We tend to think of pain as a quantity with a cause that can
be identified and a level of intensity that can be characterized. However, Joanna Bourke, a British historian, tells
a different story. In her book, Story of Pain: From Prayer to Painkillers, she convinces us that pain is a much more
elusive entity.
“….pain describes the way we experience
something not what is experienced.
It is a manner of feeling….Crucially, pain is not an intrinsic quality
of raw sensation; it is a way of perceiving an experience.”
It is well known that expression of pain is a learned
response that varies from one culture to another, from one gender to another,
and from one generation to another. It
is also well known that extreme physical injuries can be endured with little or
no pain, and that extreme pain can be experienced with no discernible cause.
There is no way of measuring pain directly. Consequently, a physician must depend on the
description of the pain by the patient or draw her own conclusions based on
evaluating the signals of pain being expressed by the patient. Given that high level of uncertainty, it is
not surprising that physicians and nurses have treated patients suffering from
pain in ways that were affected by biases and baseless assumptions. Treatment was accorded to patients based on
race, ethnicity, gender, and age. What is surprising is that biases and
baseless presumptions have not disappeared as medical knowledge has been
accumulated; instead, many have largely persisted in modern times.
Bourke’s study is limited to the English-speaking countries
and is thus dominated by Britain and the United States. Not unexpectedly, when matters of race or
ethnicity arose Anglo-Saxons always seemed to be identified as the ideal “race.” Since pain was to them such a real and
compelling sensation they assumed that their superior intellectual development
rendered them more sensitive to all stimuli.
People the Anglo-Saxons didn’t respect (everyone else except a few
Northern Europeans) were generally assumed to be incapable of experiencing pain
at the same level because of inferior physical and mental development. Jews weren’t well-liked but they couldn’t
conveniently be classified as mentally inferior. It was assumed that Jews were hypersensitive
to pain and lacked the ability to control their response to it because they
were culturally or racially deprived of the fortitude provided by an
Anglo-Saxon heritage.
These beliefs had a great deal of influence on the manner in
which people were treated over the centuries.
“….slaves, ‘savages’, and
dark-skinned people generally were routinely depicted in Anglo-American texts
as possessing a limited capacity to truly feel,
a biological ‘fact’ that conveniently diminished any culpability amongst their
so-called superiors for acts of abuse inflicted upon them.”
These beliefs about the inferiority of the people the
British wished to conquer and colonize were extremely convenient. In the context of medical treatment, this led
to less attention being paid to the pain suffered by certain classes than to
others.
Gail Collins provides a startling example of how this
presumed insensitivity was put to use by physicians in America's Women: 400 Years of Dolls, Drudges, Helpmates, and Heroines. There was a horrible tragedy that could
befall women in giving birth. It was
referred to as a vesico-vaginal fistula.
“During childbirth, the wall
between their vagina and the bladder or rectum ripped, leaving them unable to
control the leakage of urine or feces through the vagina. The condition had been recognized for
centuries, but some historians believe that it increased when doctors began
delivering babies [replacing midwives] and inserting their instruments into the
womb.”
A surgeon, J. Marion Sims assumed the task of trying to
surgically repair this devastating condition in 1845
“J. Marion Sims, an Alabama
physician, devised an operation that successfully closed the fistulas and let
these tormented women resume their lives.
But the discovery came at a horrifying cost...He experimented with
surgical techniques while the [slave] women balanced on their knees and elbows,
in order to give them a better view of what he was doing....Four years later he
finally succeeded in repairing the fistula of a slave named Anarcha....It was
Anarcha’s thirtieth operation, all of them performed without
anesthetics.....Sims claimed that the women had begged him to keep trying his
experiments and it’s possible that was true....But they were still slaves with
no real option to say no, and Sims chose to work on them in part because he
believed white women could not endure the kind of pain he was inflicting.”
As Bourke makes clear, this assumption about
insensitivity to pain by certain classes of people is not something relegated
to the deep, dark past.
“….in the words of a
gynaecologist in 1928, forceps were rarely needed when ‘colored women’ were
giving birth because ‘their lessened sensitivity to pain makes them slower to
demand relief than white women’.”
“From the 1980s onwards, surveys
showed that minority patients being treated for pain associated with metastatic
cancer were twice as likely as non-minority patients to be given inadequate
pain management. Even after major
operations, certain patients, Chinese for example, were likely to be given less
pain relief than white patients, in part because of assumptions that they had a
higher threshold for tolerating pain. In
a study of people treated for long-bone fractures at the UCLA Emergency Medicine
Center in Los Angeles in the 1990s, Hispanics were twice as likely as
non-Hispanic whites to receive no medication for pain.”
Women were subject to much analysis on the part of the
males who created conventional wisdoms.
While continuing to refer to them as “the weaker sex,” it was generally
acknowledged that women were better able to endure pain than men. Some of the justifications for this
assumption were more interesting than others.
“In one particularly pessimistic
account in 1910, women’s resilience was simply ascribed to their ‘long practice
in suffering the blows of the male’.”
A more politically correct and more compelling view held
that since women were provided the unavoidable task of delivering children,
nature, or God, must have provided them with the wherewithal to deal with the
associated pain.
Women’s reward for actually being the stronger sex
(regarding pain) was to be continually provided with less pain relief than men
might receive in similar circumstances.
Bourke cites studies that indicate this pattern has persisted into the
current century.
Animals and, incredibly, infants suffered due to
constantly changing biases and assumptions.
As noted in the beginning, physicians cannot measure pain, they can only
guess at it based on claims or actions provided by the patient. Both animals and newborn infants are unable
to provide the appropriate signals that convey what a physician is capable of
recognizing as true pain. Therefore,
they were left to the mercy of guesses and assumptions.
“Indeed, one of the main reasons
why some scientists regarded it as legitimate to vivisect animals was because
they did not behave as if they felt pain to such an extent as the human species’,
as one commentator put it in the 1920s.”
Eventually, as animals were used more and more as surrogates
for humans in the testing of medicines and medical procedures, it became
necessary to learn more about animal pain, and in fact to quantify it.
The history of infants and pain is discussed in Infants, Fetuses, and the Complicated Issue of Pain. Towards the end of the
nineteenth century physicians began to assume that infants felt little if any
pain. Prior to that, they had assumed
that infants were extremely sensitive to pain.
The net result was that in a period when anesthetics and analgesics were
readily available, infants were not likely to receive much consideration when
it came to pain.
“The author of Modern
surgical Technique (1938), for instance, claimed that ‘often no anesthetic
is required’, when operating on young infants: indeed ‘a sucker consisting of a
sponge dipped in some sugar water will often suffice to calm the baby’.”
Around 1980, the consensus changed again and concluded
that infants did in fact experience pain.
However, that does not mean that infants were destined to be coddled.
“A study in 1995 revealed that
pre-term infants were subjected to an average of sixty-one painful procedures
while in the neonatal intensive care unit.
In another study, published in 1987, neonates were subjected to about
three invasive procedures an hour. In
addition, neonates were actually less likely to be given analgesia than older
children.”
As we have noted, there were classes of people who
systematically received less pain care than others: infants, women, minorities,
and poor people. It is important to
realize that this discrimination existed within a system whereby inadequate
levels of pain relief were being delivered to all. The medical community has recognized this as
a problem and has even created a term to describe the under treatment of pain: oligoanalgesia.
Bourke suggests several reasons why there might be a
reluctance to administer sufficient pain treatment. One explanation was lack of training. Pain management receives little attention in
the education of most doctors and nurses.
Another is the development in the medical community of a culture which
declares its goal to be pain reduction, not pain elimination. If the patient is tolerating pain then what
is the problem? A third explanation
rests on a fear of overmedicating patients.
Many pain suppressors are potentially addictive and both patient and
physician can suffer if addiction should develop.
This latter issue puts physicians in a difficult
situation. At the same time they are
being told to be careful and not under medicate, and be careful and not over
medicate. Dannielle Ofri provided an
excellent example of how difficult this could be in practice in a New York Times article: The Pain Medication Conundrum.
It seems that after centuries of medical advancement,
doctors and nurses are still reduced to listening to patient complaints,
evaluating their expressions of pain, and guessing as to what the level of pain
might actually be and how they should respond.
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