty percent reported pain.  As the nocebo effect shows, a mere suggestion can produce pain as surely, if not perhaps as consistently, as an electrical shock.

Writers, while free to mine the latest medical research into pain, are not required to explode myths or stamp out error.  They need not take a position on differences between pain and suffering.  Human characters immersed in error may create a truer story than the narrative of know-it-all specialists.  Moreover, myths usually survive because they embody or contain contradictory truths, or poignant half-truths.  Why do people continue to employ pain to describe almost any state of distress?  Pain serves in English-speaking cultures as a potent metaphor.  He is in pain over the agonizing loss at football.  The death of a favorite dog is unbearably painful.  And the like.  Anguish is regularly described as pain.  Grief, sorrow, and torment are described as pain.  One response would be to police such usage, in order to discriminate distress from pain.  Writers, however, rarely opt for the police.  They are more likely to explore the problematic cultural and metaphoric transfers that project pain onto various distressful, unpleasant states.  They will gravitate toward the cognitive and affective qualities that researchers now increasingly recognize as constitutive of pain, which therefore link pain with related non-pain states such as sorrow, grief, and anguish.  Writers, free to pursue anecdotal evidence ordinarily banned from legitimate research, may well point out, in the guise of fiction, directions that researchers would be wise to follow.

My own beliefs about pain have created a modest paper trail.  I have been pretty consistent—across the years—in the position that pain always involves both mind and body.  My preferred account of pain is “biocultural,” since I believe people unknowingly absorb cultural meanings and practices concerning pain.  Culture also embodies cognition and emotion: it instructs us in how to feel, think, and act, so that even our resistances or innovations posit such cultural knowledge and feeling.  There is always, I believe, a biology of pain, even if only the biology of altered brain states, as when volunteers report pain in response to a harmless stimulus, or when a placebo effect kicks in.  Pain, I believe, is a perception, not a sensation, so it always evokes the mysteries of human consciousness.

The question that this issue of Hospital Drive addresses, indirectly, is how we understand pain as lived experience and as fantasy projection. Pain specialists may find something important here in the fictive or nonfiction narratives of their medical colleagues. 

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