Pain (14 page)

Borrowing the motif of feedback, information processing, and cybernetics from their colleagues in computer science at MIT, Melzack and Wall's theory offered a new approach informed by a view of the person in pain as a complex processor of information.
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A great deal of evidence questioned the notion that there was a specific pain pathway or a “pain cell” in the brain—they called this model “specificity theory.” If this model was correct, how could researchers explain phantom limb pain, for example? Another theory (so-called pattern theory) suggested that there were no specific pain transmitting fibers, because “all fiber endings … are alike, so that the pattern for pain is produced by intense stimulation of nonspecific receptors.” As Melzack and Wall saw it, both theories failed to account for such mysteries as phantom pain, placebo relief, and variations in pain perception.
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The idea in gate control theory that electricalstyle gates could close to complete circuits and transmit pain impulse but that those gates could be controlled by multiple means was scientifically vague yet culturally appealing. The theory offered no specificity about actual mechanisms operating these gates in any one person. But that was never the point; everyone's gates operated according to a different logic.

Melzack became the theory's chief entrepreneur as well as an effective critic of the dominance of surgery, psychiatry, and drugs in pain relief. Lobotomy, psychiatry, and drugs were, of course, under attack from other liberal elements that cast medical authority as a form of social control. Melzack believed that these fields dominated as pain relief methods by historical accident, merely because they happened to be well-positioned specialties after the Second World War, just at the moment when pain assumed greater importance in society. Surgeons and drug specialists had seized pain as their own, but the care of pain patients did not belong to them inherently. These accidents of history need not be permanent; “if we can recover from historical accident, these [alternative] methods deserve more attention than they have received.” Doctors, pain practitioners, scientists, and others needed to open their minds to unconventional approaches to therapy. This was the cultural work that gate control theory would do.
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This was no mere theory in the narrow sense but a sociological critique of entrenched power and practice. Pain management was being controlled by economic interests, critics contended. Surgeons, drug companies, and psychiatrists circled around the pain complainant, ready with costly drugs and harmful neurosurgery when other methods would do. If this was the pain economy, Melzack and Wall were not part of it; they had no ties to the pharmaceutical industry, they had no professional interest in being pain managers themselves. In the context of the 1960s, one could see how their arguments might be received as fresh, disinterested, objective, and revolutionary.

Where was the line, then, between true and false complaints? Who could judge the suffering of another? When was extraordinary relief necessary? These questions gathered political force in the 1960s. Asked aggressively, insistently, and skeptically, they amounted to a critique of established medical and of social norms. So while doctors like Robert Shaw of Harvard would decry “pathological malingering” as an evil of the times, the disease “a product of social welfare,” other doctors embraced the spirit of liberalism. In Shaw's formulation, even obviously feigned pain (motivated by a person's effort to obtain secondary gains such as disability benefits), could be designated as a legitimate, albeit psychological, disease—“pathologic malingering.” But as Shaw himself noted, the doctor's very skepticism of the “sufferer” and his confrontational attitude could
sometimes make matters worse.
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This thinking adapted for new times ideas about the personality and psyche of the pain complainant from a decade earlier. But now other physicians, pointing to the work of Melzack and others, contended that pain, all pain, was not a product of indulgence but a response to social oppression and ought to be taken more seriously and relieved.

FIGURE 2.2.
Psychologist and pain theorist Ronald Melzack, speaking on gate control theory in a 1965 film, “The Puzzle of Pain.”

Image courtesy of National Film Board of Canada.

Already, by the mid-1960s, this new thinking was having a modest impact, which expanded as more and more people cited gate control theory as justification for unconventional thinking and experimentation in relief. Gate control theory offered a new cadre of pain managers a framework for managing the growing diversity of pain complaints, as sufferers navigated the fine line between social sympathy and scorn. Because gate control theory was inclusive, it pushed the managers of relief like Bonica to liberalize their methods. It moved pain managers to consider radical and so-called “alternative” remedies—opening their minds to hypnosis, mind cures, and placebos. In an atmosphere of innovation and social
experimentation, the drive toward therapeutic diversity was unavoidable. As one observer later noted, this “more complex view of the pain phenomenon logically opens the way for a much more diversified attack on pain than was formerly customary.”
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This radical idea pushed liberal medicine and liberal law to expand their horizons; even the most far-reaching avenues of relief needed to be explored.

By 1968 (a year wracked by war, protest, race riots, political assassinations, and social turmoil), pain managers across government, law, and medicine grappled openly with pain's many and intersecting complexities. On the heated questions of disability and government, as one scholar noted in 1967, “The three problems which have recently given the courts the great difficulty … are 1) the shift of the burden of proof to the Secretary … [pressed to prove why any given plaintiff should be ruled ineligible]; 2) the role of pain in disability [following the
Page
precedent]; and 3) the place of so-called personality disorders in the disability scheme.” Seeking to call public and professional attention to pain, in 1968 the National Institute of General Medical Sciences threw its resources behind a new film,
Threshold
. Over the next few years, sixteen million viewers saw the award-winning production on television. The film also introduced thousands of dentists, doctors, nurses, and civic groups to the issues now swirling around this controversial field.
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The profile of pain managers and theorists (Bonica, Melzack, and others) continued to rise, along with the argument for continued liberalization.

By the end of the decade, liberal pain theory opened the way to new forms of cultural understanding bordering on cultural relativism in relief; nothing better captures this trend than Mark Zborowski's 1969 book,
People in Pain
. Zborowski studied Italian, Jewish, Irish, and so-called Old American (Anglo-American) men in a Bronx, New York, veterans hospital and concluded that “cultural relativity, which allows for the acceptance of a pattern of behavior in one group and its rejection in another, is also expressed in attitudes toward pain.” What was important to Zborowski, an anthropology student working with luminaries like Ruth Benedict and Margaret Mead, was that these men's cultural identities shaped their perceptions and experiences of pain. He anchored his claims about his subjects by leaning on the insights of Bonica and Beecher and critics of medical authority like Thomas Szasz, who portrayed psychiatric diagnosis as a form of social control. His subjects were men,
and he understood that gender norms shaped how and whether they behaved. “Behavior that is appropriate for women or children may be unbecoming for men. According to contemporary norms, soldiers should not cry, but the Greek heroes of the Trojan War shed tears without shame or guilt.”
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For ethnic men, pain meant different things; their pain behavior, Zborowski contended, reflected deeply internalized cultural values and ethnic affects.

FIGURE 2.3.
Advertisement in
Business Screen
for the widely seen 1968 film
Threshold
, produced by Tracy Ward for the National Institute for General Medical Sciences.

Image courtesy of History and Special Collections for the Sciences, UCLA Library Special Collections.

Culture, not science, defined what pain meant, who was considered the ideal pain patient, and how he or she would be treated; this was the bold political contention. Zborowski's core proposition was that Jews, Irish, Italians, and Anglo-Americans responded to pain differently, drawing on cultural norms and experiences—the Anglo-American's rational asceticism and trust in expertise, the Jewish veteran's “preoccupation with the symptomatic meaning of pain” and his lack of “anxiety-relieving devices,” and so on. Like the sociologist Irving Zola years earlier, Zborowski examined these responses to pain in light of the “transmission of cultural values and norms within society” and “the diversity and relativity of cultural patterns.” The danger of Zborowski's analysis was that cultural relativism could blur into outright ethnic typecasting, sometimes becoming one and the same. The Jewish veterans were complainers, made frequent demands on others about their pain; they were also suspicious of doctors. For Zborowski (himself Jewish, having published previously on the Russian shtetl), this understanding should lead not to stereotyping but to sensitivity; ethnicity was a fixed category of identity and a useful framework for understanding and responding to society's diverse pain-relief needs:

Like the Jewish patient, the Italian patient is often described as a person who makes no effort to control his emotional reactions to pain, who demands attention, and who freely expresses his pain by sound and gesture. On the whole, the behavior of the Italian patients is seen as nonconforming to the standards of the hospital, which emphasizes restraint and self-control. However, in speaking about the Italian patients, members of the hospital staff frequently mention a number of their positive character traits, such as personal warmth, congeniality, and good humor.

Italians were therefore trusting but vocal but also present-oriented—so that when pain diminished they ceased complaining. The Irish veterans, by contrast, tended to ignore pain to such an extent that it did not seem to exist. Like Jews, they were also highly suspicious. The “Old American” was the most stoic and rationalizing of the lot, insisting “that he does not want sympathy or attention, but merely the opportunity to show his working potentialities … [He] is the ideal patient, a model used as an example not only by the people who are directly involved in relieving his
condition, but also by members of other groups who, although they are also Americans, do not have the adjective old included in their national identification.”
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The very idea that pain, first and foremost, was culturally defined was disconcerting for any pain manager who believed there should be objective professional guidelines for relief, but the cultural move reflected so much about the era's tensions, as political movements along lines of race, gender, and sexual identity confronted medicine and its norms.
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As Zborowski noted, “Members of the medical profession are reluctant to differentiate patients according to religion, race, or nationality … Therefore, it is not surprising that a number of doctors at first expressed strong disapproval when asked about ethnic differences in response to pain. Some even implied a racist character of the research.” The very idea of ethnic pain put doctors ill at ease. Only after Zborowski convinced them that the research did not “threaten their professional and moral integrity” did some cooperate. Then, “many offered information that reflected … actual impressions formed during medical practice among the multinational and multicultural population of New York City.”
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In time, Zborowski's book (standing alongside gate control theory) would become an important support in the pain field's and society's grappling with cultural difference. Attention to culture in health behavior exposed a deep contradiction. On one hand, the book called for cultural sensitivity in medicine and for physicians to pay attention to cultural differences when assessing pain and bringing relief. On the other hand, the book was also a crude work of cultural stereotyping—casting patients as familiar ethnic stereotypes (complaining Jews, stoic Anglo-Americans). In this sense, the book reflects much about the conundrum of how to read pain into culture and culture into pain.
People in Pain
also revealed the forces of cultural relativism pushing American society in new directions and informing these questions of ethnicity, identity, compassion, and relief as the 1960s came to a close. Judging pain was never more complex, for the question of who was in pain now took pain managers deep into the psyche and into the complexities of cultural difference.