The New York Review of Books - USA (2022-06-23)

28 The New York Review

Where Does It Hurt?

Laura Kolbe

The Song of Our Scars :

The Untold Story of Pain

by Haider Warraich.

Basic Books, 307 pp., $30.00

An Anatomy of Pain:

How the Body and the

Mind Experience and

Endure Physical Suffering

by Abdul- Ghaaliq Lalkhen.

Scribner, 244 pp., $28.00; $17.99 (paper)

Hurts So Good:

The Science and Culture

of Pain on Purpose

by Leigh Cowart.

PublicAffairs, 237 pp., $28.00

For the sixteenth- century barber-

surgeon Ambroise Paré, pain was a

deadly liar. When French soldiers

returned from battle with shattered

limbs on which wounded tissue had

already died, Paré warned fellow sur-

geons not to take a patient’s word for it

in deciding where to amputate: “For I

know very many deceived as thus: the

patients pricked on that part would say,

they felt much paine there.” Taking the

report of pain as a sign that the tissue

was still viable, a well- meaning surgeon

might spare it and amputate farther

down the limb, leaving a necrotic zone

behind that would soon result in sepsis

and death.

Paré provided the first robust account

of phantom- limb sensations, the faux

sentiments that made the brain think

that an attached but dead limb— or

even a long-absent amputated one—

was still experiencing movement, tem-

perature, pain, and other phenomena.

He speculated that the cause might be

the patient’s imagination, or perhaps

that the severed nerve endings “retire”

back toward the brain, taking their

store of sensation with them in retreat.

René Descartes, born a few years

after Paré’s death, developed aspects

of his mind- body dualism from his own

experiences on the battlefields of the

Thirty Years’ War. Discarding Paré’s

hunch that the peripheral nervous sys-

tem might be involved—“I recognize

no sensation save that which takes

place in the brain,” Descartes wrote—

he nonetheless saw that the peculiar

experiences of amputees could tell us

much about more common physical

suffering.

Where is our pain, exactly? And what

is it? The personal histories of Haider

Warraich, Abdul- Ghaaliq Lalkhen,

and Leigh Cowart, the authors of three

new books on the subject, suggest that

they have privileged insights: War-

raich is a physician with chronic back

pain, Lalkhen is an anesthesiologist

who specializes in treating patients

with both acute and chronic pain, and

Cowart is a self- identified masochist

who has experienced both unintended

physical traumas and a dizzying num-

ber of intentional episodes of acute

pain. Each of their books does a fine

job of summarizing our current under-

standing of the human nervous system,

the known variables that appear to af-

fect the brain’s response to pain, and

intriguing new directions in clinical

research that may bring more useful

therapeutics.

In The Song of Our Scars Warraich

describes how he suffered a back injury

as a young man doing bench presses:

“a loud click,” then “agony.” En route

from the gym to the emergency room he

is hypersensitized, feeling “every small

bump, even the fine clefts between pave-

ment panels.” We come closer, perhaps,

to the character of his experience when

he describes the pain, having become

chronic, as “an infestation.” But much

of his use of the first person simply re-

inforces the expected: that his pain is

less i ntense when he is happy, d istracted,

or feeling loved; that it is worse when he

is depressed, anxious, or bored.

Cowart (who uses they/them pro-

nouns) opens Hurts So Good, their

investigation of the many subcultures

of “pain on purpose,” by describing a

BDSM encounter with a new partner.

Thick rubber bands on Cowart’s arms

make them see “orange and white in

the backs of my eyelids,” bringing a

kind of cognitive clarity, “like if you

could inflate a balloon inside my skull

and make it fill the whole area.” There

is sweat, vibrators, zip ties, and more

rubber, but beneath the array of props

we just learn that “everything hurts”

and that at the end of the ordeal, “I felt

bad, and then better.”

In An Anatomy of Pain Lalkhen

describes what a pregnant woman in

labor is like before he administers an

epidural: “An individual who would

normally present a reasonable and

calm image to the world but who is

now reduced to a feral and illogical

specter.” (The phrase “feral and illog-

ical” may say more about the language

problem with pain than it does about

the woman.) Elsewhere, he writes of an

encounter with a patient with fibromy-

algia: “I have never met a lonelier per-

son than someone suffering with pain.”

Perhaps this yawning gap—between

someone who’s in pain and someone

who isn’t—speaks to the perplexing na-

ture of pain more than any inventory of

zip ties or physicians’ case histories.

In everyday language and experience,

we might say that the most ordinary

instance of pain arises when tissue is

injured and we feel a concomitant nox-

ious sensation—the feeling that arises

when a hand touches flame, for exam-

ple. But many people also experience

unpleasant physical sensations, such as

headaches or gut cramps, that we sense

correlate with a psychological injury—

the exposure of something shameful

about ourselves, perhaps, or the death

of someone we love.

Moreover, there is the sort of pain,

as “real” as a scraped knee but unlo-

calizable, that can accompany a tor-

menting psychological malady, like

William Styron’s particular experi-

ence of depression as the “diabolical

discomfort of being imprisoned in a

fiercely overheated room.” And finally,

there is suffering that locates its cause

in an injurious physical event but is ex-

perienced in ways that might surprise

the sufferer and their clinicians—head-

aches, stomach cramps, and intense

emotional distress, perhaps, after sur-

viving a severe burn.

Ordinary usage might ascribe “pain”

to all four of these examples of suffer-

ing. Pain from an injury to the body,

however, is what we usually mean and

is what the rest of our commonsense

understanding flows from. Today one

of the predominant models in scientific

circles is the psychologist Ronald Mel-

zack’s “neuromatrix of pain.” Coined

in the 1990s, the term implies that pain

arises from a complex array of neural

inputs, in relation to one’s genetics as

well as environmentally provoked de-

velopments in the brain and nervous

system. Some of the inputs that feed

this matrix come from nociceptors (pe-

ripheral nerve endings detecting pain-

ful stimuli), but there are many other

inputs relating to stress, inflammation,

memory, and mood. The neuromatrix

is mutable, or in biological terms “plas-

tic,” and the characteristic “neurosig-

nature” for one’s headache or back

pain is both uniquely one’s own and

forever a work in progress.^1

It would be nonsensical, both in

everyday speech and in contempo-

rary neuroscientific terms, to say that

someone is in pain but not aware of it.

Someone who does not yet experience

suffering from a shark bite because they

are distracted by the effort to survive is

not in pain yet, though a great deal of

nociception may be happening in the

nervous system. By the same token, it

would be nonsensical to say that some-

one was mistaken about having pain:

they may be mistaken as to its cause, its

location, or its remedy; or the impor-

tance they ascribe to their pain may be

annoying or socially inappropriate; or

they may of course be willfully lying.

But it is not possible to believe oneself

to be in pain and to be wrong.

Paré and Descartes were both right

that pain is not “in” a festering gunshot

wound, nor is it wholly bluster or lin-

guistic sloppiness when contemporary

speakers say that it “pains” them to

witness or think about something hor-

rible. The International Association

for the Study of Pain (IASP), an influ-

ential organization of researchers and

clinicians, currently uses the following

definition of pain, last revised in 2020:

“an unpleasant sensory and emotional

experience associated with, or resem-

bling that associated with, actual or po-

tential tissue damage.”

Critics of Melzack’s neuromatrix

model and of the IASP definition note

that the concept of pain is perhaps

getting too broad to be useful. Just as

the elastic waistband is wearing out on

pain- related terms like “trauma” and

“violence,” so that they now have room

for almost everything but may also no

longer stand up to cursory inspection,

so too does pain’s language problem

become a practical one, in which some

conceptual clarity might help both suf-

ferers and clinicians.

For starters, let’s take “acute” and

“chronic” pain. While non clinicians

often think that “acute” means some-

thing like “severe” or “urgent,” clini-

cians mainly use the term to talk about

Shannon Cartier Lucy: Tied-up Daffodils, 2018

Shannon Cart

ier Lucy/Lubov Gallery, New York

(^1) For a recent valuable primer on the
various aspects of the nervous system
that interact to produce, modulate,
and relieve pain, see Richard Ambron,
The Brain and Pain: Breakthroughs
in Neuroscience (Columbia University
Press, 2022).
Kolbe 28 32 .indd 28 5 / 25 / 22 4 : 03 PM