Elsevier

Social Science & Medicine

Volume 49, Issue 6, September 1999, Pages 727-736
Social Science & Medicine

`Total pain', disciplinary power and the body in the work of Cicely Saunders, 1958–1967

https://doi.org/10.1016/S0277-9536(99)00098-2Get rights and content

Abstract

Pain first emerged as an area of clinical specialisation in the 1950s, but more recently has attracted wider interest from social scientists and clinicians who seek to expand its understanding to incorporate ideas about meaning, embodiment and culture. So far there have been few empirical studies which focus on how ideas and practices about pain are changing in modern healthcare. This paper addresses these issues through a specific case study of the early writings of Cicely Saunders in the period 1958–1967. A professional training in the three disciplines of nursing, social work and medicine, coupled with a strong personal religious faith, provided the biographical context for the development of Cicely Saunders' concern with pain. Through these influences we find in her work with dying patients an emphasis on pain as a key which unlocks other problems and as something which requires multiple interventions for its resolution. From here the concept of `total pain' is formulated, to include physical, psychological, social, emotional and spiritual elements. This concept, which proved so important to the development of hospice clinical practice, is shown to have paradoxical and conflicting implications. Adopting current ideas about the social theory of the body, `total pain' may be formulated either as a nomenclature of inscription, or as a nomenclature of facilitation. It is suggested that both of these may be at work in the discourse of `total pain' and that an appreciation of each enhances our understanding of the concept.

Introduction

The emergence of a new social scientific and clinical interest in pain is a welcome development which seems set to expand. Central to recent discussion has been the notion that pain must be conceived as something altogether more complex than sensation alone and that the biographical, social and cultural contexts in which it is located and experienced are essential both to fuller understanding and to appropriate care. Thus Bendelow and Williams (1995) concentrate on the transcendence of the biomedical paradigm of pain and seek to establish in its place ideas from the phenomenology of embodiment and the sociology of emotions. From a nursing perspective Quint Benoliel (1995) draws attention to the shift from pain relief to pain management in clinical research and practice, a move made possible in part by increased recognition of the psychological dimensions of pain. Morris's wide-ranging analysis begins from the premise that pain “emerges only at the intersection of bodies, minds and cultures”, moving him to focus attention on “the neglected encounter between pain and meaning” (Morris, 1991, p. 3).

These commentators all draw attention to ways in which biomedical discourses of pain have been changing in the second half of the twentieth century. In particular Baszanger (1998) has shown how pain has been emerging as a clinical specialty since the 1950s, when Bonica, 1953, Bonica, 1960, Beecher, 1959 and others Maher, 1955, Turnbull, 1960 first developed clinical studies which took into account the need for attention to `chronic' as well as `acute' pain and argued for a wider, more multi-disciplinary approach to research and treatment. This transition involved a shift from the laboratory to the clinic and included the creation of a `world of pain' which would be addressed by teams of experts in specialist pain centres, whose interests were quickly to fragment into highly specialised sub-fields concerned with acute pain; terminal pain; cancer pain; chronic neuropathic pain and chronic post-operative pain (Baszanger, 1998, p. 102). So whilst the purely positivist view of pain had focused on the physiological signals sent to the brain when some part of the body is subject to physical injury, correctives to it had begun to appear as early as the 1930s when Sauerbruch and Wenke's work was published in German and sought to combine medical and philosophical discussion on pain (Sauerbruch and Wenke, 1963). The same decade also saw the publication of the work of Leriche (1939) on The Surgery of Pain in which he argued that laboratory studies cast little light on the `living pain' of clinical and day to day experience. Over time therefore it is possible to detect a widening of interest, from acute, mainly post-operative pain, to the question of chronic pain. Some of this new interest focused on the apparent purpose or function of pain. In the acute context, pain was seen as functional in drawing attention to injury or as an indicator of the need for rest and recuperation. By contrast chronic pain appeared dysfunctional and without adaptive purpose. It was partly because of this that the study of chronic pain became open to influences from the human sciences. Chronic pain in advanced, terminal disease, the subject of this paper, posed particular challenges at the level of meaning.

Bendelow and Williams, in setting out the agenda for a sociology of pain, call for “an approach which sees pain as physical and emotional, biological and cultural, even spiritual and existential” (Bendelow and Williams, 1995, p. 160). Surprising then, that they and other recent writers on the sociological, cultural and historical aspects of pain are almost completely silent about the work of Cicely Saunders. Even Baszanger's substantial volume can manage only three lines on Cicely Saunders' contribution and these contain no reference to the work on pain (Baszanger, 1998, p. 64). This may well be because the Saunders writings have until recently been chiefly known only within the palliative care specialty. Yet it was Cicely Saunders who in the course of her clinical work with dying people coined the term `total pain' precisely to capture the multiple dimensions, called for by later commentators, and who in so doing furnished the modern hospice movement with one of its most powerful concepts Baines, 1990, Storey, 1996. This paper therefore has two purposes. First, it seeks to uncover the archaeology of Cicely Saunders' thinking about `total pain', through an analysis of her early writings in the decade prior to the opening of St. Christopher's Hospice, which she founded in 1967. Second, it explores the implications of `total pain' in the light of recent commentary on the social theory of the body, finding within the concept some contradictory tendencies.

Section snippets

Method and context

The present paper arises out of a wider collaborative programme of work concerned with the history of hospices and palliative care1. The programme has included archival cataloguing and preservation (Lydon, 1998) as well as analysis of documentary sources; it also involves the establishment of an archive of oral history interviews with key founders of hospice and palliative

The archaeology of `total pain'

Experience as nurse, almoner and doctor brings a certain breadth to Cicely Saunders' writings, even from the earliest years. Neither is Christian language missing from these professional publications. One reviewer, noting this, urged medical readers not to quit because of it, lest they “lose a great deal of very practical instruction in devices for the relief of pain and distress and the skilful use of drugs” (The Lancet, 1960, p. 735). There is an interesting distinction between sources in

`Total pain', disciplinary power and embodiment

What were the conditions of possibility which allowed the concept of `total pain' to emerge in this way and at this time? And how might we view such a development from a theoretical perspective?

I have already indicated that `total pain' is a paradox. On the one hand it seems to humanise physical suffering, to acknowledge that pain has to be understood as something including but greater than, physical matters of sensation. In this sense pain is being used as a key to unlock other clinical

Acknowledgements

Financial support is acknowledged with gratitude from: the Wellcome Trust (Grant No. 043877/Z/95Z); the Sir Halley Stewart Trust and the Royal Society. I thank my colleagues on the project, Neil Small, Paul Lydon, Gilly Pearce, together with Clare Humphreys and David Cantor for their interest and support. I am grateful also to Margaret Jane and Jane Seymour for help in preparing this paper.

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