musingsonwomenshealth.com

Reflections on 40 years as a doctor in Women's Health

Does Pain pay the income of each precious thing?


Why is pain? Even after all these years, I am still confused. It is true that I have likely lived on the periphery of its delivery route; pain has not been a constant companion but, rather, an occasional acquaintance rattling the gate: an unexpected guest who seldom apologizes for their inconvenient arrival and usually prevents me from closing the door on them. I am uncertain whether it is their physical presence that disturbs my otherwise solitary existence, or the changes they force upon my usual routines that bothers me the most. Is pain physical or mental? Or is each of them egging on the other like a youngster trying to share the blame with his friend for a broken window?

I suppose that, as someone with only occasional discomforts, I should not presume to speak for the pain of those who, despite their best efforts cannot not live without it; I have nothing to compare with something to which they have become unwillingly accustomed. But pain can be like that I’m told: irascible, grumpy, and insistent.

Your pain is not my pain; no matter how empathetic I am, no matter how colourful your description, I cannot feel it like you do. Or is that too facile: that pain is a physical sensation with emotional overtones that the sufferer can only attempt to describe as one might a flavour, or perhaps a colour? Still, we have all experienced pain, so can I not imagine what yours must be like and how you are probably feeling?

An experience I had many years ago while I was still in my first year of Medical School makes me wonder just how much the physical interacts with the emotional when it comes to pain. I had just had my appendix removed the previous evening, and in the morning, I decided to get out of my hospital bed under the influence of a recently-administered narcotic. As I limped to the door of the room, my surgeon happened by, accompanied by a small troupe of more senior students doing  their rounds on the surgical floor. She asked me how I was feeling so soon after her surgery and had a twinkle in her eye for some reason.

“Fine,” I answered, still guarding my movements as I leaned against the door frame.

“Any pain?” she asked, her smile radiant.

I thought about it for a moment and then shook my head.

But she was insistent. “On a scale of ten (they still used that pain scale then), how would you rank it…?” She really wanted me to think about it.

“Uhmm… Well, if I have to grade it… I suppose maybe a 2.” But she cocked her head at the answer, so I revised it. “Okay, maybe a 3 then…” But it was something different, really -something I had difficulty identifying. “I mean I can still feel the pain, but it’s not really pain… I know it’s there, but it hardly bothers me or anything… I’m not sure how to rank non-pain.”

The surgeon obviously liked that answer and evidently wanted to make it a teaching moment for me and her acolytes. “The morphine I ordered post-op was a stand-in for your own endorphins -the chemicals your body manufactures to allow you to function while you get assistance for your injury: like a soldier wounded on a battlefield, for example.”

I remember being flattered that I was being included with the other students in the lesson, but even then, I still wondered if she was being too reductionist about pain. Maybe emotions were an important component of pain that we shouldn’t try to explain away. Just how mechanical was it? Did there really have to be physical damage to something before we felt pain? Or was I overthinking the duality of pain: that it was always something which was an important physiological response -an evolutionarily derived mechanism both to deal with injury and perhaps the ability to allow escape from its cause. Was it a response you fiddled with at your peril…? And for that matter, wasn’t it important for my pain to announce itself to someone else so they could help me? Wasn’t it also a social construct as much as a personal one?

I suppose now that I am retired I have more time to think about such things, though. Not long ago, I happened upon an article that touched on the politics of pain -what it looks like, and how it is used. ‘How a sensory stimulus feels is mediated by appraisal, and that appraisal is situated in terms of the personal experience of the individual, the degree of attention applied to the wound, to the immediate occasion of the injury (danger, fear, reassurance, safety) and to the cultural repertoire of pain concepts that provide the framework for expression.’[i]

Unfortunately, you can’t always tell that someone is in pain from what you see: ‘The face of pain is no less situated than any other expression. Sometimes it smiles. Sometimes it frames a scream.’ So, apart from personal report, how might we detect its presence -or perhaps more importantly, is it important for that report to be believed?

That pain might be invisible is obvious -we don’t all advertise our discomfort; but in the article, there is a painting by Edvard Munch that explains it to me in a way I hadn’t considered before. It is called (in English) ‘Despair’, and the figure in the foreground is a man leaning against a fence: ‘The face of the figure… is featureless – not an absence of expression, but simply nothing in the place of a face: not a mask, but deletion. The pain is mapped instead onto the sky. If, for the man, pain was ineffable, one needed only to look up to access it. This profundity of suffering put the pain everywhere.’

For me, that picture describes the wordless reality of pain: it can be both physical and emotional. It’s not something simply reducible to endorphins and nociceptors; it is something far more profound than that -far more important. It is an experience that transcends facile descriptions; it is ineffable…

[i] https://aeon.co/essays/pain-is-not-the-purview-of-medics-what-can-historians-tell-us

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