Chapter 4

Pain and civilization

It has been well documented that, with the demise of Catholic practices of mortification, the moral virtue of pain was replaced, in 18th-century Europe, with the opposite notion that by no means was pain necessary for salvation, or even as an indication of moral virtuosity. On the contrary, pleasure emerged as the principle of the virtuous, with a turning away from pain as a personal and social evil. At the same time, the 18th century saw the dawn of the ‘age of sensibility’, in which heightened practices of civility and urbanity seemed to bring with them a more acute capacity for suffering, both physically and emotionally. As the Utilitarian era dawned, which defined the Good according to an aggregate of pleasure and happiness, it seemed that the most civilized members of society were all the more likely to succumb to the pains of civilization. Here enters the quotidian language of nerves and the nervous, the rise of the modern hysteric, and thereafter the neurasthenic, neuralgic, and shell-shocked. Pain in the modern period became a problem not because there was suddenly more of it, but because it became apparently pointless. No moral end was served by it. In sweeping away the moral purpose of pain, there was a correlative increase in anxiety about coming to be in pain.

Pain politics

Pain has never been entirely the province of the sufferer. Intellectuals, philosophers, doctors, nurses, and legislators have had a disproportionate stake in saying what it is, who has it (and who doesn’t), and what should be done about it. In short, pain has been defined, delimited, and determined by a legion of people not so much in pain as in power. The 18th-century preoccupation with ‘civilization’ was not only defined by cultural, intellectual, and economic markers, but also by sensory and experiential distinctions. Those who self-identified as living within civilization were compelled to try to understand what set them apart as humans. This was a highly gendered, highly racialized, and distinctly classed process of establishing a framework for inclusion and exclusion. Humanness itself seemed to be measurable, with civilized men being the most human, and ‘savages’, working-class people, and also women and children, being among the least. The distance to animality among some configurations of human being was narrowed to a small mark of distinction. For those identified as female ‘savages’ or female children, the distance to a bare animal existence was practically nothing.

A major distinguishing marker of these gradations of humanity was the capacity to feel pain, or degree of sensitivity to pain. The schema of pain sensitivity might seem absurd on first reading, but we live with the legacy of this ordering. The politics of pain still affect the treatment people tend to receive when they complain of pain in clinical settings. In order to make sense of some of the remarkable historical categorizations of pain sensitivity, it is helpful to look at the ways in which this still happens today. A number of studies from across Europe and North America have found, repeatedly, that women report their pain to a greater extent than men. The mode of their reporting is also marked by affective behaviour that is stereotypically ascribed to women: tears, emotionality, etc. Men, on the other hand, are thought to under-report their pain, as part of a perception of the unmanliness of complaint and of pain tolerance or forbearance as a masculine quality. The clinical results of this gendered behaviour, which is not reducible to biological or genetic differences in the vast majority of cases, but which is learned behaviour within certain cultural environments, are significant. The assumption that women over-report is coupled with a tendency to under-treat, under-medicate, and take them less seriously in their expressions of pain. Conversely, men, assumed to under-report, are given more attention and, to a corresponding degree, more narcotics for their pain. A direct causal connection between gendered behaviour (and experience) and variable administration of analgesics is difficult to establish. The relationship is, however, highly correlated.

These gendered behaviours are learned in childhood. Very young infants do not demonstrably differ along sex lines in their manifestations of pain. Despite knowledge that these culturally inscribed differences do affect how pain is experienced—what people report probably does bear on how they feel—the treatment of pain in medical settings has tended to imply that there is a pain reality below the surface and beyond the superficial indications uttered by the patient. This adherence to a sort of ‘pain standard’ endures in practice, even though many studies, such as that by Carly Miller and Sarah Newton on ‘Pain Perception and Expression’, have confirmed that best practice should follow the maxim, ‘Pain is whatever the experiencing person says it is, existing whenever he or she says it does’.

Birth and infant pain

This particular iteration of a ‘pain standard’ is by no means a timeless one. The shifting rhetorical constructions of civilization have set the standard at many different and often wholly contradictory levels. Across the history of modernity, as Joanna Bourke has shown in The Story of Pain (2014), children were assumed to be both less and more sensitive to pain. By far the more damaging in the annals of the history of childhood has been the former, which peaked from the late 19th century and endured until at least the 1980s. All manner of agents, from doctors and surgeons to priests, philosophers, and scientists, claimed that babies—being barely sentient—were wholly or partially insensitive to pain. Injury, surgery, and illness could, therefore, be passed over without due concern. These conclusions were reached through historical understandings of how to gauge painful experience in another. Since reason was so inherently tied to speech, a being that could not speak its pain was assumed not to be able feel pain at all (the same went for animals). Enlightenment thinkers even questioned whether human infants had an immortal soul at birth, or whether this emerged later with the onset of a clearly identifiable sentience. No immortal soul: no pain. Even though such discussions have long since become arcane, the notion that babies don’t have a particularly acute sensitivity to pain endured well into the 20th century. Lack of complete brain or nervous-system development, coupled with concerns about the administration of opiates in babies, led to a general conclusion that it was safer to assume that infants felt no pain. In any case, if they did, it was assumed they would carry no lasting memory of it and be none the worse for it.

While babies certainly do suffer pain, there is no clear way to establish the exact nature of it. Some psychologists who maintain a universalist position have tried to demonstrate the similarity between the pained facial expressions of infants and mice, among other animals. There is widespread evidence, as presented by Martin Schiavenato and others, of a ‘common and universal expression’ of pain that is ‘hardwired and present at birth’. This facial expression, however, may only tell us of the presence of pain and not about its experience. We do not know, because we cannot directly access how the infant feels, what the experience is like. Parents comforting the infant whose ears hurt as an aeroplane ascends or descends know that the experience is painful, but also that the child’s suffering is based on a lack of understanding of what is happening, why, and how to remedy it. As adults, we can only imagine what it would be like not to understand. We stretch our sympathies, but we are ontologically bound by experience. Doubtless, there is significant emotional involvement in the child; but what will later be articulated as ‘fear’, or as ‘anger’, or as ‘anxiety’ remain inarticulate in the infant. What we can say with certainty is that children subjected to pain in early life are likely to suffer long-term consequences, including changes in the central nervous system and changes in the biological stress response in adulthood. In short, infants who undergo painful interventions in the early stages of life are made more susceptible to pain, considered as a holistic experience involving mind, body, and society. It is highly likely, according to Gale Page, an expert on the ‘biobehavioural’ effects of pain experiences in infancy, that pained infants grow into adults who have heightened avoidance behaviour and ‘social hypervigilance’, and whose pain sensitivity is correspondingly higher. Clearly, the inchoate fears of infancy are deeply involved with, and have a lasting effect on, the experience of pain.

If pain in babies has been the source of confusion in the setting of the ‘pain standard’, the means of their arrival has long bewildered doctors. The history of ‘modern’ and ‘civilized’ society is marked by the increase of medical intervention in childbirth. The history of recorded knowledge about childbirth has largely excluded insights from women themselves. Since the institutions of both learning and medicine have been the provinces of men only for most of their history, the best first-hand sources of what it is like to give birth were neglected until remarkably recently. With the drift of Western childbirth away from home and into clinical settings from the late 19th century, so women themselves became alienated from a community of shared experience and colloquial knowledge, heightening fears and anxieties about parturition.

Giving birth has always been laborious, and certainly dangerous, but an increase in fear corresponding to uncertainty can be correlated with a heightened experience of pain. Here the idea of pain as necessarily something unpleasant might mislead us into thinking that the most fundamental act in the continued existence of humans must be, and have always been, terrible. Many women today do not recognize this as an accurate description of what happens to them in childbirth. Doubtless, there has always been pain, and doubtless it was often unpleasant, but a context of community knowledge, reassurance, and experience helped diminish fear and therefore affected the quality of pain. Terror became more acute in part through the disempowerment of women who lost agency and control over birth. Through the 18th century and into the 19th, women’s accounts of their own anticipation of childbirth relate more frequent fears and more complete assignation of responsibility to medical agents.

The gradual re-classification of childbirth from a natural procedure to a medical one was the slow encroachment of the institutions of medicine into women’s autonomy over their own bodies. This was the result of women themselves having become isolated from discourses, cultures, and communities of ‘natural’ birthing. The result has undeniably been a reduction in both infant and mother mortality, but it is questionable whether the 20th-century history of ‘civilized’ childbirth contained either less pain or more pleasure. Birthing options today in many countries have returned a measure of contextual control to women, empowering them with both knowledge and reassurance to limit birth trauma and fear.

Race

Perceptions of racial difference have had an equally marked effect on both the experience and treatment of pain, as pain became the sole province of medicine through the 19th century. Received opinion among 19th-century ‘civilized’ opinion makers was that ‘primitive’ women gave birth without much pain or discomfort, partly because their physical racial differences made them less sensitive, in accord with their ‘natural’, animal-like existence. Civilization itself came bundled with more pain, since it was in part defined by heightened sensitivity and a closeness to emotional upheaval. While a recent attempt by Zatzick and Dimsdale to nail down substantial differences among diverse ‘races’ found no discernible variation in controlled tests, there are nevertheless strong prevailing cultural currents that stratify pain sensitivity and pain threshold according to crude delineations of human types. Just as with the question of age, perceptions of pain sensitivity among various ‘races’ have changed over time. In the natural philosophy of the 18th century, through the birth of anthropology and evolutionary biology in the 19th, African ‘types’, for example, were considered to be basically insensitive to pain. However, a more recent study based at the University of Florida found African Americans to be much more sensitive to pain than people with ‘European’ ancestry. The second half of the 20th century saw a protracted contest among American scholars with different disciplinary and ideological motives to map pain according to racial origins, with Jews in particular being marked out as more sensitive to pain. Basic pain schemes reinforced cultural stereotypes that usually originated among white, male privilege groups. As Kenneth Woodrow and others have shown in research published in Psychosomatic Medicine, formulations such as ‘men tolerate more pain than women’ and ‘Whites tolerate more pain than Orientals, while Blacks occupy an intermediate position’ were commonplace, though they were refuted nearly as often as they were produced. It is striking the extent to which research in this vein still continues, with the primary quest being to discover a genetic explanation for variation in pain sensitivity, even though the analytical category in question is often not race at all, but ethnicity, which is not genetic but cultural. Even when such genetic research has been somewhat sensitive to cultural behaviour and identity, it nevertheless aimed to ascribe different pain signatures to different cultural groups in order to open up the possibility of ethnically tailored clinical pain treatment and management, thereby attempting to transform a cultural product into a fixed biomedical standard. Whether well intended or otherwise, these kinds of studies and opinions can be viewed as part of a politics of pain that has largely been constructed and controlled from within the medical and societal establishments of ‘civilized’ opinion. The history of such opinions about whose pain counts most and whose pain does not even register as pain at all has shown both a marked tendency to change over time as well as a lack of reflexivity concerning the assumptions and privileges that underlie such research. The onus on the pain validity of white, ‘civilized’ people has in many ways followed the changing discursive and material construction of civilization itself.

Urban nerves

The rise of the industrial city, and specifically of electrification, had a profound effect on the perceived nature of pain. Until the 1870s, throughout industrializing Europe, nervous illnesses had been bracketed as humoral imbalances, melancholy episodes, mania, and hysteria (Figure 7). These conditions, whether construed psychologically or, as in the case of hysteria, physiologically, were strongly gendered. They were especially female and, when occurring in men, were thought to be signs of effeminacy or sexual inversion. They tended to be treated outside of the strictly medical definitions of illness or disease. Insofar as these conditions were painful, it was generally understood that this ‘pain’ was not real, but ‘in the mind’, or else driven by a lack of emotional control under the influence of errant wombs and wanton libidinousness. These categories of mental and bodily disturbance went through changes in both nomenclature and gendering in the last quarter of the 19th century and through the first decades of the 20th, accelerated by the explosion of urban populations, mechanical innovations, and, most importantly, war.

7. Hysterical woman yawning, Nouvelle iconographie de la Salpêtrière (1890).

Modernity in civilization could itself be a threat to corporeal wellbeing. Victims of railway accidents who walked away without serious or lasting injuries nevertheless endured lasting manifestations of trauma that could not be definitively ascribed to the effects of physical lesions. ‘Railway spine’ was coined in the 1860s to define this new pathology, which was assumed to be an injury of the nervous system that science at that time could not see, but which must necessarily have existed. The notion of post-traumatic stress has slowly emerged from these roots, but with an important shift in emphasis. ‘Railway spine’ was either a mental aberration or a ‘somatic’ illness, with the latter view held especially by the leader in studies of the condition, John Eric Erichsen (1818–96). Irrespective of the fact that no physical or bodily pathology could be detected, he assumed that the body had been involved in physical forms of motion—the body incorporated into industrial forms of mechanical power—that had adversely affected it. Experts of nervous disorders were on the rise, looking for somatic explanations for emotional pain. There was no shortage of dissent, notably from Jean-Martin Charcot (1825–93) in Paris, but new connections between body, nerves, and psychological trauma were being forged.

If (all too common) railway accidents provided a steady stream of patients, the condition of railway spine was still confined to a mere few. Of more general concern was the mass pathology of a growing bourgeoisie, with refined sensibilities, low tolerances for pain, and a susceptibility for being overwhelmed by the very environment that had produced, sustained, and captivated them. Cities were becoming electrified, lit at night. Stimulation of the senses and of the body was beyond an individual’s control, with an onslaught of attraction and distraction coming twenty-four hours a day. The modern neurasthenic was born, being of a pathological nervous state, unable to cope with the pain induced by the complexities of urban and urbane existence. In the last decades of the 19th century, neurasthenia was typified by a host of ailments, from fatigue to headaches, high blood pressure, and low, brooding depressions. The strong gendering of hysterics as female gave way to a new order of nervous diseases that struck men and women alike. As industrial civilization, without a care for irony, drove its inhabitants into the slaughter of the First World War, nervous illness would increasingly be associated with combat trauma, and therefore men. The pains of civilization were, to those who suffered them, all too real and all too debilitating. But the history of civilization shows how pain was created, moved, invalidated, and validated, all the while shifting its ground and touching different groups. The high stakes of validation depended, to a large extent, on whether or not this pain or that could be entered into. The male hysteric of the 1880s was afforded little sympathy. By the 1920s, the same symptoms had a new pathology, a new set of treatments, and—for a while at least—the compassion of whole populations.