‘On truth, doubts, and pain: The significance of ideas of objectivity’ – a contribution to our special edition collection of pain in the medical humanities, by Daniel Goldberg
One of Elaine Scarry’s significant insights into the nature of pain is one of its basic paradoxes: pain is simultaneously one of the most privately certain and publicly doubted phenomena in Western social life. Rob Boddice (2014: 3) extends this point in his recently edited anthology on the history of pain, noting ‘[h]umans are involved in a never-ending process of bearing witness to pain or of choosing not to bear witness’. The critical question thus becomes what are the factors that determine whose pain is heard and validated, and whose pain is silenced. What determines which voices matter?
A number of pain scholars have supplied compelling and thoughtful answers to this question (e.g., David Morris, Lucy Bending, , Jean Jackson, and Martha Stoddard Holmes, to name but a few). But in this short post I wish to provide a complementary explanation drawing from interdisciplinary history, focusing especially on disability history and on the history of ideas. Specifically, I want to suggest that we can only understand modern anxieties over the truth of pain complaints, as well as the constant doubt and skepticism that swirls around pain like a sandstorm, by comprehending crucial changes in Western ideas of truth, doubt, and objectivity in the modern era.
In what follows, I shall share some arguments and sources drawn from my ongoing work in the history of pain without lesion in mid-to-late 19th c. America and Great Britain. Although one should always be wary of reducing the value of history to instrumentalism, I want to argue that the history of pain can shed a very great deal of light on why pain remains an extremely active nexus for doubt, suspicion, and skepticism.
To begin with, we have to understand what is meant by reference to objective and subjective illness evidence of illness. Yet our widely shared concepts of objectivity did not simply spring Athena-like in the 21st century. Ideas of objectivity have a history, one that is hugely important in understanding why and how the apparent subjectivity of pain has come to code for deception. The framework I rely on arises from Lorraine Daston and Peter Galison’s . Around the middle decades of the 19th c., a new idea of objectivity begins to take hold: mechanical objectivity. Two central criteria define this schema: First, there exists an emphasis on the elimination of as much of the investigator’s influence in the knowledge-making process as is possible. Second, any ensuing representation of the natural object under investigation – for the history of objectivity literally is a history of scientific imaging – must maintain perfect fidelity to the specimen itself, imperfections and all. The objective driving both of these criteria is that the Truth of the matter is invested in the natural object itself, and adulterating influences are to be removed to the maximum extent possible to enable the mechanisms of nature to speak for themselves, to reveal their truths. Mechanical objectivity has critical epistemological implications; it supported changing 19th c. ideas of truth, certainty, and knowledge.
What does this have to do with pain? An enormous amount. First, the chronology is not coincidental. A new model of objectivity is waxing at precisely the same time as the birth of the clinic itself – profound changes in ideas of truth and knowledge are coextensive with profound changes in ideas of medicine and medical practice. Second, the epistemic emphasis in mechanical objectivity centers on the natural objects of inquiry. In the context of illness and medicine during the long 19th c., these natural objects increasingly came to be understood as the stuff of pathological anatomy. As physician-historian Robert Martensen (2004: 95) points out, Western medicine’s reliance on anatomical learning is its most distinctive knowledge-making characteristic. Increasingly, most kinds of disease began to be investigated and defined in terms of the discrete material pathologies with which the illness sufferer’s complaints could be clinically correlated.
Although the objectification of illness enabled by pathological anatomy and clinical correlation have proved extraordinarily powerful in a variety of ways, it does not follow that the Clinic’s success is unqualified. What of illness complaints that frustrate the schema? Pain without lesion – the term chronic pain did not arise until the 1960s – by definition tends not to present with the kinds of perceptible lesions that facilitates clinical correlation. Under a mechanical objectivity paradigm, the Truth of the matter is invested in the natural objects of disease. But where such objects cannot be discerned, the disquieting possibility is that the truth value of the illness complaints might mirror the nothingness; where the anatomical objects (lesions) do not exist, the pain does not, either.
19th and even early 20th c. disease nosologies were nothing if not fluid (at least 15-20 different terms and illness descriptions code for pain without lesion), and frameworks of mechanical objectivity were no less so. In his elegant analysis of railway spine, a particularly contested condition, historian Ralph Harrington (2003) points out that Victorian physicians as a rule believed in the validity of the illness, and readily accepted that so-called ‘nervous shock’ were ‘seated’ within the patient’s nervous system even in the absence of pathological lesions. However, I would add that these healers still cast the Truth of the patient’s illness complaint in terms of the material objects of disease; railway spine still has roots in the physical structure of the nervous system itself. As I have argued in prior work, there was little doubt among most 19th c. physicians who treated nervous disease whether so-called organic lesions existed. The problem was merely, given the state-of-the-art, a technical difficulty in locating such lesions. Thus, in his 1866 treatise On Railway and Other Injuries of the Nervous System, surgeon Sir John Erichsen notes ‘where the physical lesion is distinct […] no discrepancy of opinion can or ever does exist’ (1866: 19). Erichsen’s tract engendered considerable controversy precisely because he insisted that railway spine was indeed rooted in material lesions of the spinal cord caused by the injury itself. Even where most other surgeons of the time rejected ‘his crude characterization of lesions in the spinal cord’, as notes, they tended to do so in terms of an ‘organicist’ framework in which the ‘causes of mental and nervous disorder’ are rooted ‘in physical injury and disease’ (1866: 221).
The final important feature of the integration of understandings of mechanical objectivity, disease, and pain in the late 19th and early 20th c. is the fact that ideas of objectivity in the modern era are far too powerful hermeneutics to be limited purely to expert medical and scientific contexts. To be sure, the history of objectivity is in an important sense a history of science, but the concept of mechanical objectivity is an epistemological scheme under which lay and expert alike ordered a particular understanding of truth and knowledge. It is, for example, no accident that detective fiction as a distinctive genre flourished in the late 19th c.; lay audiences were keenly interested in the way that informed and expert observers could, by inquiry into the natural world and its objects, determine the Truth of a disputed matter of fact. (It is also no accident that the paragon of this genre was created by a physician).
Although commentators have noted the development of several additional concepts of objectivity through the 20th c., I want to suggest that as an epistemic framework mechanical objectivity is still extremely important in shaping our understandings of the truth of various illness complaints. This is partly why diagnostic imaging of chronic pain remains common in the Western world, despite overwhelming evidence of its lack of efficacy. Moreover, it is not simply health care providers and medical imaging equipment manufacturers who desire utilization; ethnographic studies report how intensely many chronic pain sufferers desire to undergo imaging procedures. If the lesion can be identified, the pain is made more real, even to those who lack the luxury of denying its reality – the pain sufferers themselves.
Under a rubric of mechanical objectivity, pain that persists in the absence of any discernible lesions is more likely to subject the sufferer to doubts and skepticism, often although not always characterized as malingering. In forthcoming work, for example, I discuss a particularly insightful case of such in the form of a wounded veteran of the U.S. Civil War, a case which does indeed end with a diagnosis of malingering from the no-doubt exasperated physician.1
This is not to suggest that 19th and early 20th c. physicians widely doubted their patients’ reports of pain without lesion. There is little evidence of this, at least among socially privileged patients. Less privileged pain sufferers, however, might well encounter more difficulties in having their expressions of pain heard, validated, and treated. It is well-known, for example, that African-Americans were widely regarded as being more “primitive” and hence less sensitive to pain, which meant that they generally merited less therapy for its relief (Wailoo 1992; Pernick 1985). Indeed, the significance of ideas of mechanical objectivity intersects with various other social variables such as race, class, and gender to shape whose pain is heard and why – then and now. But where pain without lesion as a rule frustrates dominant framework of mechanical objectivity, it is not surprising both that pain stigma seems so common and so enduring, and that it is the most marginalized and vulnerable among us who seem most likely to be stigmatized.
This guest contribution was written by Daniel Goldberg, Assistant Professor in the Brody School of Medicine; East Carolina University. The subject of pain, and especially its inequitable undertreatment, was the subject of his doctoral dissertation in the medical humanities (University of Texas Medical Branch, 2009), which was received with distinction. Goldberg has published a monograph on pain (2014) and multiple articles exploring pain from interdisciplinary perspectives that have appeared in a variety of outlet (law, policy, public health, ethics, history, medical humanities, etc.) He was fortunate to serve as a Fellow in 2012 with The Birkbeck Pain Project, and has lectured on pain at local, national, and international settings. His current research on pain emphasizes connections between the history of pain and its present inequitable undertreatment in the West, with a particular focus on the past and present experience of stigma that pain sufferers seem so likely to endure. A paper developing some of his views on these subjects in context of S. Weir Mitchell’s interest in phantom limb pain is forthcoming in a history of science journal in 2015.
You can follow Daniel on Twitter with @prof_goldberg
Correspondence to Daniel Goldberg
I realize that this reference is cryptic, but because prior publication rules are being interpreted by journals with increasing exactitude, the precise details unfortunately cannot be discussed here.
Bending, Lucy. 2000. The Representation of Bodily Pain in Late Nineteenth-Century English Culture. New York: Oxford University Press.
Boddice, Rob. 2014. Hurt Feelings. R Boddice (ed), Pain and Emotion in Modern History. Basingstoke: Palgrave MacMillian, pp. 1-16.
Daston, Lorraine J. & Galison, Peter. 2007. Objectivity. New York: Zone Books.
Erichsen, John Eric. 1866. On Railway and Other Injuries of the Nervous System. London: Walton and Maberly.
Foucault, Michel. 1994. The Birth of the Clinic: An Archaeology of Medical Perception. Translated by Alan M. Sheridan Smith. New York: Vintage Books.
Harrington, Ralph. 2003. On the Tracks of Trauma: Railway Spine Reconsidered. Social History of Medicine, 16(2): 209-223.
Holmes, Martha Stoddard. 2009. Fictions of Affliction: Physical Disability in Victorian Culture. Ann Arbor, M.I.: University of Michigan Press.
Jackson, Jean E. 2005. Stigma, Liminality, and Chronic Pain: Mind-Body Borderlands. American Ethnologist 32(3): 332-353.
Martensen, Robert L. 2004. The Brain Takes Shape: An Early History. New York: Oxford University Press.
Morris, David B. 1991. The Culture of Pain. Berkeley: University of California Press.
Moscoso, J. 2012. A Cultural History of Pain. Basingstoke: Palgrave MacMillan.
Pernick, Martin S. 1985. A Calculus of Suffering: Pain, Professionalism, and Anesthesia in 19th Century America. New York: Columbia University Press.
Scarry, Elaine. 1985. The Body In Pain: The Making and Unmaking of the World. New York: Oxford University Press.
Smith, Lisa Wynne. 2008. ‘An Account of an Unaccountable Distemper’: The Experience of Pain in Early Eighteenth-Century England and France. Eighteen Century Studies, 41(4): 459-80.
Wailoo, Keith. 2014. Pain: A Political History. Baltimore: Johns Hopkins University Press.
Wailoo, Keith. 1992. Dying in the City of Blues: Sickle Cell Anemia and the Politics of Race and Health. Chapel Hill: University of North Carolina Press.