Medical science can only tell us so much. To understand pain, we need the cultural tools of history, philosophy and art

Pain experience is not a human universal. It has a history. It changes over time and from place to place. Elaborating this history exposes the politics at the core of attempts to measure, validate or dismiss the experience of people in pain.

The language of pain, stretching back to antiquity, conflated the emotional and the physical. The overlap of grief, anguish, despair and sorrow with physical pain lies at the heart of vernacular expressions of suffering in Ancient Greek, Latin, Arabic, Urdu, Hindi and Chinese, as well as in English and other European languages. For thousands of years, the statement ‘I am in pain’ was an emotional as well as a physical claim. While this semantic overlap seems consistent, the precise conceptualisation has varied enormously, from ὀδύvη (odúnē, Ancient Greek) to dolor (Latin), to wajaʿ (Arabic), to dard (Farsi, Hindi and Urdu), to tòng (Chinese). Moreover, there is a rich history of the iconography of the ineffable: representations of pain that, while it could not be uttered, was nonetheless expressed. By documenting the historically situated processes of experiencing and expressing types of pain, it is possible to show both an enormous variety while insisting upon a long history of the braiding of the emotional and the physical. This has the effect, in turn, of implicitly de-naturalising and situating present-day experiences of pain and of disrupting two centuries of modern medical expertise.

Take, for example, the concept of grief in ancient Greece: ἄχεος (ákheos). It is one of the key terms for grief or distress at the heart in the Iliad, but it is also one of many words in Greek for pain/suffering. Despite the association of Achilles with other passions, it is grief-pain that he embodies in his very name, and it is in the name of this pain that most of Achilles’ violent actions are carried out in the final books of the epic. You might object that Achilles is a fictional character, a demi-god; that this pain is merely literary, not literal, and not human. Yet the Iliad framed ideas and practices of virtue, belief, warfare and ritual for centuries. It was key to Greek self-fashioning in the classical period. It was the central intertext of Plato’s Republic. If Greeks learnt how to do pain, they learnt it, in part, through Achilles.

Those pain practices changed over time, despite the preservation of the stories. In the Iliad, when Achilles learns of the death of Patroclus, his friend, comrade and maybe lover, he flings himself into the dirt and tears out his hair, while his attendants all wail. When the body is finally recovered, Achilles is all tears, wails, groans and cries. He is like a lion whose cubs have been killed by a hunter, whose pain is quickly directed in anger (χόλος, khólos) and revenge. When Achilles’ mother finally arrives to deliver his new armour, she finds him still clinging to Patroclus’ dead body, openly weeping.

Yet by the time of Plato many of the apparent virtues of the Iliad were in question. On an Attic red-figure volute-krater from about 460 BCE, perhaps some 300 years after the Iliad was first set down in writing, the figure of Achilles is discovered by his mother precisely at this moment of his grief. The artist does not show Achilles in tears, clinging to the body of Patroclus; instead, Achilles is depicted alone, entirely veiled in a shroud, save for the top of his head and the symbolically important heel of one foot.

Veiling, according to the research of Douglas Cairns, became a prominent display rule in ancient Greek culture, precisely to conceal tears and the expression of grief. The scene is newly realised to make it conform to accepted practices in classical Athens, for the open shedding of tears would have contravened social norms. The vulnerability evinced by grief is shielded by the veil, both to protect the pained from a loss of status and to protect witnesses from the painful sight. The veil is the symbol of grief, a sign of pain that serves to conceal it. The artist shows a greater fidelity to the pain scripts of the 5th century BCE than to the epic poem of three centuries earlier, to spare the viewer – the user, the holder – from the spectacle of unconstrained grief. Achilles’ grief had become difficult to handle socially, difficult to read experientially. The veil, then, was the expressive way of saying, without words and without facial expression: ‘I am in [a particular kind of] pain.’

The face is featureless: not a mask, but deletion. The pain is mapped instead on to the sky

In a different milieu, the Norwegian artist Edvard Munch understood the potentiality of wordlessness and of the blank face. The blankness of his own pain(ted) visage demonstrates another sign of ineffable, emotional pain, that is nonetheless expressive and learnable. Fuelled by the Danish philosophy of Søren Kierkegaard’s angst and mired in grief, poverty and suicidal thoughts, Munch was plunged into fortvilelse, a mixture of despair and violent grief.

This painful bearing inspired many of his paintings, including The Scream (1893), but undergirding them was a single experience, which he jotted next to his preparatory sketch for the painting Fortvilelse (Despair, 1892), reproduced here in a translation by the contemporary poet Eirill Falck:

I walked along the road with
two friends –
the sun set
the Sky suddenly blood
– and I felt as a gust of melancholy –
a sucking pain under the heart
I stopped – leaned against
the fence tired as death
over the blue-black fjord and city
laid clouds of blood dripping
{…} smoking blood
{…} My friends walked on and
I stood quivering with an open wound
in my breast … quivering with anxiety
I felt tearing through nature
a great unending shriek

Munch transfigures, in these words, the experience of a physical, humoral pain – his melancholy, his pain under the heart – into the pain of the world, where the sky bleeds and nature screams, not audibly, but sensibly. The inadequacy of Munch’s description of his own pain is marked by his erasure of the lines that attempt to express it. And while all the words would be eliminated entirely in the final painting, the erasure of the personal and physical embodiment of pain is mapped on to the painting. The face of the figure, leaning against the fence, is featureless – not an absence of expression, but simply nothing in the place of a face: not a mask, but deletion. The pain is mapped instead on to the sky. If, for the man, pain was ineffable, one needed only to look up to access it. This profundity of suffering put the pain everywhere. Munch’s language of pain, ultimately, was paint. The concepts required to express it are in evidence. They are situated – melancholy and angst, mixed with the bruised city and the bloody sky – and distinct. To access this pain requires cultural knowledge.

Comparable contemporary pains also require different kinds of knowledge. Think, for example, of the pain knowledge required for the singer Lady Gaga (aka Stefani Germanotta) to express the lasting effects of trauma after she was raped at age 19, and of the pain knowledge we require to read about it and make it intelligible to ourselves. In an extraordinary interview in 2021 for Apple TV+, part of the series The Me You Can’t See on mental health, she described the ‘full-on pain’ she felt, before a numbness that meant she could not ‘feel’ her ‘own body’. The physiological manifestation of emotional pain led doctors to search the interior: ‘I’ve had so many MRIs and scans where they don’t find nothing,’ she said. All of the symptoms, in fact, stemmed from the rape. ‘[Y]our body remembers,’ she said. ‘The way that I feel when I feel pain was how I felt after I was raped.’ This ‘total psychotic break’ lasted ‘a couple [of] years’, where ‘getting triggered’ would bring back the full terror of physical and visceral pain.

Such pains are now increasingly validated, both culturally and medically. They have nothing of nociception – the reduction of pain to sensory perception – and nothing of physical injury, but they are of the body, of the mind, and of the world in which they are situated, in a complex dynamic. Lady Gaga’s words, increasingly common currency in the present – of mental health, of psychotic breaks, of MRIs and triggering – are the right words, the correct cultural script, for the validation of her pain.

Such accounts represent a moment of epistemological and cultural upheaval. Medical scientists in the 19th and 20th centuries had striven to pin down pain – to objectify how it works, how it feels, how to see it, and how to measure it. They attempted to isolate the physical pain caused by injury and disease from disturbances of the mind, in the hope of a mechanical explanation of pain that could be mapped on to the logics of prevailing civilisational assumptions about race, gender, age, class and species. As such, the skin and the face of the adult white male became the benchmark for pain sensitivity. At various historical junctures, women, infants, Jews, African Americans and Indigenous people from various countries were considered insensitive or oversensitive, disproportionately expressive of pain (complainers), or else entirely brutal, like other animals. The insensate correlated, at times in the late 19th and early 20th centuries, with the criminal classes, who might also be identified, according to the prominent research of Cesare Lombroso, by their incapacity to feel pain.

The challenge of pain was not solved by metaphors of electronic engineering

At the core of these attempts to stratify sensation was the implicit assertion that pain was a physical phenomenon, expressive of the relation between peripheral nerves and the brain. Through most of the 20th century, Western medical scientists laboured under the misconception that the experience of pain could be pegged to a scale of intensity. The greater the stimulus, the greater the pain. The more serious the wound, the more serious the pain. It is one of those apparently obvious correlations that have no foundation. The experiences of the war-wounded on a grand scale provided doctors with a wealth of empirical information that inconveniently disconnected damage from pain. Large wounds did not always hurt.

These mysteries pointed researchers to the dynamics of nervous signalling: the traffic was not just in one direction, from the periphery to the centre, but also from the centre to the periphery. How a sensory stimulus feels is mediated by appraisal, and that appraisal is situated in terms of the personal experience of the individual, the degree of attention applied to the wound, to the immediate occasion of the injury (danger, fear, reassurance, safety) and to the cultural repertoire of pain concepts that provide the framework for expression. While in the 1960s these dynamics came to be understood in terms of an innovative model called the gate control theory (responsible for the automatic regulation of the messaging between the brain and the periphery), the challenge of pain was not solved by metaphors of electronic engineering. For, while it went part of the way to explaining the varieties of physical pain experiences, it did not solve the problem that, often, great pain could be found even in the absence of lesion. And then there was chronic pain. Neurological research alone could not provide an answer to pains that endured.

A logical drift towards the unpredictability of pain and a multidisciplinary acknowledgement that experience is mutable ought to have been forthcoming, but the biological universality of pain processes and the objective readability of pain, either from the skin or from the universal pain face, remained attractive propositions. The quest for the universal pain face, based on the flawed notion that the expressive musculature was directly representative of inner experience, had been ongoing since the 17th century, and remains so. From mice to men, researchers have tried to pin down the pain face, but to no avail.

The face of pain is no less situated than any other expression. Sometimes it smiles. Sometimes it frames a scream. Sometimes it grits the teeth. The face, per Munch’s depiction of it, is not by itself a reliable indicator of anything. There was a turn, in the late 1970s, toward a biopsychosocial understanding of pain that aggregated biological function, psychological disposition, and social situation. The experience of pain seemed always to depend on all three. Yet, in practice, the disciplinary logics of academia meant that pain research continued in its separate siloes. Around the same time, a group of prominent pain doctors crafted a formal definition of pain to address a fundamental lack of a consistent taxonomy of pain across the disciplines. They threw a bone to the psycho- and to the social, but essentially preserved the relationship of pain to damage.

That definition from 1979, which was the foundation stone of the International Association for the Study of Pain (IASP), read as follows: ‘[Pain is an] unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.’ The insistence on ‘tissue damage’, which maps neatly on to the concept of nociception at the heart of physiological research on pain, relegated emotional suffering and chronic pain without lesion. The emotional pain experience of humans through the ages seemed lost. It is not that such pain wasn’t a subject of research, but that the formal framing of pain in sensory and traumatic terms (trauma, from the Ancient Greek τρῶμᾰ for ‘wound’) limited the extent to which the biopsychosocial model could succeed.

The inadequacy of that 1979 definition was finally acknowledged in July 2020, when the IASP added a list of revisions and qualifications:

• Pain is always a personal experience that is influenced to varying degrees by biological, psychological, and social factors.
• Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons.
• Through their life experiences, individuals learn the concept of pain.
• A person’s report of an experience as pain should be respected.
• Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological wellbeing.
• Verbal description is only one of several behaviours to express pain; inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain.

No one approach has the tools to crack pain, so to speak

These revisions formally propose a radical transformation not only in the way pain is treated, but in the way it is researched. That it is always personal belies any attempt to objectify; that it is formally separated from nociception means that all forms of pain without lesion – emotional pain, some kinds of chronic pain, social pain – fall under the medical purview; that pain is acknowledged to be a learnt concept raises the question of how it is learnt and who or what frames this conceptual education; that subjective accounts of pain are taken seriously means that medical processes of validation no longer have recourse to diagnostic measuring tools that would deny the patient voice; that pain is not necessarily adaptive (evolutionarily purposeful) means that the social and psychological causes and consequences of pain states can be taken seriously; and, finally, that pain does not have a universal signifier in language opens the door to the recognition of a world of pain expressions that go beyond the word.

All of this – from the perspective of millions of sufferers of chronic pain, emotional pain (grief, loneliness, depression, psychological trauma, and so on) and mysterious pain conditions such as chronic fatigue syndrome – is welcome news. To pain researchers outside both medical science and clinical research, a great challenge and an opportunity emerges. For this meaningful turn to the subjective and to the processes of conceptual learning, coupled with the acknowledgement that pain does not need to have an element of physical damage, marks the encroachment of medical science upon the humanities. It especially resonates with the historian, who explores the vicissitudes of pain experience in different times and places. As a historian of pain, I take seriously the problem that pain is a multidisciplinary affair. No one approach has the tools to crack it, so to speak. But the changing orientation of pain studies within medical science now demands that disciplines such as history be acknowledged as producers of pain knowledge that has a bearing on what medical science understands pain to be and how it should be treated.

Historical pain knowledge is actively useful. A conscious engagement with pain studies prompts a historiographical revision that re-casts the history of painful experience according to the terms in which the IASP has now defined it. If people were in pain when they said they were, suddenly the archives seem to overflow with pain testimony. Medicine may not have always validated such pains, but they can be validated now. To do so emphasises the need to learn situated concepts of pain and to read for expressions that go beyond the word and beyond the expectation of particular faces of pain. For, to whatever extent the IASP accedes that pain is learnt, it remains difficult to see the power dynamics that inhere in the encounter with medicine, whether a patient presents with a broken leg or a broken heart or, indeed, whether the ‘patient’, the literal sufferer, seeks out medicine at all.

Therapeutic processes have their own inertia. Patient and medical authorities each read from invisible cultural scripts how to navigate and negotiate an instance of pain, the experience of which is being mediated precisely by and through those scripts. The politics of diagnosis, the logics of prescription, the cultural fabric that underwrites medical validation and dismissal – all this is typically invisible, or apparently natural, in the encounter of the person in pain with someone else, be they doctor, friend or stranger. By showing, through historical example, the social and cultural dynamics that operate in such encounters, and how the (in)validation of pain is contextualised, patients and medical authorities alike can be better equipped to ask questions of one another: to see and read the politics of pain.