Oh, My Aching Back

Roy Porter

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.

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