32 The New York Reviewand economic order largely dependent
on slavery, the labor and property
of colonized peoples, or both, it was
highly convenient to believe that “un-
civilized” people did not experience
much pain. Warraich reminds us that
Silas Weir Mitchell, better known for
bringing Paré’s concept of phantom-
limb pain to a wider audience after the
Civil War’s epidemic of amputations,
believed that “being civilized” brings
“intensified capacity to suffer.” This
assumption persisted into the twentieth
century, along with the contradictory
belief that people of greater degener-
acy and lesser moral fiber make more
fuss about their pain. Jewish and Irish
people, wrote one British surgeon in
1929, “made the most noise on the op-
erating table.”
Incredibly, this spurious distinction
in pain sensitivity by racial or social
type persists today, even among health
care workers. During my final year of
medical school at the University of
Virginia, my classmates and I briefly
found ourselves the topic of unwanted
news coverage when the results of a
study came out: in a survey on our un-
derstanding of the physiology of pain, it
turned out that about 40 percent of my
white classmates believed that Black
patients had literally thicker skin than
white patients and also required less
pain medication.
People called the survey results dis-
graceful, and they were. But they were
not a bolt from the blue. Many other
studies demonstrate lower apprecia-
tion by medical professionals for pain
experienced by Black patients in the
US, and commensurately lower rates of
pain medications prescribed, even for
children. As Warraich shows, one large
2015 study found that those who came
to the emergency department with ap-
pendicitis were less likely to receive
opioid medication (an appropriate
therapy for the excruciating abdomi-
nal pain that can accompany this con-
dition) if they were Black, even when
the data was adjusted to control for the
children’s reported level of pain or the
documented severity of their illness.
When we regard the pain of others,
their gender affects our perceptions,
too. On the one hand, a recent study
demonstrated that subjects watching
male and female patients do painful ac-
tivities tended to rate the women’s pain
as lower in severity, and were more
likely to suggest psychotherapy for the
female patients and pain medication for
the male patients. On the other, women
are actually prescribed opioids more
often, at higher doses, and for longer
courses than men, and are more likely
also to be prescribed benzodiazepines
(a class of medications better known
by their various brand names, such as
Ativan, Valium, and Xanax), which
increase the risk of the respiratory
and cognitive side effects of opioids.
Perhaps we both disbelieve women’s
accounts of pain and also want to give
them whatever is most likely to silence
them fastest.
But people also seem to regard their
own pain differently depending on who
is watching and listening. Warraich de-
scribes another small study that deliv-
ered identical painful stimuli to Black,
Hispanic, and non- Hispanic white
subjects while observing their brains
using functional magnetic resonance
imaging (fMRI). It found that, on aver-
age, Black subjects rated their pain as
more intense than other subjects did,a finding that correlated with more in-
tense activity in parts of the brain as-
sociated with chronic stress and anxiety.
This difference diminished, however,
in a study of similar design when Black
subjects reported their pain to clinicians
who were also Black. (Interestingly, His-
panic subjects reported more pain when
speaking to a Hispanic clinician, and
clinician race did not significantly affect
the reports of white research subjects.)
Another study showed that women
rated the pain of a given stimulus lower
when they held hands with their ro-
mantic partner. “The touch of a loved
one,” Warraich concludes, is “a potent
painkiller,” one that he links to “the
so- called love hormone itself, oxyto-
cin,” which activates “one of the body’s
most potent shields against suffering.”
In Hurts So Good, Leigh Cowart dis-
cusses the hypothesis that “behavioral
synchrony,” movement with others,
“acts as a binding agent, a love spell of
sorts,” which can activate our “home-
brew morphine” (the body’s endoge-
nous opioids) and “the weed version,”
the body’s endogenous cannabinoids.
Rowers and runners, for example, ap-
pear in some studies to have higher tol-
e r a n c e fo r p a i n w h e n t h ey wo r k o ut w it h
others. Cowart connects this with the
larger thesis that the social opprobrium
around certain kinds of pain- seeking
(when it is sexualized, associated with
personal risk, or connected to a dispar-
aged subculture) assumes a sharper,
clearer line between “good” and “bad”
pain than actually exists.It must be said that the studies most
likely to earn wide- eyed summaries
in books of popular science like these
are not those with the largest sample
sizes, greatest statistical rigor, or most
successful replicability on subsequent
retrials. The studies we talk about
are often the ones that confirm things
we like to believe. The hand- holding
study, for example, was conducted on
twenty- two childless heterosexual cou-
ples aged twenty- three to thirty- two—
hardly a picture of women in general,
or couples in general. The fMRI study
examining subjective pain reports by
race used just eighty- eight participants.
When it comes to sex and pain per-
ception, a growing number of animal
studies show that female animals ex-hibit more signs of distress and aver-
sion to unpleasant stimuli than males
do, and experiments at the cellular
level suggest this may relate to the way
that estrogen modulates other signaling
mechanisms in the body. But electro-
cuting rats is a far cry from presuming
to understand why two human beings
with a near infinite catalog of variables
(race and gender being among the la-
bels we are socialized to find more sa-
lient) report differently about the same
experience.
The philosopher Daniel Dennett
famously called the two poles of an-
imal brain- and- behavior studies the
“romantics” and the “killjoys,” the
former more likely to make much of
animal– human corollaries and the lat-
ter quick to point out the limitations of
such thinking. The same schema could
be applied to clinical researchers more
generally: some are oriented toward
synthesizing explanations, others are
by nature and practice more cautious
and tend to resist the seductions of ex-
trapolation. However these two types
are actually divided in the academy
and the lab, one thing is clear in the
bookstore: the romantics get the trade-
book deals, since they promise to tell
us about ourselves.
Our appetite for explanation is large,
because most of us have at some point
deeply desired to convey what our own
pain is like, or to know what that of
another is like, and have run into prob-
lems. It’s the old question of whether
everyone sees color the same way, but
with higher stakes: whether a person’s
pain is communicable and commensu-
rate with another’s can affect how much
we might feel we owe one another emo-
tionally, socially, and politically. For
health care workers, the relative ineffa-
bility of pain makes those of us largely
free of it, yet involved in its treatment,
“like chefs who have never tasted their
own food,” as Warraich writes. Some
clinical tools try to get at this more tex-
tured account of pain. The McGill Pain
Questionnaire, for example, asks re-
spondents to select from an impressive
array of adjectives, like “flickering,”
“gnawing,” “scalding,” and “rasping.”
If this expansion of clinical vocabulary
leads to a comparable enlargement of
clinical imagination when it comes to
what patients experience, this will be
an advance indeed.A famous passage in Wittgenstein’s
Philosophical Investigations argues
that having a “private language” all to
oneself is impossible. He uses pain as
a chief example of what our intuition
tells us might come closest to private
language: in a world where others do
not display feeling or speak about
their hurt, a child may invent a name
like “pain” for what he feels when his
tooth aches. Yet the child’s precocity
is in fact only a novel maneuver within
public language, which already “shows
the post where the new word is sta-
tioned”—our shared communication
strategies in language already mark out
idea- spaces where the right word will
fit.
Reading Warraich’s, Cowart’s, and
Lalkhen’s first- person accounts of ex-
periencing or witnessing pain, though,
I understand the force of that intuition
Wittgenstein goes to lengths to dis-
prove: in the mouths of most speakers
and the ears of most listeners, it can
feel as though we’re all talking about
something different and not putting
much across. While each book pro-
vides a handy summary of the state of
the neuroscience research on the topic,
a reader may well feel they haven’t
yet been told the story of what pain is
really like.
Of course, a pure shriek of agony is
unlikely to engage listeners for very
long either. Though the unbroken
scream became something of a sta-
ple of twentieth- century performance
art, passing with minor modulations
among Yoko Ono, Marina Abramovic,
Tracey Emin, and others, such stunts
often stand in meek fealty to their wall
text. We need circumlocutions, though
ideally ones that don’t stray far from
where the shriek is centered. In The
Body in Pain, Scarry talks about the
dilemma of Amnesty International
letters, which want to convey the real-
ity of torture sufficiently to inspire ac-
tion, while at the same time exercising
“the greatest possible tact” so that the
reader does not flee aghast.
The great artists and writers may
be our best hope in this regard, being
perhaps “feral and illogical” enough
to expect the unreasonable: that they
will tell us what it’s like, and that we
will then truly know. As I was reading
all these books, I started jotting down
works I remembered that had indelibly
marked my conception of pain and had
conveyed more to me than these sci-
entific accounts ever could. The hero’s
dying aria in an undergraduate produc-
tion of Handel’s Hercules, in which he
cannot remove a poisoned shirt that
burns him alive. The final section of
Marie NDiaye’s novel Three Strong
Women, in which a reluctant migrant
from West Africa undergoes a series of
torturous injuries to her legs and gen-
itals. The gangrenous club- foot burst-
ing from its corrective box in Madame
Bovary. The post operative recovery in
Infinite Jest of a character who refuses
opioids after a gunshot wound.
In Italian they say that “the tongue
hits where the tooth hurts”—we can-
not help fretting at our most tender
places. That the instrument of our self-
scraping is the tongue—la lingua, also
“the language”—will surprise neither
dentists nor writers. Nor, in fact, any-
one who has sought to articulate this
protean stinging, ripping, gnawing,
aching, chafing thing that, for conve-
nience or out of frustrated resignation,we call “pain.” (^) Q
́
EARLY ALZHEIMER’S
A shelf of memory calving into the sea
like an Antarctic glacier on TV
these scenes of climate change
heightening the senescence
we try to fathom day by day
as yet another point of reference
quietly crashes away
—Richard Sieburth
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