SOME PHILOSOPHICAL CONSIDERATIONS ON PAIN* J. J. D E G E N A A R * D .P hil. (Stellenbosch) |UNE 1979 P H Y S I O T H E R A P Y / have p u t on these m asks to show you m y face M aurice English I N T R O D U C T I O N 1 thought I knew w h at pain w as u n til I w as asked to say w h at the w ord “p a in ” m eans. T hen, as is usual •n such cases, I realised my ignorance. H ow ever, I Ho not th in k this is an isolated experience o r an experience peculiar to philosophers. I t is a com m on experience, it applies to m any everyday w ords and no oerson who tries to define such w ords escapes the sobering effect o f th is basic hu m an ignorance. T he noint o f these rem arks is n o t to apologise in advance |>r the q uality o f this p a p e r, bu t to draw o u r a tten tio n {b the difficulty o f defining everyday w ords in spite of the fact th a t th e experiences referred to by such w ords are very m uch p a rt of o u r lives. A nd, as in the case of the feeling o f p ain , it can be very crucial to o u r lives. In the w ords o f P etrie (1967 : 1): “T h ere is n o th in g in hu m an experience m o re central th an o u r capacity to feel, an d no aspect o f this so crucial as our capacity to suffer, perhaps m ore p articu larly to suffer from extrem es o f physical p a in .” A nd even if one would like to add o th er capacities equally central to human experience these additions w ould n o t, I think, detract from the d isru p tin g n a tu re o f suffering in the lives o f men. In concerning oneself philosophically w ith the concept of pain, th ere are different ways o f a p p ro ach in g the problem. O ne can, f o r exam ple, tak e account o f the various theories of p a in , w h eth er neurological, psycho­ logical or philosophical, and on the basis o f this research construct o n e ’s own theory; o r one can con­ struct a m odel w hich illum inates th e experience of p ain as well as the v ario u s theories o f p ain ; o r show th a t more basic th a n these theories o f p ain is a p h ilo so ­ phical anthropology, a view of m an, assum ed b y these theories; o r explore th e problem of p ain in term s of the body-m ind relatio n sh ip , th a t is, in term s of dicho­ tomy, interaction o r id en tity betw een bod y and m ind; a look a t th e discussion o f p a in in analytical circles fi which problem s related to the privacy of sensations and the know ledge o f o th er m inds are b ro u g h t to the fore; o r discuss the ex istentialist ap p ro ach to p ain in terms of suffering as an exDression o f th e hum an condition; o r explore th e m eaning o f the term etym olo- gically, pain being derived from p oena (L atin) which means punishm ent; or assess the m oral app ro ach to pain as a necessary co n d itio n fo r the grow th o f person­ ality; o r look a t the problem s related to a theodicy, for example, th e logical links betw een concepts such as pain, evil and sin, and the justification o f a good God w ith regard to an evil creation; o r com pare the different ways in w hich the religions o f the w orld have treated th e problem s of pain and suffering. I m ention these various ways of ap p ro ach in g the problem of pain n o t to create the im pression th a t I am capable of follow ing them all, b u t to draw y o u r atten ­ tion to w h at can b e included u n d er th e head in g of Philosophical considerations on pain. M y m odest task Head D en artm en t o f P olitical P hilosophy, U niversity of Stellenbosch. Paper read a t P ain Sym posium , preceding 13th N ational C ouncil M eeting 2 3 - 2 7 A p ril 1979. in this p a p e r is to look a t som e descriptions of p ain and to construct a m odel w hich w ill, I h o p e, throw some light on the experience o f pain. In o rd e r to achieve this, I m ust first p a y a tten tio n to the problem o f m ethod and to th e fact th a t a p lu ra lity o f descrip­ tions o f p ain is possible. T his analysis will th en be follow ed by a discussion o f th e neurological, psycho­ logical and philosophical language-gam es, illustrating in each case th e n atu re and value o f these games in presenting us w ith descriptions o f pain. In conclusion I propose looking at som e im plications o f th is m ore com prehensive view fo r o u r ap p ro ach to th e problem o f p ain in respect of th eo ry and practice. P L U R A L I T Y O F D E S C R IP T IO N S One o f th e first things th at strikes one in o n e’s research o n pain is th e fact th a t different groups o f people talk ab o u t p ain in different term s and in different contexts. N eurologists speak in term s o f nerve im pulses, psychologists in term s o f em o tio n al qualities, philosophers in term s o f sensations, feeling, suffering and m eaning, and theologians in term s o f g u ilt and punishm ent. I t w ould be a m istake fo r one o f these groups to th in k th a t th e ir use o f th e w ord in th e ir chosen context, th e ir language-gam e, is the o n ly valid one. T his illustrates an im p o rtan t p hilosophical point, nam ely, th a t w ords are n o t only used to refer to things in a one-to-one correspondence, but th a t people operate m u ltifario u sly w ith w ords an d th at o n e m ust take into account th e different contexts in w hich w ords behave according to contextual rules. T his is w h at is m ean t by the language-gam e in w hich a w ord operates. T his contextualisation o f statem ents in o rd er to gauge the m eaning o f w ords is not an im poverishm ent o f u n d er­ standing. O n th e contrary, it is an enriching activ ity as I w ould lik e to show in m y analysis of the concept of p ain . F o r th e m ore one can accom m odate valid descrip­ tions of p ain , th e b etter o n e’s understanding o f th e concept. T h is p o in t a b o u t the pluralism o f descriptions is also m ade by Sternbach (1970). H e states th a t w e becom e prisoners o f the w ords we use to describe p a in w ith the result th a t we are “u n ab le to fre e ourselves fro m th e w ords to come u p w ith a fresh d escription . H e points o u t th a t one’s choice of a definition depends o n one s profession, and nientions th e follow ing n in e descrip­ tions: p ain is art elem entary sensation, a com plex perception, an affect (em otion), a neurophysiologic^l activity, a neurochem ical stress reaction, reflex ad ap ­ tive behaviour, the resu lt o f internal psychic conflicts, in terpersonal m an ip u latio n , and th e hu m an condition. M elzack (1973) is also struck by th e v a rie ty o f pheno­ m ena w hich one has to take into account in u n d er­ standing th e m eaning o f th e w ord “ p ain ’. A ccording to h im : “th e w ord ‘p a in ’ represents a category o f experiences, signifying a m u ltitu d e o f different^ unique events having different causes, an d characterised by different qualities varying along a n u m b er of sensory and affective dim ensions.” Instead o f saying th a t the w ord “p a in ” represents a category o f experiences or th a t it is a “ linguistic label fo r a rich v ariety of ex­ periences an d responses” (M elzack and W all, 1968). Sternbach prefers to say th a t p ain is an ab stract term w hich refers to m any different phenom ena fro m w hich one m akes a selection, depending o n w hether one is, fo r exam ple, giving a neurological, physiological, be­ h av io u ral, subjective o r p sychiatric description. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 30 F I S I O T E R A P I E JUNIE 1979 S te m b a c h ’s ap p ro ach is p h ilosophically im p o rtan t because h e concerns him self w ith a basic epistem ological problem , th a t is, a p ro b lem related to the th eo ry of know ledge. T h e expression “linguistic parallelism ” is in tro d u ced b y h im to describe this ap p ro ach w hich allow s o n e w o rd to be used to re fer to different p h en o ­ m ena. A ccording to this view “none o f these events has any in h eren t relatio n sh ip to o n e an o th er. I t is we who have a rb itra rily im p o sed on all o f them the com m on concept ‘p a in ’. I f we can rem em ber th a t there is no single real thing th a t is pain, b u t ra th e r th at ‘p a in ’ is an abstract, un ify in g concept th a t we o u r­ selves h av e a rb itra rily im posed on a g reat m any different kinds o f things, then p erh ap s we can free ourselves to th in k and deal m ore effectively w ith problem s w hen they arrive. T h ere need n o t be any argum ents a b o u t w hich is the ‘rig h t’ approach, because all these parallel approaches a re ‘rig h t’. T h a t is, each describes som e different things in different ways, and each ap p ro ach is internally consistent and follow s the 19TO) ° Wn ®am e >nvest>8a t ' o n ' ” (Stem bach, O n th e basis o f this ap proach he constructs a useful schem a w hich illustrates the varieties o f tactics fo r treatin g ch ro n ic pain. I t gives one at the sam e tim e a good idea o f th e Variety o f phenom ena covered b y the concept o f pain. T h e schem a (Sternbach, 1970) is as follows. surgery neurological physiological b eh av io u ral subjective p sychiatric analgesia increased sensory in p u t tranquillizers m uscle relaxants anti-depressants, aversive conditioning cognitive dissonance desensitization hypnosis religion existentialism dynam ic o p eran t fam ily (“gam es”) Common concepts: In p u t: reducing “ p ain-like” stim uli O u tp u t: enhancing incom patible responses P rin cip le: breaking associative links betw een old stim u li and p ain responses. T h e schem a is v alu ab le in th a t it n o t only illustrates th e v ariety o f phenom ena covered b y th e concept of pain b u t also highlights the com m on p rin cip le basic to the v ario u s tactics fo r treatin g ch ro n ic pain. T h is is the com m on p rin cip le of dissociating stim uli and re­ sponses. Im p lied b y this p rin cip le is th e idea th a t pain is th a t association o f stim uli w ith responses w hich results in an u n p leasan t experience w hich h u rts a person a n d fro m w hich he w ants to b e freed. In his essay S tem bach does not use th is definition o f pain, nam ely th a t it is an unpleasant experience w hich h urts a person, b u t I find it necessary to introduce this com m on d escrip tio n to throw light on w hat the five types o f scientists m ean w hen th ey use the term “p a in ” in th e ir different areas o f research. T h is defini­ tio n allows fo r th e v ariety o f p a in phenom ena m en­ tioned b y Sternbach, b u t a t the sam e tim e it m akes th e p o in t th a t in each o f these approaches there is a concern w ith pain. T h is concern, w ith p ain is show n b y the neurologist, fo r exam ple, w ho severs a nerve to block a n im pulse o n the- assum ption th a t thereby h e is treatin g a person fo r a n -u n p le a s a n t’ experience w hich hurts. I differ fro m S ternbach in th a t I w an t to start from everyday experience in w hich th e experience of pain is a reality to w hich a v ariety o f descriptions can be applied. I hold th erefo re th a t th e w ord “p a in ’ is noi o n ly a n ab stract concept ap plicable to a v ariety 0f p henom ena, b u t th at the v ariety o f phenom ena is itself the result of a v ariety of approaches to a reality called p a in as it is pre-scientifically experienced. By means o f these approaches the reality of p a in is objectified into a v ariety o f phenom ena each w ith its ow n status and structure. T hanks to th e v ariety o f approaches to w hich a v ariety o f phenom ena corresponds the rich tex tu re o f the reality o f p a in can be expressed. Each ap p ro ach has its own rules, and statem ents can be judged to b e rig h t o r w rong according to these rules and in term s o f the consistency o f th e ir application. E ach form s a language-gam e o f its ow n, b u t no m ethod should claim to be th e only language-gam e, the only ap p ro ach , the only strategy, possible in coping w ith the reality of pain. T h e n eurological phenom enon, fo r exam ple, does n o t do the w o rk o f the psychological- phenom enon and th e psychological phenom enon can n Jj tak e the place o f th e n eu ro lo g ical phenom enon. B om . a re necessary if we w ant to u n derstand th e reality of pain. I have alread y pointed o u t th a t a v ariety o f descrip­ tio n s of p ain is possible, b u t instead o f dealing w ith as m any descriptions as a re possible I p ropose th a t we reduce them to th ree types o f description. By doing th is I am really constructing a philosophical m odel of m an. As a p h ilo so p h er I see no o th er w ay o u t o f the com plexity o f descriptions available to us. I f one takes as startin g p o in t th a t a h u m an being is in pain o r that p a in is in th e h u m an being, th e n one should allow for a t least th ree m ain descriptions o f m an w hich w ill correspondingly be applicable to pain. T hese three k inds o f descriptions are based on the trad itio n al distinctions betw een body, m in d and person. I am prop o sin g th a t w e take a hu m an being to be a reality o f w hich it is possible to give descriptions in terms o f body-language, m ind-language, and person-language. By “b o d y ” I m ean th e physical and an ato m ical dim en­ sion o f m an, b y “m in d ” th e experiencing an d conscious dim ension, and by "p e rso n ” the m eaning-giving and social dim ension. M any descriptions are possible w ithin each dim ension, b u t I choose the follow ing three m ethods as representative of each of the th ree kinds o f descriptions, nam ely, neurology, psychology and philosophy. A ccording to m e one can give th re e equaUf^ basic descriptions o f m an in e ith e r neurological, p sy c h f^ logical, o r philosophical language. C orresponding to these three languages as applied to th e reality o f a h u m an being, th e re a re th re e objectifications o r struc­ turin g s o f m an possible, nam ely, th e phenom enon of body, th e phenom enon o f m ind, an d th e phenom enon of person. T hese three objectifications o f the reality of a h u m an being, hav in g as th e ir p urpose three different k inds o f research a b o u t th e sam e reality, can also be seen as abstractions, th a t is, as structures abstracted fro m th e concrete reality o f everyday experience, fo r the purpose o f research and understanding. T hese rem arks on th e reality o f a hu m an being can also be applied to the reality o f p ain in m an. P a in can also b e approached in th ree different ways depending on w h eth er one describes p ain in term s of body, m ind o r person. T h e reality o f a hum an being in p ain can b e described in neurological, psychological, o r philoso­ ph ical language. I claim that, b y com m anding all three languages a b o u t p ain , we n o t only enlarge o u r picture of w hat it m eans to be a m an in p ain , b u t we also im prove o u r chances of h elping him . In o rd e r to give m ore content to th is th eo ry of the th reefold description o f m an in p a in I intend dis­ R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) cussing system atically the neurological, th e psycholo­ gical and the philo so p h ical language-gam es insofar as they throw light on the reality o f pain. N EU RO L O G ICA L L A N G U A G E -G A M E W ithin the n eurological language-gam e th ere are three theories o f p ain w hich deserve o u r attention. All three theories are good exam ples o f th e m ethod used jn neurology and correspondingly of the kind o f object the neurological phenom enon is. Specificity theory F o r a long tim e th e neurology o f p ain was dom inated by a th eo ry of sensation according to w hich different sensations excite different nerves. I t was th o u g h t th a t “specific tracts in the nervous system had specific functions and projected to specific cortical regions”, (de V illiers, 1977). T h is theory assum ed a fixed, direct- line com m unication system fro m the sk in to th e b ra in enabling a specific one-to-one relatio n sh ip betw een a >srtain stim ulus dim ension and a corresponding psycho- ' sgical dim ension. A ccording to von F rey, w ho dis­ tinguished fo u r cutaneous sensory m odalities o f touch, w arm th, cold and pain, in fo rm atio n is carried fro m four kinds o f stim uli tranducers in the skin along four pathw ays to fo u r specific receivers in th e b rain . T h e specificity th eo ry is rejected on the basis o f psychological evidence (m any psychological v ariables beside sensory in p u t q ualify pain), clinical evidence (the . phenom enon o f p h an to m lim b pain) and physio­ logical evidence (there is no evidence fo r th e fo u r m odalities isolated b y von Frey. T h ere are specific receptors b u t they are m ore “p lastic” th an he sug­ gested). E x p erim en t has show n th at th ere is differen­ tiation o f sensory receptors w hich “show an infinite degree o f v a ria b ility in th e ir sensitivity to stim uli from the env iro n m en t” , (de V illiers, 1977). A ccording to N oordenbos “pain m ay arise from virtually any type of stim ulus or m ay be the result o f afferen t patterns which m ay travel via any available p ath w ay ” . (Baken. 1968). Pattern theory A ccording to this th eo ry the basic determ inants of pain are stim ulus intensity and central sum m ation. T his th eo ry gives content to rem arks such as “pain is su m m atio n ” (S herrington) and “p a in is too m u c h ” (N oordenbos). R eacting against th e one-to-one relation- , flip betw een stim ulus and p ain , p attern th eo ry intro- <(uces the concept of the p attern in g o f th e input. It interprets sensation th erefo re not in term s o f specific info rm atio n received b u t in term s o f sp atial and tem poral p attern s o f nerve im pulses received by the central nervous system .The p attern ed in fo rm a tio n is m ade available to th e central nervous system b y a net­ w ork o f specialised receptors w hich translate w h at h a p ­ pens on the p erip h ery on b ehalf o f the centre. A ccording to M elzack (1973) “ the (peripheral) p a tte rn th eo ry fails to provide an ad eq u ate account o f pain m echanism s. It does n o t recognise the facts o f physiological specializa­ tion. It does n o t specify the kinds o f p attern s th a t m ight be related to pain. I t provides no hypothesis to account fo r the detection of p attern s b y central cells.” T h e psychological and clinical evidence m entioned as c riti­ cism against specificity th eo ry also ap p ly to p attern theory. T h e p attern theory , how ever, does have the v irtu e th at previously experienced te m p e ro -sp a tia l. patterns can b e learned and rem em bered and recognised. Gate-control theory T h e th ird theory, know n as th e gate-control theory, com bines elem ents o f b o th specificity and p attern jUNE 1979 31 theories. I t allows fo r specialisation an d patterning. T o this it adds th e influence o f psychological processes. In the w ords o f M elzack (1975): “B asically, th e theory pro p o ses th a t a n eutral m echanism in th e dorsal horns o f th e spinal cord acts lik e a gate w hich can increase o r decrease the flow o f nerve im pulses from perip h eral fibres to th e central nervous system. Som atic in p u t is th erefo re subjected to th e m odulating influence o f th e gate b efo re it evokes p ain p ercep tio n and response. T h e degree to w hich th e gate increases o r decreases sensory transm ission is determ ined by th e relative activ ity in large-diam eter (A -beta) and sm all-diam eter (A-delta and C) fibres and by descending influences fro m the b rain . W hen th e am ount o f in fo rm atio n th at passes th ro u g h the gate exceeds a critical level, it activates the n eural a re a responsible fo r p a in ex­ perience and response.” O ne o f the assum ptions m ade by this th eo ry is the in tro d u ctio n o f “filters” th a t m o d ify im pulses th at arrive. It also allows fo r psychological processes to influence p ain perception b y acting on th e gate-control system. N evertheless, m any problem s are left unsolved. F o r exam ple: W hat is th e n atu re o f the psychological p henom ena? A nd how can th e ir influence be tran s­ lated into neurophysiological language? T hese rem arks on the neurology o f p ain illustrate the logic o f the n eurological language-gam e. W hat strikes a philo so p h er is th e follow ing: th e m ethods used, th e in ev itab ility of hypotheses, th e in tro d u ctio n o f m etap h o rs (such as pathw ay, gate, and filter), and th e realisa tio n th a t in ad d itio n to n eurological concepts m ental concepts are necessary f o r an adequate descrip­ tio n o f pain. In h is discussion o f these th ree theories de V illiers (1975) concludes th at “w e do n o t experience pain at one site in th e nervous system b u t th ro u g h o u t its-en tire stru ctu re fro m th e sim plest sensory receptor; to its ‘highest centres’ in a com plex in teractio n o f intensity o f stim ulus and psychological re a c tio n ”. R ejecting the v alid ity o f iso latio n ist concepts such as “physical p a in ” and “em o tio n al p a in ” he calls fo r a concept of pain w hich sees pain as “a to ta l experience o f a p articu lar p erso n ality ”. PSYCHOLOGICAL L A N G U A G E -G A M E T h e psychological language-gam e can be illustrated in term s o f th ree them es: firstly, th e psychosom atic aspect o f p ain ; secondly, th e dim ension o f suffering; and th ird ly , the influence o f m ind o n body. T h e p ro b ­ lem discussed u n d er th e psycho-som atic aspect o f pain is related to p ain having an em o tio n al dim ension to it. T h e second sectioti looks at suffering as th e fact o f undergoing pain as a total experience. T h e th ird thenie discusses th e ways in w hich m ind can influence the q u ality o f the p ain experience. Psycho-somatic aspects o f pain In the previous section w e have already draw n a tten tio n to the fact th a t neurological concepts w ere found to be in adequate in describing pain!' M ental concepts w ere felt to b e necessary in f i l l i n g 'i n the picture. R a th e r than speaking o f physical p a in and em otional pain we decided to talk ab o u t th e total experience o f pain to w hich b o th neurological and psychological descriptions are applicable. A ccording to Sternbach (1968): “I t is n o t pain w hich is m ental o r physical, functional o r organic, psychic o r som atic, b u t o u r ways o f th in k in g a b o u t p a in and the systems o f term s we use to describe p ain w hich m ay be so dichotom ized. A ll p a in can be described in b o th languages, th e psychological and physiological. P a in itself is n o t one o r th e other. B ut because p a in can P H Y S I O T H E R A P Y R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 32 be described in b o th m ental and physical term s, p ain is tru ly a psychosom atic concept. F ro m this p o in t of view all p a in is real; an d all p ain is also psychosom atic since b o th m ental and physical d escriptions are po ssib le.” T rigg (1970) discusses this “ p arad o x ” o f pain in the follow ing w ay: “I t is a sensation in so far as it can be localized an d has its o rig in in a stim ulus, an d it is an em otion in so f a r as it disturbs one and m akes one th in k o f it as b ad in som e way. T h e p arad o x is im m ediately rem oved if th e two strands are separated, an d it is realized th a t th e usual experience o f pain involves both a sensation an d an em otion d irected at it.” P a in refers to th e w hole p ain experience w hich is a com bined sensation and em otion experience. Suffering Suffering can be described in term s o f the bearing o r u ndergoing o f pain, distress an d injury. I t is a hu m an reactio n to m any kinds o f events o f w hich p a in is b u t one. In the context o f this essay the em phasis will be on the undergoing o f p ain as th e un p leasan t experience w hich h u rts a person. T h e psychological language-gam e stresses the role o f consciousness, in th e experience o f pain. T his has already been sefcn in the previous section on the psycho-som atic aspect o f p a in in w hich sensation was linked to em otion. In this section I w ant to lo o k at the fact th a t p a in can infiltrate and occupy the w hole o f consciousness an d cause suffering. T ich en er m akes this p o in t in respect o f too thache: “T h e p ain o f a toothache is localized at a p a rtic u la r place, ‘in the to o th ’; b u t th e unpleasantness o f it suffuses the whole o f p resen t experience, is as w ide as consciousness. T he w ord ‘p a in ’ . . . often m eans th e w hole toothache experience.” (M elzack, 1973). M etz (1975) suggests th a t because o f th is aspect of pain , nam ely th a t it infiltrates th e w hole o f conscious­ ness, we should take the- d isru p tio n o f hu m an ex­ istence as fra m e o f reference fo r an analysis o f pain. D escriptions o f p a in experience reflect the intensity o f this d isruptive experience, fo r exam ple: “T he p a in is so excruciating, I wish I were d ead ” ; “the p ain drives me m a d ”; “th e p ain em bitters m y life ” ; “the pain engulfs m e ; I dread the m om ent the p a in re tu rn s”. T his last exam ple points to an aspect o f p ain w hich also deserves atten tio n , nam ely, th e extent to w hich an tic ip a tio n o f p ain can b e seen as its w orst aspect. T h ere a re cases in w hich an ticip ated p ain imposes m o re suffering th a n th e actual experience o f the “p a in ­ ful event. In these cases past experience an d anxiety w ill place a crucial role. Stem bach (1968) distinguishes betw een b rie f and chronic pains. In the case o f a b rie f , p a in the stim ulus is external, o n e tries to avoid it and a psychological d istance is possible. “W ith chronic o r in n er pains there is no o bject to regard, o r to avoid. T h e p ain over­ w helm s us. W e cannot place a psychological distance betw een ourselves and the h u rt, and we are n o t m erely threatened, b u t invaded an d occupied. It is n o t any longer a m a tte r o f having a body th a t has a h u rt m em ber, b u t we are a body th a t is alm ost entirely p ain .” In this state one usually experiences loneliness the feeling o f being abandoned, and the feeling o f being punished. S tem b ach (1968) relates these experiences to p ain -as-punishm ent phantasy. W h atev er the n a tu re o f these experiences o n e cannot deny th a t they do accom ­ pany th e u ndergoing o f intense pain. B ut it need n o t b e th e case. T h e suffering person can find v arious strategies to cope w ith suffering as w ill be m ention ed in the section on th e p hilosophical language-gam e. In th is context it can be p o in ted o u t th a t n o t only can suffering be in terp reted in various ways, but that even th e relatio n betw een p a in and suffering is not one o f exact p ro p o rtio n . It depends o n m any psycho- logical factors w hich p ain an d w hat am ount of p ajn causes suffering. A ccording to H ic k (1968): “T h e extent to w hich a given q u an tity o f th e p a in sensation causes us to suffer, an d comes to d eterm ine the qu ality o f our consciousness, varies enorm ously both fro m person to p erso n and fro m tim e to tim e fo r th e sam e person.” T h is p roblem will be discussed in the next section. T h e influence o f m ind on body T h e th ird psychological them e concerns the way ;n w hich th e m ind influences th e q u ality o f th e pain experience. T h is has been discussed in v ario u s ways by m any w riters. I lim it m yself to a few exam ples from w hich, I hope, it w ill be clear w h at was im plicit in th e tw o previous sections, nam ely th a t p a in is not m erely the having o f certain sorts o f sensations, but also a response to these sensations, a taking up o f ? certain a ttitu d e tow ards them . In this sense p a in is IK relatio n al concept. T h e kinds o f relations w hich are iif- volved w ill be discussed in th e rest o f th e essay. T h e psychology o f p a in can be illustrated by a variety o f exam ples tak en fro m th e follow ing areas: ethnic and cu ltu ral patterns and th e ir influence on th e experience o f pain, self-to rtu re cerem onies, the death o f martyrs, the role o f past experience, atten tio n , anxiety, depres­ sion, suggestion (placebos), au d io analgesia, hypnosis, m otivation, and th e conscious in terp re tatio n o f the significance o f pain. The first question th a t o ne can ask in respect of all these cases is: how does the m ind influence th e body? H ow do psychological factors influence p ain ? O ne way o f answ ering this question is to describe the processes in term s o f n eurological language w hich m akes use of th e m etap h o r o f the n eurological g ate being either closed o r opened by a process in itiated by th e mind. T his process results in eith er preventing the tran s­ m ission o f noxious im pulses in positive attitudes (for exam ple, m o tiv atio n ) o r enhancing th e ir transm ission in negative attitu d es (for exam ple, anxiety). Bonica (1978b) argues: “In view o f the decent data, it is not taking a n u nreasonable degree o f scientific license to suggest th a t v ario u s em otional, m o tiv atio n al, and affective facto rs can stim ulate parts o f the brain w hich, thro u g h corticofugal im pulses, have the capa­ b ility to p revent transm ission o f noxious im pulses jf~ the dorsal h o rn an d at different levels o f th e neurax^j O n th e o th er hand, un d er a p p ro p ria te conditions psychologic factors can ‘open th e gates’ at v ario u s levels o f the neuraxis and thus enhance transm ission o f noxious im pulses to the b ra in w ith consequent g reater pain experience.” , T h is exposition does n o t answ er the q uestion o f th e n a tu re o f th e in itial m ental stim ulation o f n eurological p arts o f the brain. N evertheless, it succeeds in highlighting th e philosophical problem of the relatio n sh ip betw een m ind and body. W hatever in terp re tatio n we give of these phenom ena, the problem o f m ind influencing body rem ains. I quote a few exam ples to illustrate this point. T h e first exam ple shows how th e m ind can play a determ in ativ e role in generating pain. B akan (1968) re­ ports the follow ing experim ent. A n investigator induces pain in the ph an to m lim b o f a p a tie n t “ by referring to som e cause o f anxiety in th e p a tie n t’s interpersonal life . . . th e possible reaction o f h is w ife to the disfigurem ent, his fe a r th a t she m ig h t leave h im and, less noticeably, his m o th e r’s illness. W hen these topics w ere introduced into the discussion, th e p atien t grasped th e am p u tatio n stum p, jerked his head tow ard the right sh o u ld er and then com plained o f having p ain . T his JUNIE 1979F I S I O T E R A P I E R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) psychologic equivocation o f p ain occurred repeatedly; j h e in tro d u ctio n o f these topics, psychologically p a in ­ ful to him , led him to behave in this m a n n e r.” T he second exam ple, is taken fro m the practice of hypnotism . Spiegel, a n exponent o f m edical hypnotism , talks o f “the a rt o f handling p a in ” w hich is taught to patients (for exam ple, cancer and m ig rain e patients) so th a t the “tyranny o f p a in ” is rem oved: T h e p atien t learns to superim pose a feeling of num bness over the pain area, an d to filter the h u rt o u t o f it. H e does this through a focused awareness, like being absorbed in a task.” (Tim e, ld69). I t is po in ted o u t th a t in these cases “the signals received and tran sm itted by the nerve fibres are n o t altered. W hat is changed is the mental perception and processing o f p a in .” T h e th ird exam ple illustrates the conscious in te r­ p retation o f the significance o f p ain and anticipates the next m ain section on the role o f the m eaning- giving activity o f th e person involved. I t is the well- known exam ple rep o rted by Beecher. “A t A nzio the wound w as often a p p aren tly construed as a good thing, ior it m ean t release fro m an intolerable situation. It Meant th e w a r w as over fo r the individual. T h ere, only one-quarter o f th e severely w ounded men (although clear m entally . . .) h a d p ain enough to w ant anything done ab o u t it . . .” (H ick, 1968) A ccording to Sauer- bruch an d W enke (1963): “T h e sufferer’s inner attitu d e can exercise a pow erful fo rm ativ e and transform ative effect. H ow a sufferer supports th e pain, how he copes w ith th e pain experience, often depends on his inner attitu d e.” T he role o f attitudes in the experience o f p ain is the them e o f the next section on the philosophical language- game. PHILOSOPHICAL L A N G U A G E -G A M E T h e ph ilo so p h ical language-gam e was already present in the previous analyses. In the neurological analysis it show ed itself in the discussion o f the epistem ological problem o f linguistic parallelism . T h e psychological analysis p roduced the follow ing p hilosophical p ro b ­ lems: the relatio n sh ip betw een em otion an d sensation, the influence o f m ind on body, and the a ttitu d e o f a person to suffering. In this section o th e r philosophical considerations will be discussed w hile the m ain threads of th e argum ent w ill be kept in m ind. T h e central them e in this section can be seen as the m oral dim en­ sion o f being a person w hich includes th e p ro b lem of responsibility and th e task to give m eaning to the Jifferent kinds o f pain. ' / I w ill concentrate m ainly on th e task o f giving meaning to p ain an d discuss o th e r problem s as they follow logically fro m this analysis. T h ere are three m ain areas th a t have to be taken into account: firstly, the ex ploration o f m eaning in term s of the biological function o f pain. In this context pain is in terp re ted as a sign w hich functions as a signal w arning m an o f a disorder in the body. Secondly, the exp lo ratio n of m eaning in term s o f the psychological fun ction o f pain. H ere pain is in terpreted as a sign w hich func­ tions as a sym bol w arning m an o f a d isorder in the m ind. T h ird ly , the e x p lo ratio n o f m eaning in term s o f the philo so p h ical function o f pain. In the th ird language-gam e p ain is in terp re ted as a sign w hich functions as a “significance” w arning m an o f a dis­ o rder in th e m o ral sphere. T h is can take on m any form s, fo r exam ple, disorders in personal integrity, interpersonal relationships, social structures, and in the w ay in w hich a person relates to the question of th e m eaningfulness o f life and death. Biological Function o f Pain N eurologically p a in is said to be p roduced by a JUNE 1979 2 33 strong stim ulus w hich tends to disorganise an d threaten d estruction o f th e tissue. H ick (1968) rem arks as follow s: “It has long been observed th a t th e p ain -recep to r system is m arkedly less sensitive th a n the o th e r sensory systems, w ith th e result th a t p ain is caused only by stim uli pow erful enough to damage, o r to threaten to dam age, th e body. Pain, says J. D. H ardy, ‘results fro m noxious stim u latio n w hich indicates the beginning of dam age to the pain-fibre ending’.” In term s o f this d escription one can say th a t p ain has the biological fu n ctio n o f a w arning signal, a function o f such im portance th at it has been described as “a benefactor to all living th in g s”. Balme m entions the th ree follow ing p rotective functions: “In the first place, p a in serves as a m eans o f alarm , draw ing o u r atten tio n to in ju ry or disease o f w hich w e m ight not otherw ise be conscious . . . In th e second place, p ain acts as an invaluable deterrent, preserving us fro m experim ents o f a dangerous o r in fu rio u s n atu re . . . In the th ird place, the sense o f p a in helps to create th a t co n d itio n o f v o lu n tary im m obilization o f an in ­ flamed o r injured p a rt w hich th e p erip h eral sympa- thetics are attem pting to secure, and w h ich is so essential a facto r in bringing a b o u t a cu re.” (H ick, 1968). O th er w riters have rejected this view o f p a in as a benefactor. L eriche speaks o f “this false conception o f beneficient p a in ”. (H ick, 1968). I t is p o in ted out th at “p a in is by no m eans always p ro p o rtio n a l to th e gravity o f th e danger to w hich it relates” (for exam ple, in the case o f a toothache). A second argum ent is based on th e fact th a t the p a in caused by fatal disorders, fo r exam ple cancer, comes too late. A th ird argum ent points o u t th at there is no po in t in a w arning if it is n o t possible to profit fro m the w arning outside th e av ailab ility o f m o d em m edicine and surgery. T hese argum ents, how ever, do n o t invalidate the view th a t p ain can be seen to have a beneficient function as a w arning signal. It helps m an to m anage h is life in th e external environm ent and to in te rp re t th e signals of acute sym ptom atic p a in as w arnings. H ow ever, when it comes to chronic p ain , the in terp re tatio n o f p a in in term s o f a positive biological value is inadequate. T he view o f p a in ’s biological function m ust m ake w ay fo r th e p ro b lem o f p ain as hu m an suffering in term s o f psychological and p hilosophical m eaning. Psychological Function of Pain In the case o f biology p ain w as in terpreted as a signal w hich w arns the organism o f a som atic dis­ harm ony. W ith in th e context o f th e psychological language-gam e p ain can be seen as a sym bol w hich w arns th e person of a m ental disharm ony. In com ­ parison w ith pain as a signal w hich reveals a som atic disharm ony, p ain as a sym bol conceals a m ental dis­ harm o n y w hich has to be discovered. It has th e charac­ ter o f a m ask w hich has to be in terp re ted indirectly. B uytendijk (1962) discusses exam ples o f p ain ex­ periences w hich m ask experiences o f anguish, unfulfilled longings, v io latio n o f o n e’s sense of justice, guilt- consciousness, etc. H e interprets these pains in term s of m a n ’s discovery th at in these situ atio n s h e is throw n back o n to his ow n resources. T h is results in a feeling o f im potence w hich overpow ers m an and he soon finds him self in pain. In these cases th e p ain is clearly an expression o f the state o f im potence caused by any o f th e above m entioned experiences. T h is is clear to the psychiatrist but n o t to the p atien t. T h e task o f the psychiatrist is to reveal to th e p a tie n t th at the m ental disharm ony is th e cause o f th e pain. T o convince the p atien t of th e tru th o f this insight is som etim es very P H Y S I O T H E R A P Y R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 34 difficult, fo r the p atien t can identify him self w ith a p a in fu l role w hich becomes “ the only answ er to a life too p ain fu l in o th er w ays.” (Spiro, 1976). Szasz (1957) speaks o f the sym bolic m eaning o f p ain and discusses the problem s w hich co n fro n t the psychia­ trist in p ro b in g the sym bol fo r in fo rm a tio n a b o u t the m ental state o f the patient. In m any instances the sam e kind o f p a in sym bolises different disharm onic conditions. H e gives som e exam ples o f m ental dis­ harm onies w hich have a social dim ension to them. A g irl’s p a in is in terp reted as a sign of h e r experience of loneliness afte r the death o f h e r parents, and o f h e r feeling o f being rejected by m em bers o f h e r fam ily resulting in a disguised cry fo r help. A m a n ’s p a in becom es a sign o f his in ab ility to cope w ith the tran sitio n fro m naval service to civilian life; u n co n ­ sciously he p ro jects into p a in both his fru stra tio n and his aggression against the a u th o rity w hich “let him do w n ”. O f this p a tie n t Szasz (1957) says: “T h e func­ tional v alu e of th e sym ptom fo r the p a tie n t was readily apparent. Indeed, it seemed as if all significant issues in his life w ere translated, so to speak, into the language o f p a in and w ere then expressed in such a m an n er th a t n e ith e r the p a tie n t n o r those to w hom he addressed him self really knew w hat he w as saying.” T h e w ay in w hich he analyses and describes these cases allows one to speak o f p a in itself as a sym bolic lang­ uage w hich has to be decoded by the doctor. The exam ple o f the p atien t unable to a d a p t him self to the social stru ctu re is decoded by Szasz (1957) as follow s: “T h e sym bolic tran sfo rm atio n s w hich the concept ‘p a in ’ has undergone in this case m ay be sum m arized as follow s: (1) T h e p a in experience is an expression o f a need fo r help (thus, also a n intrapsychic defence against anxiety). (2) T h e com m unication o f p a in is a request fo r help. (3) W hen the request is fru strated , the p e r­ sistence o f the p a in becomes a sym bol o f being re­ jected: ‘I t still h u rts . . .’ (4) T h e repeated com plaint of p a in is also a disguised fo rm o f aggression (retrib u ­ tion) against the fru stratin g , rejecting a u th o rity (physi­ cian, N avy, p arent, etc.).” In o u r analysis of the biological fu n ctio n o f pain we d e s c r ib e d .it as a signal w arning the p a tie n t o f a th reat to th e body. In this analysis of the sym bolic m eaning o f p ain, p a in is seen as a language in w hich the person expresses sym bolically his request fo r help, his com plaint a b o u t u n ju st treatm ent, his attack on a u th o rity , his fru stratio n s, anxieties, unfulfilled long­ ings, etc. In this sense p ain has a com m unicative aspect. I t is in this context th at we can see p a in as a mask w hich sym bolically introduces us to the hu m an being in pain. T h is rem ark throw s light on th e m otto o f this p a p e r: “I have p u t o n these m asks to show you m y face”. If w e do not succeed in in terp re tin g the m asks w e will n o t succeed in u n derstanding and heal­ ing the person w ho cries fo r help. Philosophical Function o f Pain In the biological context p ain was seen as a signal of disharm ony in the body. In the psychological context it functioned as a sym bol of dish arm o n y in the m ind. In th e philosophical context it can be seen as a “significance” w hich w arns o f a disharm ony in the m o ral o rder w hich calls fo r an in ten tio n al act of personal involvem ent. T his disorder can express itself in term s of d isharm onies in personal integrity, re ­ lationships, and in social structures. In certain cases the p ain becom es the o p p o rtu n ity fo r u ltim ate con­ cern in w hich questions a b o u t the u ltim ate m eaning of life are raised. In all fo u r cases the lib eratin g act o f personal involvem ent is crucial. In a sense one can say th at the p h ilo so p h ical fu n ctio n of p a in is its chal­ lenge to a person to becom e p ersonally involved in w h at is happening and to respond in a creative way through m eaning-giving activity. T h ere is indeed no easy w ay out o f the p a in situation. B akan (1968) introduces a n interesting m odel to illu strate his concept o f the resp o n sib ility o f the in d i­ v idual in respect o f p ain , w hich is w o rth m entioning in this context. H e proposes th a t the conscious ego should be seen as the m a jo r telic centre o f the hu m an organism . T h e w ord “telic” is derived fro m “ telos” w hich means p u rpose o r goal. T h e hum an organism is seen as an organic w hole w ith a h ierarch y o f telic centres under the dom in io n o f the conscious ego as the m ajo r telic centre. P a in is described as a “m an ifestatio n of telic d ecen tralizatio n ” , in w hich a low er telos takes on m ore im p o rtan ce than it should and consequently distorts the balance. P a in can then be seen as “the dem and on the conscious ego to w ork to bring the decentralized p a rt back into the unity o f the organism . P ain is the im perative to the ego to assum e the responsibility of telic cen tralizatio n . . . ” (Bakan, 1968). T his is only a m odel, but it is a useful m odel fo r it highlights thdS creative ro le o f the conscious ego. It is this respon-H sibility o f the person in respect o f p ain th a t I intend discussing in th e next fo u r sub-sections. D isharm ony in Personal Integrity P a in can play an im p o rtan t ro le p hilosophically in calling a person to becom e involved in the m oral quality o f his life by taking resp o n sib ility fo r his deserved p ain, and in illustrating th at he can control his life courageously in cases o f undeserved pain. Illich (1975) describes p a in in positive term s by stressing the im p o rtan t m o ral ro le it can play. H e talks of the healing pow er o f p a in and th e m oral n a tu re o f patience in suffering. H e can do this because he sees p a in as an in v itatio n to the suffering person to ask questions a b o u t the q uality o f his life. A ccording to h im “m edical civilization tends to tu rn p ain into a technical problem and thereby to deprive suffering o f its in h eren t personal m eaning. P eople u n learn to accept suffering as an inevitable p a rt o f th e ir conscious coping w ith reality and com e to in terp re t every ache as an in d ic a to r of th eir need for the in terv en tio n o f applied science.” (Illich, 1975). H e defines suffering as “an autonom o us p erform ance u n d er the im pact o f p a in ”. T h e expression “autonom ous perfo rm an ce” refers to the p e rso n ’s responsible relatio n sh ip to his p ain , hisr w illingness to accept the challenge o f pain. I) In o rd e r to accept this challenge the p atien t needs^ a culture, a context o f values, to help h im in terp re t the p ain . O ne can follow Illich in saying th a t to suffer p a in is to raise a question, and the context o f shared values helps one to articu late p a in in a m eaningful way. In the w ords o f Illich (1975): “T he act o f suffering is shaped by culture into a question w hich can be stated and shared.” T o be divorced from these shared values is to be lost in a very real sense and to becom e a victim o f o n e ’s pain. B oeyink (1974) speaks o f “redem ptive p a in insofar as it enhances and m ain tain s th e m oral elem ents in life, w hether it be v irtu e (courage), freedom o r th e fulfill­ m ent o f m oral obligations to o n e ’s fellow s”. In the case o f accepting deserved p ain one can develop a sense of responsibility fo r th a t p ain , and change o n e ’s life­ style accordingly. “A sense o f justice requires the recognition o f responsibility fo r the p a in o f o n e ’s m aking. Such pain is the sum m ons to fidelity to o n e ’s self and physical well-being, calling one to re-o rd er o n e ’s life .” (Boeyink, 1974). In this context pain-killing drugs, anaesthesia and an tac id tablets can have a negative effect in convincing th e p a tie n t th a t it is not JUNIE 1979F I S I O T E R A P I E \ R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) vet necessary fo r h im to change his unhealthy living. In the case o f accepting undeserved p a in the suffering can also have a redeem ing quality, p a rtic u la rly for others. T h is act of courage enriches th e person and sets an exam ple fo r others. I t illustrates the fact th a t man can control his ow n life. It can also lead to a sense of com m unity am ong the sharers of p ain in settings such as hospitals. A cceptance o f undeserved pain can fu rth erm o re dim inish suffering because it takes the place of guilt, grief o r sadness w hich th em ­ selves also cause suffering. (Boeyink, 1974). D isharm ony in Interpersonal R elationships In the discussion o f the psychological fun ction of pain I referred to th e exam ple m entioned by Szasz (1957) of the girl w hose involvem ent in p ain was caused by h er experience o f loneliness afte r th e death of her parents and by h er disto rted in terpersonal re­ lationships. If one assumes th at hu m an life has a relational structure, this kind of d isto rtio n can easily ]e understood. P ain can then indeed be a sym ptom of disturbed dialogue. M etz (1964, 1975) has done im portant w ork in show ing th a t p ain takes place in an intersubjective w orld and th a t one m ust pay atten tio n to th e ro le of disturbed dialogue in und erstand ing p ain . T h e dialogue w ith the psychiatrist can be o f help in restoring th e dialogue w ith the w orld a ro u n d the p atien t by helping h er to understand th e situ atio n o f w hich she is in­ evitably a part. T his dialogue w ith the psychiatrist also underlines the im portance of dialogue in general, w hich points to the fact th a t m an has no d irect access to him self but only through th e w orld and thro u g h the eyes and reactions of o th e r hu m an beings. In a certain sense m an is a gift to him self thro u g h the acts of others. M etz (1975) relates the case-history o f a p atien t w ith an extrem e fo rm of trigem inal neuralgia. T h is was his second severe attack. T h e first attack o f p ain was term inated by severing the nerve. T h e p ain was so intense the second tim e th at he could not speak. T he neurosurgeons decided o n surgery, b u t b efo re this o p eratio n could be p erform ed M etz had th e o p p o r­ tu n ity to tre a t the patient. It was only when th e h istory of the p ain was contextualised w ith in th e h isto ry o f the patient th at the causes o f the pain w ere discovered. F o r various reasons th is person isolated him self socially. Mis relatio n sh ip to his w ife was reduced to silence. JVhen M etz realised th a t the attacks o f neuralgia occurred during periods o f social isolation he decided that the cause of p a in was disturbed dialogue. T he p atien t and w ife w ere confronted w ith this in te r­ pretation. T hey decided to attend the sessions con­ jointly. T h e p atient was w illing to co m m unicate by w riting questions and answ ers on a slate. G radually they started talking to one another, and gradually the pain disappeared. T h e first tim e the p a tie n t was healed by surgery, the second tim e by breaking thro u g h his social isolation and by overcom ing disturbed dialogue. N o t the doctor b ut th e w ife as the m ain p artn er in th e dialogue played the crucial role in the p a tie n t’s recovery of health, illustrating clearly how a d isorder in interpersonal re­ lationship can cause pain, and how a restored dialogue can cause p a in t a disappear. D isharmony in Social Structure We have seen th at p ain is not an ab stractio n o u t­ side a person. B ut n eith er is a person an abstraction outside hum an relatio n sh ip s and social structures. (Berger, 1967). T h is throw s light on the fact th a t in JUNE 1979 P H Y S I O ou r discussion o f th e psychological language-gam e personal exam ples w ere given w hich involved inter­ personal relationships and social structures. Szasz (1957) gives the exam ple o f th e m an w ho was treated fo r persistent a b d o m in al p ain o v er a long period w ith o u t any change in his condition. P sychiatric tre a t­ m ent revealed th at his p a in had to be linked w ith the fact th a t the term in atio n o f his to u r o f naval duty was draw ing near. T h e tran sitio n to civilian life entailed an im p o rtan t change in his to ta l life p attern . H e fo u n d a job sim ilar to the one he did in th e navy. A t no stage did he feel th at he was confronted by a “p ro b le m ” . But in actual fact he was looking fo r guidance. In the absence o f help he experienced a rejection o f au th o rity w hich in his case w as the o rg an isatio n w hich “ rejected” h im after m any years o f service. In this exam ple the p ain becom es a sign o f his inability to cope w ith the tran sitio n fro m naval service to civilian life. H is fru stra tio n and his aggression ag ain st the au th o rity w hich “ let h im dow n” w ere unconsciously projected into pain. T h is case could be seen m erely as an exam ple o f a person w hose p ain reflects his inability to a d a p t him self to new situations. I w ant to suggest th a t there is also a social dim ension to this problem , nam ely, how to relate to o n e ’s w ork w hich is an in ­ volvem ent in a n o rg an isatio n al and social structure. M odern social p h ilosophy gives p rio rity to the fact th at m an is a social being and holds th a t social struc­ tu res q ualify hu m an behaviour. In this they follow the view o f M arx th a t “m an is a netw ork o f social relatio n sh ip s” co-determ ined by social structures. These structures also influence th e way in w hich a person understands him self and w h at h appens to him . I f these structures a re n o t conducive to healthy living condi­ tions and if they do n o t p ro v id e fo r the basic hum an needs o f all citizens and fo r the full developm ent of th e ir potentialities, and if these stru ctu res fu rth erm o re take on a n a u th o rita ria n n atu re and stifle hum an re­ lationships, causing different kinds of alienation, then the in dividual w ill surely be influenced to experience and define him self in a negative way. In such cases th e experience of p a in and suffering will inevitably reflect the negative social structures. M anganyi, a black psychologist, talks of the w ay in w hich the social structures in South A frica are reflected in the body im age o f the black m an. T h e b ody im age is the internalised conception an individual has o f his physical self, and because o f th e negative social stru c­ tu re the black m an has a negative conception of his black body. T h is leads to “p a in ” and “suffering” w hich should be overcom e. One w ay of doing this is to reject the w hite view of the black body as expressed in social structures an d as internalised by th e Blacks. In his ow n w ords: “W e have to erad icate the negative socio­ logical schem a o f the black body as p rescribed by w hites.” (M anganyi, 1973). The P roblem o f U ltim ate M eaning In all these cases it is possible th a t the situ atio n of pain is also used to raise the p ro b lem o f the u ltim ate m eaning of life. T h is usually happens in cases of term inal illness. A good exam ple o f this type of con­ sid eratio n is found in “T h e D eath o f Ivan Ilyitsh (Tolstoy) in w hich the realisation o f the inevitability o f o n e’s ow n death triggers off a fu ndam ental question­ ing of th e qu ality o f o n e ’s life. If one agrees w ith B akan (1968) th at “p ain is also indicative o f the fact th at death will eventually ensue”, and that each pain provokes the question, ‘D oes this m ean th at I will d ie?’ ” then one can im agine m any situations in w hich pain becomes “ the touchstone o f u ltim ate concern . If one links ultim ate m eaning w ith the reality of H E R A P Y 35 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 36 love it n o t only has im plications fo r the life o f the patient, b u t it also throw s lig h t on th e quality o f caring fo r people in sociable surroundings. T h e p o in t is to help them to overcom e the loneliness o f pain, n ot to feel cut off fro m hum anity, and to experience th a t suffering is n o t only an individual problem w hich isolates b u t a hum an problem w hich calls fo rth love. Sternbach (1968) draws o u r a tten tio n to the fact th at “the re lie f o f p a in is typically associated w ith com fort, love, and expressions o f caring, and w ith the reduction o f anxieties related to the w ithdraw al o f love.” I t is in the context of th e problem of the ultim ate m eaning o f life th at it m akes sense to look a t the p lu ra lity o f answ ers given by w orld religions to the questions o f p a in and suffering (Bowker, 1970), and to tackle the problem o f theodicy (H ick, 1968) w hich sets o u t to reconcile a good G o d w ith an evil w orld. IMPLICATIONS OF THIS VIEW T hese philo sophical considerations on p ain have various im plications w orth noting. I discuss th ree o f these, nam ely th e im plications fo r theory, m ethod of research, and therapy. M y rem arks o n these them es will be arran g ed un d er th e follow ing headings: the im portance o f an adequate p ain theory, the need fo r an in terd iscip lin ary approach, and the necessity o f a m ultiple th erap eu tic strategy. Importance o f an Adequate Pain Theory T h e philosophical language-gam e has shown how im p o rtan t an adequate p ain theory is, n o t only for th e m edical scientist and p ra c titio n e r b u t also fo r the patient, his fam ily and friends. A ll o f them m ust realise th a t the w hole m an is involved and th a t in cases w here p ain is clearly a hu m an cry fo r help the lib eratio n fro m pain cann ot b e achieved w ith o u t a realisa tio n o f th is fact. In th is sense th e re is a close lin k betw een curing and caring. In b o th his books on p ain M etz (1964, 1975) stresses the im portance of an adequate th eo ry o f pain, fo r in m any cases p atien ts suffer p ain because o f th e applica­ tio n o f an in adequate theory. H e relates exam ples of patients who w ere o p erated on m any tim es fo r the sam e com plaint w ith o u t success. Instead o f giving heed to th e sound advice of th e d octor to bring the experience o f p ain in agreem ent w ith the m edical assessm ent of the case one p a tie n t dem anded a th ird op eratio n . A gain w ith o u t success. A ccording to M etz (1975) this p atien t was a victim o f a physiological p ain th eo ry w hich does n o t allow fo r th e possibility o f p ain w ith o u t a physio­ logical cause. P a in is then only described in term s of a bodily defect an d n o t as som ething directly linked w ith the situ atio n in w hich the p a tie n t lives. T h e p atien t sees his p a in experience in term s o f a p ain theory prevalent at th a t tim e. A nd, according to M etz, this is n o t difficult to understand, since we live in an age in w hich “scientific” insights constitute th e w orld-view fo r m an. I t prescribes the w ay in w hich m an experiences and understands his life. In this sense a p ain theory prescribes fo r a p atien t how to experience and u n d er­ stand his pain. O n the basis o f these argum ents M etz calls fo r a b ro a d e r ap p ro ach in o rd er to help all con­ cerned to come to grips w ith th e problem o f p ain in a m ore hu m an way. I t is only by listening w ith an open m in d th a t w e can discover the p erson in th e pain. The Need for an Interdisciplinary Approach A serious search fo r an adequate th eo ry o f p ain will inevitably lead to a realisatio n o f the lim itations o f specialisation and consequently o f th e need fo r an in terd iscip lin ary ap p ro ach to th e problem . (G raham 1967). B onica (1978a) m entions th ree reasons fo r in ’ adequate m anagem ent o f ch ro n ic p ain : lack o f know­ ledge, in ad eq u ate ap p licatio n o f cu rren t knowledge, and problem s o f com m unication. In his discussion o f the in ad eq u a te ap p licatio n o f cu rren t know ledge and of th e im p o rtan ce of dorology (the science of pain), he touches on the problem o f specialisation and th e resul- ta n t lack o f an in terd iscip lin ary ap p ro ach (“collaborative m u ltid iscip lin ary research”). H e p oints out th a t “the cu rren t progressive trend tow ard specialization is con­ ducive to each specialist view ing pain in a narrow ‘tu b u la r’ fashion. T hus, the anaesthesiologist attem pts to tre a t all patients w ith nerve blocks, the neurosurgeon by cutting the so-called pain pathw ays, the psychiatrist by tra d itio n a l psychotherapy, etc. T his type o f ‘tu b u la r’ vision is p a rtic u la rly likely to occur when a specialist practices alone and sees these p atien ts in isolation. The factors preclude view ing the p ain problem w ith the perspective o f th e m any diagnostic and therapeutic strategies w hich m ay be ap plicable to the p a rtic u la r, problem in choosing w hich a re best fo r the p a rtic u la ij p a tie n t.” (B onica, 1978a). " It w ould be a great pity if the insight into the im portance o f a m ore com prehensive theory gains gro u n d w hile research is continually conducted on the basis of separation. I do n o t know w hat the present policy and p ractice is w ith regard to interdisciplinary ap p ro ach . G ra h a m (1967) talks of the harm ful practice o f sep aratio n w hich is deplored by the groups involved but w hich nevertheless continue to exist. W hatever the state o f affairs is, m y analysis calls for an adequate th eo ry o f p ain translated into an inter­ d iscip lin ary program m e o f p ain research, a tru ly c riti­ cal co-investigating dialogue, resulting in a m ultiple th erap eu tic strategy. The N ecessity o f a Multiple Therapeutic Strategy T he rem arks m ade by B onica in fav o u r o f in ter­ disciplinary research should sound fa m ilia r by now. In the previous sections o f this essay I have paid a tten tio n to the advantage o f a p lu ra lity o f p ain des­ c rip tio n s in com p ariso n w ith a “ tu b u la r” approach. W e have seen th a t a p lu ralist ap p ro ach introduces one to a rich v ariety o f facts th a t w ould otherw ise n o t be available. I t m akes us m ore flexible in o u r approach to the reality o f pain. But it n o t only helps us to b ro ad en o u r u n d erstan d in g b u t also to give us b etter th erap eu tic strategy. I f we can play m o r * language-gam es and use m ore kinds o f descriptions we should be capable o f coping b etter w ith a p ain situation. A m u ltip licity o f descriptions alread y p oints th e way to a m u ltip le strategy in th erap eu tic situations. Sternbach (1968) speaks o f the neurological, physiological, be­ h av io u ral and affective approaches as fo u r explanatory systems w hich all have im plications fo r m edical prac­ tice. I have reduced the p lu ra lity of descriptions to th re e language-gam es an d in term s of this analysis one will have to stru ctu re o n e’s th erap y along the lines presented by the three phenom ena o f body, m ind and person. I have said th a t a hu m an being is a reality w hich can be described in neurological, psychological and p hilosophical languages. T h is rem ark has also been m ade a b o u t pain. P a in is also a reality to w hich neurological, psychological and philosophical descrip­ tio n s are applicable. T he im plication o f this fo r therapy is th a t one w ill have to ascertain in each situ atio n w hat strategy to apply, fo r exam ple, w hen to ap p ly surgery, w hen psycho-analysis, and w hen dialogue. In stressing the need fo r in terd iscip lin ary research, th e im portance o f a p lu ra lity o f descriptions, and the necessity o f a m ultiple th erap eu tic strateg y one m ight JUNIE 1979F I S I O T E R A P I E R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) lose sight o f th e crucial role o f an in teg rated ap proach to & person in his pain. T h erefo re, I w ould like to conclude by linking th erap y w ith integration. I f in te ­ gration is o u r key term then the task o f th erap y w ould he n o t to lim it the reality o f p a in to the context of the body and to the context o f the m ind, b u t to place it in the a p p ro p ria te context of the fullness o f hum an existence. F o rm u lated in an o th er way: the p a in should he placed in the b ody and in the m ind w hile b o th body and mind are integrated into the w orld o f persons whose lives a re threatened and who are in need o f help. T herapy should th erefo re be integrated into th e attitu d e of caring fo r persons. A nd the p urpose o f th is caring is n o t p rim a rily to be in the service of th e conservation of the hum an body, b u t ra th e r in th e service o f the destination o f hum an life. I t is in th e fram ew ork o f this philosophical language-gam e th a t one realises th at pain is m ore than som ething to b e abolished. F o r hum an beings are m ore than patien ts th a t have to be treated. They are persons who are threatened in th e ir existence and are crying fo r help. T h erefo re th e p h ilosophy of . Jain views th erap y o f pain as a caring in term s o f the destination o f hum an life. A nd taking the w ords of Camus into account th a t “ there m ust be a destiny th at does not have to w ait on d e a th ” we m ight say th a t this questiorl o f hum an d estination rem ains the final chal­ lenge fo r p atien t and doctor and friend alike. 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Theos publishing H ouse. W ordsw orth, J. C. (1954): Pain and other Problem s. L ondon: Allen an d U nwin. Zborow ski, M. (1969): People in Pain. San Francisco: Jossey Bass. Z em ach, E. M. (1971): Pains and Pain-feelings. R atio, 13 N r. 2, p p 150- 157. T H E NATURE OF A CU TE PAIN P. A. FO STE R * As an anaesthetist I w ould say th a t you should not a ssu m e th a t the anaesthetist is necessarily a n expert on acute pain sim ply because this speciality controls — usually successfully — p a rt o f th e pain caused by th e surgeor): ’T h e reaso n is th a t th e very routine n a tu re of the surgical assault encourages a narro w ap p ro ach to the handling of pain relief w hich often, unfortunately, does n o t extend m uch beyond th e operating theatre. T he treatm en t of postoperative pain in fact often leaves m uch to be desired. T o avoid th e an aesth etist’s close-up view o f pain, 1 w ould like to pain t fo r you a b ro ad er picture including som e perspective and even a horizon. T o begin som ew here in the fo reg ro u n d , let us first state th a t th e anim al body stays in contact w ith and reacts to its environm ent by circuits in th e nervous system we call reflex arcs. T hese a re b u ilt according to the simple p la n o f — R E C E P T O R SE N S O R Y N E R V E C E N ­ T R A L L Y L O C A T E D SY N A PSE M O T O R N E R V E ->■ E F F E C T O R O R G A N . P ain is p a rt o f a com plex e lab o ratio n o n this them e w hereby an acutely received stim ulus th a t exceeds a certain threshold m ust be perceived to be so unpleasant th a t im m ediate avoidance is dem anded. A t this p o in t may I em phasise th a t A cute P ain is an essential an d valuable indicator fo r th e body, which we should only ignore u n d er special circum stances — .such as during surgery. ) C hronic pain does no t necessarily play such a valuable Jxunction. . . T h e first step in th e consideration of acute p ain is to look a t the pathw ays in th e pain m echanism . T his not only helps to u n derstand th e n a tu re o f pain b u t gives an insight in to how to tre a t it. T o re-em phasize the p oint already m ade, pain, in all its aspects, is an elab o ratio n of th e basic reflex arc w hich m ay be divided into — D A T A A C Q U IS IT IO N D A T A P R O C E S S IN G -► E X E C U T IV E M O T O R P R O G R A M M IN G . W e can look at these th ree phases separately an d then see how they m ay interact. T h ere are a few o f th e sim ple facts ab o u t pain th a t need to be clearly understood. T h ere are tw o types of pain — a “fast p a in ” , som e­ times called th e “first p a in ” th a t arises fro m the skin, localizes the site o f injury, leads to the initial w ith­ draw al reflex and does not outlast the stim ulus. I t is conducted along th e A a group o f fine m yelinated * P rofessor an d H ead, D e p a rtm e n t o f A naesthesia, U niversity of Stellenbosch an d T ygerberg H ospital, t P ap er read a t P ain Sym posium , preceding 13th N atio n al C ouncil M eeting 23 - 27 A p ril 1979. fibres, an d is appreciated in th e cerebral cortex afte r passage in th e spinothalam ic tracts. F ollow ing this comes th e “slow p a in ” or “ real p a in ” , the persistent pain th a t follow s in ju ry an d leads to a different so rt of reflex response — th e guarding, rigidity o r spasm th a t protects an injured part. T h e p a th ­ w ay here is along unm yelinated fibres w hich are^ slow conductors, hence the descriptive nam e. A p preciation is in subcortical b rain areas subserved by the spinoreticulo- diencephalic tracts. “R eal p ain ” pathw ays arise fro m skin a n d deeper tissue, an d autonom ic pain fibres m ingle w ith th e som atic fibre input w hich makes it possible to feel pain fro m deep organs referred to the surface of th e body. T he th ird spatial dim ension of pain — d ep th — is often not as accu rate as th e surface location. Perhaps the m ost im p o rtan t reason fo r th e distinction betw een th e tw o types o f pain is because m orphine is only effective in slow p ain pathw ays. T hus m orphine on its own cannot be an effective anaesthetic, since it does not influence “fast p a in ” , but only pain fro m injury alread y sustained. P ain is p roduced by fo u r sorts o f stim uli— (a) M echanical injury either to nerves o r th e ir endings; (b) T h e therm al extrem es of h eat an d cold; (c) E lectrical stim uli w hich directly fire sensory nerves an d can produce pain w ithout m uch injury; (d) C hem ical pain, p roduced by m any substance? eith er applied to tissue o r liberated in tissue. The first three are d irect effects on o rd in ary nerve fibres or nerve endings, th ere being no specific pain receptors. Pain is th e in terp re tatio n o f the intensity and d u ratio n o f a w ide variety of stim uli carried along ordinary nerves. . . C hem ical pain is significant because it is also an indirectly produced p ain secondary to tissue damage. It m ay be caused by the potassium liberated fro m injured cells, an d by acid m etabolic substances, o r by the horm ones o f injury an d inflam m ation. Substances such as histam ine, bradykinins an d prostaglandins a re fo r us extrem ely im p o rtan t in acute pain because we have the chem ical antagonists to use against them . A spirin is a specific brad y k in in antagonist an d a n in h ib ito r of prostaglandin synthesis. T he recent in troduction o f in tra ­ venous aspirin into South A frica is thus a n exciting new a d d itio n to our arm am en tariu m against pain. So also, one should u nd erstan d th a t oxygen lack, inade­ quate b lo o d supply, venous congestion, swelling, are causes of pain th a t are treatab le by simple physical means such as massage, positioning, m obilization, cold or an oxygen mask. Surely this is how pain should be ideally treated — at its source w ith physical m eans and R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )