Pain (15 page)

If pain was cultural, then what could this mean for relief? By the end of the decade, sufferers and pain managers both saw the radical subjectivity of pain as an open invitation to explore ever more unconventional
relief methods—from saline injections into the spinal column to dorsal column stimulation to LSD and acupuncture. The gateways to relief were now swung wide open. Looking back from 1970, John Bonica reflected that the gate control concept was “appealing because it helps explain certain peculiar phenomena of pain.” Gate control theory had energized his field. The theory endorsed diversity—welcoming alternative medicines, legitimizing emotions and feelings, and pushing the patient's consciousness into the foreground of legitimate medical and legal discussion.
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By the early 1970s, gate control had become a metaphor for an era rich with new therapeutic and political possibilities. It encouraged speculation and individualized relief, from drugs to surgery to hypnosis to many other ways of manipulating the mind and soothing the body. Even those concerned about the hippie-related menace of LSD noted that, among that drug's “bona fide medical uses and benefits …, it has been used as a ‘death therapy' to help dying people face the end more serenely and with less pain.” In its vagueness about what or who controlled the pain gateways, the theory endorsed a laissez-faire, even libertarian, approach to relief. Conventional science seemed unsuited to the task of truly understanding and judging pain. As a Boston psychiatrist concluded in 1971, “In evaluating chronic pain, a search for evidence that pain exists is fruitless and irrelevant.” With multiple pathways now posited—neurosurgery, drugs, hypnosis, psychotherapy, and even the use of electrical stimulus—to “switch off” pain—an era of social and therapeutic diversity was at hand.
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Like many who had been in the pain field for decades, the British neurology researcher P. W. Nathan was deeply ambivalent about the theory that awakened his sleeping field. An elder statesman in pain research, he scoffed at the theory's unconventional path to popularity, swept into fashion it seemed by the cultural currents of the time. Resting on almost no experimental foundations, the gate control model had an appeal that ran far ahead of the flimsiness of any scientific, clinical, and laboratory findings. Yet Nathan gave gate control theory his begrudging support because, despite its many failings, it had encouraged new pain interventions. The theory
worked
, in a manner of speaking, because it had opened up the field to experimentation that had been wildly productive for pain medicine. “Although the theory has led to the successful treatment of
chronic pain, this does not mean that it is correct,” he noted wisely. “Ideas need to be fruitful, they do not have to be right. And curiously enough, the two do not necessarily go together.”
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Fruitful it was. Buoyed by the theory, new practices in pain management flourished—the multidisciplinary pain clinic, the idea of patients controlling their own analgesia dosage, and even the rise of alternative relief like hypnosis, acupuncture, and electrical stimulation.

Pain theory had become political, even revolutionary, in several new ways—by challenging professional norms and authority, by encompassing social and cultural suffering more broadly, and by welcoming alternatives and experimentation. Methadone for relief of heroin addiction was one contentious incarnation of this liberal broadening of relief. In 1967, the pain of withdrawal from methadone was seen as far less severe than withdrawal from heroin or morphine—adding to the drug's valorization as an answer the urban heroin crisis. By the early 1970s, critics on the left and right contended that methadone was not a true salve. Commenters on the left argued that the problem of pain ran deeper in society, for addiction itself was a “reaction to the excessive pain of social and economic deprivation … anesthetiz[ing] the individual against pain,” which methadone could not erase. On the right, methadone as pain relief seemed a charade—substituting one form of addiction for another. So where methadone's advocates continued to argue that the drug provided needed relief from the craving for heroin (without the euphoric high of heroin), detractors saw methadone abuse as a new and growing problem; for them, this liberal therapeutic solution to pain had now become a problem in itself.
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By the early 1970s, established pain managers like John Bonica admitted that true expertise on this disputatious topic, pain, did not exist. Speaking in a 1970
CBS
television broadcast, “The Mystery of Pain,” he admitted that “the response of the individual [to pain] depends on a great variety of factors.” Pain response was “influenced by age, by sex, by culture, by ethnic background. It is also greatly influenced by what the pain means to the individual—is it a bad omen, or is it something not so bad.” Pain, he noted, was so intimately tied to culture and personality that no scientist could speak on pain better than those who experienced it.
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Yet, as they watched this radical cultural turn in theory and relief unfold, pain managers grew worried that they might be losing the professional control
they had worked so hard to build. Had society become too expansive in its endorsement of liberal relief? Had the gates swung open too wide?

For the pain judges and managers standing watch at the gates of relief, the frustrations of the early 1970s were many. It was one thing to open one's mind to subjective pain as real pain, but it was quite another matter to open the way for all forms of pain (even cultural pain) and all forms of relief stretching beyond the bounds of their professional control. John Bonica's own openness would be pushed to the brink by global events in 1972 when, in the wake of President Nixon's surprise visit to China, acupuncture became a new American fascination. As one news report put it, “Nothing in the American rediscovery of China has excited the popular imagination more than acupuncture anesthesia.”
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For pain professionals, it raised many questions—most importantly about how Western medical expertise and the now established field of pain medicine would respond to this wisdom from the East. Eight years after Robert Kennedy's observations on the unknowable nature of black pain for white Americans, Nixon's trip framed another cross-cultural question: Could Americans understand Chinese pain and incorporate its system of relief?

The détente between President Richard Nixon—who had built his career on anti-Communism since the 1950s—and Chairman Mao TseTung sent ripples across American medicine. The curious case of journalist James Reston, who was part of an advance team before Nixon's visit, put Chinese medical practices in an unexpected spotlight. The journalist developed appendicitis and needed immediate care. Reston's appendectomy was unremarkable, done using conventional Western sedation. Afterwards, however, his postsurgical pain was successfully treated with acupuncture therapy. The case personalized the encounter between American and Chinese cultures. Asked to comment on this new development in pain care, American specialists enjoyed the attention. For many, acupuncture's apparent effectiveness confirmed the wisdom of the gate control theory and its liberalizing influence on medicine. Gate control helped “explain (and legitimate) acupuncture, which most Western physicians had dismissed as a clever trick of autosuggestion.”
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Speaking on such
issues, Bonica's status rose; he was now discussed as a founding father of the field. Melzack's stature as a visionary rose as well.

Acupuncture was at once politically fascinating, culturally appealing, and professionally challenging—it was, in short, a quintessential “alternative” to American pain management. It quickly became a cultural symbol in the United States, a reference point in the political conversation on China policy. For those on the left or moderate right preaching a new openness to the Communist East, the method suggested the possibility of an intellectual détente. It embodied a hope. By bridging the East-West divide on the level of pain care, perhaps this ancient, long-hidden knowledge concealed within a secretive Maoist regime might emerge to enlighten the West and the world. This was certainly Mao's agenda. In the United States, acupuncture satisfied another need—a continuing hope for unorthodox, “alternative” breakthroughs in relief that meshed neatly with countercultural, New Age, and “hippie” ideals. As with other forms of disputed relief (methadone, DMSO, and so on), here too the hope for relief married both clinical and political ideals.

Acupuncture—suddenly in great demand by relief-oriented Americans—nevertheless posed a professional challenge for the cadre of pain managers who had defined the field in Bonica's time. Few of these experts had any familiarity with the needle technique, but their patients pressured them to have an opinion on it in a hurry. The letter that Bonica received from a woman named Eileen Mullan, writing from Florida in 1973, was typical. She had tried everything available in the United States to relieve the “terrible affliction” on one side of her head, to no avail: “After years of injections, nerve resections, morphine, electric shock treatments, etc., etc., I finally received some relief. Now I am starting [to experience] the symptoms on the other side of my face and acupuncture has been suggested, the question is, where do I find a qualified acupuncture practitioner? … I am appealing to you, if it is possible, to recommend someone … My thoracic surgeon … does not know anyone.” A few months after Nixon's trip, a colleague in Florida wrote to Bonica for help with the rising demand from frustrated patients: “Dear John: I am literally being flooded with requests for referrals of patients to acupuncture centers … Regrettably, I know of very few physicians who are currently involved in acupuncture. Do you have any information that I can
use … qualified physicians to whom I can refer patients?” The need for information on the practice was clear to Bonica and the entire medical profession. New regulatory issues had suddenly appeared. What standards should be used to determine whether acupuncture worked or whether clinics would be licensed? Who would control the practice, and what would be its relationship to traditional drug-based anesthesiology? As a recognized leader in the pain field, Bonica was thrown into the public spotlight—peppered with questions of local, political, and global significance. Did the Chinese technique work? Was its popularity driven by ideology or by efficacy? Could it succeed in the United States? How could it be integrated into the American system of relief?
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The pain expert had no ready answers.

Now a formidable leader of the field, Bonica urgently needed to understand acupuncture in practice—either to validate its effects and to incorporate it into multidisciplinary pain care or to prove that it was another type of quackery. In June 1973, he packed his bags and left for China. His mission, with several other American physicians and officials, took him to Chinese hospitals where he tape-recorded interviews with practitioners, attended operations, spoke with patients, and investigated the benefits and limits of this stereotypically Eastern mode of pain relief seeking a passport to the West.

In China, Bonica learned that pain relief was deeply intertwined with Maoist politics all the way down to the bedside. As an American on foreign soil, he saw acupuncture and pain in China in a political light and in a clinical light.
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For him, the two were inextricably conjoined. One could not separate claims about efficacy from the political questions surrounding Eastern wisdom and truth contending for Western recognition. Attending one operation, he observed, “We were given a simple gown, mask, cap and sandals and entered and saw first the application of acupuncture on a patient who was to undergo a partial gastrectomy and subsequently a patient … 33 years old, who had a diagnosis of tuberculoma and was to undergo a thoracotomy and a possible lobectomy.” He carefully documented the procedures: “They placed 2 needles in the paravertebral region, one about the 5th or 6th thoracic level and the other the 9th, with the incision in between. And they had another needle in the right hand focal point and another in the forearm … They applied electrical stimulation …
and after 20 minutes of this an incision was made.” Bonica observed how people treated with acupuncture fared, taking pictures during the operation when allowed to do so.

FIGURE 2.4.
John Bonica (standing with camera) documenting acupuncture procedures during his 1973 trip to China, and assessing implications for pain relief in Western medicine.

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

Watching one alert patient closely, he noted, “Blood pressure rises … he showed tenseness in his face.” The preparation for the procedure was elaborate. Attendants “had taught the patient how to breathe,” and during the operation the “patient continued to talk with the anesthetist who frequently rubbed the center of his nose and spoke in a quiet voice.” Yet what was also clear to Bonica was the oppressive weight of ideology in the operating room. When he asked the patient his opinion of acupuncture, he was surprised that “the patient undergoing the lobectomy commented that he was pleased to have the opportunity to participate in this kind of anesthesia which was only due to the progress promoted by Chairman Mao.”
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Who could ignore this politics of pain? Obviously, pain and relief were deeply embedded in the politics of reform in Mao's China.