When Dr Leah Kaminsky sent her essay to us in August 2013 for inclusion in Open Field Issue 3, we were struck by her unique position as a medical practitioner and writer to discuss how we all struggle to describe bodily pain. Her essay is a thoughtful, nuanced piece that we decided to share in full here because the topic of pain, empathy and writing has been in the media lately. Dr Kaminsky was early to the conversation and, we believe, one of the most compelling and informed thinkers in it. Read on…
As a physician it is routine for me to ask my patients to describe their physical pain. More often than not I am met with silence; a complete loss for words. The problem with trying to describe pain is that the normal grammar and syntax of language are inadequate. Yet, in order to try and alleviate someone’s pain, or to translate it back to them as the body’s news, I need to understand its precise location and nature. My training in medical ritual provides me with certain tools in order to assist me with asking the ‘right’ questions. I recite them like a priestly litany each time:
Where is your pain?
How long have you had it?
Is it sharp or dull?
Is it worse on movement or at rest?
Does food aggravate or alleviate the pain?
Is there anything you can do to make the pain better or worse?
Is it constantly there in the background, or does it come and go?
If 10 is the worst pain you have ever experienced, how would you rate your current pain on a scale of 1 to 10?
In taking a medical history, pain is characterised according to location, chronology, severity, aggravating and alleviating factors, and associated symptoms. When words are not enough to describe pain, this can lead to frustration all round. Despite my best intentions to coax them in the right direction, my patients’ vague, inarticulate mumblings test my own patience and slow me down when I am under huge time pressure to see others who are filling up the clinic, waiting for their turn to tell me about their own pain.
This inexpressibility of pain weighs heavily on my patients, made worse by the difficulties I face as their physician in trying to elicit expressions of pain from them. Where the hell are words when trying to describe Hell? I try and make it easier for my patients and for myself; I resort to pulling out classic tricks of the trade – the Faces Pain Rating Scale, which dispenses entirely with the need for words. Or I might hand them the McGill Pain Questionnaire, and ask them to tick the appropriate adjectives to describe their pain – quivering, shooting, drilling, stabbing, cutting, pinching, cramping, crushing, burning, stinging, blinding, piercing, excruciating. In my haste, I interrupt their narrative, trying to force it into my profession’s preferred outline, streamlining it into a formulaic process.
Yet, I never feel I truly get under someone’s skin and completely understand what they are feeling. The literal day-to-day description of pain inside my consulting room is limited when it comes to conveying the true experience. Even though there is use of metaphor, it is often clichéd and hackneyed. Hannah Arendt writes in The Human Condition: ‘Indeed, the most intense feeling we know of, to the point of blotting out other experiences, namely, the experience of pain, is at the same time the most private and least communicable of all.’ Elaine Scarry in The Body in Pain puts it this way: ‘Physical pain has no voice, but when it at last finds a voice it begins to tell a story.’
David Biro, in his book The Language of Pain, says: ‘Pain is a universal black hole into which language disappears.’ Words are replaced by preverbal screams and shrieks, groans and moans. Or sheer silence. Language is actively destroyed by pain. It is only when I move from the clinic to the literary world that I turn to fresh metaphor and imagery to convey a character’s suffering. Fiction serves to distil the essence of the experience of pain in a far more powerful way than medical history- taking ever could. Literary works recreate and succeed in expressing so richly the felt experience of physical pain.
The use of fresh metaphors in fiction adds depth to expressions of physical pain and enables us to share the experience at a deeper level of understanding and empathise more with suffering. It is arguably more difficult to write a good pain scene than a good fight or sex scene, which are often simply a matter of good choreography.
I turned to history for early depictions of physical pain in literature, starting with the Old Testament. The only suffering I found was in 1 Samuel 4:19-20: ‘His daughter-in-law, the wife of Phinchas, was pregnant and near the time of delivery. When she heard the news that the ark of God had been captured and that her father-in-law and her husband were dead, she went into labour and gave birth, but was overcome by her labour pains. As she was dying, the women attending her said, “Don’t despair; you have given birth to a son.” But she did not respond or pay any attention.’
The wife of Pinchas remained silent and withdrawn. Yet, throughout the Bible, God’s invisible presence is felt or asserted by the changes brought about in the human body, whether it be through toil, childbirth, natural disasters and war, or the boils, leprous sores, infestations with plagues, or a myriad other manifestations of illness, even including meat extruding from a starving people’s nostrils after they have devoured too much quail. These scenes of wounding often occur in the context of doubt in a merciful, omnipotent God.
Beowulf, one of the earliest Anglo-Saxon texts in the history of narrative, describes Grendel the monster terrorising the great hall of the King of the Danes. Beowulf comes from afar to slay Grendel. The reader is witness to the monster’s pain as he dies at Beowulf’s hand. ‘The monster’s whole body was in pain, a tremendous wound appeared on his shoulder. Sinews split and the bone lappings burst…he is hasped and hooped and hurpling with pain, limping and looped in it.’ Alliteration affords translator Seamus Heaney’s words a poetic flow and cadence, which is contrasted to the visceral, almost onomatopoeic sounds of the text as Heaney renders the monster’s pain achingly tangible to the reader.
German philosopher Neitzsche shouts at his pain: ‘I…have called it dog. It is just as faithful, just as obtrusive and shameless…and I can scold it and vent my bad mood on it, as others do with their dogs, servants and wives.’
J.K. Huysmans writing about pain in 1959, also calls it names: ‘the useless, unjust, incomprehensible, inept abomination that is physical pain.’
I trawled through my favourite works of contemporary fiction, searching out lines, paragraphs, scenes which depict physical pain. Who can forget the birth of Kitty’s baby in Tolstoy’s Anna Karenina, or Tristram Shandy’s nose crushed by forceps on his entry into the world? The blistering sunburn and the unquenchable thirst of a boy trapped on a raft with a Bengal tiger, in the middle of the ocean in Life of Pi.
In desperation I turned to that source of serious research, Facebook, asking my cyberfriends to come up with a Lit Owie hit list. Chris Adrian, a paediatrician who writes fiction borne from the depth of his experience working with chronically ill children won the race, closely followed by all of classic Russian literature. A literary hangover in Bonfire of the Vanities cracked a mention, someone in intractable pain from terminal cancer in Richard Power’s Gain, Norman Rush in Mortals, a scene in one of Doris Lessing’s novels from in which a woman in labour has her legs tied together until the doctor arrives. Ouch! In Affliction, Russell Banks creates a protagonist who suffers from an excruciating toothache, then has him extract his own tooth.
I looked carefully at a work of fiction I admire – the novel Peace by American author Richard Bausch – to see how he goes about portraying physical pain. I cornered and interrogated him at my last MFA residency at Vermont College of Fine Arts, when he was Visiting Distinguished Writer. When I asked him how he writes about pain, he leaned back in his chair, placed his hands behind his head and whispered: ‘I read poetry. It’s “the thing itself ” you get in poetry. I pay attention to the details. Let them speak for themselves. Less is more.’ By way of example, he then recited part of The Iliad in a booming voice: ‘he fell clattering upon his armour.’
I was schooled in the poetry of Banjo Paterson: You’ll Come a Waltzing Matilda with Me, etc. Bausch told me to read Emily Dickinson. Which I did. This won’t be news to most of you, but here, to my astonishment, is what I found:
Pain – has an Element of Blank by Emily Dickinson
Pain – has an Element of Blank –
It cannot recollect
When it begun – or if there were
A time when it was not –
It has no Future – but itself –
Its Infinite contain
Its Past – enlightened to perceive
New Periods – of Pain.
Pain – expands the Time by Emily Dickinson
Pain – expands the Time –
Ages coil within
The minute Circumference
Of a single Brain –
Pain contracts – the Time –
Occupied with Shot
Gamuts of Eternities
Are as they were not –
There is a pain – so utter by Emily Dickinson
There is a pain – so utter -
It swallows substance up –
Then covers the Abyss with Trance -
So Memory can step
Around – across – upon it –
As one within a Swoon –
Goes safely – where an open eye –
Would drop Him – Bone by Bone.
Bausch believes as a writer you must learn to trust your instincts, even though you may often feel you can’t. ‘Always use direct, concrete language when conveying pain or horror. In Peace, I wrote around atrocity. I never showed it.’
Peace is a story about war. It is 1944 and a group of American soldiers are on a scouting mission, led by an untrustworthy Italian guide, up a freezing, snow-covered mountain in the pounding rain, searching for enemy positions to report back to base. The extreme weather conditions hamper their trek.
‘The muscles of their legs burned and shuddered, and none of them could get enough air… They kept on, and were punished as they went. Ice glazed their helmets, stuck to the collars of their field jackets, and the rain got in everywhere, soaking them to the bone.
And, later: ‘But it had been so cold, and the rain kept coming down on them. They had got numb, maybe even drowsy – the drowse before you lie down and freeze to death.’
This, against the backdrop of atrocities being committed in the village down in the valley by German soldiers, which is only stated once, and all the more chilling for that. Bausch says: ‘Those soldiers weren’t even aware of what was going on until they heard the shots and their Italian guide (the Devil incarnate) told them the Germans were shooting the Hebrues.’
Not a word is wasted in Bausch’s prose. I asked him how he achieves this. ‘Work on a piece to get the worked-on quality out of it,’ he said. ‘Transcend your own moral limitations. There’s a moral universe… I don’t work in extremes of emotion. Writing is a practice. You need to be calm, cold and calculating when you write. Zoom out. Have the detachment of a surgeon. I’m singing when I write about pain or war. Some writers are so judgmental; their writing becomes overwrought and heavy on the page. Find the real language for pain: it’s in the details, the concreteness of things, the action and the drama of it.’
Virginia Wolf lamented the absence of literary representations of pain. Real physical pain does not simply resist language; it actively destroys it, rendering a sufferer mute. The paradox lies in the fact that it is precisely when we are confronted with a real life crisis of pain we may seek solace, reassurance and words for our personal suffering in the world of the imagination. As Elaine Scarry puts it: ‘the only other state that is as anomalous as pain is the imagination.’ Yet when we turn to literary fiction we are better able to find a voice for our pain.
In Bausch’s explanation of how he writes a scene of pain, he told me that he imagines it, then works his way through it. Trying to imagine someone else’s pain is what I do for a living as a physician – or rather, what my profession should do, but sadly, doesn’t do very well. My writerly brothers and sisters outshine us in this department. If imagination and physical pain live in the same realm, then perhaps using one to describe the other may elicit greater empathy. And if she writes well about physical pain that is exactly what a writer brings to the page to engage the reader. In order to imagine a character’s pain, a writer needs to empathise with them, and truly get under their skin.
My patient, Mrs Turnoff, will be ninety-three this February. She was born in Russia, lived through the Second World War in Shanghai and moved to Australia in 1959. She has outlived all her friends and family and spends her days re-reading her favourites – Tolstoy, Chekhov, Akhmatova. She has been coming to see me twice a week for the past ten years. In my profession we call her a Heartsink – a patient who makes your heart sink as soon as you see them seated in your waiting room yet again. Every time I ask her, ‘How are you?’ she replies in Yiddish, using first person plural, ‘Mir lebt.’ We are living. ‘How can we be? she says, going on to list all her complaints: ‘Our head feels like last week’s leftover kugel, our feet are so swollen we may as well be wearing puffer fish slippers, rats and cockroaches are running up and down our spine, gnawing away at our nerves, our hair is falling out so we are beginning to look like a mangy old boiler hen ready to volunteer to dive in head first into the chicken soup pot. But what’s the use of complaining, Dr Leah? How could you ever understand the pain we are in?’
You may not be surprised to learn that Mrs Turnoff and her wonderful descriptions of her bodily aches and pains have made their way right into the heart of my novel.
Dr Leah Kaminsky is a Melbourne-based physician, writer and author.