Pain is imbricated in clinical and experimental histories where the transformation of subjective experience into scientific measure was a form of political physiology.1 Tracing a history of pain in medicine, Joanna Bourke notes that the application of ether substances in surgical pain relief for surgical applications was not until 50 years after the discovery of this substance, as its widespread use was intertwined with Romantic preoccupations about the democratic distribution of happiness that pushed the pain relief agenda as a legitimate goal during the Enlightenment. Davyâs discovery of ether was framed by vitalist concerns about the effect of an under-stimulating gas vis-Ă -vis pain as an over-stimulant, both seen to put patients at risk.2 As it became possible to render a person insensible to pain while keeping them alive, the principle of application of pain relief was grounded in forms of calculation of preferable suffering . Pernickâs history of anaesthesia demonstrates that the application of pain relief relied on the acceptance of suffering ratios and probabilities of death , and that the âutilitarian professionalismâ that guided the early development of anaesthetics was itself rooted in physiciansâ âsearch for a moderate consensus ideologyâ3 that would allow them to bridge disciplinary cleavages. Choices between maintaining life and alleviating pain were affectively grounded, as physicians understood their professional duty as âdemanding the unhesitating infliction of extreme suffering in order to save livesâ.4 Social position, race, and gender and age played a major role in this form of calculus, effectively determining who would and would not receive anaesthetics , and to what degree. In some instances, pain was seen as a positive experience that could be beneficial. Physicians counted in their duties to âbolster the courage of patientsâ,5 seeking to actively âdevelopâ their moral qualities through pain management. In contrast, patients were dismissed as responding emotionally while under the influence of anaesthetics , and the encounters between practitioners and patients were seen as dangerous even for practitioners, as the application of anaesthetics was perceived to threaten the social, sometimes also the sexual order between patients and their clinicians. Indeed, as Bourke argues, the development of anaesthesia was enmeshed in wartime logics and logistics, practical barriers that determined the availability of pain relief remedies, as well as defective equipment and incomplete medical training that added up to unequal pain relief provision, grounded in moral anxieties and spiritual dangers.6
Turning pain into an object of medical study âinvolved separating clinical pain from laboratory pain, and most importantly, separating chronic pain from acute painâ .7 The history of anaesthetics is based on instrumental correlations that attest to the reality of pain, based on certainties such as the fact that âa small prick with a needle in the finger causes tolerable pain, whereas a strong blow with a hammer to the same place normally unleashes severe painâ.8 Correlational measures of pain and tissue damage were predicated on assumptions about the stability of pain as an object of investigation, privileging purely mechanical values of sensation as data since these produced replicable results. Although judgements such as these provided pain with unique characteristics, and its status as research object,9 these same judgements imbued chronic pain with a problematic status: not only is it a private experience to which no one but the person in pain has direct access, but it resists medical actions and explanations in its persistence. As social, emotional, and psychological domains are brought to bear on the aetiology and definition of pain, clinical research has progressively veered away from early theories of pain that followed the Cartesian model of an isomorphic relation between pain and tissue injury .10 Yet, as Goldberg has noted, pain without lesion became an object of consistent epistemic stigmatisation in clinical research and practice well into the twenty first century, supported by the rise of a culture of mechanical objectivity and evidence-based practice and backed by historic paradigmatic court rulings.11
Definitions of chronic pain have been notoriously difficult to standardise.12 The long-term effects of chronic pain do not easily map onto prognostic values and indicators.13 Biomedical health narratives imagined pain through metaphors of survival which depend on the recognition and elimination of pain. Contraposing the pain-free body to the body afflicted by pain, pain is seen to trigger a form of warfare,14 calling for action-oriented technical responses to tackle its effects and for long-term adaptive approaches to healing. Indeed, âa good lifeâ should not be painful or difficult, nor lived through the kind of alienated senses of subjectivity and relationality that often arise from anomalous long-term pain.15 However, although ubiquitous forms of pain transverse religious, cultural, and historical boundaries,16 social scientists have long known that pain derived from long-term illness is not universal, and neither are its effects.17 Persistent pain is, rather, anomic,18 escaping systematisation in a coherent system of meanings or values. Pain may be an event of total loss that fractures any and all notions of totality.19 It may be a fluid state across patterns of flare and remittance in which, alongside the endurance of pain itself, there is an inability to restore levels of function held prior to painâs inception.
Thinking through emotional and communicational aspects as critical to pain experience, Bendelow and Williams argue for an approach to pain beyond models focused on sensation and based on the Cartesian split between body and mind.20 Against the medicalised view, Bendelow and Williams recast pain as an experience of being in the world, irreducible to the qualities of sensation, and grounded in communication processes at the intersection between biology and culture . Pain extends beyond individual bodies to inhabit practices, relations of care , regulations, pharmacokinetics and multiple, partially connected practice cultures that normalise notions of health and ability, producing pain no longer only as sensation, but as an epistemological, social, and political ecology. People who live with pain long term trace their pain to personal experiences of misdiagnosis, stigma, and undertreatment, to the extent that, analysing the global patterns that make chronic pain endemic, Manderson and Smith-Morris argue that âincreasingly, chronic, long-term conditions are not naturally occurring ones, but are those for which the political will and economic resources are simply not brought to bear for a given communityâ.21 As the prevalence of chronic conditions becomes an increasingly ubiquitous global public health concern,22 the increased prevalence of chronic pain is linked to factors shaping access to resources, socio-economic status, stress at work, occupational status, race, and education, locating pain across relations between policy and politics . Correlations between pain and disability highlight, furthermore, that feeling pain and being in pain are not co-terminous. People with lower incomes are not only more likely to be more disabled by pain, but research demonstrates that there is a relation between social conditions and the intensification of pain.23 For Wilkinson and Kleinman , social suffering is now an extension of illness made routine in everyday life by the force of stigma, material deprivation, and compounding forms of epistemic, medical, and political injustice.24
In this context, new questions are emerging across academic disciplines about the relation between pain experience and pain expression, which point to complex entanglements betw...