The Complex History of Pain: An Interview with Joanna Bourke

By knowing how people in the past

have coped with painful ailments, perhaps

we can all learn to “suffer better.”

Joanna Bourke, The Story of Pain

In her groundbreaking new book The Story of Pain: From Prayer to Painkillers (Oxford), renowned British historian Joanna Bourke explores how the understanding of the human sensation of pain has evolved over the past three centuries in the English-speaking world. Based on her wide-ranging research on “discourses, institutions, laws, and medical, scientific, historical and philosophical structures,” she contends that pain is a unique individual experience, not an objective one, and that historical and cultural context inevitably colors an individual’s experience of pain. And individual descriptions of pain such as “splitting headache” to “hot stabbing pangs” to “a clashing of two bull goats” matter because these expressions reflect how a person senses pain.

Professor Bourke has carefully studied the language and science of suffering and recounts the often contradictory attempts to comprehend, communicate and relieve pain. She traces a marked change in the view of pain. Through the nineteenth century, many people saw pain as message from God: that pain was redemptive, that submission to pain would perfect the spirit. In contrast, that view has largely given way in recent decades to the attitude that pain is a curse that must be quelled. Medical science still attempts to identify and relieve pain as wrestles it with the concept of pain and persistent misunderstandings.

And cultural misperceptions have often resulted in exacerbation of agony. Professor Bourke details how prejudices about race, gender, class and age have influenced medical treatment and resulted in neglect or cruel abuse. For example, until the mid-twentieth, it was believed widely that newborns and infants did not experience pain. Many scientists also once saw the lower classes and blacks as virtually insensitive to pain with a consequent high tolerance for brutal working conditions. This unfairness runs like a red thread through the history of pain and, Professor Bourke observes, the burden of suffering continues to fall disproportionately on the poor, minorities and women.

Professor Bourke’s book has been praised for its originality, extensive research, vivid prose, and erudition. Sander Gilman wrote in the Irish Times: "Joanna Bourke’s brilliant study of pain shows us exactly why pain is both so very personal to each of us and so elusive to scientific description, even in the 21st century." John Cottingham commented in Tablet: "What Bourke has given us is an extensive and beautifully organized collection of materials that will serve as an invaluable resource for researchers from many different disciplines. It is a formidable scholarly achievement, which sheds a varied and often unexpected light on one of the most pervasive and challenging aspects of human existence." And, in Lancet, Richard Bennet called the book "Enthralling . . . Drawing on philosophy, history, medicine, literature and even theology, The Story of Pain invites us to look again at a fundamental aspect of human life, and to reconsider the richness and the poverty of pain."

Joanna Bourke is Professor of History at Birkbeck, University of London, and Fellow of the British Academy. She is the prize-winning author of nine books, including Dismembering the Male: Men's Bodies, Britain, and the Great War (1996); An Intimate History of Killing (1999)(Winner, Wolfson History Prize and Fraenkel Prize in Contemporary History); Fear: A Cultural History (2005); Rape: A History from 1860 to the Present (2007) (U.S. Title: Rape: Sex, Violence, History); What it Means to be Human: Reflections from 1791 to the Present (2011); and Wounding the World: How Military Violence and War Games Invade Our World (2014) (U.S. Title: Deep Violence: Military Violence, War Play, and the Social Life of Weapons). In the past few years, her research has focused on questions of humanity, pain, and militarization. She is also an award-winning broadcast consultant a regular newspaper correspondent.

Professor Bourke graciously responded by email from London to a series of questions on her work and her historical study of pain.

Robin Lindley: Professor Bourke, you’re a renowned expert on the history of human behavior and particularly on physical and psychological trauma, war, fear, killing and rape. What drew you to study these aspects of history? Do you have a background in medicine or psychology as well as history?

Professor Joanna Bourke: My degrees are all in history but I have been working in the history of medicine and psychology for a long time now. I always learn such a lot talking to physicians, health-care professionals, psychiatrists, psychologists, anthropologists, and philosophers. In my view, these are the disciplines that have the most to offer us in terms of intellectual responses to current crises.

Robin Lindley: How did you come to write your new book on pain and its history?

Professor Joanna Bourke: The book was born of pain. I remember very clearly when I decided to devote years to thinking about pain. I was in hospital after a major operation and was in excruciating pain. My morphine pump was obviously not working and I was too much of a “good patient” to disturb the nurse who was clearly overworked, having to deal with an entire ward of post-operative patients. In order to distract myself, I tried to read. A friend had given me a copy of Virginia Woolf’s brilliant essay “On being Ill” (1928). In it, she points out that people have the rich language of Shakespeare for love but only a thin one for pain. Lamenting the “poverty of the language” of pain, she argued that:

English, which can express the thoughts of Hamlet and the tragedy of Lear, has no words for the shiver and the headache…. The merest schoolgirl, when she falls in love, has Shakespeare and Keats to speak her mind for her; but let a sufferer try to describe a pain in his head to a doctor and language at once runs dry.

I remember my partner arriving and (distraction having partly worked!) I remember telling him about Woolf’s argument that pain is incommunicable, beyond language. After a while, I noticed that he was silent. I asked what was wrong: he told me that for something beyond language did I realise that I had been speaking about it non-stop for an hour?! I was hooked. Perhaps it is not that people in pain find it impossible to communicate their suffering but that witnesses to pain don’t want to hear.

It is also the case that I have worked on many topics related to pain in the past. Most of my work, however, has been about the infliction of pain. I have written a history of how British and American men killed in major conflicts of the twentieth century, on rapists, on militarization, on fear, and what it means to be human (which turns out to have a lot to do with violence towards other humans and non-human animals). It seemed logical to turn to the victims and their suffering.

Robin Lindley: As you eloquently write, pain is difficult to describe and to define. I realize it’s complicated, but how have you come to view pain?

Professor Joanna Bourke: This is the most difficult thing about pain – what actually is “it”? It can refer to a heart attack and a heartache. It is a pinprick and an ocular migraine. We can feel pain when the limb that “feels it” is not present (i.e. phantom limb sensations); many people don’t feel pain even when dreadfully injured (as in combat or extreme sports). They can suffer, yet be lesion-free, as in chronic pain states. So-called “noxious stimuli” can excite a vast array of emotions, including distress (face-to-face with a torturer), fear or panic (crashing through the car windscreen), anticipation or surprise (the moments after a knife or heart attack), relief (self-cutting), or inspire joy (childbirth).

I conclude that it is useful to think about pain in adverbial terms: it describes the way we experience something not what is experienced. Pains are modes of perception: pains are not the injury or noxious stimulus itself but the way we evaluate the injury or stimulus. Pain is a way-of-being in the world or a way of naming an event. So, as an historian, the real question becomes: how have people done pain and what ideological work do acts of being-in-pain seek to achieve? By what mechanisms do these types of events change? As a type of event, pain is an activity. The definition enables us to take seriously people’s perceptions and descriptions of suffering.

You will also note that I use the terms “pain” and “suffering” interchangeably. That is deliberate. I want to question the distinction between the mind and the body. Of course, the Cartesian distinction between body and mind or soul is deeply embedded in our culture and people-in-pain typically highlight one aspect of the pain-event over another (I am in physical pain because I burnt myself while making coffee; I am psychologically suffering because I have fought with my lover). Nevertheless, mental pain always involves physical events – neurochemical, muscular, nervous, and so on – and physical pain does not exist without a mental component. My burn depresses me; my sadness weighs down my body.

Robin Lindley: You stress that pain is a private and a public experience. What do you mean?

Professor Joanna Bourke: Pain is something we each experience “as ours.” But there is no such thing as an entirely private pain. Pain experiences do not emerge naturally from physiological processes, but always in negotiation with social worlds. From the moment of birth, infants are initiated into cultures of pain. As they mature, people responsible for their socialization pay attention to some tears, and not others. Hands are smacked as they reach for flames. Some cuts are kissed better; some bruises, overlooked. It makes a difference if you are a boy. It matters if you are poor. People in pain learn how to “suffer silently” (like me when trying to be a “good patient”!) or “kick up a fuss.”

I also explore the public character of pain through philosophy (Ludwig Wittgenstein is extremely helpful) and anthropology (the fact that in different cultures there are different “pains”).

Robin Lindley: You describe how pain perception has evolved over the past three centuries. Is the major change the shift from seeing pain as redemptive or a message from God until the early-20th century to now seeing pain as an evil that must be controlled or eradicated?

Professor Joanna Bourke: I think that is an important shift, but we shouldn’t exaggerate it. After all, many people retain a profound belief in spiritual powers when they are in pain. The main shift is that they are less likely to tell health care professionals about the religious resources they employ (in addition to the biomedical ones) when dealing with pain. This is in stark contrast with what took place in the past, where spiritual and biomedical practices were seen as complementary.

Robin Lindley: How have technical and scientific advances such as anesthesia, pain medication and diagnostic imaging influenced the history of pain?

Professor Joanna Bourke: When the pharmaceutical possibility of eradicating acute pain was limited, endurance could be valorized as a virtue: the introduction of effective relief has made passive endurance perverse rather than praiseworthy. Stripped of its mysticism and its history in foundational theological texts, pain has become an evil in itself, unequally distributed (afflicting the saintly as carelessly as the sinner).

Pain has also been demoted diagnostically. In the eighteenth and early nineteenth centuries, pain narratives (that is, patients talking about their suffering) were valued as contributing to accurate diagnosis – as well as being an integral part of the healing process itself. So physicians encouraged patients to talk about their lives and aches. Increasingly, however, pain narratives were stripped of any significance beyond the rudimentary information imparted by the cry “it hurts, here!”

In other words, from the mid-nineteenth century, pain narratives became mere “noise,” serving little diagnostic purpose. For clinicians, the person’s misery was reduced to its separate component parts (nervous, visceral, chemical, neurological, and so on) within the body. Protracted grumbling by patients was little more than an impediment to the future “conquest of pain.” For patients, complex and elaborate pain narratives became shameful (might their very “richness” indicate malingering, exaggeration, or liability?) and potentially indicative of their status as “bad patients.”

What we have today is the Visual Analog Scale, which consists of a line, with either end labeled “no pain” and “the worst pain imaginable”: patients are asked to point to the position on the line that best represents their degree of pain. More recently, the “holy grail” of objective detection and measurement of pain is brain imaging. This technology eradicates the subjective person-in-pain altogether. She is not required to speak; she is not even required to point. Her body is expected to tell its own story. The complex phenomenon of being-in-pain is reduced to one, rather small, part of painful experiences. The person-in-pain effectively disappears: the bedside chat is replaced by a brain scan projected against a screen.

Robin Lindley: Could you please explain your conclusion that there is “nothing democratic about pain?”

Professor Joanna Bourke: There has never been anything democratic about pain. In 1896, at the fiftieth anniversary of the first public administration of surgical anesthesia, physician Silas Weir Mitchell read out his famous poem, “The Birth and Death of Pain.” It contained the lines:

This [pain] none shall ‘scape who share our human fates:

One stern democracy of anguish waits

By poor men’s cots, within the rich man’s gates.

He could not have been more wrong. Pain is always embedded in inequitable economic relations. Individuals are born into worlds not of their own making. They accommodate and acquiesce, struggle and submit, to the environmental and social contexts within which they find themselves, but always from a starting point that is not of their own choosing. Individuals generally don’t choose pain; structural inequalities foster it upon some groups significantly more than others.

The poor, minority groups, those working in hazardous occupations, and so on are more likely to suffer. In the late twentieth and early twenty-first centuries, elderly, very young, poor, and working-class patients, as well as those from ethnic minorities, continue to be strongly affected by prejudices about their high threshold for perceiving pain. The result? They are routinely given fewer analgesics, and at later stages of their afflictions, than other pain patients.

Furthermore, underprivileged people might not only struggle to have their cries heard, but may themselves not register a painful-situation as pathological simply because such experiences are so typical – an example is working-class women whose lower-back pain are not interpreted as symptomatic of a real painful disorder but simply as an everyday, normal sensation. The assumption that pain “disrupts biographies” (a highly influential sociological concept from the 1980s) may only be the case for fortunate members of our communities. For the rest of us, being-in-pain might just be our expected biography.

Robin Lindley: I was struck by the misconceptions about pain based on prejudices about class, race, gender and even age. What are some examples of prejudicial notions and cultural assumptions about pain that you found particularly striking?

Professor Joanna Bourke: This was one of the most shocking things for me. It was strongly believed in the past that some people simply did not feel, or not much. There were “natural hierarchies” of feeling. This so-called Chain of Feeling put animals, non-Europeans, working-class people, and children at one end of the sensitivity scale and white European males at the other. Because those at the lower end of the Scale did not truly feel, they could be mistreated and given les pain relief: it justified the vivisection of animals, the abuse of slaves, and the under-treatment of the poor.

Of course, there were contradictions in the way the Chain of Feeling was interpreted. For instance, on the one hand, non-European peoples could be denigrated as possessing lesser bodies: their position at the lower echelons of the great Chain of Feeling was due to their physiological insensibility. Yet, on the other hand, and often in the same context, they could also be designated as inferior on precisely the opposite grounds: excessive sensitivity. The alleged insensitivity of workers, immigrants, and hysterics was proof of their rudimentary nervous systems and thus humble status, yet the profound sensitivity of these same people was also proffered as evidence of their inferiority (they lacked strength of will).

For me, the greatest surprise concerns the changing views about whether infants felt pain. The sentience of infants shifted from exquisite sensitivity in the eighteenth century to almost total insensibility to pain from the 1870s and then back again to acute sensitivity from the 1980s. In other words, in the eighteenth century infants were assumed to be exquisitely sensitive to painful stimuli -- this belief was at the heart of eighteenth century debates within the professionalization of pediatrics. The sensitivities of infants to painful stimuli was disrupted with the development of experimental embryology, and, in particular, work (Paul Emil Flechsig) showing that nerve fibers developed at different rates: neonates were not fully “wired.” Increasingly, infants were portrayed as similar to animals, possessing reflexive responses to painful stimuli rather than true sentience. This view justified giving children as old as ten inadequate pain relief – or withholding it altogether. As the author of Modern Surgical Technique (1938) claimed, “no anesthetic is required,” when carrying out even major operations (such as amputations and heart operations) on young infants: indeed, “a sucker consisting of a sponge dipped in some sugar water will often suffice to calm the baby.” As late as the 1970s, over half of children aged between four and eight years who had undergone major surgery – including amputations – in American hospitals received no medication for pain. Dismissive attitudes towards the sensual worlds of infants and young children only changed significantly from the 1980s.

Robin Lindley: What did you learn about pain and stoicism experienced by combatants in wartime?

Professor Joanna Bourke: I am interested in the very different ways pain is written about in British and American memoirs. In memoirs based on the American Civil War and the First World War, men insist on their passive, stoic resignation in the face of wounding. This is resolutely jettisoned in memoirs about the conflict in Vietnam. Instead, pain is an excuse for lurid evocation of the body dismembered and aggression. There was little stoicism in these later accounts; pain was presented as an excuse for extreme cruelty (“let’s slaughter all the bastards!”).

Robin Lindley: You note that pain narratives or descriptions may cause distress in readers or listeners. Has that notion ever concerned you or become an issue in your teaching or writing about trauma, pain and other troubling concerns?

Professor Joanna Bourke: Yes, talking and writing about pain can risk inflicting pain on the listeners. I worry about this in my own research and writing. It was particularly acute for me not in this book, but in another one I wrote entitled Rape: a History from the 1860s to the Present, where I analyzed the excuses that rapists gave for their actions. Their words try to harm women. No amount of distancing myself from their comments could negate the fact that simply repeating their distortions threatens to construct women victims as passive victims. It is crucial to repudiate the rapist’s insistence on his agency, his power, over that of others. I was also anxious to ensure that my words would not frighten female readers. I put a lot of effort into the language I used – but it is impossible to know whether I was successful or not.

Robin Lindley: Professor Peter Mere Latham is an overarching figure in your history of pain. Who was he and how is he significant to the study of pain?

Professor Joanna Bourke: I was surprised by Latham’s role in my book. He was one of the most renowned physicians in nineteenth century London, working at the Middlesex Hospital and then St Bartholomew’s, and (like his father) was appointed Physician Extraordinary to the Sovereign. As I state in the introduction, much of my life has been spent eavesdropping on the voices of women and the downtrodden, minorities and the dispossessed. But this voice addressed me in the confident tones of a Victorian patriarch. I decided to give him a prominent role, however, because he was simply so insightful about the nature of pain.

One question Latham came back to time and again is: “what is Pain?” He insisted that “things which all men know infallibly by their own perceptive experience cannot be made plainer by words. Therefore, let Pain be spoken of simply as Pain.” In other words, we need to take seriously whatever people say is “painful.” This definition is profoundly respectful towards the ways peoples in the past have created and recreated their lives. It allows for multitude, even conflicting, characterizations of suffering. It does not impose a judgment about how people-in-the-past (or, indeed, today) ought to characterize pain Crucially, the definition enables us to problematize and historicize every component of pain-talk. It allows us to explore how the label “pain” changes over time. Of course, I disagreed with many of his other assumptions (which I discuss in the book) but would like to think that, if we had a time machine, Latham and I would be able to sit around a dinner table and have an interesting discussion!

Robin Lindley: With modern anesthesia and pain medications, is pain any less important an issue now than it was before these advances?

Professor Joanna Bourke: Pain is pain. It is difficult to comprehend just how agonizing it must have been to endure a major operation before the availability of anesthetics. It may even be the case that the availability of pain relief has made pain more unacceptable.

Robin Lindley: What projects are you working on now? What is the Birkbeck Trauma Project that you direct at the University of London?

Professor Joanna Bourke: Recently, I published a book on militarization in Britain and America. It is entitled Wounding the World: How Military Violence and War Games Invade Our World (2014) (U.S. Title: Deep Violence: Military Violence, War Play, and the Social Life of Weapons).The book explores how military practices, technologies, games, language, entertainment and symbols have invaded our everyday lives. I ask why military practices, technologies, and symbols are so pervasive. What is the relationship between everyday violence and weapon research? What is being done in “our name”? Although men and boys are more drawn to the delights of play guns, war games, and military history, I don’t think we can let women off the hook. Only through understanding the history, science and ethics of weaponry can we begin to talk about what can be done to forge better worlds.

I am also the director of The Birkbeck Trauma Project, which evolved from a project on pain that was funded by the Wellcome Trust. It builds on the research carried out when I wrote The Story of Pain. I wanted to explore the complex meanings of trauma as embedded in its Greek root, τρaυμα, which refers to physical wounds as well as emotional ones. The Birkbeck Trauma Project brings together researchers primarily in history, but also in literary studies, anthropology, medicine, and neurology.

My specific project at present is the study of the political, military, commercial, scientific, and social agencies devoted to developing ways to inflict the most debilitating wounds in other people. What is the science of wound ballistics? Where does it draw its ideological power? What enables “good men” to do evil? Why do some forms of suffering “not matter”? These questions, and others, are explored in relation to three key themes: history, science and ethics.

Robin Lindley: Is there anything you’d like to add on what you hope historians and others will take from your groundbreaking book on pain?

Professor Joanna Bourke: I would love to engage with other scholars working in the field. There is such a lot of brilliant work being carried out. Tell me about yours!

http://www.bbk.ac.uk/history/our-staff/full-time-academic-staff/joanna

Robin Lindley: Thank you very much for sharing your insights Professor Bourke.