How Does It Hurt, by Stephanie de Montalk

How Does It Hurt, by Stephanie de Montalk (Biography & Memoir)

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‘It was pelvic pain and it started slowly in November 2003, two weeks after a fall. I slipped on the marble bathroom floor of a Warsaw hotel and bounced off the sharp edge of the bath, breaking three ribs on the lower left side. The pain was intermittent at first. It was also familiar. . . .’

In How Does It Hurt?, acclaimed poet and biographer Stephanie de Montalk tells the story of the chronic pain that has invaded her life for more than ten years. She considers how her early experiences have been cast into fresh relief by what she has endured, then goes back in time to investigate the lives and works of three writers who also lived with and wrote about pain: ‘the consolator’, English social theorist Harriet Martineau (1802–1876), ‘the vendor of happiness’, French novelist Alphonse Daudet (1840–1897), and ‘the imago’, Polish poet Aleksander Wat (1900–1967). Through these explorations De Montalk confronts the paradox of writing about suffering: where we can turn when the pain is beyond words?

A unique blend of memoir, imaginative biography and poetry, How Does It Hurt? is a groundbreaking contribution to the understanding of chronic pain, and a spellbinding literary achievement.

From: How Does it Hurt, by Stephanie de Montalk

THE SHIRT OF NESSOS

AN ESSAY ON THE EXPERIENCE OF WRITING ABOUT PAIN

Pain is an unpleasant sensory and emotional experience with actual or potential tissue damage, or described in terms of such damage.

The International Association for the Study of Pain (1979)

We don’t like to talk about pain—are somehow ashamed by it and try to shrug it off. Well, enough with that. Pain is a crucial part of our medical tales. It needs to be articulated, then confronted—even if, sometimes, the pain is beyond words.

Dana Jennings (2009)

We are determined to raise the profile of pain. […] There is a lack of awareness that pain brings side effects and mortality. It reduces life expectancy. To do nothing is not an option.

Professor Richard Langford, President of the British Pain Society (2012)

In 2003, I slipped and fell heavily on a marble bathroom floor in Warsaw, injuring my pelvis. As the acute pain of that accident turned first into the severe chronic pain of an obscure nerve entrapment, and then into the intractable neuropathic pain of nerve damage, I became aware of much awkwardness around, and reluctance to speak plainly about, physical pain—continuing pain, in particular.

Initially, there were commiserations—pain after an accident is expected. The expressions of interest and sympathy were followed by appreciative assumptions that the trauma, having been treated, had healed, leaving an inconsequential degree of discomfort. However, as the pain persisted, the sense of solidarity turned to inklings of disbelief and dismissal. I found myself struggling to describe the pain, and even to speak of it. Increasingly, I felt emotionally isolated—exiled in the realisation that pain’s forestalling of language was limiting understanding, fellow feeling and also, it seemed, compassion. I could admit that I, too, might once have been dubious about the severity of another’s invisible, ongoing pain. Although I had personally experienced a range of acute or temporary pain, and as a former nurse had cared for patients in pain, a state of non-cancer pain, for which strong narcotics were taken daily for years outside hospital settings, had rarely occurred to me. Neither had I registered the disparity between palliative end-of-life relief and control of unbearable pain when life must continue.

I encountered others whose chronic pain—that is, a continuous pain lasting six months or longer—was doubted. I read their anonymous blogs and postings—sufferer to sufferer—on Internet forums. I observed them in pain specialists’ clinics reading magazines and walking to and from the consulting rooms without obvious signs of physical distress. I saw them, uncomplaining, in the wider community, struggling to adopt the roles of supportive partner, attentive parent, sharing friend. And I perceived that, beyond the online listings of symptoms and the advent of storytelling as therapy, despite the prevalence of self-help texts and the growing interest of scholars, the ‘patient voice’ as a source of empathic disclosure—as, wrote nineteenth-century French author and sufferer Alphonse Daudet, a ‘solace and relief […] a mirror and a guide’—remained in relatively short supply.

I wondered again about the reluctance to speak about pain. Was it initiated because for many people, including those afflicted by pain, physical distress, like death, is threatening, beyond understanding?

Emily Dickinson wrote:

Pain has but one Acquaintance

And that is Death—

Each one unto the other

Society enough.

Pain is the Junior Party

By just a second’s right—

Death tenderly assists Him

And then absconds from Sight.

Did the origins of this hesitance to speak about pain also lie in primitive mistrust of weakened ‘tribe’ members; societal expectations of stoicism; the paucity of reflection on bodily torment in literature? Was the linguistic derivation of ‘pain’, from the Ancient Greek poine, meaning ‘penalty’, and the Latin poena, meaning ‘punishment’, relevant? In which case, had a primal part of the public mind remembered that to be in pain was to have incurred suffering sent by the gods for wrongdoing? (I had not forgotten my mother’s response, ‘I wonder what you were doing to deserve that’ when, as a child, I fell ill or had an accident.) How about the riddling nature of pain as unequivocally present for the sufferer, yet a cause for doubt in a bystander for whom another’s pain cannot be shared or confirmed? Or was the evasion principally related to a one-dimensional interpretation of pain based on the long held model of acute pain—a response evident, I noted, even amongst health professionals?

‘The act of verbally expressing pain,’ said Elaine Scarry in The Body in Pain (1985), ‘is a necessary prelude to the collective task of diminishing pain.’

In 2010, I set myself the task of examining the lived reality of chronic physical pain as a PhD in Creative Writing entitled How Does It Hurt?: Narrating Pain. I hoped to bring visibility and a measure of clarity to the condition—to break the cycle of misunderstanding, silence, isolation. In particular, I wanted to confront the paradox of writing about personal pain, notwithstanding physical pain’s resistance to verbal expression; and to determine where the greater challenge lay: in finding descriptors for the ‘raw sensation’ of pain; or in communicating the emotional and mental implications that constitute suffering.

I stalled. Could I round out this complex and intensely personal territory and identify it as the sum of its physical sensations and psycho-social interactions? Could I research and write against continuous pain, lying down? What form should my thesis take?

‘The artist is extremely lucky,’ said John Berryman in a Paris Review interview, ‘who is presented with the worst possible ordeal which will not actually kill him. At that point he’s in business.’

Should I write a novel or a pathography? Would the flexibility of a memoir or personal essay be most appropriate, as pain pushed me this way and that?

Amorphous and abstruse, physical pain flickers at the edges of thought, communication and medical science, defying description and, when extreme, reducing verbal expression to a pre-language of moans and cries. Hidden deep within a network of cells and synapses, it can only be independently verified by a functional MRI (fMRI) of the brain, in which it may be seen as flares of light as it occurs. In an absence of precision treatments capable of targeting its transmission symptoms, it resists complete and enduring relief. When it does desist, it is likely to be recalled less for its sensory actuality than for the psychological response engendered by that actuality. ‘The mind is its own place,’ wrote Milton in Paradise Lost (speaking for Satan), ‘and in itself / Can make a Heaven of Hell, a Hell of heaven.’

The link between mind and body in the pain experience—a relationship surely integral to the understanding and verbal communication of pain—has proved as elusive as the parameters of consciousness. A key to uncovering this connection appears to lie not only in knowledge of the way in which pain-activated neurons, viewable on fMRI, connect with the felt and perceived experience of pain, but also the understanding of ‘the complex nuances of [the neurons’] language’. To date, as New York Times journalist and chronic pain sufferer Melanie Thernstrom pointed out in her work of personal narrative and reportage The Pain Chronicles (2010), all these scans offer is ‘a silent film of a concert’: a performance in which the musicians’ movements are seen, but the components of the music they are playing—the melody, harmony and balance, the contours, tensions and resolutions—are unknowable.

Increasingly, the inexpressibility of pain is seen to hinder medicine’s inability to manage it. In order to render a rounded account of physical pain, it may be necessary to ‘test’ ourselves, in the words of Michel de Montaigne, ‘in the thickest of pain’. Yet, of such testing, Montaigne—born in 1533 and generally viewed as one of the first writers to fully explore pain autobiographically—admitted that although when experiencing pain he remained ‘capable of speaking, thinking, and answering as sanely as at any other time’, he found that his abilities became less steady, ‘being troubled and distracted’. Consequently, and given the inconsistencies of his symptoms and the interruptions of his imagination, Montaigne found himself limited to assessing his pain state ‘only by actual sensation, not by reasoning’.

How can we rationally and analytically communicate physical pain? The challenges of doing so persist, notwithstanding the advances in neurobiological pain research and the inroads scholars have made into the nature and meaning of pain, which demonstrate connections between the anatomical, physiological and psychological vocabularies of pain, and those of history, philosophy and culture. Despite, too, our current public preoccupation with wellness, and, in the thrall of the Internet’s encouragement of confession and storytelling, an unprecedented outpouring of the difficulties and mysteries of being in pain—the latter supplementing, even replacing, the face-to-face assistance of medical professionals, family and friends.

It is particularly striking that, by comparison with the reflections on mental and emotional distress that have played central roles in poetry, nonfiction and drama, literature’s contemplation of physical pain has been marginal. While feelings of isolation, loss, grief and despair are an integral part of severe and chronic physical affliction, non-scientific writers (autobiographers in particular) have focused on the psychological anguish of mental suffering.

As I have found, it is impossible to share fully the sensory and emotional impact of chronic pain with anyone but a fellow sufferer. The difference between acute pain and chronic pain is worth reiterating—for, regardless of significant developments in the science of pain since the mid-1960s, much societal, and even medical, understanding of pain remains based on what it is to be in acute pain.

Acute pain, the purpose of which is protective, is temporary: it warns of harm, attends healing and passes, having run a largely predictable course of hours, days, weeks or even months. It ranges from the mundane to the unbearable: from the discomfort of a sprained ankle to the agony of the rack. It is depicted in literature, dramatised in films, reported in the media. For sufferers who cannot articulate the acute pain of their injury, illness, surgery or childbirth, the failure of language, although perturbing, is transient.

Chronic pain, as we know, serves no obvious beneficial biological function. In The Culture of Pain (1993), David B. Morris characterised chronic pain as a state as different from acute pain as is cancer from the common cold. In The Pain Chronicles, Dr Clifford Woolf, a Harvard professor of neurobiology, described chronic pain as ‘a terrible, abnormal sensory experience, pathological activity in the nervous system’—confirming that chronic pain not only defies pain’s evolutionary warning and protective mechanisms, but also, in outliving its original function, becomes a pathological condition of itself. Unlike acute pain, writes Morris, the wearying constancy of chronic pain, upon both the sufferer and the ‘patience and goodwill’ of friends and carers, ‘constitutes a radical assault on language and on human communication’. This is a complex pain, personally, medically, socially. It wears on long after an injury or disease has been treated or has apparently healed, with no end in sight. It is, therefore, life changing: a debilitating state of elusive diagnosis, failed intervention and irreversible tissue impairment. At its most consuming, it is akin to the pain of terminal disease, without the heroic ‘combative image’ and prospect of final easement. An authority on pain research, James L. Henry, has reported research that shows chronic pain as second only to bipolar disorder as a cause of suicide.

As control over once fatal injuries and medical conditions is asserted, and despite advances in the science of pain and the alleviation of acute pain, the incidence of chronic pain reaches epidemic proportions. Today, advises Canadian education professor and chronic pain sufferer Lous Heshusius, there is a greater number of chronic pain patients than the combined total of those living with diabetes, heart disease, obesity and cancer.

One in six New Zealanders (around 700,000) suffer from varying degrees of chronic pain. In America, 100 million people (one third of the country’s population) live with unrelieved pain; of this number, some 10 million are significantly disabled.

I imagined, as I began to explore chronic pain, that all the untold stories of sufferers were surrounding me, pressing in on me, reinforcing the importance of telling my own story within a broad study of the state of being that is pain and the imaginative framework of literature.

Why, I wondered, given the heightened profile of pain in medical research, scholarship and via the worldwide web, is chronic bodily distress, and in particular the ‘patient voice’, still sparingly mirrored in literature? Is the disparity between the outpourings online and the paucity of personal pain narratives in literary form related to the respective readerships’ understandings of chronic pain? Could it be attributable to the fact that Internet communication can become a spontaneous and heartfelt exchange between anonymous sufferers, in a language ‘ready-made’, while literature requires a writer to distill ‘[t]he dialect of a village high upon inaccessible mountains’ into local, approachable images, rhythms and sounds? William Carlos Williams observed that the greatest challenge to ‘really good writing’ is that of transferring to the imagination ‘those things that lie under the direct scrutiny of the senses’. How then is one to bring the intense sensory scrutiny of persistent bodily pain to a visible and persuasive reality?

Moreover, why does social and even medical misunderstanding of chronic pain remain commonplace? To what extent is sufferer isolation significant? Once chronic pain takes over, not only do all parts of a patient’s life become challenging, but many relinquish their relationships rather than attempt to ‘incorporate them into their altered lives’, as one authority in pain management, Scott M. Fishman, has observed. The lived experience of chronic pain is ‘not well tolerated. It’s naturally uncomfortable for people who aren’t suffering to be in that place.’

When considering the verbalisation of pain, antiquity (as with most things!) is the place to start. In The History of Pain (1993), Roselyne Rey explained that not only do the texts of Ancient Greece, like the Iliad and the Odyssey, ‘make up part of a common Western cultural identity which has continued to the present day,’ they also place ‘much emphasis on pain’.

The ancients were aware of the differences in the communication of acute as opposed to chronic pain. Acute pain was the pain of the epic genre—of heroic battle and wounds and exhaustion. It was described in terms of ‘the extent to which the subject is engrossed in pain, and how he or she perceives it with respect to time and to its origin: long-lasting and fast, sharp or cutting’; importantly, it referenced the causative instrument and its simultaneous definition of the received sensation. Chronic pain, as the pain of the tragic genre, assumed a quality ‘radically different’ from those found in the epics. This is a pain that ‘teaches us not only about pain but also about suffering in the most physical, tangible and blunt way’. Physical distress of this nature was perceived as ‘consuming’, as ‘devouring’, as a ‘being which takes possession of the subject, invades it and takes over’: the sufferer is fed upon by pain, which gradually strengthens as the victim weakens. Only the cry survives. Wrote Rey of such pain, ‘the Greek texts simply say that it is unapproachable, αποτιβατος (apotibatos) and intractable.’

The inability to communicate chronic pain and the isolation that results were addressed by Sophocles in Philoctetes, in the plight of Philoctetes abandoned on the island of Lemnos with a festering—possibly gangrenous—leg. The play is a sustained depiction of the toll of unrelieved pain on the sufferer’s language, emotions and spirit. But, as Sophocles made clear, there is more to Philoctetes’ anguish than the agony of a pain that he describes as ‘beyond words’: there is the additional trauma of suffering in exile. ‘I looked everywhere / but all I found around me was my pain,’ Philoctetes cries. There was no one, the chorus sings, ‘to answer him with sympathy / when he cried out against the plague / that ate his flesh and made him bleed’. Sophocles further suggested, in the scorn and desertion of Philoctetes’ compatriots, that the utterance of pain does not necessarily engender the fellow feeling and compassion that would lessen the sufferer’s isolation.

In the poem ‘Surgical Ward’—an exploration of the collective silence imbued by post-operative pain—W.H. Auden acknowledged the way in which pain diminishes the function of language as a means of personal expression and a carrier of social narrative. Here, in a mood of subdued suffering, hospital patients are exposed to degrees of pain and ‘isolation’ that cannot be imagined by those who inhabit ‘the common world of the uninjured’—where, although happiness and anger and ‘the idea of love’ can be shared, physical pain cannot. ‘They are and suffer; that is all they do,’ Auden told us. They ‘lie apart like epochs from each other’. They are ‘remote as plants’. All the while, the ‘healthy’ cannot recall an everyday ‘scratch’ beyond its healing.

The way in which we use language, suggested immunologist and poet Miroslav Holub in his poem ‘Brief reflection on the word Pain’, is integral to our understanding of pain—a proposition which acknowledges that the word pain, as ‘a pretence of silence’, both expresses and suppresses the existence it describes:

Wittgenstein says: the words ‘It hurts’ have replaced

tears and cries of pain. The word ‘Pain’

does not describe the expression of pain but

replaces it.

Thus it creates a new behaviour pattern

in the case of pain.

The word enters between us and the pain

like a pretence of silence.

It is a silencing. It is a needle

unpicking the stitch

between blood and clay.

The word is the first small step

to freedom

from oneself.

In case others

are present.

The context for Holub’s poem was Ludwig Wittgenstein’s discussion of ‘private language’ in his posthumously published Philosophical Investigations (1953)—in which, having pondered the possibility of communicating the most private parts of our lives, Wittgenstein decided that communication is possible, as long as we can locate the experience in its societal, and therefore shared, dimension.

Imagine a language in which a person could write down or give vocal expression to his inner experiences—his feeling, moods, and the rest—for his private use?—Well, can’t we do so in our ordinary language?—But that is not what I mean. The individual words of this language are to refer to what can only be known to the person speaking: to his immediate private sensations. So another person cannot understand the language.

Wittgenstein asked, ‘How do words refer to sensations?’ answering that ‘verbal expression of pain replaces crying and does not describe it’. He further enquired, ‘In what sense are my sensations private?’ before deciding ‘I know I am in pain’, and concluding this means nothing more than ‘I am in pain’. He finally wondered whether a word or sign associated with a private sensation would have a grammatical structure, and concluded that words privately defined in one’s mind lack the ‘stage setting’ that allows language to make sense, or carry meaning:

When one says, ‘He gave a name to his sensation’ one forgets that a great deal of stage setting in language is presupposed if the mere act of naming is to make sense. And when we speak of someone’s having given a name to pain, what is presupposed is the existence of the grammar of the word pain; it shews the post where the new word is stationed.

Literature as a potential ‘setting’ in which to make sense of and share physical distress was addressed by Virginia Woolf in her 1926 essay ‘On Being Ill’. Pondering the ‘spiritual change’ and potential for self-reflection when health fades, Woolf, herself recovering at the time from an influenza-like malaise, asked why, ‘considering how common illness is […] it has not taken its place with love and battle and jealousy among the prime themes of literature’? She suggested that the reason could lie primarily with literature’s preoccupation with the mind and ideas—with the notion ‘that the body is a sheet of plain glass through which the soul looks straight and clear, and save for one or two passions such as [the physical manifestations of] desire or greed, is null, and negligible and non-existent’. She found that a significant factor in the hindrance of literary description is the ‘poverty of the language’. ‘English,’ she famously said, ‘which can express the thoughts of Hamlet and the tragedy of Lear, has no words for the shiver and the headache.’

It has all grown one way. The merest schoolgirl, when she falls in love, has Shakespeare or Keats to speak her mind for her; but let a sufferer try to describe a pain in his head to a doctor and language at once runs dry. There is nothing ready-made for him.

Perhaps an inability to describe pain is underpinned, she deliberated, by reluctance to tamper with the ‘sacred’ English language—to introduce speech ‘more primitive, more sensual, more obscene’. Maybe the sufferer’s impaired concentration, memory and reasoning is a bar to literary expression. Possibly, the isolating effects of illness are also in some measure responsible: the hesitance of the healthy to engage with the unwell, to add other people’s burdens into their busy working and personal lives; reluctance to consider pain part of the ‘daily drama of the body’; the sufferer’s preference for solitude in an absence of empathy in the ‘army of the upright’? The invalid’s need for fellow feeling can never be met, Woolf decided—in which case, ‘Here we go alone, and like it better so.’

In her seminal 1985 meditation The Body in Pain, Elaine Scarry considered Woolf’s statement about the ‘poverty’ of the language of pain: ‘True of the headache, Woolf’s account is of course more radically true of […] severe and prolonged pain.’ Scarry, whose work arose out of the shift in thinking about pain that started with developments in the science of pain in the mid-1960s—when the perception of pain as a symptom of illness was tempered by the possibility that the symptom was the illness—concluded that pain ‘does not simply resist language but actively destroys it’. This resistance to language, suggested Scarry, is not limited to English: its origins are less in linguistic inflexibility and cultural difference than in the ‘utter rigidity’ that is physical pain’s essential characteristic—a distinction marked by pain’s inability to relate to an external object. Examining pain’s ‘shattering of language’—an attribute ‘essential to what [pain] is’—Scarry decided that bodily pain is an interior state of consciousness that ‘unlike all our other interior states’ lacks a ‘referential content’, or object, ‘in the external world’. In short, she said, ‘we do not simply “have feelings” but have feelings for somebody or something’, meaning that ‘love is love of x, fear is fear of y, ambivalence is ambivalence about z’. Physical pain, however, is ‘not of or for anything. It is precisely because it takes no object that it, more than any other phenomenon, resists objectification in language.’ Besides, proposed Scarry, although pain’s interior abstraction can be linked to visible objects, like, for instance, a scalpel to a scar, it owns no substantive faculties in and of itself by which it can be identified or described. Contrast pain with imagination, she suggested, framing consciousness within these polarities: ‘While pain is a state remarkable for being wholly without objects […] the only evidence that one is imagining is that imaginary objects appear in the mind.’

Not all informed commentators agree with Scarry’s central premise. As Louise Hide, Joanna Burke and Carmen Mangion (the guest editors of 19: Interdisciplinary Studies in the Long Nineteenth Century, 2012) have noted, Scarry’s claim that ‘the experience of pain is unshareable because it is a private, subjective event that “[…] has no referential content” has been vigorously refuted by a growing number of historians and literary scholars.’ While they acknowledged that Scarry’s theory ‘opened a rich new vein of scholarship, which has turned the focus away from pain as an entity in and of itself towards the narratives of “people in pain”’, they were also of the view that ‘[s]uffering bodily pain […] can generate language and creative expression.’

Vincent Crapanzano thus asked in Imaginative Horizons: An Essay in Literary-Philosophical Anthropology (2010), ‘Are there not in fact other “states” that are as “objectless” as physical pain? Does it follow that the “objectlessness” of a state prevents it, nearly prevents it, from being rendered in language? Were this so, we would have to deny the power of figuration. Our whole poetic tradition.’ Interestingly, Hilary Mantel has taken issue with Woolf’s statements about ‘poverty of language’. In her personal narrative ‘Diary’, written following abdominal surgery for intestinal obstruction (the likely legacy of seven years’ endometriosis), Mantel explored a recovery marked by drug-induced hallucinations, exhaustion, the ‘shaking progress to the bathroom’, post-operative complications, including apparent wound dehiscence, and days when ‘the difference between a neutral experience and an experience of slowly building misery’ was as little as a nurse taking ‘a single extra minute to settle a patient comfortably’.

Mantel wrote, of Woolf:

For the sufferer she says, there is ‘nothing ready-made’. Then what of the whole vocabulary of singing aches, of spasm, of strictures and cramps; the gouging pain, the drilling pain, the pricking and pinching, the throbbing, burning, stinging, smarting, flaying? All good words. All old words. No one’s pain is so special that the devil’s dictionary of anguish has not anticipated it. There is even a scale you can use to refine it. […] Pain may pass beyond language, but it doesn’t start beyond it. The torture chamber is where people ‘speak’.

And she questioned Woolf’s credentials for commenting on the language of physical pain, suggesting that, in the ‘shuttered room called melancholia’, ‘Virginia only has decorous illnesses’; that ‘she is seemly; she does not seep, or require a dressing trolley’. (Since the context of Mantel’s essay is the temporary ‘itching, burning of the process of repair’, was she saying that the ready-made words for pain—the words that do not start beyond language, including the sounds of excruciation extracted in the torture chamber—relate to communication of acute pain? And was she implying, in the light of her own history of persistent pelvic pain, that the pain that ‘may pass beyond language’ is more complex chronic pain?)

Ten years earlier, Lucy Bending, too, denied Scarry’s referential assertions. In The Representation of Bodily Pain in Late Nineteenth-Century English Culture (2000), Bending was less concerned with ideas of pain, as she put it, ‘as an ultimate sensation, than with arguments over the meaning and interpretation of pain’. She posited that although language may ‘disintegrate’ in the presence of extreme sensations (say, of torture and war), ordinarily, the reference of pain to, or the association of pain with, other experiences in order to give it meaning, ‘draws suffering into association with something else’. Pain, as a ‘shared cultural phenomenon […] can be incorporated into structures of language and expression’. Bending examined this argument against the ways in which pain was expressed in Victorian literature—when ‘fiction was awash with physical suffering’, and many authors wrote in the belief that enduring physical suffering underpinned human existence. This shared understanding was found in the linking of metaphors and similes with physical sensations and suffering. As an example, Bending cited Dickens’s A Tale of Two Cities, in which the character Jarvis Lorry finds that ‘the coach (in a confused way, like the presence of pain under an opiate) was always with him’. (In Book 1, Jarvis Lorry—travelling on the mail coach along a robbery-prone route towards a mysterious mission, distrustful of his three physically anonymous and vaguely disquieting travelling companions—drifts in and out of a restless sleep.) Addressing the capacity of Victorian writers for describing the reality and alien nature of significant physical suffering, Bending did, however, agree that the language of pain may, in Woolf’s words, ‘run dry’. But she noted also the strong belief that to maintain silence was to conform to the conventions of creation and demonstrate ‘allegiance […] to the suffering Christ’. Further, she observed a tendency, on the part of writers of personal narrative, to withhold frank communication of pain in deference to reader sensibility. She was convinced, in other words, that physical pain can be shared, and that metaphor is a means of referring pain, or the meaning of pain, to external structures in ways that take account of this shared basis of pain. Scarry’s claim that there is no language for pain, Bending concluded, is likely to cause sufferers to feel helpless in the face of their own suffering.

The debate has continued. Arne Johan Vetlesen, Oslo philosophy professor and author of A Philosophy of Pain (2009), considered Scarry to be turning our thinking towards the ‘prejudice of our age’ that has seen the subjectivity or introspection of mental suffering overshadow the objective actuality or fact of physical pain ‘psychologically as well as morally’. Have we forgotten, he asked, that, as Scarry pointed out, ‘Physical pain is able to obliterate psychological pain because it obliterates all psychological content, painful, pleasurable, and neutral?’

David Biro, a New York dermatologist and literary scholar who found himself powerless to express his own physical suffering, is another who supports Scarry’s concept of pain as objectless and therefore unshareable. In The Language of Pain (2010), Biro—whose reflections integrate narratives from real life, and from literary non-fiction and fiction—considered pain’s linguistic elusiveness in terms of its ‘lack of intentionality’ and its ‘inaccessibility as a bodily event’. Pain, he wrote, belongs to that inner part of our existence which consists of such states as thinking, perception, dreaming and feeling ‘connected or directed to objects in a manner essential to our comprehension of them’. However, pain’s absence of connection or linkage to concrete or tangible objects results in a want of the verification they bring to ‘inner experience’. In effect, said Biro, ‘the only thing pain is about is itself’.

Significantly, Biro acknowledged visible physical harm as a potential exception to the concept of pain as objectless, because the wounds or implements of harm ‘are accessible to others’. In this respect, he said, the resultant pain, which is likely to arouse recognition in, or be more difficult to dismiss by onlookers, will be easier for the sufferer to describe. Nonetheless, the pain of an obvious injury, or of a weapon (say, a gun) or visible source, appears to remain ‘more inside us than outside us’; besides, later, when the gun has gone and the tissue damage has healed, the pain may persist—a ‘disconnection’ not found in any other inner experience (a statement which raises questions regarding the comparability of the invisible lingering of pleasure and grief). Biro also found that injuries that can be seen by others function not only in terms of connecting pain to language, but also as precipitating pain language, as in the case of medical consultations and pain scales (such as the Visual Analogue Scale where 1= very mild pain, and 10 = agonising pain).

Biro wrote The Language of Pain in order to promote the development of a ‘rhetoric of pain’—an objective, he believes, that would be assisted by strengthening the links between medicine and literature and encouraging the use of metaphor. Words, if and when they come, ‘almost exclusively take the form of something or someone acting on our body, forming our core metaphor for the experience’. The goal, he admitted, is ‘idealistic’: for while the initiatives he proposed may encourage linguistic communication of pain for some, expression will not always be possible. Biro’s belief that filling pain’s hazy perceptual and conceptual boundaries with the metaphorical language of visible or describable objects is challenged by Susan Sontag, who rejected metaphoric concentration on the negative aspects of physical illness. ‘My point,’ Sontag wrote in Illness as Metaphor (1978) in the wake of the cancer that instigated her ‘enquiry’, ‘that the most truthful way of regarding illness—and the healthiest way of being ill—is the one most purified of, most resistant to, metaphoric thinking.’ (Sontag’s concerns were the epitomes of past and present chronic illness at the time of writing: tuberculosis and cancer—the latter now arguably overtaken by chronic pain.) However, as Anne Hunsaker Hawkins pointed out in Reconstructing Illness: Studies in Pathography (1999), we live amidst images—and ‘[e]ven Sontag realises this, observing in AIDS and Its Metaphors, “Of course, one cannot think without metaphors.”’ More recently, Martha Stoddard Holmes, in her essay ‘After Sontag: Reclaiming Metaphor’, found the use of metaphors to describe illness to be ‘transformative magic’ in terms of their potential to support diagnosis and treatment and alter the attitudes of medical professionals ‘toward embodiments and illness’. After she was diagnosed with cancer, Stoddard Holmes discovered that, influenced by Sontag, she was unable to ‘make metaphors or spin out narratives’—a deficiency, she believes, that may have slowed the medical response. Her ‘metaphor-making’ capacity returned only when, undergoing chemotherapy, she felt a need to speak of the strangeness of her experience.

The isolation and reduced communication that chronic patients experience, and their need for a narrative, have been analysed by a number of medical and academic authors writing for a ‘broad audience’. Amongst those who have written most perceptively and eloquently here are Arthur Kleinman and David B. Morris. ‘Chronicity,’ explained Kleinman in The Illness Narratives: Suffering, Healing and the Human Condition (1988), ‘for many is the dangerous crossing of borders, the interminable waiting to exit and re-enter normal everyday life, the perpetual uncertainty of whether one can return at all.’ Kleinman (who, a small note advises, suffers from chronic asthma) found that this state of affairs, so taxing for the patient, is also difficult for the practitioner, as it is for the relatives and friends who share the land of ‘limbo’, who also experience hurt, bewilderment, anxiety and loss. In this respect, he stressed the need for clinicians to engage in ‘empathetic witnessing’—to encourage patients to talk about their illnesses, because there is alleviation in witnessing and assisting them to make sense of their experience.

David B. Morris, writing in what is possibly his most influential work, The Culture of Pain (1991), advanced the desirability of a bio-cultural, rather than a biomedical, approach to communicating pain. Like Biro, he saw the need to develop a dialogue between medicine and literature, which will spill over into the general population. And, like Kleinman, he has sought to give voice to the neglected testimony of patients. But Morris has gone further, saying that it is also necessary ‘to recover the voices that speak most effectively for patients in the essays, poems, novels, plays, and other genres we call literature’.

The challenges for a writer bringing pain, particularly chronic pain, to the page are manifold. While words may be summoned for the ‘raw sensation’ of acute or temporary pain—whether in plain speech, instinctive or constructed metaphor, or the more extended imaginings of metonymy—conveying personal physical distress that is severe, constant and chronic or terminal, means negotiating the dark ‘heart and soul’ of the pain experience. It also involves making an individually complex pain universally acceptable—a task marked by Virginia Woolf’s observation that ‘[w]e do not know our own souls, let alone the souls of others. Human beings do not go hand in hand the whole stretch of the way.’

The unburdening of cause, ordeal and effect that embodies a writer’s impetus to move beyond straight description of personal suffering in search of rationalisation or meaning was examined by sociologist Arthur W. Frank in The Wounded Storyteller: Body, Illness and Ethics (1995). Frank, for whom Storyteller became a ‘survival kit’ as he attempted to make sense of his own experience of a heart attack followed by testicular cancer, wrote of shifting the negativity inherent in such narratives, including notions of passivity and the ‘ill person as a “victim of” disease and then recipient of care, toward activity’. Frank’s view was that just as the wounded may be taken care of, as narrators empowered by their injuries and through the force of their stories, they may, in turn, take care of others. In doing so, they both awaken the will to be heard and restore the facility for expression that trauma and treatment have lessened. Storytelling of this sort, according to Frank, broadly encompasses (and, arguably, interweaves) three categories of illness narrative: the ‘restitution’ narrative, with its emphasis on cure and the means by which recovery will be achieved; the ‘chaos’ narrative, which is concerned with long or chronic suffering, and an absence of relief and mitigating insights; and the ‘quest’ narrative, in which the transforming power of an illness enables the patient to become someone different’.

But it is not easy to relate and to listen to such stories, no matter how therapeutic watching oneself write and hearing oneself speak. And physical pain, as a ‘tightly interconnected and constantly shifting mesh of the physical, the psychological, and cultural—continually reforming and redefining the person-in-pain’, is, by this definition, likely to be especially resistant to achieving all-important narrative and emotional proximity. This problem of proximity is most readily directed to chronic pain, in which the contradictions between cause and cure and the components of ‘the constantly shifting mesh’ are least understood, and the need to explain is greatest. Theorists may shower pain with meaning, rationalists apply principles of reason and knowledge, behaviourists examine patterns of activity and thinking and writers of literary fiction pursue the readily dramatised interventions of acute pain. But in the first instance, chronic pain memoirists (writing against constant pain, mental fatigue and ‘heavy-duty’ medications) must confront matters of veracity and ‘subjective speculation’ (can non-cancer pain really be that bad?). Such issues touch on the ‘feat of manipulation’ by which, wrote William Zinsser in Inventing the Truth: The Art and Craft of Memoir (1998), a memoirist ‘arrive[s] at a truth that is theirs alone’, and is, in the end, ‘the only truth a writer can work with’. They must also allow for the likelihood that unless the pain is physically overcome, spiritually transcended or released in death, the story will struggle to achieve shape, narrative drive, a definitive end. And they will be aware that unlike acute pain, which, ‘familiar’ and finite, readily evokes a reader’s concern, chronic pain’s faltering reference points and less audible ‘keening and howling’, may elicit a less sympathetic response.

After more than a decade of intense intractable pain, Lous Heshusius, in Inside Chronic Pain, indicated that narrating pain is as much a matter of others’ receptivity to the message as to the form the message takes. She asked: how can one put such pain ‘on paper? Love would be easier.’

Or joy, or pleasure. Things people desire. Then you can evoke that which cannot be said. The reader will gladly fill in the meanings left unsaid by the words. Trying to speak of chronic pain, on the other hand, the unsaid meanings are not easily imagined. For who wants to know what constant pain is like? How to tell of this dark, dark place?

As I have discovered during the writing of this book, chronic pain does not always yield to objective analysis, especially not by a sufferer. My attention, therefore, in what follows, to memoir, personal essay, poetry (to the various forms of what has been described as ‘pathography’), has endorsed my decision to allow the poetic to give to reason ‘its most famous license’, and interpret what has been observed. Because pain has many lines of vision, it may preclude narration in a language that writer and reader can share. With this possibility in mind, I accept that pain can be effectively communicated only between sufferers. I also deduce, given the inability of medical science to determine where the connections between pain and suffering lie, that it is the apprehension of suffering—of the elusive constituents connecting the melody and mood of pain’s ‘silent concert’—that, for me (as for many), is the greater challenge of narrating physical pain.

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