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Pain - a compassionate science

Professor Wall's popularising book, Pain: The Science of Suffering (MAPS OF THE MIND), analyses an experience that touches us all, but which we seldom talk about. He dismisses traditional medical teachings as myth and demonstrates the complexity of the subject in a readable book that will increase awareness and understanding.


Pain is essential, but we avoid it as much as we can. Without pain we would die from injuries and diseases we failed to notice. Pain is familiar, but we understand little about it; it is the most common reason why patients visit doctors, but few of them have had much training in the subject. After four years in medical school "the fully qualified doctor usually emerges with only three to fours hours of tuition on pain." That last comment is a quote from the book and demonstrates Professor Wall's insight into the predicament of chronic pain sufferers. He understands because he is an acknowledged world expert on the subject. He understands deeply because he has cancer.

Patrick Wall comes to his subject from a background in clinical practice, academic research and scientific study. He was joint proposer of the "gate" theory of pain and joint inventor of the TENS machine (See Note 1). He is a thoughtful and sympathetic man whose concern for patients comes through in this most readable of medical books. Pain: The Science of Suffering is a popularising book, but it is high time someone popularised this neglected subject.

The classic understanding of pain is that pain fibres in the nerves connect to a pain tract in the spinal chord, which communicates with the pain centre in the brain (presumed to be the thalamus). This brief outline is still taught to trainee doctors, but Patrick Wall's book dismisses it as a "hundred year old myth". Pain is far more complex, and understanding it requires an open mind and a sympathetic attitude. Pain does not behave in predictable and consistent patterns that can be reduced to simple formulae. Nor does it respond identically to similar treatments in different patients. It is affected by the patient's mind - though that does not mean it is "in the mind" in the sense that some arrogant physicians occasionally hint to distraught sufferers.

As a striking example of the mind's effect on the experience of pain, the book shows a photo of President Ronald Reagan seconds after he had been shot in the chest (1981). In the emergency of the attempted assassination, Reagan's unconscious mind gave priority to escape and his face displays alertness rather than agony. Not until he was safely on his way to hospital did the President report the pain, which proved that a bullet had entered his body. This mental feat is not exclusive to humans, as is demonstrated by another picture showing a racehorse winning the 1980 Epsom Derby 150 yards after he broke a leg. Pain is a necessary response to illness or injury, but it is neither simple nor automatic. The body's control systems, whether human or animal, are able to edit internal nerve messages to suit the over-riding demands of survival. Complex over-ride systems of this kind may well be implicated in the unpredictability of pain.

The rules governing the development and marketing of drugs demand that prospective medications are tested against placebos. Professor Wall does not dispute the need for such tests but highlights the degree of misunderstanding that surround the "placebo effect". The 'all in your head' brigade of ill-informed medical practitioners assumes that the body is a complicated chemistry set, which will respond to an appropriate dose of the 'right' substance; so, when an innocent sugar-coated pill produces relief in their patients, they sneer. They fail to recognise the significant role that placebo plays in most effective treatments. Demonstrating a placebo response does not prove anything about the genuineness of a patient's pain.

Professor Wall does not spare the ignorant or arrogant among his medical colleagues, but is fulsome in his praise of recent advances in anaesthesia and pain management. After generations of the "stop making all that fuss" method of pain management, anaesthetists, as a body are making their influence felt in this field. Treatments of all kinds are hampered unless the patient co-operates, and few patients willingly co-operate with procedures that hurt. Pain control in the operating theatre has led to pain management in the wider field of medical services and increasing numbers of hospitals now run pain clinics. The ideal pain clinic provides an adequate staff supervised by enough qualified anaesthetists to meet the requirements of sufferers. Less ideal clinics are still a step forward in a movement that has a long way to go, but has made a promising start. We may hope that the publication of this popularising handbook will inspire more medical students to enter the field and increase the depth and availability of pain management services.

This book examines acute and chronic pain, pain with obvious causes and pain that is less easily explained. It looks at the ways we experience pain and the ways we react to pain in others. It examines the expectations of various cultures and the prejudices we sometimes encounter from healthcare professionals. It also reviews a range of conventional and 'alternative' therapies. This comes from a man who has given his life to understanding patients as well as therapies. The undeserved personal experience of his own cancer, and its treatment, lends extra authority to his analysis. Professor Wall is capable of writing long-winded scientific manuals filled with complex medical jargon - and a search through medical libraries will find his name attached to many such tomes. However, in Pain: The Science of Suffering, he has produced an affordable paperback that most readers will find accessible - and helpful.

Derrick Phillips - 2000



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