Inventing Pain Medicine: From the Laboratory to the Clinic (review)

“Chronic pain definitely seems to create a crack in the dualism underlying our modes of thought” (p. 295). Is pain a thing of mind or body—or both? And if the physician’s powerful detection technologies cannot “find” it in the body, where and what is the patient’s suffering? As anthropologist Isabelle Baszanger shows, this philosophical fracture runs throughout the pain-medicine field—through its history, its political structure, and its clinical work. One of the things I most admire about the book is that Baszanger, having embarked on an ethnographic study of pain clinics in France and realizing that the history of the pain field was essential to her analysis, made a serious commitment to this added scholarly task and set herself to learn and understand that history. The result is a bidisciplinary study of rich insight and compelling interest, one that leads the reader to confront the question of “what medicine really is” (p. 305).

Baszanger presents two interlocking arguments: the inscription of the history and theory of pain medicine in clinical practice, and the inscription of clinical practice onto the body and the person of the patient. She begins by tracing the history of the modern pain-medicine field, focusing on three key figures: anesthesiologist John Bonica, whose 1953 book The Management of Pain redefined pain as a multidisciplinary medical problem and a disorder in its own right; and psychologist Ronald Melzack and physiologist Patrick Wall, whose 1965 gate-control theory she terms the “theory for the construction of a world” (p. 57). The newly forming world, which took on tangible form with the founding of the International Association for the Study of Pain in 1973, represented a political alliance between two distinct perspectives toward “Bonica’s package”: the “core object” of pain, and the multidisciplinary approach (p. 105).

One group, following Bonica’s lead, sought to establish pain as the legitimate object of medical education and practice and to improve its management through standard therapeutic modalities—analgesics, anesthetic block, and, more recently, neurostimulation—which help many, but not all, chronic pain patients. The second group, drawing on Bonica’s vision of pain as a multidisciplinary problem, and on the work of psychologists Wilbert Fordyce and Richard Sternbach, as well as Melzack and Wall, has situated pain—in particular, intractable chronic pain—in the person, at the nexus of sensation, cognition, emotion, and behavior. Physicians working from this perspective may use any of the standard modalities, but the emphasis is on behavioral modification: on assisting the patient to reinterpret the components of experience that have been learned as pain. Baszanger places this second approach within the analysis of David Armstrong, and William R. Arney and Bernard J. Bergen, of “a new medical logic” (p. 46) that expands the clinical gaze outward from the body to “the whole patient” and his/her experience of illness, and suggests that the pain clinic may be the model for the medical management of chronic disease at the end of the twentieth century.

From history, Baszanger moves into anthropology. Her detailed observations of patient consultations at two French pain clinics, one representative of each perspective, and her separate interviews with physicians and patients at the clinics, inform her differential analysis of medical work and power relations. At the first clinic, the physician assumes control of the pain and its treatment; the patient is object and spectator. At the second, the physician and patient work together to interpret and reshape the patient’s experience in relation to the pain; the patient is subject and actor, but again, and intensively, object. The reshaping applies to the total patient and, if the therapy is to succeed, the physician’s interpretation must prevail. The patient is allowed neither autonomy nor real knowledge of his/her own pain.

This is a troubling view of holistic...