Constructing Pain

Historical, psychological and critical perspectives

Robert Kugelmann

• Publisher: Routledge
• Year: 2016
• Print ISBN: 9781138841208
• eBook ISBN: 9781317554752
• Topic: Psychology
• Subtopic: Applied Psychology
• Index: Psychology

Everyone experiences pain, whether it's emotional or physical, chronic or acute. Pain is part of what it means to be human, and so an understanding of how we relate to it as individuals - as well as cultures and societies - is fundamental to who we are.

In this important new book, the first in Routledge's new Critical Approaches to Health series, Robert Kugelmann provides an accessible and insightful overview of how the concept of pain has been understood historically, psychologically, and anthropologically. Charting changes in how, after the development of modern painkillers, pain became a problem that could be solved, the book articulates how the possibilities for living with pain have changed over the last two hundred years.

Incorporating research conducted by the author himself, the book provides both a holistic conception of pain and an understanding of what it means to people experiencing it today. Including critical reflections in each chapter, Constructing Pain offers a comprehensive and enlightening treatment of an important issue to us all and will be fascinating reading for students and researchers within health psychology, healthcare, and nursing.

Part I
Constructing pain historically

This part of the book examines several distinct moments in the construction of pain in the modern world. To begin, there is the development of anesthetics in the nineteenth century. The context in which they were used is as important as the substances themselves. The context was medical. When physicians used anesthetics, they were applying them to the body understood anatomically, as an object for treatment. As a result of the widespread acceptance of anesthetics, the anatomical image of the body became socially relevant as never before. This is important because, phenomenologically speaking, anatomy gives a truth about the body, not the truth. Ether and its kin promised “the death of pain,” as the neurologist and poet, Silas Weir Mitchell, hoped on the fiftieth anniversary of its first use. In the wake of this transformation of the experience of pain, with analgesics and anesthetics promising an end to pain, was the understanding that pain was ideally acute: here today and gone tomorrow.

Following this transformation, the late nineteenth century constructed “real pain” – that is, sensory pain associated with the stimulation of nerve endings in the anatomical body’s periphery. Other pain not conforming to this prototype became somehow less than real. In the middle of the twentieth century, this sensation theory of pain came under fire as Cartesian. We find three ways in which the notion of pain was broadened: the gate control theory, the operationalized definition of pain, and the notion of pain behavior. These more contemporary ways of constructing pain open up to phenomenological considerations, which Part II shall address.

1
Constructing Modern Pain

“The conquest of pain”

Anesthetics and painkillers transformed the existential possibilities for the experience of pain and what people do about it. These innovations of the nineteenth century built upon earlier developments. The most significant of these is discussed in the following section.

The anatomical image of the body

Even though anatomy had been practiced for several centuries, a humoral image of the body still held sway in the eighteenth century. That began to change by the turn of the nineteenth century, and “the study of anatomy, both theoretical and practical, was seen as the cornerstone of all medical teaching” (Bonner, 1995, p. 142). Anatomical images of the body also served to differentiate an emerging medical profession from that of other practitioners, as Stelmackowich (2012) indicates in a discussion of the development of illustrated medical textbooks at the beginning of the nineteenth century: “These new diagrams and illustrations constituted new visual and discursive practices and were crucial in developing the professional and institutionalized discipline of medicine” (p. 51). In addition to the study of anatomy, and perhaps even more important, was a new concentration on “morbid anatomy” or pathology. Initiation into pathology, whereby the innards became visual objects – in contrast to the fluxes and flows of the humoral body – became “the prerequisite for a medical career” (Stelmackowich, 2012, p. 52).

With the introduction early in the century of the stethoscope, the patient’s silence, rather than his or her narrative (Reiser, 1978), became an increasingly established part of the “medical gaze,” to use Michel Foucault’s (1973) term for the visualization of disease in the anatomical image. This image – the corpse opened up anatomically – became the royal road to knowledge of the living body. Whereas today such knowledge is assumed, it is important to signal what an innovation this type of knowing was. Phenomenological studies of the history of this change (Bishop, 2011; Duden, 1991; van den Berg, 1972) show that the anatomical image meant an alienation from the flesh of the living being; Romanyshyn (1989) calls the anatomical image the “abandoned body” – that is, the body of no one. Before the medical gaze and its abandoned body, physicians relied on patient narratives in order to interpret what was wrong with the patient’s health. In Illich’s (2005) words, earlier medical discourse focused on the question “how is that ‘who’ who you are today” (pp. 125–126). That is, the question asked about the person’s story of who he or she was. It asked about embodied living. Illich calls this embodied living the “felt body,” the body that the person is. The anatomical image promises better know-how in treating illness, but this technological advantage has come at a price. In some measure, this book is a study of the consequences of the anatomical image for the construction of pain.

For many people living at the time when the abandoned body was becoming the ground of medicine, this alienation was felt deeply. Into the nineteenth century, dissection was punishment added to execution – and often more feared because of the ways in which the Christian teaching on the resurrection of the dead was understood: “People viewed dissection as a desecration of the corpse and believed that it would impede resurrection and deny the survival of identity after death. While execution was a threat to one’s life, dissection was an assault on one’s soul” (Hulkower, 2011, p. 23). Only in the 1830s did American states begin to pass legislation authorizing the use of unclaimed dead paupers for dissection. Legislation for the donation of one’s body after death – changing what had been punishment into a gift of the living – occurred only after 1968 (p. 25). Earlier, with the demand for cadavers exceeding the supply, the crime of “body snatching” was profitable, leading to such incidents as a riot in New York City in 1788, with mobs sacking hospitals and kidnapping medical students (p. 24). In 1828, the trial of William Burke and William Hare took place; Burke and Hare found that murder provided a more ready supply of fresh corpses than grave robbing. They were convicted and executed for murder. This infamous pair had an indirect connection with the physician who will serve as our occasional witness to the changes that occurred in the nineteenth century: Benjamin Ward Richardson (1828–1896).

A representative of the time of transition

Throughout this chapter, we will have occasion to draw on Richardson’s testimony. He was a British physician who contributed significantly to medicine and public health. He does not represent everyone involved in the story of the transformation of pain, but he did witness some of the key changes. He was a medical student in 1846, the year that surgical anesthesia was first used to wide acclaim in Boston, and he witnessed the transition to painless surgery firsthand. He started medical studies at Anderson University in Glasgow in 1845; in addition to pursuing anatomical studies there, he also attended a course on the anatomy of the brain given by Robert Knox. Richardson praised Knox’s knowledge of anatomy, although Knox had been vilified because he had bought cadavers from Burke and Hare. Knox had not been prosecuted, but life in Edinburgh had become uncomfortable, and he left town. Suffice it to say, Richardson acquired the medical gaze in his studies with Knox. He did not finish medical school in Glasgow (a result of his own illness), and he completed medical studies at St. Andrews. He later moved to London, becoming a member of the Royal Academy of Physicians in 1857 and a fellow in 1865 (Wallis, 2004).

The abolition of pain: anesthetics as substance and symbol

The psychological philosopher Alexander Bain brought together the British empiricist tradition, which conceptualized the human mind in terms of sensations and their associations, and the emerging physiological psychology. In discussing the “emotions of action,” Bain (1859) used the term anæsthesia to refer to ways of allaying “mental excitement” (p. 186, note). The term was new: “I have gladly adopted the term ‘anæsthesia’ into the phraseology of mental science” (p. 188, note). In the pursuit of some goal, we can experience anæsthesia, or “the quieting of consciousness,” because of our rapt attention. Bain mentioned other anesthetic means, mental and physical, including the “important additions derived from the recent introduction of Ether and Chloroform” (p. 187, note). Bain affirmed the view that all societies have their chemical means of altering consciousness: “Alcohol, Tobacco, Tea, Opium, Hemp, Betel, and the other narcotics, are the resort of millions, for the production of mental elation, or soothing irritation and pain” (p. 235). For Bain, anesthetic action was a natural process that had recently seen chemical enhancement with the introduction of ether, chloroform, and nitrous oxide.

Nitrous oxide and ether had been used prior to 1846, and not only by the romantic poets Coleridge and Southey, who inhaled nitrous oxide in the 1790s (Papper, 1995). There had been public exhibits of nitrous oxide, with the public invited to inhale, and the British artist “Robert Seymour… in 1830… portrayed the forcible use of laughing gas as a remedy for nagging wives” (Pernick, 1985, p. 86). Nitrous oxide, synthesized by Joseph Priestly in 1772, had been used as an intoxicant since 1799. Ether, on the other hand, had been around for centuries. It too was used as an intoxicant, either inhaled or drunk; its first surgical use was by a dentist, William Thomas Green Morton, in 1846. Nitrous oxide came into surgical use a bit later, ether and chloroform being preferred.

The term anesthesia was fairly new, although it was used before Bain incorporated it into psychological discourse. Halttunen (1995) writes that “in the early eighteenth century, the term ‘anesthesia’ had referred to a defective lack of feeling; by the end of the century, it had come to connote a ‘positive medical relieving of feeling, a blessing rather than a defect’” (p. 310). That meaning was further refined. According to Stanley (2003), “the term ‘anaesthesia’ seems to have been first used in 1833 when the Lancet published a translation of a French article discussing the condition of ‘diminution, or total loss, of bodily sensation’ with a view, ironically, to its cure” (p. 285). Thus, before the actual introduction of surgical anesthesia, the idea and the term were in circulation.

The introduction of surgical anesthesia

The introduction of surgical anesthesia in 1846 was one of those events that stand out as forever changing the human condition. Morris (1991) writes that anesthetics “transformed our cultural assumptions about pain” (p. 64). Anesthetics symbolize the rift between our experience of pain and that of those who lived before the mid-nineteenth century. The ground had, however, been long prepared, and anesthetics materialized a change in cultural evaluations of pain that had appeared earlier, with the rise of a culture of “sensibility” in the English-speaking world: “The eighteenth-century cult of sensibility redefined pain as unacceptable and indeed eradicable and thus opened the door to a new revulsion from pain, which, though later regarded as ‘instinctive’ and ‘natural,’ has in fact proved to be distinctly modern” (Halttunen, 1995, p. 304). Halttunen claims that “middle-class sensitivity to pain” “contributed to the late eighteenth-century intensification of medical efforts to discover an effective form of anesthesia” (p. 309). In this stress on the sympathetic viewing of the pain and suffering of others, pain became obscene, simultaneously intolerable and exciting.

The events of the 1840s, then, presuppose an ongoing shift in cultural values, making more urgent the elimination of what was no longer tolerable. Crawford Williamson Long, a Georgia dentist, first used ether surgically in 1842 (Dormandy, 2006). But Long was not well connected, and Morton’s demonstration of the surgical use of ether in a Boston medical classroom in 1846 proved to be decisive in getting anesthesia circulating in the medical community at home and abroad. The fame of anesthetics for surgery spread rapidly, not only because their effectiveness had been demonstrated but also because the means for rapid diffusion were available by ship, by railroad, by telegraph, and by newspaper. Before the end of 1847, surgeons in Britain, France, Germany, and Australia employed surgical anesthesia. In his memoirs, Benjamin Ward Richardson (1897) recalled that while he was a medical student in Glasgow,

news came from America by the ship Arcadia that the abolition of pain had been made manifest there in the operating theatre at Boston, U.S.A. In London, Liston, following up the plan of Wells, Morton, and Jackson, had removed a limb painlessly by letting the patient previously breathe the vapour of ether, and we were soon to see the advantages of this immortal advance in the profession of medicine, the most striking advance, probably, that the world has ever witnessed.

(p. 78)

This “immortal advance” altered the existential possibilities for pain in our lives.

News of the new way of performing surgery spread quickly. By early 1847, American newspapers were reporting on Morton’s demonstration of ether. The Vermont abolitionist newspaper The Voice of Freedom published “Inhalation of Ethereal Vapor” (1847, January 7), picking up John C. Warren’s account from the Boston Medical and Surgical Journal of December 6, 1846. Early 1847 saw similar newspaper accounts across the country. After Simpson used chloroform in November 1847 in Edinburgh, that report also spread across the United States. In “Chloroform” (1848, January 28), the Vermont Phoenix reported Simpson’s discovery and quoted from the Boston Olive Branch, which “requested Dr Hitchcock, Dentist of this city, to furnish us with a report of some of the cases connected with the success of its application” (p. 3). Hitchcock included testimony from the Rev. Mr. S., who had several teeth and roots removed:

I called on Dr Hitchcock, who administered the vapor of fifteen or twenty drops of the Chloroform, and extracted the teeth without producing the least pain. – The time employed in the whole operation did not exceed thirty seconds. While inhaling it, I experienced scarcely any uneasiness. No unpleasant effects followed its influence.

(p. 3)

...

Table of contents

• Cover
• Title
• Copyright
• CONTENTS
• Acknowledgments
• Series editor preface
• Introduction
• PART I Constructing pain historically
• PART II Phenomenology and semiotics of pain
• Index