Exploring the History and Psychology of Pain: Beyond the Clinical Setting

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Title: The Story of Pain: From Prayer to Painkillers
Author: Joanna Bourke
Publisher: Oxford University Press
Publication date: 2014
Price: $34.95: hardcover, 416 page


“Pain may even kill. It may overwhelm the nervous system by its mere magnitude & duration.”

—Peter Mere Latham, 1871

From a child’s tears to a burn victim’s agonizing moans, pain is a universal experience deeply enmeshed in what it means to be human. In 1977, the International Association for the Study of Pain (IASP) called together a diverse group of specialists to definitively answer the question: what is pain? They concluded that pain is an “unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”

Pain comes in varying degrees of hurt, but IASP’s dry academic definition—the most cited in the literature of pain management—certainly does not capture the soul-searing distress associated with untreated late-stage cancer pain. The literature is replete with articles and studies on pain management, and although there are numerous handbooks and reference guides, perhaps the most comprehensive book on pain to date is Cancer Pain: Assessment and Management, edited by Eduardo D. Bruera, MD, and Russell K. Portenoy, MD. It is intended for a wide range of clinicians with varying degrees of expertise in the care of cancer-related pain.

But pain is an intriguing subject that reaches far beyond the clinical setting, and for those readers of The ASCO Post who enjoy a rich and challenging literary read, prize-winning scholar Joanna Bourke has delivered the goods with her new book, The Story of Pain: From Prayer to Painkillers. Ms. Bourke—a well-known British historian and frequent BBC contributor—has penned nine previous books on subjects including modern warfare, rape, and military medicine. She approaches The Story of Pain in painstaking prose that delves into the history and psychology of the experience.

Be forewarned: This book is not for the casual reader, but after the first 10 or so pages, the book reveals its magic. Aside from a few forgivable missteps, this is a read that nourishes and provokes thought and discussion.

Pain and Gender

In chapter 3, “Metaphor,” the author gives a heady interpretation of the language of pain, from militaristic to religious to the deeply human ways in which fragile people try to describe their intimate agony. It took the oncology community decades to finally develop patient-centered tools to describe pain, but a number or a score doesn’t describe what a patient feels inside and how he or she views the cancer that is causing the pain. One of the interesting parts of this chapter describes the gender gap that exists in how patients view cancer, often within carefully circumscribed social norms.

One woman interviewed by the author used the domestic sphere to describe her chronic pain: “I visualize my cancer pain as something similar to the cleanup you do before Christmas: You are scrubbing really hard and you are going on and on and you may demolish some jar and scrub the paint away from the furniture and you regret that and think that it may have been enough with only some soft dusting, and then you cry thinking it will never be clean.”

For a 30-year-old man, cancer was a battlefield, not housework: “It is some foreign stuff around my body that we will beat and kill. So those soldiers they are sending in now, they will drive it back as far as possible and keep it in place.”

Between discussions of pain and perception and the way people communicate about their pain, the author weaves reflective narrations into the content, some of which wax too philosophical, but most serve as an underpinning for the difficult subject she’s dealing with. For instance, “The most common metaphor in pain-speech deifies pain as an independent entity. In this way, pain was something that assailed a non-participating body; it might be omnipotent, but could still be fought while leaving the body intact.”

Metaphors aside, pain can be frightful, and its shadow hovers over each page of the book. Although the oncology community has made significant strides in treating cancer pain, undertreated pain remains a challenging issue that needs heightened attention.

The unnecessary suffering of undertreated pain was most vividly captured in Ms. Bourke’s book by the words of a terminally ill cancer patient in hospice. The year was 1961: “I would say the pain was so bad that I dreaded anyone touching me and when anyone knocked my bed or came near to me, the first thing I said to them was ‘please don’t touch me. Please don’t move me’…. It was an obsession in a way because it was all around me, I was buried in pain.” Tough to read, especially when this woman’s horrible reality is still shared by millions of cancer patients around the world who don’t have access to morphine.

Religion and War

The author’s skill as a historian is on full display in the chapters on religion and war. The graphic descriptions of wounds and surgeries in a preanesthesia era are not for the faint of heart. And while the author’s skill at describing battlefield amputations and operations without anesthesia might make some queasy, her discourse on religion will surely inspire ire, especially in her accounts of pious suffering, when religious followers were instructed on how they ought to comport themselves when in pain. In fact, pain was thought to be a redemptive tool that brought enlightenment.

Ms. Bourke writes about the religious state in the late 1700s: “Suffering has a role in promoting personal as well as spiritual rebirth. Pious acceptance of pain would reap rewards in terms of strengthening moral fiber and stature.” One has to wonder if this morality clause of pious suffering was deemed more beneficial for the wretched poor than for the gentry.

Fittingly, the book’s last chapter is called “Pain Relief.” After a brief discussion about the history of analgesics, Ms. Bourke tackles the issue that readers of The ASCO Post will embrace: undertreatment of pain. It is a complex issue filled with sociopolitical minefields, most of which she navigates with assuredness.

Sometimes, however, the analysis seems dated or off the mark: “Too often, medical personnel become overly accustomed to suffering or, in psychodynamic terms, attempt to avoid counter-transference when dealing with severely afflicted patients so they keep tight reins on their emotions.”

This kind of jargon falls way short when attempting to explain the root causes for undertreatment of pain. Ms. Bourke should have consulted with oncology nurses about the physiologic processes that occur when dealing with “severely afflicted patients.”

Sensitivities and Biases

The author’s most convincing section of “Pain Relief” is when she explores cultural sensitivities and biases that lead to undertreatment of pain. It’s clear that she knows this area well, and the reader will enjoy her passion.

She again wades into choppy waters, however, when trying to explain the economic hurdles of pain relief in developing nations. “Analgesics can be expensive; poorer patients have less access to insurance. Sufferers have no real choice.” Wrong. Analgesics are cheap. There are myriad political, social, cultural, and economic reasons for lack of access, none of which are discussed in this volume. Unfortunately, these stumbles come at the end of the book, and it is content that oncologists might judge harshly because it speaks to issues they deal with daily.

Ms. Bourke ends her otherwise wonderful book by telling the reader: “A painful world is still a world of meaning.” True, but a less painful world is better, and we have the tools to make it so. That’s a point that the author doesn’t make clear enough. ■