Pain and Emotion in Modern History. Boddice R (ed). Basingstoke: Palgrave Macmillan, 2014
Reviewed by Dr Deborah Padfield
Visual Artist and Research Associate, UCL CHIRP Interdisciplinary Research Fellow, Slade School of Fine Art
Pain and Emotion in Modern History claims to be ‘a rich exploration of the affective expression of pain, the emotional experience of pain (with or without lesion) and the experience of others’ pain as pain (sympathy, compassion, pity, tenderness ‘ (p.1). Referencing and building on the work of others, for example Scarry, Moscoso, Bourke, Cohen and Hodgkiss, this book more than justifies that claim. It is a fascinating collection of essays from a variety of disciplines and practices, which, woven together, produce a profound discussion of pain and emotion.
Boddice starts from the premise that not only is pain difficult to communicate, but also to define, describing it as ‘at best a confusing label; at worst … hopelessly inadequate’ (p.1). What is refreshing is that the book attempts to unpack its complexities through a conviction that pain’s ‘polyvalence’ is expressed not only linguistically but ‘bodily, orally’ and ‘emotionally’ (p.1). The understanding and experience of pain is framed as socially, culturally and historically constructed. Boddice asserts that it is through the drive to communicate pain, to translate it into words, grimaces, images – the search for metaphors with which to capture it – we literally ‘figure out’ what it is. What I also find appealing about this work is its emphasis on the person witnessing as much as on the sufferer, thus acknowledging witnessing and suffering as inexorably interlinked.
The book draws on the expertise of a wide range of historians, literary and philosophical scholars, a practicing artist and those in the medical humanities from a variety of countries, to unpick and reveal intersects between pain and emotion. The result is a patchwork of perspectives building on and cross-referencing each other so that the sum is more than the parts.
Javiers Moscoso’s graphic descriptions of treatment for cancer pain in early Modern Europe highlight the tensions between local and official medical knowledge, and the desperation of those willing to undergo any treatment in the search for a cure, ranging from eating the ‘raw and palpitating flesh of local green lizards’ (p.20) to doses of between one and six spoons of arsenic, thus leaving themselves open to fraud and quackery (not irrelevant today). The fact that sufferers recovered from some of these terrifying practices highlights the power of hope, exercised within what Moscoso describes as a framework of emotion and fear. He does not get drawn into a detailed discussion of the ‘placebo effect’ but asserts the value of historians for illuminating interpretation of sources. He also alludes to the interplay between objective evaluation and subjective accounts provided by patients, paving the way for discussion of patient narratives, which is taken up in subsequent chapters. Already rich in detail and analysis, Moscoso argues convincingly that a greater historical analysis is needed of the ways in which fear and pain have been counterbalanced by promises and expectations, in what he terms an ‘economy of hope’ (p.31).
Continuing to place the understanding of pain within historical and cultural frameworks, Paulo Santangelo takes us to Late Imperial China, where he analyses the main terms used for representing physical suffering, revealing pain as located within the collective imagination and a ‘whole body-mind-heart’ system (p.36). Exploring this interaction of emotion and sensation, Santangelo builds on the work of Moscoso, Bourke and others, evidencing ways in which the perception and experience of pain is influenced by its cultural context. He reveals a semantic ambiguity within the Chinese figures for pain, which collapses physical, emotional and moral conceptions of pain expressing injury, wound, damage, and harm with distress, including sad-grief-distress, worried-grief distress and being broken hearted. Citing a range of Chinese medical treatises, Santangelo shows how many early texts express the belief that states of mind were able to influence physical pain. He concludes that the interconnection between body and heart-mind in early Chinese medical texts is ‘more strongly emphasized than in modern Western cultures perhaps because of the lack of a Platonic imprint of soul-body dichotomy‘ (p.47).
The current IASP definition for pain is up for scrutiny in the following chapter by David Biro, who asks whether affective states –‘construed as injuries to the mind – can trigger the same kind of pain as injuries to the body’ (p.53) Biro argues for a re-definition of pain broadened to accommodate psychological and emotional as well as physical injury to reflect feelings of injury to the person rather than to the body. Biro approaches the subject from a uniquely privileged position as physician, patient and literary scholar, making him particularly sensitive to the importance and difficulties of expressing, conceptualizing and defining pain and the critical relationship between language and experience. Using examples largely taken from literature as well as the paintings of artist Frida Kahlo, Biro illustrates how people suffering from psychological pain also use metaphors related to physical injury, and argues that there are neural correlates for both physical and psychological pain. He concludes ‘Pain is the aversive feeling of injury to one’s person and the threat of further, potentially more serious injury. It can only be described metaphorically’ (p.61).
The relationship between physical and psychological pain and the challenge of invisible pain are taken up by Joanna Bourke in the context of phantom suffering. She uses the case of Lieutenant Francis Hopkinson, a first world war amputee, to explore two debates within medical practice, that of the relationship between lesion and suffering, and theories of the emotional basis for suffering, which, she argues, prompted the current psycho-social model of pain.
Bourke charts how medical attention initially focused on Hopkinson’s physiological phantom limb pain and not on his psychological pain. Hopkinson, like many others, found it increasingly difficult to persuade his doctors that his suffering was ‘real’, which reflects the double layer of suffering for those with chronic pain; not only do they live with pain itself, but as Scarry highlighted (1985), the doubt of others serves to increase pain. Bourke relates how medical reports increasingly reported Hopkinson as of a ‘marked neurasthenic type … highly introspective type and very resentful’ (p.72). The problem, as Bourke clearly shows us, is that Hopkinson came up against the privileging of physiological injury over emotional injury and the clinical beliefs of the time that stump and phantom limb pain were essentially ‘neurotic’ in nature. What is more shocking is the conclusion of R.D. Langadale Kelham, who in the 1950s carried out a four year study of 200 men with phantom limb pain, and concluded that the person affected was ‘more often than not a person with an unsatisfactory personality. … who, becoming obsessed by his symptoms, and brooding upon them and his disability, tends to dramatise their degree, using undoubted exaggerations in his description of his sufferings’ (cited p.73). Bourke’s fascinating journey through the life of Hopkinson ends with the conclusion that even though one might have expected him as a white male from a privileged class who had served as an officer to have elicited sympathy, the tragic reality was that ‘the invisibility of his wound – his stump seemed to be ‘normal’ and the limb that burned like fire did not exist – trumped all scientific theorizing. Theories about physiological pain pathways, psychiatric pathologies. psychosomatic symptoms … failed to ease suffering that was anything but ‘phantom’’ (p.84).
The book moves from the intensity of the microscopic narrative to Wilfred Witte’s macroscopic review of the treatment of phantom limb pain from the beginnings of the nineteenth century to the present day, where the bio-psychosocial model and multi-disciplinary treatment have become the norm. Some of the now shockingly negative attitudes Bourke described are echoed here with Witte reporting amputees with phantom limb or stump pain being described by physicians as ‘abnormal’ or ‘deficient’. The chapter ends on a hopeful note with the Sub–Committee for Stump Nerve Pain of Amputees (1968 – 1970) and the Federal Ministry of Labour advocating that the condition not be judged by a single specialist based on symptoms, but by physicians from various disciplines and patients whose voices now had to be heard, ‘so that the categorization of abnormal and deficient had to be dropped’ (p.101). Witte highlights the achievements of American anaesthetist John Bonica, whose work marked a turn in chronic pain therapy, publishing The Management of Pain in 1953 and, in 1961, realizing his concept of a pain clinic with a multidisciplinary structure at the University of Washington in Seattle. Witte asks whether changes in pain therapy corresponded not only to advancements in anaesthetics but also to linguistic changes where the narratives of patients gained significance, and language shifted towards theories of cognition and aims of ‘managing’ rather than ‘curing ‘chronic pain.
Noemi Tousignant tackles the institutionalization of pain diagnosis and measurement in the USA, which she claims has tied pain to ‘more-than-sensory’ experience, ‘to selves and thus to emotional experience’ (p.112). The chapter traces the ‘quest for reliable pain-measuring technologies since the turn of the century’ (p.111) and is a fascinating exposé of attempts to quantify subjective experience, charting early attempts to exclude emotion in the search for objectivity to Beecher’s work in the 40s and 50s, which argued that pain sensation was indivisible from the reaction to it. Tousignant argues convincingly that Beecher’s work was ‘an important episode in the historical process of authorizing emotion as a component of anything worth calling ‘pain’’ (p.124).
Sheena Culley’s chapter moves us from the history of pain measurements and the analgesic clinical trial to analgesia itself – here the history of aspirin. Drawing on ways in which aspirin was marketed historically for anything from a sedative to a stimulant for physical and/or emotional pain, and on the writings of key figures such as Jan McTavish, David Morris, and Michel Foucault, Culley explores how aspirin and its successors have shaped cultures of pain and how the social construction of the feminine that they presented influenced a gendered understanding of pain. Culley concludes that, with the introduction of depression as a recognized medical term and the surge of antidepressant drugs from the 1960s onwards, aspirin and other over the counter medicines stopped being marketed as cures for emotional pain, and thus the image of the neurotic or hysterical woman disappeared. However, she hypothesises that the image of the hysterical female has not disappeared entirely from our understanding of pain ‘whether she resides in the discourse of chronic fatigue syndrome or of anorexia, or in a particular framing of female depression’ (p.145), arguing that ‘it remains for scholars in the medical humanities to continue to analyse the contemporary entanglement of biological and cultural aspects of pain and disease’ (p.145).
Liz Gray explores the suffering of animals, asking how, in the context of pain being an emotion as well as a sensation, can we truly understand the experience of another, particularly when that other is an animal? Here we have no shared language and no shared language of facial expression. Viewing the publication of Darwin’s ‘The Expression of the Emotions in Man and Animals’ of 1872 as a watershed in the research of expression of emotion, and drawing on the work of the Scottish naturalist physician William Lauder Lindsay and his contribution to comparative psychology, Gray outlines how animals’ capacity to experience emotional pain was accepted in part because of an acknowledgement that they suffered physical pain. She claims (slightly alarmingly) that Lindsay’s interest in the animal mind stemmed from his experience as a physician at the James Murray Royal Lunatic Asylum. Physical restraint of the ‘insane’ had been shown to be damaging to emotional and mental health. Similarly, Lindsay concluded that the causing of physical pain to animals was (unsurprisingly) linked to the development of mental health problems. Gray concludes with Lindsay’s belief that ‘The asylum, as a house for the mentally damaged of society, ought to have been a site for compassion and humanitarian care, as with every laboratory and even every home’ (p.161).
Danny Rees focuses on the expression of pain in humans, taking his title down in the mouth from Gillray’s depiction of a patient being bled by his doctor, Breathing a Vein, (1804). The image captures the essence of this book as it reflects the facial expressions of witnesses as well as those of sufferers. Rees makes a distinction between the visual expression of pain and the language used to describe it, feeding into a larger discussion on the inexpressibility of subjective experience. However, his focus remains on the history of representations of facial expressions for pain, which he regards as visual dimensions of emotions and valid ‘representations of internal states‘ (p.165). Rees traces ways in which early anatomical and scientific experiments defined the face of pain, contributing to the concept of ‘universality’ (p.166), asking why the face has been the locus of ‘repeated, probing attention’ (p.166). Referencing Amanda Williams, Rees begins by articulating the functionalist position that expressing pain in a way others can read aids survival ‘the function of pain is to demand attention and prioritize escape, recovery and healing‘ (p.166). He gives an informed and detailed account of the historical inconsistencies of approaches to expression from the Ancient Greek Sculpture Laocoon, through Charles Le Brun, Charles Bell, and Charles Darwin to Dr Guillaume Benjamin Amand Duchenne (who experimented with trying to separate the movement of facial muscles expressing emotion from the experience of feeling emotion) to Italian physiologist Angelo Mosso. After a fascinating historical journey through sculpture, etchings and photography, Rees concludes that ‘a range of historical meanings can be derived from a common (set of) expression(s)’ (p.185).
Whitney Wood takes a detailed look at the relationship between fear and pain in childbirth narratives of Late Victorian Canada. She begins with the words of Lucy Ronalds Harris in the late 1860s whose memories of fear and anxiety from the birth of her first child marred subsequent experiences of pregnancy. Other examples, such as Lucy Maud Montgomery (author of Anne of Green Gables) who wrote of her ‘martyrdom of misery, partly physical, partly anxious’ (p.191), are woven into an overview of the changing medical and cultural perceptions of the female body during the nineteenth and early twentieth centuries, as well as a wider discourse on the collapse of divisions between emotional and physical pain. Wood draws on leading figures such as Bourke, Bending, Scarry and Morris to expose the power relations within the rhetoric surrounding emotion and pain to refute the idea that ‘pain can be logically divided into two separate types, physical, and emotional or mental’ (p.192). Wood argues that the dismantling of female networks, caused in part by increasing migration in the second half of the nineteenth century, contributed to a greater willingness among middle class women to accept physician-assisted and hospital-based births, feeding into a growing pathologisation of pregnancy and childbirth. She ends by concluding that women not only conformed and contributed to existing medical discourses but ‘were active participants in the process of medicalising childbirth’ (p.198).
Scarry runs like a seminal vein through this book, her claim that pain achieves its unshareability in part as a result of its resistance to language provoking attempts to prove its shareability. Daniel Grey’s chapter The Agony of Despair: Pain and the Cultural Script of Infanticides in England and Wales, 1860-1960 begins by arguing just that, that pain is not only ‘shareable’ but shareable via visual, textual and oral means, and ‘that it is assigned historically and culturally specific meanings by those who witness and experience it’ (p.204). He picks up the relationship between pain and fear, exploring how and why the closely ‘entwined experiences of pain, shame and fear, became – and remained – key elements of the construction of infanticide in England and Wales for at least a century‘ (p.205). Grey observes how both the Infanticide Act of 1922 and its amendment in 1938 allowed women who killed their babies to be convicted of manslaughter instead of murder if they were deemed to be suffering from a ‘mental disturbance’. Grey reveals that both lay and professional opinion of the time stressed that it ‘was the combination of physical pain and mental anguish that was primarily to blame for the crime’ (p.205). He examines the narratives of pain through his examination of infanticide cases, demonstrating that both lay and medical opinion expected to interpret ‘potential signs of physical pain and emotional distress on the part of the defendant when giving evidence’ (p.205). Grey argues that descriptions of both physical and emotional pain were central to attempts at understanding infanticide in the nineteenth and early twentieth centuries. He concludes with the acknowledgement of a potential risk in examining accounts of physical and emotional pain of eliding specificities while ignoring the broader shifts in culture and society in terms of gender relations, observing how these scripts of women’s bodily and emotional pain do not fit with the equally contested discourse surrounding ‘the killing of infants by their fathers’ (p.215).
Continuing with the theme of understanding another’s pain, Linda Raphael turns to fiction. Chiming with Moscoso’s assertion that we are as likely to sympathise with pain through a fictional representation as any real-life experience, Raphael argues that when we read fiction ‘we have access to characters’ inner lives in a way that gives form to feeling’ (p.220), something David Biro might also agree with. She hypothesises that fictional representations ‘involve us cognitively and emotively in human experience’ (p.220) picking two stories involving a parent and child to explore ways in which language and face to face encounters sometimes facilitate and sometimes hinder understanding another’s pain. Drawing on a range of philosophers, Raphael asks what happens ‘to the self in this focus on sympathizing with the other’ (p.222). It is a particularly apposite question in a book that places so much emphasis on witnessing pain and the encounter with the sufferer. She concludes that to regard pain as ‘a stimulus to heterogeneous emotional responses is one way to avoid misunderstanding the other, despite the considerable limits on our ability to fully imagine the emotional experience of another’ (p.239).
James Burnham Sedgwick continues the focus on the person witnessing pain, here considering those who have the unenviable task of observing, investigating, recording or judging the atrocities examined at the International Military Tribunals (IMTs) in Nuremberg and Tokyo, following World War II. Sedgwick’s research highlights ‘the powerful and unexpected ways in which pain (direct physical, indirect psychological or other forms) can manifest itself in personal and historical change’ (p.243), arguing that the process of observing pain can transform into pain itself. He asks ‘Is all pain equal? Can it be shared?’, which could be viewed as a preoccupation of this book. Once again drawing on Scarry (1985), who argued that ‘what is “remembered” in the body is well remembered’, Sedgwick suggests that fixing pain and its legacies in the body neglects the scars of the mind. He adds the unsettling insight that even when shared at a distance, ‘the trauma and pain of others can cause psychosomatic changes in the self’ (p.244). It is a beautifully written, reflective and scholarly contribution, pulling together many of the themes from earlier chapters while examining the authenticity of suffering. He observes that the drive to overcome traumatic memory through ‘speaking out’, through art and through writing, can provide cathartic release for sufferers, acknowledging that there is a consensus around ‘bearing witness’, which for him makes intuitive sense. However he warns that ‘simply by investigating and hearing the cathartic release of survivors, participants in court and related institutions become vulnerable to a new set of disruptive collateral emotions’ (p.245). His words echo those of David Biro when he advocates a more inclusive definition of pain and trauma, ‘pain felt in observing and confronting humanitarian crises engenders emotional, spiritual, moral, professional and even physical alternations that include but are by no means limited to psychological change. All of this counts – or should count – as pain, even trauma, in the right conditions’ (p.249).
Witnessing and documenting pain is further examined by the artist Johanna Willenfelt in the final chapter. Willenfelt explores the representability of physical pain in what she terms ‘inter-bodied relationships and encounters’ (p.260), asking ‘how the emotive transient and transformative space of contemporary art might contribute to new understandings of the notional experience of sharing pain.’ This chapter serves as a fitting finale to a fascinating book as it presents its own distinctive take on the enigma of sharing pain while resonating with many of the themes outlined in earlier chapters. Focusing on her project Documenting Bodies (2010), Willenfelt states that she will be primarily ‘thinking through and with’ her own artistic practice and the ‘interplay between the medical sphere and the artist’s studio’ (p.260). However, I would have preferred more focus on her practice and less dependence on theoretical discourse, although this may have been the context in which she found herself or the perceived expectations of her readers. A fascinating point she brings to the discussion is the notion that ‘sharing pain’ must be understood equally ‘as the relationship one maintains with oneself as well as the one we enter into with objects and things in the outside world’ (p.272). This has echoes of Irigaray’s argument that it is respect for the self as much as for the other that allows speakers to enter the communication process successfully (Irigaray 2008). There is a charged moment in the text where Willenfelt discovers narrations by patients, doctors, surgeons and post-mortem examiners in the medical and surgical archives of the General and Sahlgrenska Hospital in Gothenburg – ‘the imprints of other people’s hurting bodies’ (p.263). These resonate with her own experience of suffering from chronic pain, activated by and intersecting with these alien pain narratives. From the archive entries she selects twenty or so to interweave and print on material, which then appear to be draped over hospital beds. The work recontextualises the narratives, weaving them in and out, not only with each other but also with those of the viewer. Willenfelt concludes by accepting that while observing someone in pain can never equate with directly experiencing that pain oneself, to have one’s suffering acknowledged by any living creature as witness is nonetheless liberating.
Many might take issue with the book’s central thesis that pain is an emotion, but few, having read it, could argue with its premise that emotion and pain are intrinsically linked. I would recommend anyone interested in the intersect between pain and emotion to go out and buy, beg or borrow a copy. Pain and Emotion in Modern History is an impressively researched must-read, presenting pain as a multifaceted, evolving, social, historical, physiological and psychological event to which we do not have, and may never have the answer.
Irigaray, L. (2008) Sharing the World. London: Continuum
Leriche, R. (1939) The Surgery of Pain (trans Young A.) London: Balliere, Tindall and Cox, p.202
Scarry, E. (1985) The body in pain: The Making and Unmaking of the World. Oxford: Oxford University Press
Williams A. C. de C. Williams (2002) ‘Facial Expression of Pain: An Evolutionary Account’, Behavioral and Brain Sciences, 25: 439