Book Review: ‘Constructing Pain: Historical, Psychological and Critical Perspectives.’

In this book, the view of pain as a ‘deficit of energy’ is dissected and dismissed as inconsistent with physiology. Similarly, pain as the opposite of pleasure is not a convincing hypothesis, as not all pain is displeasing, and disagreeableness is not equivalent to the experience of pain... the systematic dissection of historical concepts of pain is a useful way to challenge our contemporary conceptions of pain and its treatment. This was an insightful read for someone working in a medical field [as I do] as it made me question the way I perceive pain, and how this may be different to the way in which my patients perceive it.

R. Kugelmann, Constructing Pain: Historical, Psychological and Critical Perspectives, London: Routledge, 2017, £34.099 pbk, 158pp, ISBN: 9781138841222

by Lottie Wittingham

In this thorough review, Robert Kugelmann charts how ideas around the polymorphous concept of pain have come about via the influence of academic personalities, and their experiences in the spheres of psychology and medicine. Drawing on the theories of figures such as Benjamin Ward Richardson 1, Henry Rutgers Marshall 2 and well-known philosophers such as Descartes and Bentham, part 1 of the book describes the dualistic concept of pain and the perceived distinction between ‘real’ and imagined pain. Beginning with the development of anaesthesia and the influence of this on the anatomical image of the body as opposed to the ‘felt’ body, the introductory chapter describes the heralding of the abolition of pain, and the consequence of this on people’s opinions on pain and its utility or otherwise. Is pain a useful signal to signify a physical ailment within the body? If so, where does chronic pain fit into this model? It is posited that the pointlessness of chronic pain perhaps accentuates how much it hurts. The ‘medical gaze’ describes pain as an indicator of bodily dysfunction and this challenges the legitimacy of chronic pain which has no ostensible ‘function’.

The theory of pain as a direct sensation felt by specific pain nerves is contrasted with the theory of pain and pleasure as direct antitheses to one another. The view of pain as a ‘deficit of energy’ is dissected and dismissed as inconsistent with physiology. Similarly, pain as the opposite of pleasure is not a convincing hypothesis, as not all pain is displeasing, and disagreeableness is not equivalent to the experience of pain. This section of the book is somewhat hard to follow, but the systematic dissection of historical concepts of pain is a useful way to challenge our contemporary conceptions of pain and its treatment. This was an insightful read for someone working in a medical field, as it made me question the way I perceive pain and how this may be different to the way in which my patients perceive it. However I wouldn’t suggest that the book on the whole was particularly accessible for clinicians, as it is written in sometimes quite technical language, often from psychological research, and hence is not particularly applicable to routine clinical practice. Indeed, it is a shame that the book is not more accessible to those who are not academics in the field, as a broader concept of historical views of pain (such as that of Joanna Bourke 3) could be a useful tool for those involved in the care of patients with chronic pain conditions. Nonetheless, as an academic text for historians and scholars of the human sciences, the text is thorough and comprehensive and it is likely to be much more appropriate for this audience.

Three challenges to the so-called ‘Cartesian dualism’ theory of pain, which distinguishes ‘real’ organic pain and ‘imaginary’ nonorganic pain, are elucidated in Chapter 3. The most persuasive and widely accepted of these is the gate control theory, in which the organic and psychological aspects of pain experience are integrated in the felt sensation of pain. This theory is consistent with the physiological findings of specific nociceptive neurons (i.e. nerves specifically for sensing pain) and also explains the observation that a felt response to a painful stimulus varies according to the situation and to psychological variables. Behavioural and psychosomatic approaches to pain are also put forward as potential challenges to dualism, although these are less convincing and, in fact, the gate control theory is the one currently taught in medical school and so is perhaps more pervasive at least in the medical sphere.

The second part of the book claims to ‘temporarily suspend belief in the anatomical image of the body’ by taking a phenomenological approach, i.e. an attempt to derive general principles and conclusions from the subjective experiences of individuals. While this is interesting as an insight into personal experiences of pain, I was left unconvinced of it as a method to verify the broader claims. Narratives are naturally a good resource to learn about subjective experiences. From an analytical and scientific perspective, the book could benefit from reference to a wider sample of narratives, including those from literature and throughout history: the limited number of samples quoted here is perhaps of restricted value, in the sense of drawing reliable conclusions. That said, the experiences which are quoted and dissected are a valuable addition to the scholarly research which forms the bulk of the book, making these observations personal and pertinent, and adding texture and depth to the discussion. The scope of the book is incredibly wide-ranging and the inclusion of personal narratives puts the whole spectrum of theories mentioned into context.

The second part of the book touches on a wide variety of topics including, but not limited to: chronic pain; pain management programmes; moral pain; and pain as attunement, as a threshold, as punishment or as a sign. Enlightening comments are made about the political and economic elements of the pain experience which are not immediately obvious to an outsider. However, I found the writing sometime nebulous and complex, which was frustrating as it detracted from the insightful points being made. In the final chapter, Kugelmann discusses moral pain, and draws upon a wealth of research to make astute parallels and distinctions between physical pain and moral pain in the form of guilt, melancholia, existential distress and a kind of weltschmerz. Reference is made to ‘feelings that the patient interpreted as the moral pain of guilt’, recalling the unfounded guilt often felt in clinical depression. This chapter may benefit from further reference and comparison to psychiatry, both historical and current – which may also function to make the findings and discussion more applicable to clinical practice.

The parts of the book which fascinated me most were the attempts to extract what our concepts of pain are, and the discussion of how our experience of them may say something about human nature. Pain itself is an incredibly slippery concept to attempt to define, and the account of our attempts to do so throughout history is revealing. The book considerably deepens understanding of the concept of pain and all its vagaries.

Lottie Whittingham is a final year medical student at Imperial College London with a degree in Neuroscience and Mental Health. She is an aspiring medical historian and her research is primarily in the history of psychiatry and gender. She blogs at https://medicalmuseumblog.wordpress.com/

Notes:

  1. Richardson, B.W., 1897, Vita Medica: Chapters of medical life and work, New York: Longman, Green & Sons
  2. Marshall, H.M., 1889, ‘The classification of pleasure and pain,’ Mind, 14, 511-536
  3. Bourke, J., 2014, The Story of Pain: From Prayer to Painkillers, Oxford: OUP