Page 17 Guide to Pain Management in Low-Resource Settings

History, Defi nitions, and Contemporary Viewpoints 5

surgeon entrusted with the responsibility of giv- ever, the “gate control theory” emphasized a strictly
ing anesthesia, he realized that the care of wounded neurophysiological view of pain, ignoring psychologi-
soldiers was inadequate. Th e patients were left alone cal factors and cultural infl uences.
with their pain after surgery. Bonica observed that Medical ethnology examines cultural infl u-
pain frequently became chronic and that many of these ences on perception and expression of pain. Th e most
patients fell prey to alcohol abuse or depressive disor- important early study was published in 1952 and was
ders. Bonica’s answer to this problem, which also af- fi nanced by the U.S. Public Health Service. On the
fected other pain patients, was to establish pain clinics basis of about 100 interviews with veterans of both
where physicians of diff erent disciplines, psycholo- World Wars and the Korean War, who were accommo-
gists, and other therapists worked together in teams to dated in a Veterans’ Hospital in the Bronx, New York
understand the complexity of chronic pain and treat it City, the investigators examined how diff erent cultural
adequately. Anesthesiology remained Bonica’s special- backgrounds infl uence pain perception. Th e veter-
ty. Only a few pain clinics existed in the United States ans were diff erentiated into those of Italian, Irish, or
when he published the fi rst edition of his textbook Jewish origin—besides the group of the “Old Ameri-
Pain Management in 1953. Th is landmark may be re- cans,” comprising U.S.-born Whites, mostly Protestant
garded as the date of birth of a new medical discipline. Christians. One result of this investigation was that
Nevertheless, it took many years before a the “Old Americans” presented the strongest stoicism
broader audience became interested in pain therapy. In in the experience of pain, while their attitude towards
the year 1973, to make this topic more popular, Bonica pain was characterized as “future-oriented anxiety.”
founded the International Association for the Study of According to the interpretation of the investigators,
Pain (IASP). In the following years, national chapters of this anxiety demonstrated an attempt to be conscious
the IASP were founded around the globe. In 1979, IASP about one’s own health. Th e more a Jew or Italian or
coined the important defi nition of pain as “an unpleas- Irish immigrant was assimilated into the American
ant sensory and emotional experience associated with way of life, the more their behavior and attitudes were
actual or potential tissue damage or described in terms similar to those of the “Old Americans.” However, pain
of such damage,” which is still valid. Th is defi nition was was still seen merely as a symptom, and non-Western
important because for the fi rst time it implied that pain cultures were not a focus of interest.
is not always a consequence of tissue damage but may It took about another three decades to change
occur without it. Western science then began to realize this situation. During the 1990s, studies demonstrated
that “somatic” factors (tissue damage) cannot be sepa- that diff erent attitudes and beliefs in diff erent ethnic
rated from “psychological” factors (learning, memory, groups around the world play a role in the variation of
the soul, and aff ective processes). Together with the rec- intensity, duration, and subjective perception of pain. As
ognition of social infl uences on pain perception, these a consequence, health workers have to realize that pa-
factors form the core of the modern biopsychosocial tients with (chronic) pain value therapists who recog-
concept of pain. nize their cultural and religious beliefs.
During the 20th century multiple pain theo- Another important aspect that attracted inter-
ries were conceived. Th e most important theory—to est was the relief of pain in patients with advanced dis-
which Bonica also subscribed—came from the Ca- ease. It was the nurse, social worker, and later physi-
nadian psychologist Ronald Melzack (1929–) and cian Cicely Saunders (1918–2005) who developed the
the British physiologist Patrick D. Wall (1925–2001). “Total Pain” concept. Chronic pain in advanced disease
Th eir theory was published in 1965 and is known as totally changes everyday life and challenges the will to
the “gate control theory.” Th e term “gate” was sup- live. Th is problem is continuously present, so Saunders
posed to describe spinal cord mechanisms regulating drew the conclusion that “constant pain needs con-
the transmission of pain impulses between the periph- stant control.” According to this concept, pain cannot
ery and the brain. Th is theory was important because be separated from the personality and environment of
it no longer regarded the central nervous system as a a patient with advanced and fatal illness. Th e founda-
simple passive medium for transmission of nerve sig- tion of St. Christopher’s Hospice in London, England,
nals. It implied that the nervous system was also “ac- in 1967 by Saunders may be seen as the starting point
tively” altering transmission of nerve impulses. How- of palliative medicine. It refl ects a change of interest in