Register Friday | March 23 | 2018

Mastering the Pain

Pain. The mere mention of the word makes us cringe

Pain. The mere mention of the word makes us cringe. Albert Schweitzer once called pain a more terrible lord of mankind than even death itself. Dr. Ronald Melzack, internationally renowned professor of psychology at McGill University, has made Schweitzer's dark lord his life's work. The neurophysiology and psychology of painhow we perceive it, transmit it through our bodies, its purpose and pointlessnessare his interest and his world. Pain is necessary to surviveit tells us what hurts, what to avoid, what action to take; it even enforces inactivity essential to recuperationbut it can also be so debilitating as to crush one's will to live. The good doctor believes peoplenot painshould be the masters of their own destiny, and that the suffering of future generations should be lessened as much as is humanly possible. Born to working-class parents in a largely Jewish section of Montreal in 1929, Ronald Melzack was a lucky boy in many ways. His father Joseph, despite working full-time in a clothing factory to support his family, opened a second-hand bookstore on Bleury Street where writers no less celebrated than Stephen Leacock would come and enjoy the atmosphere and good company. Back then the family fortune, or lack thereof, meant that university for Melzack's older brothers Jack and Louis was out of the question. But the ongoing presence of Leacock and other literary lights provided the brothers with an education few schools could offer. Louis, just thirteen years old when he took over behind the counter, eventually built that little store into one of Canada's largest retail bookselling chains: Classics Bookshops. So the shelves stayed well stocked. Sherlock Holmes, breaking down from sheer boredom, turned back to his old source of comfort: a seven-percent cocaine solution in a hypodermic needle. His trusted friend and partner in sleuthing, Dr. Watson, entered the room. "Damn you, Holmes, I use that for medicinal purposes! It is not for you to use in artificial mental stimulation." Knee deep in higher learning while dusting off books during the summer months to earn his pocket money, young Ronald knew he wanted something altogether different for his livelihood - but he wasn't sure what yet. His indecision almost led to his flunking out of his first year at McGill. Nothing seemed his forte - Physics, Math, Chemistry - until he found Psychology. He approached the chair of the department, Donald O. Hebb, and transferred his course load and his destiny. With Hebb as his thesis advisor, Melzack's first experiments focused on irrational fears in dogs. He noted how they recoiled from skulls, umbrellas opening up, and balloons being inflated. He also noted, when he lit matches, that the group of dogs raised in humane isolation would - after sniffing and recoiling like any normally raised dog - return repeatedly to sniff the flame. They lacked what one famous physiologist called an "imperative protective reflex"; they had not learned to feel the pain. That pain was a learned experience, and therefore linked to the inner workings of the brain, fascinated Melzack, and he had found the subject for his Ph.D. thesis. Later in his career, while at the University of Pisa, Melzack continued his study of irrational fears, this time in ducks. To his surprise, regardless of whether they had been raised in isolation or a natural environment, all ducks had the same hard-wired fear of hawks. The puzzle of pain continued and literature on the subject (Marquis de Sade notwithstanding) was not exactly filling up any bookshop, including the one run by his family. No, Melzack needed to travel through the realm of physiology, deep into the territory of the brain, if he wanted answers. Stones in his bladder, Napoleon III is in agony. He must speak before his public but is weak and helpless. He finds some solace holding his arm against a flame. If he cannot alleviate his suffering, at least he can change its direction. Between the dogs and ducks, enter one William Livingston (Dr. Livingston, I presume) of Portland, Oregon, who ran a physiology laboratory within a department of surgery, something quite unique in 1954. Melzack spent three years studying with Livingston and other experts, learning everything he could about human physiology. Livingston also invited him to study at his pain clinic which, along with another run by Dr. John Bonica of Seattle, were the first two clinics of their kind ever established. It was at Livingston's pain clinic that Dr. Melzack first encountered the phenomenon of phantom limbs and phantom pain (feeling movement and intense pain despite the absence of the limb). He studied a female patient in her seventies who was having a second leg amputated as a result of diabetes. The case was remarkable not merely for the intense phantom pain she experienced, but because the patientintelligent, well-spokenwas able to give detailed expression to her feelings. Some words expressed the sensory elements of pain, some the emotional elements, and some related to evaluative properties. Terms such as stabbing, shooting, burning, searing, scalding, throbbing, beating, excruciating and nauseating, which Melzack wrote down from their conversations and collected from any literature he could find on the subject, formed the lexicon of pain we use so matter-of-factly today.  Melzack took these terms and used them as a means to qualify and quantify, to break down the monolithic face of pain, creating what ultimately became known in 1971 as the McGill Pain Questionnaire. After his later duck research in Pisa, a job opened up for a physiological psychologist at the Massachusetts Institute of Technology (MIT) and Melzack seized the opportunity. It was there, in 1959, that he met biologist Patrick Wall and the pursuit of pain reached a new level. The two collaborated on The Textbook of Pain, a major contribution to the field, and published papers in prestigious journals like Brain (whose editor, Russell Brain, was a neurologist who later rose in rank to become - sans blague - Lord Brain). But the crowning achievement of their collaboration was yet to come. From the pairs early papers and conversations arose, in 1965, the famed "Gate-Control Theory of Pain," first published in Science, which broke the mould on all previous theories. Up until then, most schools of thought differed little from Rene Descartes' concept, originally proposed in 1664, that pain is like a bell-ringing alarm system whose sole purpose is to signal injury to the body; that stimuli travel up to the brain and the brain registers them. The Gate-Control Theory, in contrast, proposes a neural gating mechanism in the spinal cord, specifically in the region of the dorsal horns, that increases or decreases the flow of nerve impulses to the central nervous system. Input is therefore subject to a modulating influence even before it evokes pain perception and response, and pain signals are further subject to inhibitory factors descending from the brain based on experience, genetics, and other psychological influences. The theory caused a sensation, but more importantly, gave rise to new questions. Melzack himself, based largely on his study of phantom limb pain, took his Gate-Control Theory a step further in later years. He postulated that the brain possesses a built-in "neuromatrix" of nerve cells that generate patterns of physical sensation - even when the body they map is no longer completely there. "Stonewall" Jackson used to ride into battle with one arm raised - to balance himself, he said - until a "friendly" bullet shattered it. Yet even with the arm amputated, and lying on his deathbed, one could almost sense his raising it to utter his last words, "Let us cross over the river and rest under the shade of the trees." It has been approximately five decades since Ronald Melzack first began to meet mankind's nemesis on a regular basis. But beyond the studies, the papers and experiments - beyond the science - Melzack still feels that people suffer needlessly. He has been moved to assail the medical establishment for hesitating to prescribe morphine or other analgesics over concerns of tolerance and possible addiction, even in cases where palliative care should take precedence and despite research that contradicts the addiction myth. His first book, The Puzzle of Pain, was dedicated to his brother-in-law Harry whose life was cut short by cancer and whom he knows suffered too much. Melzack's own brother Louis, who early on in his life helped surround Ronald with knowledge and fill his mind with ideas, surrendered to the same scourge last year. He too, suffered, making Schweitzer's words toll again, the knell more mournful than ever. Melzack knows some of his message regarding needless or excessive suffering is getting through. Soldiering on with his research and his goal to better educate the medical establishment, he is re-editing The Textbook of Pain (henceforth to be called The Handbook of Pain Management), scheduled for release next fall. For him, research begets more research and there is always something else to prove. If pain is indeed a dark lord, then Ronald Melzack is a radiant beam of light.