Tag: pain

Eighteenth-Century Pain and the Modern Problem of Measuring Pain

Posted on April 12, 2013 by - Early Modern History, Experimentation, Hans Sloane's Personal Life, History of Medicine, History of Science, Letter-writing, Patients, Remedies

The offending machine. A Saskatchewan example. Image credit: Daryl Mitchell, Wikimedia Commons.

I read the news about the recent study using fMRI to measure physical and emotional pain intensity right after a visit to the physiotherapist for help with my migraines. (I’ve been a migraineur since the age of eleven when a Tilt-a-Whirl ride gave me a case of whiplash.) Although there is not always a close relationship between life events and scholarly work, my migraines have shaped my interest in patients’ illness narratives. It is as both scholar and sufferer that I am troubled by the fMRI study’s implications.

Running through much of the pain scholarship is the assumption that it cannot be adequately represented by language or truly understood by others.[1] Chronic pain’s invisibility makes it difficult even for people close to a sufferer to sympathise. There has been a recent shift to trying to understand pain holistically, with the development of pain clinics where sufferers can receive treatment from a variety of health practitioners and the focus is on mind-body integration. But scientific studies of pain still often come down to one question: can you tell how much pain a patient is experiencing, either in relation to his own pain, or that of others? To this end, many have tried to find ways of measuring pain.[2]

The news is all abuzz, with headlines such as “Study shows pain is all in your head, and you can see it”. Like many previous studies, the latest attempts to provide, as Maggie Fox at NBC News puts it, an “objective way to measure pain”. Researchers applied heat-based pain to volunteers, then measured the changes within the brain using fMRI. They were able to identify a person’s relative pain, such as when one burn feels worse than another, as well as the influence of painkillers. The results of this study have the potential to be very useful when treating patients who are unable to talk or unconscious.

But there is an unsettling aspect to the study—or at least to the way in which it is being reported—in that it tries to distinguish between a real, objective pain and the experienced pain. According to the lead researcher Tor Dessart Wager quoted in the above article, the tests reveal that people really do feel pain differently: “Let’s say I give you a 48-degrees stimulus and you go ‘This is okay; I can handle it’ and I might say ‘Oh, this really hurts’… My brain is going to respond more strongly than yours. We are using this to track what people say they feel.” In other words, some people are wimps and some are stoic—and patients cannot be trusted to report the truth.

An unhelpful distinction at best: it misses out the psycho-social experience of pain of why one person might feel the pain more keenly. Age, ethnicity, status and sex all play an important role not just in a sufferer’s experience of pain, but in how others perceive what the experience should be and the trustworthiness of a sufferer’s account of pain.

It is also a potentially dangerous distinction, reinforcing as it does the idea that pain needs to be measured objectively and that technology provides the answers. The problem, as Daniel Goldberg tweeted yesterday, is that:

A report in Scientific American explains the study’s implications for chronic sufferers. The fMRI was also used to measure coping tactics for the heat-induced pain, such as mindfulness, meditation, imagination or religious belief, revealing that such methods reduce pain. Pssssst… about that: we’ve known this for a while. These sorts of methods were used long before we had effective painkillers and are frequently used by modern chronic illness sufferers.

Will measuring pain ‘objectively’ really benefit the sufferer? The use of technology for chronic pain provides a mere (if very expensive) bandaid and, to make matters worse, undermines one of the most important elements in a successful doctor-patient relationship: trust. Sometimes looking at a historical case can pinpoint the modern problems.

Lady Sondes just before her marriage. Miniature of Lady Katherine Tufton by Peter Cross, 1707. Image Credit: Victoria and Albert Museum, London.

Catherine Watson, Lady Sondes, wrote to Sloane several times between 1722 and 1734 about an unspecified illness.[3] Although she was in her late 30s, she had a litany of complaints that made her feel as “old and decayed” as someone aged fifty or sixty. Her pains ranged from headaches, gnawing leg pains, and “fullness” in her head to a stiff lip, constant fear, memory loss and “rising nerves”. She described the ways her daily life was affected. Besides being constantly distracted by pain, she worried about her legs giving out from under her or losing her memory so she would be unable to do the household accounts. These were problems for a woman who prided herself on running a large household successfully. Her descriptions were circular and repetitive, even boring, but reflected her ongoing experience: the physical pains, often not severe, nagged constantly at her throughout the day, and the fear and anxiety of what the pain might mean was all-encompassing.

Her symptoms did eventually pass, allowing her to once again go “about Busiynesse”, but the treatment had been difficult. Lady Sondes began to consult Sloane by letter when she disagreed with her regular physician’s diagnosis of hysteria. While Dr. Colby considered her ailment to be hysteria, Lady Sondes did not feel that she could trust her full story to him. Hysteria was associated with overly delicate women and a mixture of imagined problems alongside real ones, suggesting that such a diganosis may have predisposed Colby to disregard her accounts of pain. She wrote instead to Sloane who treated her “with great kindness and care”. It was not until Colby rediagnosed her as having a blood condition that she began to trust him again. A large part of Lady Sondes’ healing came from the ability to express her narrative. Sloane was not physically present; the greatest therapy he could have provided was reading her letters and answering her specific, stated concerns.

Chronic pain, with its messy emotional bits and day-to-day dullness, is encompassed within an entire life, not just a few moments spent inside a machine while clutching something uncomfortable. A crucial component of effective therapy is the trust between doctor and patient, allowing the patient to create a narrative, to be heard and to be understood. If a physician is primed to distrust a patient’s account, whether through a diagnosis or reliance on technology, the healing process will be thwarted. Sure we can measure pain, but when it comes to chronic pain, it’s not really the question we should be asking.

[1] This comes from Elaine Scarry’s influential book, The Body in Pain: The Making and Unmaking of the World (Oxford: Oxford University Press, 1985).

[2] For example, the famous McGill Pain Questionnaire. See R. Melzack, “The McGill Pain Questionnaire: Major Properties and Scoring Methods”, Pain 1, 3 (1975): 277-299.

[3] I discuss this case and others from Sloane’s letters in my article, “ ‘An Account of an Unaccountable Distemper’: The Experience of Pain in Early Eighteenth-Century England and France”, Eighteenth-Century Studies 41, 4 (2008): 459-480.

An Old Sick Gentleman and a Family Scandal

Posted on October 22, 2012 by - Conferences, Early Modern History, Family, Patients

I first discovered the Newdigate family when I was a Ph.D. student. Elizabeth Newdigate’s medical letters to Sloane read like a soap opera, filled with heartache and family disapproval. But it wasn’t until several years later that I realised just how dysfunctional the family was.

This week, I’m giving a paper on her father, Sir Richard Newdigate, who wrote a curious pamphlet that gives a fuller picture of the family’s problems: The Case of an Old Gentleman, persecuted by his Own Son (1707). For several years, he had been embroiled in legal difficulties with his children, including financial disputes, an attempt by two of his sons to have him declared a lunatic, and a complaint by four of his daughters in the House of Lords about his “cruel Severities and unreasonable Usage and Practices”. Newdigate hoped to defend his tarnished reputation.

Throughout his account, Newdigate referred to himself as an “Old Sick Gentlemen” – which indeed he was. When the troubles started in 1701, Newdigate was in fine health. He had just undertaken a lengthy tour of France with no ill effects. But his health steadily deteriorated at pace with the arguments, leaving him a broken old man before he died in 1709. Although Newdigate did not mention the physical pains of ageing, he repeatedly identified himself as “old” and used terms of emotional suffering (“persecuted”, “afflicted”, “lacerated”). What seemed to wound him most was the attempt to have him declared a lunatic. This would have removed all his legal authority over his estates and person.

Sir Richard emerges as a sympathetic character in his account, an old man who was being bullied by his children. The story evokes images of King Lear, although Newdigate specifically referred to the Bible (Genesis 9: 18-29): Ham’s shaming of Noah by refusing to cover his father’s nakedness. In pursuing their demands, the Newdigate children had allowed their father to be roughly assaulted by ruffians, chipped away at his paternal authority, accused him falsely, and stopped providing care. Fear and social isolation exacerbate physical pain and cause emotional suffering. Newdigate’s accounts centered on two main anxieties associated with old age: the steady decline of authority and the absence of caring children.

Biographers of Newdigate, such as Eileen Gooder (The Squire of Arbury: Sir Richard Newdigate, Second Baronet and His Family, 1644-1710) roundly condemn Newdigate’s children, providing evidence of what a good father he had been – of course basing their interpretation on Newdigate’s accounts of himself as a poor old man. But the story may not be so simple. Two adult children had also been committed, hinting at a real strain of mental illness in the family. And the suggestions in medical records that the daughters’ darker allegation of “unreasonable Usage and Practices” might have been true. Tracing the truth of the story through the Newdigate family records is part of my ongoing research.

Sir Richard Newdigate’s success in fashioning himself as an elderly victim reveals much about the wider cultural anxieties about aging. The real suffering that came with old age was not mere physical discomfort, but the fear of being abandoned or preyed upon by one’s family. Newdigate drew on these concerns to elicit sympathy from his readers and to re-establish his reputation: who could blame an “Old Sick Gentleman” who had been vulnerable to his demanding children?

 

On Sloane’s assistance to Elizabeth Newdigate, see my article, “Reassessing the Role of the Family: Women’s Medical Care in Eighteenth-Century England”, Social History of Medicine 16, 3 (2003): 327-342.