17,99 €
Mehr erfahren.
- Herausgeber: John Wiley & Sons
- Kategorie: Geisteswissenschaft
- Serie: Key Themes in Health and Social Care
- Sprache: Englisch
Pain in one form or another is probably the most common symptom presented to medical and healthcare professionals. Long a subject of biomedical interest, more recent biopsychosocial theories have extended the study of pain as a concept which is highly individual in the way it is experienced. Today's landscape offers a broad array of approaches to understanding pain and, crucially, to alleviating its impact. This concise and accessible volume aims to make sense of what is at first sight an eclectic mix of theoretical and practical work on pain, from a distinctly sociological perspective. While there has been much quantitative medical research on pain, in exploring sociology's important contributions to this field Elaine Denny offers insight into the world of those living with pain and the meaning it has in their lives. She provides readers with a range of explanations of pain and various influences on the experience of pain, critically analysing competing schools of thought and embedding this work in the everyday practice of providing care. The result is an illuminating volume for students of health and medical professions studying pain, the body, and the sociology of health and illness.
Sie lesen das E-Book in den Legimi-Apps auf:
Seitenzahl: 298
Veröffentlichungsjahr: 2017
Ähnliche
Contents
Cover
Title Page
Copyright
Introduction
1 Historical Perspectives on Pain
Issues in the study of history
Concepts of pain in antiquity
Pain and Christian teaching
The Enlightenment
Disappearance of the sick-man
Foucault and the birth of the clinic
The pain of surgery
The hysterical woman
The early twentieth century
The gate-control theory of pain
Summary
2 Sociological Theory, Concepts and Pain
Sociological traditions
Structuralist theories
Social action theories
Interpretive theories
Feminist theories
Foucault and power
Sociology of the body
Summary
3 The Experience of Pain
Illness narrative
Examples of illness narratives
Biographical disruption
Acute pain
The experience of torture
Summary
4 Care and Care Services for Pain
Caring for someone in pain
The perspective of health professionals on levels of pain
Pain rating scales
Pain during procedures
Pain clinics
The hospice movement
Alternative and complementary therapy
Adherence to medical advice
Summary
5 Structures of Diversity and Pain
Gender
Gendered pain
Genital mutilation
Race and ethnicity
Culture
Age
Disability
Summary
6 Pain as a Contested Experience
What do we mean by ‘contested’ and ‘unexplained’?
Contested illness
What makes these illnesses contested?
Unexplained symptoms/illness
Uncertainty
Being believed
Summary
7 Emotional Pain and Suffering
Emotions
Suffering
Mental health
Psychologising pain
Infertility
The biopsychosocial model of pain
Summary
8 Health Professionals’ Perspectives on Pain
Doctors as the legitimate experts in health and healing
Guided discovery and diagnosis
Heartsink patients
Clinicians’ perceptions of levels of pain
Clinicians inflicting pain
Summary
Concluding Thoughts
References
Index
End User License Agreement
Guide
Cover
Table of Contents
Begin Reading
Pages
ii
iii
iv
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
181
182
183
Key Themes in Health and Social Care series
Alan Cribb and Sharon Gewirtz, Professionalism Nick Fox, The Body
Janet Hargreaves and Louise Page, Reflective Practice
Pain
A Sociological Introduction
ELAINE DENNY
polity
Copyright © Elaine Denny 2018
The right of Elaine Denny to be identified as Author of this Work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.
First published in 2018 by Polity Press
Polity Press65 Bridge StreetCambridge CB2 1UR, UK
Polity Press101 Station LandingSuite 300Medford, MA 02155USA
All rights reserved. Except for the quotation of short passages for the purpose of criticism and review, no part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the publisher.
ISBN-13: 978-1-5095-2722-9
A catalogue record for this book is available from the British Library.
Library of Congress Cataloging-in-Publication Data
Names: Denny, Elaine, author.Title: Pain : a sociological introduction / Elaine Denny.Description: Medford, MA : Polity Press, [2017] | Includes bibliographical references and index.Identifiers: LCCN 2017021111 (print) | LCCN 2017022759 (ebook) | ISBN 9781509527212 (Mobi) | ISBN 9781509527229 (Epub) | ISBN 9780745655543 (hardback) | ISBN 9780745655550 (pbk.)Subjects: LCSH: Pain. | Pain--Social aspects.Classification: LCC BF515 (ebook) | LCC BF515 .D466 2017 (print) | DDC 306.4/61--dc23LC record available at https://lccn.loc.gov/2017021111
The publisher has used its best endeavours to ensure that the URLs for external websites referred to in this book are correct and active at the time of going to press. However, the publisher has no responsibility for the websites and can make no guarantee that a site will remain live or that the content is or will remain appropriate.
Every effort has been made to trace all copyright holders, but if any have been inadvertently overlooked the publisher will be pleased to include any necessary credits in any subsequent reprint or edition.
For further information on Polity, visit our website: www.politybooks.com
Introduction
Pain in one form or another is probably the most common symptom presented to healthcare professionals and has long been a subject of biomedical and psychological interest. More recently, biopsychosocial theories of pain have also emerged. The work of Melzack and Wall (1965, 1968) in describing and refining ‘gate-control theory’ has been very influential in extending the study of pain beyond a measurable concept to one which is highly individual in the way it is experienced. However, this work has been set within a naturalistic framework, and only much more recently has a sociological analysis of pain been attempted. While students in the natural and social science disciplines have access to discrete bodies of knowledge, students in the health professions, and indeed people searching for explanations for their own pain, tend to make use of an eclectic mix of theoretical and practical work. This can, however, lead to confusion over seemingly disputed territory and conflicting arguments and conclusions. Making sense of the competing arguments may be a difficult task for people not versed in appraising different forms of evidence. With that in mind, this volume seeks to be accessible without being simplistic.
To that end, I will begin by clarifying how certain terms will be used in the book. ‘Clinicians’ or ‘health professionals’ are used as generic terms for physiotherapists, nurses, doctors, etc., working in clinical practice. The phrases ‘long-term condition or illness’ or ‘chronic disease or illness’ reflect how the terminology has changed as ideas about those living with these states of health have changed. I tend to employ the terms used in the studies I cite, but in other places adopt the common distinction between ‘disease’ and ‘illness’: the former understood as a medically diagnosed condition, the latter as the experience of living with health problems. However, it must be acknowledged that there is no clear boundary between ‘normal’ and ‘pathological’, and it is this that frequently results in tensions in health and healthcare.
You will also come across concepts that are problematised in some parts of the book but used uncritically in others, such as that of diagnosis. Similarly, in some places it may seem that binary oppositions such as that between acute and chronic pain are not being challenged as false divisions. These concepts and distinctions are so universal and hegemonic that the English language does not always offer alternative terms that would allow us to recognise the contested nature of the dominant discourse that surrounds them. Where relevant, I have highlighted the contested nature of these concepts, but elsewhere, in order to avoid repetition, I have left them unchallenged.
Finally, the word ‘experience’ is used frequently throughout the book, and its meaning may appear to be somewhat taken for granted. Unless interpreted differently in relation to the studies cited, I adopt the definition given by Kleinman and Seeman, who argue that ‘experience’ is not ‘a deep and individual subjectivity’, but rather represents ‘the intersubjective, felt flow of events, bodily processes, and life trajectory which always takes place within a social context’ (2000: 234). Here the link between the personal, the cultural and the social is acknowledged: experience does not take place in a vacuum, but is mediated by cultural and social structures, which will be utilised to explore individual narratives.
Much of the medical research on pain has been conducted using quantitative methods, and although this provides information on large numbers of people, it tends to lack context. Sociological research in the area has mainly utilised qualitative approaches. This does not produce results that can be generalised to the wider population, but it does give us insight and understanding in relation to the world of those living with pain, the meaning it has in their life, and how they make sense of it. It can also seem that the results of such research are usually negative, but, as C. S. Lewis states, ‘Pain hurts. That’s what the word means’ (1940: 105). It may be that those who are in the most extreme forms of pain, or those whose pain is not managed well, are more likely to take part in research that gives them a voice.
If you suffer from pain, particularly long-term pain, you may find that parts of this book, or the individual stories it presents, resonate with your own experience, or help you to understand or make sense of your life. Unfortunately, though, you will not find a new treatment to try, or anything that will ease your pain. The book is an exploration and examination of various facets of pain from a sociological perspective. There are many authors and researchers on pain whom I have not cited, and one criticism of the study may be that I have neglected a classic text or respected authority. My focus here is on an exploration of pain that attempts to be illuminative, rather than exhaustive, in its use of the literature.
My own interest in exploring pain began in the late 1980s when I was researching women’s experience of in vitro fertilisation (IVF). I interviewed a woman and her husband who had – at great expense, both financial and personal – gone through three cycles of IVF, all of which had been unsuccessful. It was then discovered that the woman suffered from endometriosis, which meant that the IVF could never have worked for her. Her husband told me that his wife had always experienced very painful menstruation, which they had repeatedly informed health professionals about, and which should have led to a faster diagnosis and treatment prior to IVF. However, his wife’s pain was never taken seriously; she was fobbed off and told that the pain was psychological and caused by her inability to conceive. This is a story I have heard many times since, as will become apparent later in the book. At the time I was left wondering how a symptom such as severe pain could be totally ignored and trivialised in the management of a patient, particularly when treatment is proving unsuccessful. It was some years later that I had the opportunity to explore these issues further, when I started research with other women who had been diagnosed with endometriosis. I discovered that the way pain is experienced and managed is highly complex and multi-layered, with assumptions and value judgements made by those experiencing pain, by those treating them, and by their significant others.
More recently I have been involved in teaching a module on the sociology and psychology of pain to health professionals studying for an MSc in pain management. The assessment involved students taking an aspect of practice relating to pain (anything from a case study to an area of health policy) and analysing it using the psychological and sociological concepts introduced in the module. Students could quite easily apply psychology to their chosen topic, but frequently had problems in seeing the relevance of sociology to what they perceived as the very personal nature of experiencing pain. However, when they discussed their assessment topics with other students and staff it usually became apparent that there were situations where a sociological analysis was a useful tool in the understanding of pain. This book is the culmination of those discussions with students and of my research, both empirical and theoretical, in relation to pain over the past fifteen years.
Bendelow (2000) argues that the most salient role for a sociology of pain is to deconstruct the rigid objectivity of the biomedical model, and to restore pain to those who actually experience it. This is what I hope to achieve by using a range of sociological concepts and empirical studies to explore the subject. Nearly 50 million Americans report suffering significant or severe chronic pain, and those with the worst levels of pain – around 40 million – have poorer health status, use more health services, and suffer more disability than those with less severe pain (Nahin, 2015). In Europe approximately 20 per cent of the adult population has chronic pain and, besides the physical and emotional cost to the individual and their family, managing it is estimated to cost more than €200 million (Van Hecke et al., 2013). A systematic review of the incidence of chronic pain in the UK suggests that between one third and one half of the adult population are affected by it, with between 10.4 per cent and 14.3 per cent reporting pain that is moderately or severely limiting (Fayaz et al., 2016).
Away from the wealthier countries of the West, chronic pain is becoming a greater health problem, as lower rates of infectious disease mean more people live into old age. Chronic pain is associated with female gender, older age (although the incidence of lower-back pain decreases with age), ethnicity and lower socio-economic status (Bridges, 2012). Fewer than 20 per cent of chronic pain sufferers attend a specialist pain clinic (Van Hecke et al., 2013). Physically, emotionally and economically, long-term pain is one of the most pressing public health issues of the twenty-first century, and is likely to become more so with greater longevity, as people spend more years of life with some degree of incapacity.
Chapter 1 sets the scene by providing an overview of pain in its historical context, some of which still has relevance today. Pain has been viewed over the centuries as a punishment from God and as evidence of sin, particularly the sin of carnal knowledge, through to Enlightenment theories, the hegemony of the scientific method, and recent explanatory models such as the neuromatrix.
In Chapter 2 we move towards a sociological paradigm by considering the work of some of the founding thinkers in sociology, as well as more recent developments in the study of pain that have moved away from the theoretical positions of the past towards more relational approaches.
Chapter 3 is concerned with the experience of pain. It starts by considering some of the ways in which sociologists have conceptualised pain, for example as biographical disruption. Here we review some of the sociological work that has captured the lives of people living with pain, how it affects their families, and the stories they tell to make sense of their experience and to inform others of its impact.
Chapter 4 moves away from the individual to think about care and carers. It looks at the provision of services, both public and private, and the pluralistic nature of provision. Here we also consider the perspective of those who live with, and perhaps care for, a person in pain.
Since the way in which pain is experienced and interpreted is not universal, Chapter 5 explores the structures of diversity and the ways in which they influence the experience of pain. The impact of gender, age and ethnicity on the experience of pain will be the focus of this chapter. However, the importance of not essentialising any one social categorisation, and not treating people as powerless agents in relation to their culture or gender, will also be acknowledged.
Chapter 6 will consider those whose pain is marginalised, and the way they describe their own experience and make sense of it in the context of their lives. Many people never receive an explanation for their pain. The consequences of being labelled as having ‘unexplained pain’ and the way that people respond to it – for example by striving to be believed and viewed as credible patients – will be explored using recent qualitative studies on the experience of painful conditions.
In Chapter 7 we move away from discussing the physical pain that is the focus of most of the chapters. For some individuals, and some health professionals, the pain they experience or encounter is emotional, and recently attention has been drawn to suffering as a painful part of life. While avoiding a dualistic approach to pain as being either physical or emotional, this chapter will look at some of the recent research on emotional pain and suffering. It will also reflect on the increasing medicalisation of that suffering.
Chapter 8 will turn from the person in pain to consider the perspective of the health professionals who treat them. It will examine how health professionals interpret and respond to pain, contrasting this with the patients’ perspectives discussed in previous chapters. How the meaning of pain and its interpretation may differ between patients and their doctors will be shown to influence the quality of communication during health consultations, and may also affect treatment.
Finally, in the Conclusion, I bring together the topics of the previous chapters and draw some conclusions about viewing pain through a sociological lens.
CHAPTER ONEHistorical Perspectives on Pain
Before examining its place in the modern world it is worth taking a brief look at pain in a historical context, because, as Abrams (1982) argues, serious questions about the contemporary world cannot adequately be answered without reference to history. The purpose of this chapter is not to provide a detailed analysis of pain in different historical periods, but to demonstrate the changing nature of perceptions and interpretations of pain, and how these are bound up with social context and with dominant ideas that are culturally and historically specific. As such, the examples discussed in what follows are illustrative rather than representative. The chapter is also unashamedly Eurocentric, since attempting to provide a global history of pain would be an impossible task in a volume such as this. Some comparative analysis will, however, feature in Chapter 5.
Healing work was the forerunner of the health-work systems that we know today, and was much more informal in nature. It was carried out by many different people – e.g. bone setters or herbalists – who competed with doctors for custom. Most healing work was domestic in nature, performed by women, and usually unpaid. While acknowledging that these different healers would have been involved in the relief of pain throughout history, the main occupational group considered in this book will be the medical profession. This is because its development and hegemony in defining and legitimising illness was a continuation of the professionalising project of the period since the Enlightenment. Doctors were historically few in number – there were fewer than 100 physicians outside London before the eighteenth century – and were available to only a small proportion of the population, but their importance grew as they increasingly gained jurisdiction over health work, and excluded or incorporated other types of healer. However, as we will go on to discuss, this did not occur because doctors were more successful than other healers at curing patients, since their domination occurred before many effective therapies were available.
Issues in the study of history
First, we need to highlight some of the problems inherent in taking a historical stance towards an issue. We should always bear in mind who wrote accounts that have been preserved, with what purpose, and how representative of society they were. Rafferty, for example, notes ‘a bias towards the preservation of evidence by those classes whose culture is mediated through the written rather than spoken word’ (1995: 52). Since the majority of the population was illiterate before the introduction of mass education in the 1870s, those classes were restricted mainly to the rich and the clergy, who had access to education.
Second, care should be taken to avoid the problem of present-centredness. That is, in seeking to study history we are necessarily taking as our starting point the knowledge and values of the present, which may not be relevant to the past. The period and context of historical documents need to be considered. Judgements based on present-day values may not elicit reliable meanings in relation to the standpoints of previous generations. Here, this will mean questioning contemporary notions of ‘pain’, ‘suffering’, ‘mind’, ‘body’ and ‘spirit’ when considering the historical uses of such terms.
A quick look through the indexes of recent books on the history of medicine – including those by Roy Porter, the eminent former Professor of the Social History of Medicine at the Wellcome Institute – reveals a dearth of entries for pain. Porter himself, in one of his few chapters on pain (written with his wife Dorothy), offers some insight into why this might be. Although some people did record their ailments, what was written down is selective and misleading, as those with the most profound symptoms had neither the strength nor the desire to record them. Some chronic pains are the exception here, for example gout, of which there are many descriptions (Porter and Porter, 1988).
Concepts of pain in antiquity
Although there is a lack of historical publications on pain, a classic text on the history of pain was published in 1993 in Paris, a few months before the death of the author from cancer, aged forty-three. In it Roselyne Rey (1995) traces the cultural perception of pain from antiquity to the twentieth century, although her focus is mainly on physical pain. Her treatise begins with the Hippocratic tradition of ancient Greece, which continued to be the bedrock of scientific medical education until the middle of the nineteenth century. Here pain is seen not as an isolated symptom, but as part of an overall assessment of how the patient looks, of their behaviour compared to how they generally behave, and of their bodily fluids, such as urine and sweat. This system of medicine placed great importance on prognosis, and the doctor’s success was judged on how well he predicted the course of disease. Pain was viewed as a vital clue in this endeavour, as well as being an indicator of the success or failure of treatment when it subsided or intensified, but it was given no other significance. Treatments for pain included the application of heat or cold, cauterisation of the painful part, and the use of narcotic herbs. Hippocratic ideas were widely disseminated throughout Asia Minor and to the rest of the known world. The work of Galen in the second century CE placed great importance on pain, both as a symptom and a mechanism. He introduced different classifications of pain that are still in use in modified form, for example ‘pulsific’ (throbbing) and ‘tensive’ (stretching) (Rey, 1995).
Rey argues that despite developing a knowledge base about the body, and classifying different forms of pain, ancient medicine did not reach any conclusions about its usefulness. This she puts down to the fact that it was based in the rival philosophical traditions of Epicureanism and Stoicism, neither of which believed that there was any value in the experience of pain. Of the two traditions, Stoicism is the most useful in tracing perceptions of pain through the ages, since its ideas on pain persisted for many centuries. For the Stoics the production of knowledge emerged from reason and a communing with nature. A belief in self-control and virtue was seen as necessary for human fulfilment. Their attitude to pain was to endure it and not become preoccupied with it. We still hear people use the term ‘stoical’ to describe someone who puts up with pain or hardship without complaint.
Pain and Christian teaching
During the Middle Ages Stoicism became linked with Christian ideas in the Western world, and the Galenic tradition influenced both the West and the Arab world. Within Europe the Christian preoccupation with Christ’s suffering may have heralded a more individualistic approach to pain, which certainly flourished during the Renaissance. Pain reminded Christians to empathise with Christ on the Cross (Newton, 2011).
In Britain, Christian teaching rooted in the notion of Divine Providence had a major influence on perceptions of pain and its meaning right up to the nineteenth century. Put simply, the idea was that God in his omniscience controls all that occurs in the universe, good and bad (McCann, 2012), and that the existence of evil or suffering can thus be explained by its having a higher purpose. These ideas survived despite the changing attitudes of the Enlightenment and the growth of scientific explanation. They are examined by the historian Hannah Newton in her work on the pain experienced by children, who are rarely the focus of historiography on patienthood, despite the high incidence of child mortality up to the end of the nineteenth century. She points to the paradox within Christian beliefs about the meaning of sickness: ‘On the one hand, sickness was often painful, frightening, and a source of spiritual guilt and grief, but on the other hand, it could be a time of spiritual and emotional fulfilment, and even occasionally joy’ (Newton, 2011: 154). If God brought pain as punishment for sin, then the sick also experienced guilt as they had brought it upon themselves. It was necessary for the sufferer to dwell upon these sins so that once they repented the sickness would be taken away. Examples of sins that children admitted to were not going to bed when their mother told them to, gluttony, and playing on the Sabbath. Children’s sickness could also be seen as resulting from the sins of their parents. The more positive effect of Divine Providence would be the emotional and spiritual comfort to be gained from the knowledge that something good would come from suffering. While the body may be hurting, its suffering is benefiting the soul by purging sin and leading to salvation in the afterlife. So pain could be suffered willingly or with resignation.
Newton’s examples come from devout, wealthy or middle-class Puritan families and may not be representative of the population, even though religiosity was widespread during the period covered (1580–1720) (Newton, 2011). Rey argues that it was the birth of the notion of the individual during the Renaissance that allowed a shift in the understanding of pain: no longer was it seen as part of a wider purpose but as something residing within the individual. It is this latter view which has been perpetuated through the development of science and the biomedical model, to which we now turn.
The Enlightenment
The Enlightenment period heralded a move away from the dominance of the Church in explaining events and phenomena, and a move towards the era of rationality and science (Rey, 1995). The development of observation and secularisation became dominant features that changed the conceptualisation of pain. Reason determined the development of ideas, observation, and experimentation on the sick, and the dissection of dead bodies added to anatomical and medical knowledge at an impressive rate. Yet, as Porter (1997) informs us, Enlightenment thinking in medicine was not monolithic, and there were many rival camps throughout Europe and America. He also points out that scientific findings were rarely accompanied by clinical improvements, which may account for the continued influence of religion noted by Newton.
Here we can offer only a very superficial description of the Enlightenment and the way it influenced thinking, but for our purposes in documenting shifts in the perception and interpretation of pain, the important point is that the era brought about a change in the way the body was viewed: from being seen as an instrument of the soul to a more mechanistic view of it as a machine operating according to natural laws. Proponents of this new thinking such as René Descartes and Isaac Newton argued that these laws were pre-existing and that discovering them would lead to a complete understanding and predictability of man [sic] and the universe. An example of this is Cartesian dualism, which held that mind and body are distinct and each is complete; that is, each can be understood without reference to the other (Hawthorne, 2007). It is often oversimplified as a mind–body split. Cartesian dualism has been widely critiqued within the sociology of pain, notably by Gillian Bendelow, and discussion of this issue will be found in several of the following chapters. Porter, however, plays down the influence of Descartes, at least in Britain, and argues that Locke’s empiricism, which emphasised the gaining of knowledge through experience, was more influential in advancing scientific investigation (Porter, 2000). Scientific explanations of pain did not, however, replace earlier thinking overnight; they co-existed with religious interpretations into the twentieth century, and indeed to some extent still do.
During the Enlightenment era treatments for pain moved away from purges and confessions of sin. While alcohol was the most common substance used for pain relief, the eighteenth century became ‘the golden age of medically prescribed opiates’, even though they had their own drawbacks in terms of being addictive and causing intestinal problems (Porter and Porter, 1988: 102). Opium was ubiquitous, mainly in the form of tinctures such as laudanum, and fairly freely available despite the fact that some of its uses were dubious and even criminal. It was taken to relieve menstrual cramps, given to babies to make them sleep, and used for many other reasons. It is often mentioned in nineteenth-century literature; for example, Mary Shelley’s Dr Frankenstein takes it to help him sleep, and the moonstone in Wilkie Collins’ novel of the same name is stolen by Franklin Blake after he is secretly given laudanum.
Debates were had over whether pain should be treated with ‘the same’ or ‘the opposite’ (similar to homeopathy) (Rey, 1995: 128). For example, the hot pain of inflammation was treated by the application of the cold qualities of narcotics, while for the pain of gangrene more pain was inflicted by the procedure of amputation, which was necessary for healing. Despite these divergent views on treatments, there was a consensus in Enlightenment thinking that the experience of pain was unacceptable and must be eliminated. Within the dominant culture of reason it seemed to serve no purpose, and was something that the medical profession had to confront, even if this involved inflicting more pain (Rey, 1995).
Disappearance of the sick-man
This historical shift in the meaning of pain has been described by Jewson as ‘the disappearance of the sick-man [sic]’ (1976: 225). He argues that between 1770 and 1870 (although these are indicative rather than exact dates) there were three modes of production of medical knowledge, each associated with a particular cosmology (or way of knowing) that determined the knowledge that was produced. At the start of the period Bedside Medicine focused on the total body complex – physical, emotional and spiritual – with the mind and body being viewed as part of the same system of pathology. Medical practitioners speculated on the interpretation of symptoms and provided individualised therapies. Hospital Medicine developed as a result of the medical upheaval in France following the French Revolution, which led to the growth of institutionalised medicine. Disease became objectified, facilitated by having many patients in one place who could be observed and examined, by developments in pathology with a focus on diseased organs rather than the whole person, and by the development of statistical analysis. The third mode of medical cosmology, Laboratory Medicine, developed in German universities from the 1840s and was concerned with diagnoses made from the study of the physiological processes within cells. So this trajectory has an orientation from ‘person to object orientated cosmologies’ (Jewson, 1976: 231) – a reductionist approach that has seen the focus shift from the whole person, through diseased organs, to abnormalities within cells as holding the key to diagnosis. It also saw a change in power relationships as the esoteric scientific knowledge that was the exclusive preserve of the medical profession achieved greater status than the experiential knowledge of the patient.
Foucault and the birth of the clinic
The French philosopher Michel Foucault (1973) also associated the move to locate illness within the body with the period around the French Revolution and the growth of pathological anatomy. In The Birth of the Clinic, Foucault uses the concept of ‘the gaze’ (or le regard in the original French) to describe a way of seeing the body which is constructed by a discourse of disease becoming visible to the clinician (see Chapter 2 for a discussion on ‘discourse’). As a form of knowledge this was facilitated by ‘a reorganisation of the hospital field, a new definition of the status of the patient in society, and the establishment of a certain relationship between public assistance and medical experience, between help and knowledge’ (1973: 196).
The years following the French Revolution saw an increase in the numbers of poor people receiving medical treatment free within the large teaching hospitals (the clinics of the book’s title) run by municipal administrations. This allowed doctors to observe large numbers of people, collect information about them, and group this according to pathological similarities. It also allowed them to experiment on a class of patients who did not possess the power to refuse. Perhaps most importantly, symptoms apparent before death could be aligned with pathological changes in organs that could be observed in postmortem examinations. The clinical gaze thus located disease within the body, but this was only possible thanks to the symbiotic relationship between body, disease and a specific medical discourse that emerged in post-revolutionary France. Medical discourse at any time is not the result of a gradual unfolding of knowledge but a shift in the way that knowledge is constructed. As Armstrong argued: ‘A body analysed for humours contains humours; a body analysed for organs and tissues is constituted by organs and tissues; a body analysed for psychosocial functioning is a psychosocial object’ (1994: 25).
The institution of the major teaching hospital as the location of large numbers of patients and thus the site of the medical gaze quickly spread to other parts of Europe and subsequently to other parts of the world. As will become apparent in later chapters, the medical discourse that emerged from this institution still influences the practice of medicine today.
The pain of surgery
It was during the nineteenth century that the greatest advances in understanding pain and developing treatments were made. Driven by scientific thinking, experimentation was under
