The Story of Pain: From Prayer to Painkillers

In the blurb to The Story of Pain, Joanna Bourke provocatively asks 'Everyone knows what pain is, surely?' Every sentient person will experience a diverse range of pains throughout their lifetimes. However, despite the constancy and universality of pain, Bourke adeptly demonstrates that the way in which we, in the English speaking world, describe, communicate, and even experience pain has changed significantly from the 18th century to the present day.

Historians have previously been reluctant to turn their attention towards the study of pain. This is partially because, Bourke suggests, historians have assumed that pain is 'outside of language, absolutely private, and untransmittable' (p. 4); a case made by Elaine Scarry in The Body in Pain.(1) Historians have assumed that 'anyone claiming to be “in pain” is in pain' (p. 3), and that we therefore cannot analyse pain as an situational and shifting object of historical enquiry. Bourke acknowledges the lure of this approach as 'profoundly respectful towards the way peoples in the past have created and recreated their lives' (p. 3). However, Bourke also notes that this approach reifies pain; understanding 'Pain' an independent ontological entity.

Bourke persuasively argues that pain is not an independent entity, but rather pain is felt, witnessed and shaped within and by the social environment. 'Pain' is how we name and perceive an event, a feeling, a sensation. Pain is not the event, feeling, or sensation itself. This is analogous, Bourke suggests, to claiming that redness is not an intrinsic property of a tomato, but the way in which we perceive a tomato (p. 7). Bourke suggests that we may better analyse pain as a 'type of event' which is moulded by social and environmental interactions, bodily comportment, and language systems. Pain is then 'rendered public through language' (p. 7).

Approaching pain as a 'type of event' enables Bourke to remain respectful of how historical peoples have described their own pains and, at the same time, to analyse how, why, and when understandings of pain have changed and been changed by the social world. The first three chapters of The Story of Pain consider the language of pain, and question why and how metaphor, simile, and analogy have historically been deployed to describe pain. The chapter Religion is particularly fascinating, and analyses theological interpretations of pain. Bourke demonstrates that into the 18th and 19th centuries theology provided the 'most prominent figurative languages and ideological justifications' for pain (p. 92), with adults and children interpreting their experiences of pain in line with religious teachings.

The following chapters, ‘Diagnosis’ and ‘Gesture’, consider the diagnostic value assigned to verbal and gestural reports of pain provided by patients. Gestures, like pain, have 'only recently attracted the attention of historians’ (p. 160). ‘Gesture’ could perhaps be well read in conjunction with Colin Jones' The Smile Revolution.(2) Jones and Bourke pay attention to gestures which signal highly contrasting emotions: gestures which symbolise pain and the smile, contemporarily associated with happiness. Both historians show that the way in which these transient gestures have been popularised and portrayed can, and indeed should, be studied. Bourke and Jones each examine the way in which medical practitioners and psychologists have aimed to capture the fleeting nature of these expressions, and to measure and quantify their meanings.

The following chapter of Bourke's book, ‘Sentience’, analyses how the medical profession have attempted to classify sensitivity to pain across various racial, class, and gendered groupings, and how the categories constructed have often reflected prejudice. ‘Sympathy’ addresses a shift from the medics of the 18th century, determined to prove themselves 'men of feeling', sympathetic to their patients, to the 20th-century model of clinical detachment. The final chapter, ‘Pain relief’, contemplates the governance and distribution of pain relief.

A theme which emerges throughout the book is the contradictory nature of historical representations of pain. As ‘Estrangement’ particularly demonstrates, communicating pain may be socially divisive, painful for the speaker and the listener. However, the communication of pain may also be socially unifying, bringing the person-in-pain comfort and 'bonds of community' (p. 52). Pain is thought to escape description and yet, at the same time, has inspired complex metaphor. To provide a small list of examples, pain has been described as a battle (p. 77), an electric shock (p. 79), an enemy (p. 75), something that ruptures, shatters, or rips apart the body (p. 62), a lightning bolt (p. 179) and a storm (p. 267). Western populations of the 20th century tend to think of pain as a terrible evil which must be prevented (p. 162), and yet theologians have emphasised the beneficial and corrective potential of pain. Many consider gestural language 'unmistakable' but physicians and caregivers have been taught how to identify it. By displaying these contradictions, Bourke skilfully highlights the changing and contingent nature of ‘pain’.

Whilst pain experiences are personal and individual, physicians throughout time have attempted to find 'objective' ways to detect and measure patient experience. Bourke highlights how medics have aimed to equip patients with a language with which to describe their pains; exemplified by the invention of the McGill Pain Questionnaire in 1971 (147–9). Medical practitioners have also invented technologies which have aimed to detect pain without recourse to patient voice, including measures of the 'face of pain', x-rays, infra-red thermal imaging, and, indeed, the modern 'holy grail' of detection and measurement: brain imaging (p. 157). Technologies which position themselves as able to identify and objectify pain often gain access to funding and resources, and are thus tied, as historian Harry Marks has emphasised, to the development of particular professions and specialities.(3)

The breadth of The Story of Pain is one of its principal strengths, as the book's fascinating and illuminating examples shift masterfully and continually across the Western world and between the 18th century and the present day. The constant juxtaposing of examples from different times and places helps the reader to understand broad historical shifts in the nature of pain and pain relief. This format also enables readers to easily see modern parallels in historical examples. The concerns stated in 1902's The London Hospital Gazette around a ‘malingering Cockney’ (p. 141), for example, clearly resonate with certain contemporary discourses around welfare entitlement. The range of sources utilised is highly impressive, and lends great weight to the book's conclusions. It would be interesting to hear Bourke's reflections on the different uses and limitations of these various sources – newspapers, medical journals, diaries, oral histories, images – in representing pain. Bourke would surely also have some highly informative reflections to contribute to ongoing debates around the ethical responsibilities and boundaries involved in working with images of pain, disease, and suffering.(4)

The broad nature of The Story of Pain makes this book of interest and relevance not only for historians of pain, emotion, and medicine, but also for scholars interested in the histories of communication, ideas, politics, class, race, gender, and age. Indeed, the way in which class, race, gender and age shape an individual's experiences of pain and pain relief is regularly considered. Bourke concludes that:

There was and still is nothing democratic about pain. Certain groups of people are more likely to suffer (the poor, minority groups, those working in hazardous occupations, and so on) and … pain relief is inequitably distributed (p. 299).

Thus Bourke has provided a remarkable book, which is both highly valuable in its own right and which also provides the groundwork and impetus for further study. Building upon Bourke's new methodology of pain and the sources already examined, historians can now conduct further focused research into various aspects of the history of pain, perhaps, for example, studying the pain experiences of a specific age group, nation, class, gender, or time period. I was personally particularly interested in Bourke's consideration of the relationship between childhood and pain. Bourke provides fascinating descriptions of how children have been instructed in verbalising, measuring, and gesturing pain, with particular attention paid to Christian children (pp. 112–18, 154–5, 168–9). Historians could build upon Bourke's work to pay further attention to the way in which children have related to, and challenged, professional and parental categorisations of pain, in the context of the changing significance placed on 'childhood' in the modern period.(5)

Bourke's introduction states that her methodology will also enable understanding of 'the discourses, institutions, laws and medical, scientific, historical and philosophical structures that underpin knowledges and behaviours associated with being-in-pain' (p. 19). Indeed, a clear 'politics of pain' emerges throughout The Story of Pain. First, the book highlights the relationship between descriptors of pain and the legal, social, political, and philosophical context. Second, the book assesses how concerns around pain have been propagated to further various 'political' agendas. To give just one example, Bourke provides a thought-provoking discussion of how scientific findings around whether embryos could feel pain were deployed within late 20th-century debates around abortion (218–22). This aspect of Bourke's work could perhaps be read usefully in conjunction with Keith Wailoo's Pain: A Political History, which assesses how liberal and conservative politicians in post-war America have debated pain and pain relief.(6)

With the popularisation of contemporary history, and the growth of an 'impact agenda', questions around how and whether historians should engage with policy-making are increasingly pertinent. Bourke closes her book with a reflection on the relationship between history and politics, stating that:

In reaching out to people-in-pain, we must always seek to identify the needs and desires of people located within specific times and places. A painful world is still a world of meaning. History can help in this process. By knowing how people in the past have coped with painful ailments, perhaps we can all learn to 'suffer better' (p. 302).

Bourke asserts that historians can play a role in understanding not only the 'needs and desires' of historical people-in-pain but also the needs and desires of people presently in pain. The Story of Pain adeptly demonstrates the interconnectivity of historical and present conceptions of pain, as well as providing a fascinating new analytical framework through which we can understand 'pain' and suffering itself. This book will surely be of interest to medical practitioners and policy-makers interested in pain, as well as to historians and the public, and could usefully inform changes in the policy and practice of medicine and pain relief.

The Story of Pain is a detailed, thought-provoking and fascinating piece of historical scholarship. Bourke’s book offers an innovative new framework for the study of pain, and provides insight into the broad shifts in the nature of pain in the Western world from the eighteenth century until the present day. Bourke’s book can open up new avenues of historical enquiry, as well as informing policy-makers and public.

Notes

1. Elaine Scarry, The Body in Pain: The Making and Unmaking of the World (Oxford, 1985).Back to (1)
2. Colin Jones, The Smile Revolution in Eighteenth Century Paris (Oxford, 2014).Back to (2)
3. Harry M. Marks, 'Medical technologies', in Companion Encyclopedia of the History of Medicine, ed. W. F. Bynum and Roy Porter (London, 2001).Back to (3)
4. Susan Sontag, On Photography (London, 1979); Susan Sontag, Regarding the Pain of Others (London, 2003); Suzannah Biernoff, 'Medical archives and digital culture', Photographies, 5 (2012), 179–202; Lalita Kaplish, 'The sick rose', Wellcome Library Blog, <http://blog.wellcomelibrary.org/2014/06/the-sick-rose/> [accessed 4 July 2014].Back to (4)
5. See, for example, Philippe Aries, Centuries of Childhood: A Social History of Family Life (New York, NY, 1962); Hugh Cunningham, Children and Childhood in Western Society since 1500 (London, 2005).Back to (5)
6. Keith Wailoo, Pain: A Political History (Baltimore, MD, 2014).Back to (6)

The author is grateful for such a generous and thought-inspiring review. The reviewer has identified some fascinating areas for continued research and intellectual engagement.