The king of (understanding) pain

 

By Mark Shainblum

Dr. Ronald Melzack is an emeritus professor of psychology at McGill who revolutionized the study and treatment of pain. His historic partnership with Dr. Patrick Wall of MIT led to the 1965 publication of the Gate Control Theory of Pain, which overturned the then-accepted view of pain as a primitive and static danger warning system. Instead, Melzack and Wall argued that psychological factors and environment play a large role, and that pain is subjective and ultimately at the mercy of the brain. Widely lionized for his breakthroughs, Melzack has been honoured with a Killam Prize, is an Officer of the Order of Canada and l’Ordre du Québec and was recently inducted into the Canadian Medical Hall of Fame.

Born in 1929 in a working-class district of Montreal, Melzack was the only member of his family to attend university. He studied psychology at McGill under the great Dr. Donald Hebb, and obtained his PhD in 1954. After postdoctoral stints at the University of Oregon and MIT, Melzack returned to McGill as a professor in the early 1960s and was instrumental in the establishment of the McGill Pain Clinic, first at the Royal Victoria Hospital and later at the Montreal General. He also developed one of the most powerful pain research tools in use today: the McGill Pain Questionnaire, which allows patients to precisely pinpoint the type and degree of pain they are experiencing. The questionnaire has since been translated into 20 languages and is accepted as a standard worldwide.

The McGill Reporter interviewed Dr. Melzack at his office in the Stewart Biology Building a few days after the Nov. 10 announcement of his induction into the Canadian Medical Hall of Fame.

How did you first get interested in the question of pain?

It was an absolute fluke. Dr. Donald Hebb was doing research on dogs raised in relative isolation. he was particularly interested in their problem-solving ability. They were well-fed and well-looked after, but they didn’t have the life experience a normal dog would have. So when these restricted dogs were let out of their cages, as they were running around, they would sometimes bash into a low-lying water pipe that happened to be in the room. They didn’t make a peep, and I thought, “these guys don’t seem to be feeling pain normally.” Until then, it never entered my mind that pain should be a field I should look into.

Is that when you started to conclude that the accepted view of pain might be wrong?

That’s right. I began to realize that pain is subjective. You may have an injury, but the injury is not the pain. That became my PhD thesis. I had puppies like Hebb’s specially raised for me, and studied their responses to things like showing them a flaming match. These guys would stick their noses right into the flame, back off for a minute, and then stick it right back in again. A normal puppy wouldn’t let you near him with a flame, and if he did stick his nose in it once, he’d never do it again!

What did this tell you?

I concluded, after this and a lot of other research on the problem, that our brain selects what comes in and keeps other things out. That’s when the idea of a gate came to me. Let’s say your brain rapidly becomes aware of an interesting stimulus. There are large fibres that move information rapidly up to the brain to indicate that something is going on, while other information moves more slowly. If that information is important, the brain will open the gate to allow it in, and shuts the gate to the unimportant stuff. That’s the gate control theory in a nutshell.

What was the prevailing view of pain when you were starting out?

Actually, it’s still the prevailing view, and one that I have been fighting all my life, that there’s a “pain system.” Common sense says that there are pain receptors in your body, in your skin and viscera, and these receptors have a pain pathway, and you can actually stimulate skin and find the pathway and it goes up to somewhere in the cortex, which is supposed to be where we feel pain.

And this is wrong?

At one time it was a good idea, but now it is hindering research. It’s simple and easy to look at, there’s lots of technology, lots of research money, but that research is going nowhere in helping us understand chronic pain. And chronic pain is the real problem.

How did you end up at the University of Oregon after doing your PhD?

I was there for three years, and it had a tremendous impact on me. It was all due to this fellow at McGill named Herbert Jasper, a brilliant neurophysiologist and one of the pioneers of EEG. I told him I wanted to do postdoctoral research and learn more about the brain. And he told me about his friend, Dr. William K. Livingston, who had an excellent little pain laboratory at the University of Oregon Medical School. The lab was small, half the size of this room, but some outstanding people went through there and spent a year or two working with him.

It was Livingston who first introduced you to patients suffering from chronic pain?

Yes, he invited me to come with him to a clinic they ran every Tuesday afternoon. They saw patients who were in terrible, chronic pain, and tried to do whatever they could to help them. He warned me that there wasn’t a hell of a lot we could do, but we tried. That is when I realized that I had no idea what pain really was. When we think of pain we thing of burning our fingers on a hot stove or breaking an ankle skiing. But you know that kind of pain goes away. These chronic patients were suffering terrible pain that basically never stopped.

And that’s when you met the famous Mrs. Hull.

Mrs. Hull had a great impact on me. She was a woman in her late 70s with diabetes. She developed gangrene and had to have both of her legs amputated. I liked her; we talked a lot, her and her marvellous husband Willy. I was a bachelor then, and I would take them for afternoon drives on Sundays, and we became quite friendly. She was a highly intelligent person with a good vocabulary, and I began to collect her descriptive words about pain like “burning,” “shooting,” “horrible” and “excruciating.”

And this was the origin of the McGill Pain Questionnaire?

Yes, from Mrs. Hull, and dozens and dozens of other patients I began to collect these pain words. I’ll read some of them to you: Flickering, quivering, pulsing, throbbing, beating, pounding, boring, drilling, stabbing, lancinating, hot, burning, scalding, searing.

Later at MIT, I met the superb statistician Warren Torgerson. He had the statistical techniques to really make this solid. We had 102 words to start with, and we ended up with something like 78. And then we asked people to rank the words: how much pain is implied by a word like “stabbing” or “searing” or “itchy”? It had never been done before.

Tell me about your phantom limb patients.

Mrs. Hull is the most vivid in my memory, but there were many others. We had a woman who had her rectum removed surgically because of cancer, but she still felt it. She had a phantom rectum. There were people who lost their genitals and yet still felt like they had to urinate and men who were amazed that they felt phantom erections. One out three women who’ve had mastectomies feel a phantom breast, though it’s usually not painful. They feel the breast, they even feel that it fills the bra cup. There are phantom everythings: Eyes, ears, noses, teeth, you name it!

And that didn’t fit the prevailing theory of pain?

It certainly didn’t. But don’t get the idea that Livingston and I were alone in this area. Dr. Harry Beecher was a U.S. Army medic during World War II, and he was treating soldiers at the Anzio beachhead. Men with terrible burns and bullet wounds would be brought to him, and he’d offer them morphine, and they’d say “Doc, I don’t feel any pain, I don’t need it.” We were very good friends when I was at MIT, and we’d talk about this, but he was still stuck with the idea of the pain pipeline. And I’d tell him it didn’t make sense. How can you say that the guy’s got pain without pain? He said it was pain perception without pain sensation. My response was, this guy’s got no pain. And what about the people who feel pain but don’t have any physical problem that you can find? We need a new theory. He was actually very pleased when the gate control theory came out.

So what does your theory say about cases like that?

Well, right now I’m saying that we’ve just got to get the hell out of the spinal cord and start looking more and more at the brain. Happily, here at McGill we now have Dr. Cathy Bushnell doing superb work in this area. When I retired, I also told the man responsible for the money, Allan Edwards, that I thought the E.P. Taylor Chair should go someone in the genetics of pain, a very new field just opening up at the time. That’s how Jeff Mogil got here.

So what does the future hold for pain research and pain control?

The future is research on how the brain creates our world: The world we see, hear, touch and feel. Pain is the doorway into that. I mean, right now, I am just a little upside-down guy on the back of your retinas. You don’t see me upside down, or jumping around as your eye jerks around. Your brain creates me. Most people don’t want to hear such a thing. They want to think that what you see is what’s out there.

So it’s all subjective?

Everything is subjective. Everything. But people don’t want to hear that.

Ronald Melzack’s First Job

My first job was working for my brother and my father, who owned a bookstore called Classic Bookshop, which later became a well-known chain. They started a little bookstore on Bleury St. near de la Gauchietière. My brother Louis was 13 years old at the time. He went to high school, but my father was unable to afford to send him to university.

The bookstore started to do well, and they moved from Bleury to Ste. Catherine St. Louis and his wife eventually turned it into the first bookshop exclusively devoted to paperbacks anywhere in the world, and it was the first time books were displayed face out.

So when I was about 13 years old, or so, I would go down to the store every Saturday and bring Louis his lunch, and my job was to dust the books. And when I got older, Louis put me in charge of the shop over the summer.