Post Road Magazine #32

An Element of Blank: Figuring Pain in Graphic Narrative

Thomas Dolinger

Pain, writes Emily Dickinson, has "an Element of Blank": "It cannot recollect / When it begun – Or if there were / A time when it was not." In The Hospital Suite (2014), a graphic pathography drawn in the sparest of lines, cartoonist John Porcellino literalizes this world-destroying blank. His intestinal tumor not yet diagnosed, Porcellino draws himself writhing helplessly in a hospital bed. "I was delirious [ sic] with pain," reads one panel. Below is a disembodied pair of eyes, quietly pleading with the reader. The next panel is not a panel at all, but the comics equivalent of Dickinson's searingly eloquent dash:

Undone by pain, the body—and, with it, the visual substructure of the narrative world—disappears. If comics is, as Hillary Chute has argued, a "procedure of… embodiment," then Porcellino's illness narrative records the gradual erasure of the drawn body and its neatly bounded world.

And yet that hurting body inevitably reappears: the "Element of Blank" gives way to another line of verse, another panel. As I trace this pattern of figuration and dissolution, I'm guided by a simple question: how does the art form we know as comics render the felt experience of physical pain? This question opens onto others: what features of pain does graphic narrative emphasize or occlude? Is the phenomenology of pain merely another facet of a broader illness experience, or does it demand more specific forms of artistic and critical attention? As attention to Porcellino's Hospital Suite reveals, comics represents an especially capacious and potent medium for conveying a form of bodily experience that has proven stubbornly resistant to representation in other art forms, both visual and textual. It is by now a critical commonplace that the verbal arts struggle and often fail to capture the felt experience of physical suffering. And yet, it is not the case that pictorial or visual art alone succeeds where words fail. Comics is an inherently hybrid form—one that is necessarily fragmentary and elliptical, that spatializes time and temporalizes space. Thanks to this very hybridity, it can hold steadily before the mind's eye a kind of human experience that all but eludes figuration.

This essay joins an ongoing conversation about the affordances of graphic narrative, a conversation recently energized by the rise of the graphic medicine movement. At the same time, it differs in both method and scope from most of the work done under the aegis of graphic medicine. Proponents of the movement most often seek to erase the clinical distinctions between the many facets of illness, to render a holistic portrait of disease as it is lived. In other words, the literature on graphic medicine tacitly accepts the increasingly prevalent—and, in many cases, very useful—biopsychosocial model of disease. It thus subsumes the sensory experience of pain into a broader aesthetic grammar of disease and disability. By contrast, in what follows I attend to a much more specific feature of comics as a visual and textual vocabulary—its strange capacity to render a form of sensation that can be neither said nor pictured.

Graphic Medicine and the Medical Humanities

The rise of graphic medicine may be traced to the birth of narrative medicine and, more broadly, of the field known as the medical humanities in the final decades of the twentieth century. The quiet success of these movements reflects a widespread concern among both patients and clinicians about gradual changes in the culture of American medicine during the postwar era. For Rita Charon, the founder of the narrative medicine movement, doctors' uninterrogated faith in ever-more sophisticated diagnostic technologies and therapeutic modalities all too often allows them to minimize the significance of the patient experience, including facets of illness and disability that no scanner or blood test can reveal. Charon argues that medicine, once an art of critical but empathic listening, has begun to abandon its commitment to the narratives constructed by patients about their own bodily experience, to treat subjective accounts of suffering with skepticism or outright hostility.

As Jared Gardner observes, the turn toward quantitative data collection and, above all, diagnostic imaging in healthcare has played a central role in this shift away from the broadly humanistic values and epistemological modesty that long characterized the practice of medicine. New forms of imaging—forms that would ultimately be reinscribed within the gestural, quivering, felt world by the hands of comics artists—promise to provide objective insights into the functioning of the human body:

As the number of "objective" images proliferated and their resolution increased

exponentially, it was inevitable that the weight accorded to those images would

grow accordingly. Each of these technologies required specialists not only to

operate but also to read them, specialists often cloistered away from

contaminating patient's narratives.

Narrative medicine represents a rejoinder to this unexamined faith in the glowing image—at its worst, a dangerous form of objectivist hubris that threatens to erode the doctor-patient relationship and to relegate the felt experience of illness to the margins of medical care. Proponents of the movement have established thriving curricula and even graduate programs in humanities departments and medical schools across the country. In their pedagogy and their scholarship, which borrow from the methods of literary and cultural studies, as well as aesthetics, philosophy, and sociology, they emphasize the centrality of storytelling and critical listening to the experience and understanding of both acute and chronic illness. Narrative becomes, then, a mode of therapeutic self-fashioning, a model for medical empathy and a diagnostic tool.

Graphic medicine might be understood as largely continuous with this project, a subfield within the larger movement of narrative medicine. The term "graphic medicine" was coined by Ian Williams, a doctor and cartoonist who has spent much of his career collaborating with scholars of comics, physicians, and cartoonists. These collaborators include Michael J. Green, a doctor who has integrated the study and even the making of comics into the medical-school curriculum at Penn State and has published numerous comics in medical journals, and MK Czerwiec, a cartoonist and hospice nurse based in Chicago whose work details her experiences on an HIV/AIDS ward. In 2015 this collective published The Graphic Medicine Manifesto, a collection of first-person reflections in both prose and comics on the intersection of graphic narrative and healthcare. As Gardner notes, the hybrid form of the work "puts to the test its authors' belief in the ability of comics to forge connections—between medicine and the humanities, between doctors and patients—that prose alone often makes impossible."

This understanding of the affordances of comics is by no means unfamiliar to historians of the form. As Scott McCloud has argued, the emergence of comics in the late nineteenth century reflected a much broader cultural shift toward visual-verbal hybridity, as artists began to explore the interactions between the two semantic systems. Comics are, by their very nature, at once elliptical and overdetermined; the form unfolds around the challenge of making meaning out of competing systems of signification, yielding a richer narrative than either alone could tell. For the authors of the Manifesto, sustained engagement with this sort of multimodal text promises to return the medical profession to its founding humanism, ultimately dissolving the rigid oppositions between data and narrative, image and word, physician and patient, creator and reader. In other words, the hybrid nature of comics—a sophisticated interplay between word and image that unfolds in time—makes the form uniquely suitable to the depiction of illness as a complex form of lived experience rather than a series of diagnostic or therapeutic categories.

Both inside and outside the academy, the Manifesto was received with nearly unalloyed enthusiasm, even garnering significant attention in the popular press. For many of its readers, the turn to comics in the medical humanities stands as a rejoinder to the suspicion of lived experience in mainstream medicine. This turn, however, is not altogether recent: scholars of comics have repeatedly emphasized that the history of the art form cannot be separated from the figuration of suffering, both mental and physical. "Illness," writes Gardner, "is arguably comics' invisible master theme, deeply woven into their genome and shaping the stories they tell, from the earliest newspaper strips (chronic allergies in Winsor McCay's Little Sammy Sneeze) through the rise of superhero comics (from Batman's PTSD in 1939 through the Fantastic Four's radiation poisoning in 1961)." At the same time, the growing interest in autobiography among comics artists has created a new formal context for the graphic pathography, or illness narrative. For many cartoonists, the ur-text of this genre is Justin Green's Binky Brown Meets the Holy Virgin Mary (1972), which unfolds in the nightmarish psychological terrain of a patient with OCD. By the mid 1990s, graphic illness narratives had begun to proliferate: Gardner cites, among others, Al Davison's The Spiral Cage (1990) and Harvey Pekar and Joyce Brabner's Our Cancer Year (1994). Indeed, according to a number of scholars, narratives about mental and physical illness have emerged as the "dominant form of nonfiction comics" in the twenty-first century.

The Phenomenology of Pain and the Language of Suffering

And yet, even in the supple medium of comics, the felt experience of physical pain all too often seems to resist attempts at representation. Elaine Scarry's The Body in Pain helps us understand that resistance. Though it does not address graphic narrative, Scarry's work remains one of the richest phenomenological descriptions of pain. "Physical pain," she writes, "does not merely resist language but actively destroys it, bringing about an immediate reversion to a state anterior to language, to the sounds and cries a human being makes before language is learned." For Scarry, pain represents the shattering of human language because it has no referential content, no intentional object. I hunger for food, dream of flowers, reflect on the events of the day, and yet I simply hurt. Pain, in other words, remains stubbornly and completely within the radius of the body, unanchored to anything outside of itself. It is at once utterly unverifiable and, for the sufferer, the most intimate form of truth, its facticity the very truth upon which all others depend:

For the person in pain, so incontestably and unnegotiably present is it that "having

pain" may come to be thought of as the most vibrant example of what it is to

"have certainty," while for the other person it is so elusive that "hearing about

pain" may exist as the primary model of what it is "to have doubt." Thus pain

comes…into our midst as at once that which cannot be denied and that which

cannot be confirmed."

For Scarry, this disjunction—the seemingly unbridgeable distance between sufferer and witness—defines the experience of being in pain. That distance erodes not merely the cognitive processes that subtend communication but the social promise of language—the human capacity to move out beyond the boundaries of the body and into a shareable world.

As critics have argued, this resistance to concretization in language may account for the surprising poverty of literary accounts of physical pain. Few novels, plays or poems present compelling portraits of the experience of migraine or neuralgia or end-stage pancreatic cancer. Most authors, all too aware of the limits of their own medium, carefully relegate the experience of the sufferer to the limits of the narrative frame. "English," writes Virginia Woolf, "which can express the thoughts of Hamlet and the tragedy of Lear has no words for the shiver or the headache…. The merest schoolgirl when she falls in love has Shakespeare or Keats to speak her mind for her, but let a sufferer try to describe a pain in the head to a doctor and language at once runs dry." While true of the headache, Woolf's claim is, as Scarry argues, even more radically true of the severe and prolonged pain that may accompany cancer or phantom limb syndrome or tic douloureux.

Scholars in literary studies, philosophy and narrative medicine, including Scarry, have nonetheless devoted considerable energy to studying attempts to render this helplessly private form of experience. Observers almost inevitably note that patients use two categories of metaphor to describe severe or chronic pain, either assigning it an agent—often a weapon—or imagining it in terms of visible (and therefore verifiable) tissue damage. In the first case, sufferers speak of needles and nails and jackhammers; in the second, of burning and laceration. As Scarry argues, these two types of metaphor converge in that they assign shape, length, color or texture to the sentient experience of pain; in short, they externalize, objectify and make shareable forms of perception without any referential content.

This pressure toward embodiment or objectification pervades the figuration of pain in many graphic pathographies. In Stitches (2009), for instance, David Small recounts the physical pain and disfigurement he suffered after undergoing surgery for thyroid cancer as a child. Ironically, the cancer was likely caused by the misguided radiation treatments administered for a series of minor ailments by his overzealous radiologist father. The operation to remove his thyroid left him hurting and all but mute, his voice reduced to a barely audible rasp. Removing the dressing in front of the bathroom mirror, David confronts his surgical scar for the first time—the site of his pain, both physical and psychological:

The full-page panel on the left depicts a moment of bodily identification and estrangement, David's sense that his skin is no longer wholly his own. The outline of the bathroom mirror becomes a panel-within-a-panel, a prison for the newly unrecognizable self. "Surely this isn't me," David protests. The body itself, suddenly personified, responds with cool cruelty: "No, friend, it surely is."

Small draws the lunar terrain of his scar with an almost mannerist aesthetic of exaggeration, his neck thrust out at the reader. The gaps in the skin are rendered with a sublime attention to texture. On the right-hand page, Small zooms in on the surgical site, the lacerated skin, the individual threads—a "crusted black track of stitches"—tying his body together "like a bloodied boot." These panels thus reflect the difficulty of rendering the body in pain, the necessity of anchoring pain to externally visible sites of injury, the jagged skin itself an objective verification of an otherwise invisible form of experience.

And yet pain, especially in its chronic forms, is often unaccompanied by any form of visible tissue damage. The rhetorical strategy of external objectification, however powerful, often fails to capture the inherent blankness of pain with which I began, its lack of any referential or intentional object. In the absence of such an object, temporal markers take on a particular importance. Consider the adjectives frequently used by both patients and clinicians to differentiate various forms of neuropathic pain: "throbbing," "flickering," "pulsing," "beating," "shooting." These descriptions imply a temporal dimension, a rhythmic on-off sensation, presence followed by absence followed by presence. This register bestows on the experience of pain a sense of temporal extension that static metaphors fail to convey. One hears this very tempo in Emily Dickinson's account of pain, one of the most elliptical and yet intimately felt descriptions of physical suffering in verse:

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.

Dickinson's characteristic ellipses here convey something of the inexpressibility of physical pain, its resistance to objectification in language. Pain eradicates the very sense of temporal continuity and extension that narrative requires; monolithic and unyielding, this infinite "It" reduces the sufferer's temporal horizon to a permanent, unchanging present. And yet the poem perdures, unfolding however tentatively in this reduced circumference, oscillating between the absolute presence—the sheer facticity—of pain and its maddening tendency to elude description.

This sort of oscillation imbues the perpetual present of pain with a palpable temporality. This effect depends largely on the formal features of poetry that emphasize the interplay of absence and presence: line breaks, the penumbra of white space around words and, in the case of Dickinson's poetry, the eloquent hesitancies of the dash. Hence the volleying of the lines between impossibly proximate antinomies: "Blank" and "recollect," "were" and "was not," "no Future" and "New Periods." For many poets, the challenge of conveying this sort of sustained prelinguistic experience remains the province of lyric poetry. Describing an excruciatingly painful flare-up of her rheumatoid arthritis, Adrienne Rich insists that poetry gives voice to forms of experience that other forms of verbal art cannot convey: "For that is one property of poetic language: to engage with states that themselves would deprive us of language and reduce us to passive sufferers."

The Hospital Suite: Drawing Pain

How might graphic narrative convey the temporality of pain without reifying it? How might the medium allow artists to depict pain as dynamic and temporal while bestowing on it an external and therefore shareable reality? Here, the analogy with poetry proves apt. As Hillary Chute argues, both art forms are invested in "extrasemantic visual rhythm," in conveying meaning through the disposition of space. To better understand that rhythm, we might turn to Scott McCloud's model of the internal dynamics of comics in his seminal work of graphic criticism, Understanding Comics. Central to this model is the tension between the individual panel—a self-contained visual and textual unit—and the sequence of panels that make up a single page or an entire graphic narrative. For McCloud, much of the aesthetic power of the form can be traced to the space between panels, the so-called gutter: akin to the white space in poetry, the gutter asks the reader to engage in an imaginative leap as she scans the page, to connect the sharply delineated worlds of individual panels into a coherent narrative and aesthetic whole. In this sense, comics demands of its readers an unusual degree of participation in the creation of meaning. One might even say that the reader assumes a subject position not wholly dissimilar to that of the physician trying to piece together the inevitably fragmentary, nonlinear account of a patient's symptoms into a coherent clinical narrative. The artwork withholds as much as it reveals and, more importantly, thematizes that very withholding, incessantly drawing our attention to its own incompleteness.

Perhaps the most compelling account of this dialectic of presence and absence comes not in a treatise on comics but in a work on twentieth-century visual art. In "The Im/Pulse to See," Rosalind Krauss defines postmodern visual culture as animated by a pulse, a rhythm that constructs the Gestalt and at the same time undoes it, "positioning us within the scene as its active viewer and outside it as its passive witness." Krauss argues that this beat works against the peculiar timelessness of the modernist image, constantly dissolving the form it constructs; it thereby relocates the aesthetic experience within the living body, "restoring to the eye… the eye's condition as a bodily organ."

This newly corporealized form of visual experience—immersive, temporal, always on the brink of dissolution—describes the aesthetic tempo of all graphic narrative, which constructs a self-contained world only to dissolve it. This tempo is all the more palpable in graphic pathography. Granted, Krauss's vaguely eroticized account of rhythm in the postmodern visual arts may seem distant from the figuration of pain in comics. And yet, this very dialectic allows comics artists to convey forms of somatic experience that would otherwise resist representation. Porcellino's Hospital Suite , for instance, records the author's descent into unbearable (and unexplained) abdominal pain. After many rounds of misdiagnosis, doctors find a benign tumor in his small intestine:

The top panel of this page gives voice, with striking economy, to a profound sense of the futility of modern medicine: though surrounded by the beeping of modern hospital machinery, Porcellino is doubled over, all but naked, his teeth gritted, his eyes closed. Despite the physical presence of his wife, Kera, he is ultimately alone. Lightning bolts of pain emanating from Porcellino's abdomen rupture the border of the panel, the very container of the narrative world. The reader then descends into the private hell of the bottom panel, where the world of the hospital—of doctors and painkillers and IV poles—suddenly disappears. The radius of narrative attention shrinks to the quivering contours of the human face. That face, streaked with sweat and dotted with stubble, is suspended in a void—a void that is nonetheless punctured by Kera's helpless murmur, muted by parentheses: "Can't you give him something for the pain?"

In these two panels, the contents of perception record the very process of perceiving. Though drawn from a third-person perspective, they body forth a rhythm of contraction followed by tentative expansion in which the narrative world is all but obliterated and then reconstituted in a fragile line, a single sentence: "Can't you give him something for the pain?" Pain may destroy language, but the language of others gradually recreates the world of the sufferer. The Hospital Suite oscillates again and again between immersion in the plenitude of the social and material world and devastating silences. After having his stomach pumped, Porcellino tries to detach himself from the immediacy of perceptual experience—the relentless onslaught of neural input—by reciting lines from the Heart Sutra, a founding text of Zen Buddhism:

Switching between a third- and first-person perspective, Porcellino depicts both the felt intensity of pain and his sudden sense of alienation from the sheer physical facticity of the surrounding world. The sweating, suffering face, depicted against a blank background, is utterly opposed to the menacing object world of the hospital lamp: the feeling, perceiving subject is completely divorced from the plenitude of the surrounding world.

These blinding circles of the light body forth the sense of utter alienation not only from the sterile facticity of the hospital room but from the very possibility of engagement with the social and material world. That world gradually dissolves into an empty panel:

The incantatory rhythm of the words all but eclipses the visible world of the narrative. This visual sequence reflects the narrowing of perception that pain entails; at the same time, it inscribes the felt experience of the sufferer within a recognizable object world. That very world reemerges as the fragile product of a perceptual process, of sentience itself:

Here, visual rhyme and verbal repetition convey the sense of an infinitely extensive present, in which the fact of sentience slows and all but stalls the forward motion of narrative: "It has no Future—but itself— / Its Infinite contain / Its Past." And yet in the bottom panel Porcellino does not simply choose to redraw the suffering face; instead, he opts for a more subtle aesthetic strategy, repetition with a difference. As a result, he creates in the reader the sense of spatialized time—an infinitely stretched moment that all but dissolves the punctual temporality of event.

Comics has a long history of depicting injury and physical pain, albeit in contexts far removed from the hospital corridor or the sickbed. In one of the earliest works in the genre, Les Amours de M Vieuxbois (1839) by Rodolphe Töpffer, the protagonist is repeatedly thwarted in love and in his many attempts at taking his own life. The superhero epic likewise features bodily damage that is most often miraculously undone in subsequent panels. More recent autobiographical works by Art Spiegelman and Alison Bechdel represent powerful challenges to this tradition, dwelling at length on the hurting body, though they are far removed from the genre of the graphic pathography.

And yet the sort of quiet lyricism that pervades graphic pathography represents largely uncharted territory for comics—a new mode of engagement with the medium itself, with its peculiar affordances. Porcellino's delicately drawn worlds are always on the verge of dissolving into a devastating blank, a blank anterior to language. Just as crucially, however, they reconstitute themselves again and again as a fragile record of the patient's and the reader's own flickering embodiment.

Works Cited/Consulted

Acocella, Marissa. Cancer Vixen. New York: Pantheon, 2009.

Charon, Rita. Narrative Medicine. Oxford: Oxford University Press, 2006.

Chute, Hillary. Graphic Women: Life Narrative and Contemporary Comics. New York: Columbia University Press, 2010.

---. Rev. of Our Cancer Year, by Harvey Pekar and Joyce Brabner; Janet and Me, by Stan Mack; Cancer Vixen, by Marisa Acocella Marchetto; Mom's Cancer, by Brian Fies;Blue Pills, by Frederik Peeters; Epileptic, by David B.; Black Hole, by Charles Burns. Literature and Medicine, 26.2 (2007): 413-429.

---. "Secret Labor: Sketching the Connection Between Poetry and Comics." Poetry Foundation. 1 July 2013. Web. 19 May 2016.

Czerwiec, MK et al. The Graphic Medicine Manifesto. University Park, PA: Pennsylvania State University Press, 2015.

Farinella, Matteo and Hana Roš. Neurocomic. London: Nobrow Press, 2014.

Gardner, Jared. "Show Me Where It Hurts." Public Books. 15 Nov 2015. Web. 2 May 2015.

Haines, Steve. Pain is Really Strange. Philadelphia: Singing Dragon, 2015.

Kleinman, Arthur. The Illness Narratives: Suffering, Healing and the Human Condition . New York: Basic Books, 1988.

Krauss, Rosalind. "The Im/Pulse to See." Vision and Visuality: Discussions in Contemporary Culture. Vol. 2. New York: The New Press, 1998. 51-75.

McCloud, Scott. Understanding Comics: The Invisible Art. 2nd ed. New York: William Morrow, 1994.

Porcellino, John. The Hospital Suite. Montreal: Drawn and Quarterly, 2014.

Scarry, Elaine. The Body in Pain: The Making and Unmaking of the World. Oxford, UK: Oxford University Press, 1987.

Small, David. Stitches. New York: Norton, 2009.

Zuger, Abigail. Rev. of The Bad Doctor, by Ian Williams, andGraphic Medicine Manifesto, by MK Czerwiec et al. New York Times. 30 June 2015. Web. 8 May 2016.




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