Where Does It Hurt?

For the sixteenth-century barber-surgeon Ambroise Paré, pain was a deadly liar. When French soldiers returned from battle with shattered limbs on which wounded tissue had already died, Paré warned fellow surgeons not to take a patient’s word for it in deciding where to amputate: “For I know very many deceived as thus: the patients pricked on that part would say, they felt much paine there.” Taking the report of pain as a sign that the tissue was still viable, a well-meaning surgeon might spare it and amputate farther down the limb, leaving a necrotic zone behind that would soon result in sepsis and death.

Paré provided the first robust account of phantom-limb sensations, the faux sentiments that made the brain think that an attached but dead limb—or even a long-absent amputated one—was still experiencing movement, temperature, pain, and other phenomena. He speculated that the cause might be the patient’s imagination, or perhaps that the severed nerve endings “retire” back toward the brain, taking their store of sensation with them in retreat.

René Descartes, born a few years after Paré’s death, developed aspects of his mind-body dualism from his own experiences on the battlefields of the Thirty Years’ War. Discarding Paré’s hunch that the peripheral nervous system might be involved—“I recognize no sensation save that which takes place in the brain,” Descartes wrote—he nonetheless saw that the peculiar experiences of amputees could tell us much about more common physical suffering.

Where is our pain, exactly? And what is it? The personal histories of Haider Warraich, Abdul-Ghaaliq Lalkhen, and Leigh Cowart, the authors of three new books on the subject, suggest that they have privileged insights: Warraich is a physician with chronic back pain, Lalkhen is an anesthesiologist who specializes in treating patients with both acute and chronic pain, and Cowart is a self-identified masochist who has experienced both unintended physical traumas and a dizzying number of intentional episodes of acute pain. Each of their books does a fine job of summarizing our current understanding of the human nervous system, the known variables that appear to affect the brain’s response to pain, and intriguing new directions in clinical research that may bring more useful therapeutics.

In The Song of Our Scars Warraich describes how he suffered a back injury as a young man doing bench presses: “a loud click,” then “agony.” En route from the gym to the emergency room he is hypersensitized, feeling “every small bump, even the fine clefts between pavement panels.” We come closer, perhaps, to the character of his experience when he describes the pain, having become chronic, as “an infestation.” But much of his use of the first person simply reinforces the expected: that his pain is less intense when he is happy, distracted, or feeling loved; that it is worse when he is depressed, anxious, or bored.

Cowart (who uses they/them pronouns) opens Hurts So Good, their investigation of the many subcultures of “pain on purpose,” by describing a BDSM encounter with a new partner. Thick rubber bands on Cowart’s arms make them see “orange and white in the backs of my eyelids,” bringing a kind of cognitive clarity, “like if you could inflate a balloon inside my skull and make it fill the whole area.” There is sweat, vibrators, zip ties, and more rubber, but beneath the array of props we just learn that “everything hurts” and that at the end of the ordeal, “I felt bad, and then better.”

In An Anatomy of Pain Lalkhen describes what a pregnant woman in labor is like before he administers an epidural: “An individual who would normally present a reasonable and calm image to the world but who is now reduced to a feral and illogical specter.” (The phrase “feral and illogical” may say more about the language problem with pain than it does about the woman.) Elsewhere, he writes of an encounter with a patient with fibromyalgia: “I have never met a lonelier person than someone suffering with pain.” Perhaps this yawning gap—between someone who’s in pain and someone who isn’t—speaks to the perplexing nature of pain more than any inventory of zip ties or physicians’ case histories.

In everyday language and experience, we might say that the most ordinary instance of pain arises when tissue is injured and we feel a concomitant noxious sensation—the feeling that arises when a hand touches flame, for example. But many people also experience unpleasant physical sensations, such as headaches or gut cramps, that we sense correlate with a psychological injury—the exposure of something shameful about ourselves, perhaps, or the death of someone we love.

Moreover, there is the sort of pain, as “real” as a scraped knee but unlocalizable, that can accompany a tormenting psychological malady, like William Styron’s particular experience of depression as the “diabolical discomfort of being imprisoned in a fiercely overheated room.” And finally, there is suffering that locates its cause in an injurious physical event but is experienced in ways that might surprise the sufferer and their clinicians—headaches, stomach cramps, and intense emotional distress, perhaps, after surviving a severe burn.

Ordinary usage might ascribe “pain” to all four of these examples of suffering. Pain from an injury to the body, however, is what we usually mean and is what the rest of our commonsense understanding flows from. Today one of the predominant models in scientific circles is the psychologist Ronald Melzack’s “neuromatrix of pain.” Coined in the 1990s, the term implies that pain arises from a complex array of neural inputs, in relation to one’s genetics as well as environmentally provoked developments in the brain and nervous system. Some of the inputs that feed this matrix come from nociceptors (peripheral nerve endings detecting painful stimuli), but there are many other inputs relating to stress, inflammation, memory, and mood. The neuromatrix is mutable, or in biological terms “plastic,” and the characteristic “neurosignature” for one’s headache or back pain is both uniquely one’s own and forever a work in progress.¹

It would be nonsensical, both in everyday speech and in contemporary neuroscientific terms, to say that someone is in pain but not aware of it. Someone who does not yet experience suffering from a shark bite because they are distracted by the effort to survive is not in pain yet, though a great deal of nociception may be happening in the nervous system. By the same token, it would be nonsensical to say that someone was mistaken about having pain: they may be mistaken as to its cause, its location, or its remedy; or the importance they ascribe to their pain may be annoying or socially inappropriate; or they may of course be willfully lying. But it is not possible to believe oneself to be in pain and to be wrong.

Paré and Descartes were both right that pain is not “in” a festering gunshot wound, nor is it wholly bluster or linguistic sloppiness when contemporary speakers say that it “pains” them to witness or think about something horrible. The International Association for the Study of Pain (IASP), an influential organization of researchers and clinicians, currently uses the following definition of pain, last revised in 2020: “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”

Critics of Melzack’s neuromatrix model and of the IASP definition note that the concept of pain is perhaps getting too broad to be useful. Just as the elastic waistband is wearing out on pain-related terms like “trauma” and “violence,” so that they now have room for almost everything but may also no longer stand up to cursory inspection, so too does pain’s language problem become a practical one, in which some conceptual clarity might help both sufferers and clinicians.

For starters, let’s take “acute” and “chronic” pain. While nonclinicians often think that “acute” means something like “severe” or “urgent,” clinicians mainly use the term to talk about time scales. Acute conditions, medical students are taught, last hours to weeks; subacute ones weeks to months; chronic ones months to years. These distinctions are helpful because the diagnostic possibilities suggested by a few days of cough as opposed to a few years of cough, or a week’s fever compared with several months of recurrent fever, are distinct. Testing everyone in urgent care for, say, tuberculosis or a blocked artery just isn’t practical. Tests are expensive and resource-intensive, and some can be painful or even harmful. “Tincture of time” sorts out a great many medical mysteries without overtaxing the clinician or putting patients through dubious ordeals.

Our symptoms do not read textbooks, unfortunately: medicine’s linguistic conventions serve as doctors’ shortcuts rather than marking firm borders. While the terms acute and chronic pain may be useful in generating a differential diagnosis—a list of things that a patient’s pain could signify—a growing body of scientific literature suggests that they are not just long and short versions of the same fundamental experience. Saying that chronic pain is the long-haul version of acute pain may be like saying that an elephant is a dog that lives an unusually long time and doesn’t eat meat.

For one thing, the peripheral nerves of people experiencing chronic and intractable pain undergo unique developments not associated with acute pain at all. One is an electrical change called long-term hyperexcitability. When hyperexcitable nerves experience small fluctuations in chemical charges across their cell membranes, this sets off a repetitive and disproportionate sequence of electrical “firings,” whereas a typical cell would only permit one firing and then enforce an electrical pause. Imagine that you impatiently hit the elevator button for your desired floor seven or eight times, thinking it’ll bring you to your destination faster. A normal elevator “understands” that you just want to go to the twentieth floor once. An aberrant, chronic-pain-like elevator takes you at your word and makes eight sequential trips to the twentieth floor, to the consternation of everyone else in the building.

Even more important, the brain experiencing chronic pain acts quite differently than it does during acute pain. Acute and chronic back pain, for example, appear to have such different neuromatrices that conceiving of them as two subtypes under the common heading “back pain” might lead to more confusion than clarity.

An estimated one in five Americans has chronic pain, and a third of those have pain that has “frequently limited life or work activities” in the previous three months. A typical therapeutic regimen may include medications that act on the cascade of cellular responses causing inflammation, that inhibit overexcitable nerve signaling, or that dampen or amplify pain signals in neurotransmitters, not to mention potential “hardware” fixes like implanted neurostimulators, as well as treatments concerning sleep, exercise, diet, and mindfulness practices.

Many of those with chronic pain—including several patients and friends of mine—feel offended or misunderstood when their clinicians suggest therapeutic approaches that might include medications such as serotonin-norepinephrine reuptake inhibitors (SNRIs) or tricyclic antidepressants (TCAs), which fall colloquially under the larger heading of “antidepressants.” Because of this categorization, people can take such advice as implying that their pain isn’t real.

In fact there are nerves and neurotransmitters throughout the body—how else does the brain receive news of what’s happening beyond its bony case?—and it is unsurprising that drugs initially prescribed for psychological distress should also show some effect (albeit limited and as yet inadequately investigated) on certain kinds of chronic pain.² Duloxetine, for example, an SNRI, is approved by the FDA for treatment of the pain associated with chronic conditions as seemingly diverse as osteoarthritis, diabetic neuropathy, and fibromyalgia.

The pain-relieving efficacy of drugs that may alter the availability of serotonin and norepinephrine—substances not thought to be central to the way peripheral nerves sense painful stimuli—aligns with the neuromatrix model of chronic pain. The distinct neurosignatures of chronic pain may in fact have less to do with real-time nociception (data coming in from peripheral nerve endings that some tissues are too hot, too cold, too inflamed, etc.) than with the deeply patterned ways our brain processes emotion, memory, and behavior.

In An Anatomy of Pain, Lalkhen worries that discussing this overlap in the brain’s responses to pain and to other forms of distress “may be reinforcing [patients’] fear that we consider the pain to be ‘all in their head.’” I, too, have often been troubled by the indignation expressed by patients in pain at what they take to be their doctor’s implication—when antidepressants or forms of talk therapy are offered, for example—that they have an illness pertaining to the psyche. Would having a troubled mind really be so shameful, so unassimilable? The extent to which “believing patients” with chronic pain has come to mean, in certain patient-advocacy groups, believing that such patients do not experience any significant mental distress indicates, I think, the depth of the ongoing social stigma around disorders of the mind and brain.

For better or worse, the placebo effect is deeply involved in all these therapies. This is mainly good news: it means that the benefit we can derive from a therapy is greater than the sum of its constituent molecules. It is an important part of the success not only of therapies outside of Western medicine’s traditional ambit (acupuncture, for example), but also of those squarely within it. Even opioids have effects that include both placebo and “nocebo” (harmful because of patient beliefs and expectations). One study of the drug remifentanil, an opioid related to the better-known fentanyl, found that making participants aware of its administration doubled its analgesic effect compared with administering it in the absence of prior cues, whereas falsely telling participants that the infusion of the drug had stopped frequently negated its pain-relieving effects.³

The downside of placebo effects is that until we quantify how substantial they are, we do not know to what extent we are needlessly enriching pharmaceutical companies and exposing people to non-negligible pharmacological risks (including withdrawal) and the possibility of organ damage (for example, from a misuse of acetaminophen).

Measuring how much pain someone is in, or how much relief they experience, turns out to be a difficult business. As has by now been thoroughly documented, Purdue Pharma, maker most famously of OxyContin, worked assiduously to ensure that safety and efficacy trials of their opioids would take place in clinical settings already influenced to look favorably on them. Purdue and other pharmaceutical companies pushed for an array of practice changes that made the assessment and treatment of pain more central, more mandatory, and more numerically focused than it had ever been before.

Many disparate kinds of pain have tended under this numerical regime to be lumped into the 0–10 rating system or a similarly one-dimensional scale. The problems with this are manifold. The numbers themselves, of course, have at best some intrapersonal validity (my sense of what intensity of pain merits a 4 might be stable over time) but no interpersonal validity (two people struck in the same place by baseballs thrown at the same speed might rate the pain quite differently). Particularly in a hospital setting, patients quickly come to understand that when they are asked to rate their pain, they are really being asked whether they want more medication, and perhaps what kind they would like. This reflects the way many doctors still write orders for analgesics in the hospital; e.g., to give acetaminophen for a pain score of 1–3, five milligrams of oxycodone for 4–6, and ten milligrams of oxycodone for 7–10.

Most important, the overall flattening effect of these tools habituates patients and providers alike to an oversimplification of everything we ought to know or be curious about when it comes to pain. What Warraich says in The Song of Our Scars about early-twenty-first-century medicine’s explosion in opioid use holds true of the hegemony of the pain score: it has “erased whatever little we knew about the nature of suffering,” and by stripping out the nuances of pain studies, it also “exaggerate[s] the biases that lead to vulnerable people’s agony going unattended.”

Pain is regarded differently depending on who’s feeling it. Elaine Scarry writes in The Body in Pain (1985) that “to hear that another person has pain is to have doubt.” The degree of our doubt is socially constructed. In the United States and Europe in the nineteenth century, with the ruling political and economic order largely dependent on slavery, the labor and property of colonized peoples, or both, it was highly convenient to believe that “uncivilized” 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 degeneracy 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 operating 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 understanding 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 disgraceful, and they were. But they were not a bolt from the blue. Many other studies demonstrate lower appreciation 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 appendicitis were less likely to receive opioid medication (an appropriate therapy for the excruciating abdominal pain that can accompany this condition) 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 activities 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 describes another small study that delivered 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 average, Black subjects rated their pain as more intense than other subjects did, a finding that correlated with more intense activity in parts of the brain associated 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, Hispanic 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 romantic partner. “The touch of a loved one,” Warraich concludes, is “a potent painkiller,” one that he links to “the so-called love hormone itself, oxytocin,” which activates “one of the body’s most potent shields against suffering.”

In Hurts So Good, Leigh Cowart discusses the hypothesis that “behavioral synchrony,” movement with others, “acts as a binding agent, a love spell of sorts,” which can activate our “homebrew morphine” (the body’s endogenous opioids) and “the weed version,” the body’s endogenous cannabinoids. Rowers and runners, for example, appear in some studies to have higher tolerance for pain when they work out with 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 disparaged 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 couples 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 perception, a growing number of animal studies show that female animals exhibit more signs of distress and aversion 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 electrocuting 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 labels we are socialized to find more salient) report differently about the same experience.

The philosopher Daniel Dennett famously called the two poles of animal brain-and-behavior studies the “romantics” and the “killjoys,” the former more likely to make much of animal–human corollaries and the latter 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 extrapolation. 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 problems. 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 commensurate with another’s can affect how much we might feel we owe one another emotionally, socially, and politically. For health care workers, the relative ineffability 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 textured account of pain. The McGill Pain Questionnaire, for example, asks respondents 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 stationed”—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 experiencing or witnessing pain, though, I understand the force of that intuition Wittgenstein goes to lengths to disprove: 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 provides 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 staple 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 reality of torture sufficiently to inspire action, 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 scientific accounts ever could. The hero’s dying aria in an undergraduate production 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 genitals. The gangrenous club-foot bursting from its corrective box in Madame Bovary. The postoperative 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 cannot 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, anyone who has sought to articulate this protean stinging, ripping, gnawing, aching, chafing thing that, for convenience or out of frustrated resignation, we call “pain.”