Does pain hurt?

As I’ve said before, cancer hurt Laura in the sense that it damaged her brain, but brain cancer itself did not hurt Laura in the sense of causing her pain. Until close to the end.  By that time, however, we could use Fentynal and morphine to blot out the headaches as soon as they started.

Laura never found an anodyne to blot out the pain she felt on account of her aphasia.  In these last few posts, we have been wrestling with how to talk about that pain.  First, we used Joan Halifax’s view of grief as being “pregnant with an absence” to describe the pain of aphasia in the five territories of grief.  We then pursued the absence of ease or comfort as similar to the idea that evil occurs when something good is defective, but quickly warned against making aphasia into a thing.  We do aphasia, just as we do pain.  As we saw in the phases of Laura’s aphasia, she hurt mostly through fear and shame, particularly the fear of disgrace, as Aristotle defined shame.  We then saw that Aristotle uses three terms to describe both fear and shame: pain, disturbance, and “bad things.”  We are now looking at each of these in turn.

The words that Plato and Aristotle used for pain seemed to become less and less associated with physical pain as they were translated into Latin and then into English, leading to a number of confusions.  You may have noticed that none of the Greek or Latin words for pain in the previous posts seemed to be sources for the English word “pain.”  In fact, “pain” comes from the Latin word poena, which means “punishment.”  We see this connection in the legal phrase describing the penalty for breaking a law as “under the pain of.”  Poena comes from the Greek word poinē, which referred to the money paid by a killer to the kin of the slain person.  More generally, poinē meant a price paid, satisfaction, retribution, requital, penalty.  Probably the word poena morphed into our modern English word “pain” because so many of the penalties in most of European history before the 20th Century were physically brutal and intended to inflict agony.

We can trace this history in the definition of “pain” in the Oxford English Dictionary, which gives as the first meaning:  “1.  Suffering or loss inflicted for a crime or offence; punishment; penalty;  a. fine … ”  In the second meaning, the OED comes closer to the meaning of the pain we have been wrestling with and hints at the history I was surmising: “2.  A primary condition of sensation or consciousness, the opposite of pleasure; the sensation which one feels when hurt (in body or mind); suffering, distress. …  In early use esp., suffering inflicted as punishment.”  The third and fourth uses cover meanings also quite relevant to this blog:  “3.  In specifically physical sense: Bodily suffering; a distressing sensation of soreness (usually in a particular part of the body). …  4.  In specifically psychical sense: Mental suffering, trouble, grief, sorrow.”.  I think only the first meaning of “pain” in the OED would be inconsistent with what Aristotle meant when he described fear and shame in terms of “pain.”

It is interesting that the definition of “pain” in a recent scientific paper captures both current usage and the history of the word.  Pain is “a somatic perception containing: (1) a bodily sensation with qualities like those reported during tissue-damaging stimulation, (2) an experienced threat associated with this sensation, and (3) a feeling of unpleasantness or other negative emotion based on this experienced threat”  (Price)   Usually we tend to think of a “somatic perception” as just “a bodily sensation,” but this definition gives “somatic perception” a new, deeper meaning by saying that it contains both “an experienced threat” and “a feeling of unpleasantness,” instead of saying that these latter two are just added on top of the “somatic perception.”  Ironically, this modern definition uses fear (“experienced threat”) to define pain.  I think that perspective deepens Aristotle’s insight rather than contradicting him because it avoids the modern tendency to try “to explain human and animal behavior in terms of the nervous system.”  Buytendijk (34) argues that not only is this tendency an “error,” it makes the mistake of looking into “the structure and function” of the nervous system for “the real origin” of “what is taking place at any given moment, and in a specified location.”

When Aristotle says that fear and shame involve “pain,” he is not talking in the narrow sense of a “somatic perception,” nor is he excluding somatic pain in the way we tend to do today when we talk about sadness, sorrow or grief.  They hurt, but not in the same way that the nervous reactions associated with damage to our body, such as burns or needle sticks, do. And, as Buytendijk warns and as we will see, there is nothing purely physical about burns or needle sticks.  How we become and remain aware of them plays as much in how they hurt as do the electrical impulses along our nervous system. Laura felt extreme physical pain a number of times during her treatment.  But she did not suffer from this pain.  She endured it to get better.  Also direct physical pain like the needle sticks did not cause her the shame that aphasia and the effects of Decadron on her GI tract did.

Fear is one of the three examples Simone Weil gives of processes that might seem to be just psychological, but “though difficult to describe are bodily and exactly equivalent to” physical pain.  The other two are grief and humiliation. (Weil  [1973] 117-118)  We will consider humiliation (as distinct from shame) in a later post.  For a quick illustration look at “How could she do that?”   And grief is explored in posts under “I will miss you.”

As we have seen, Laura’s aphasia itself challenges a narrow understanding of what it means to hurt.  We have been talking about the pain of Laura’s fear and shame about her aphasia.  But I want to return to the question whether aphasia hurts and argue that aphasia itself belongs on Weil’s list of the equivalents of physical pain.

No one administered the McGill questionnaire to Laura.  Given her condition, it would not have been possible.  As someone who lived with her through this, I do think that this questionnaire can help us compare Laura’s aphasia-pain with what we usually call physical pain.  There are three dimensions on the scale. In the first, sensory-discriminative dimension of pain we sense when, where, and how not! moves on, in, and through us.  Then in affective-motivational dimension of pain, we generate feelings of not! (dislike) and move towards fight, flight, or rest.  In the third cognitive-evaluative dimension, we assess what is going on and its likely results. (Gawande 125-126, Scarry 7-8, Melzack and Torgerson, Lumley et al. 945.)

Few of the words on the sensory dimension of the scale fit Laura’s aphasia.  Perhaps, flickering, jumping, and dull.  On the affective dimension, she certainly reacted as if she felt her aphasia was exhausting, suffocating, frightful, punishing, and wretched; on the evaluative dimension, unbearable, spreading, numb, and dreadful.  Over the course of the period between August and November 2008, her present pain index (PPI) for aphasia went from mild (frustration at not remembering words when she was reading a bedtime story to Anne Mei) to excruciating (when she was punishing herself by repeating the same fruitless exercises over and over).


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