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Book review: Pain the science of suffering

Pain the science of suffering: PD Wall. Weidenfeld and Nicolson 1999 pp178 £14.99, ISBN 0 297 84255 2

Patrick Wall is an intellectual colossus in the pain world, and he has written a lovely book. There is something magical when a wise person looks back over the field which they have studied for many years. This book has that magic, clear writing coupled with insight.

The science is leavened by stories, vignettes about people and their pain. These Professor Wall uses to illustrate the complexity of pain, and to show how daft it is to expect simple solutions when the problem is anything but simple. The science is physiology with some pharmacology, and is written for an intelligent lay reader. It is followed by chapters on pain with obvious cause, and pains without such obvious cause. These are clearly and fairly written. The misery of fibromyalgia, for instance, is not dismissed just because we don't understand the cause.

Chapters about treatments allow Professor Wall to expand his important theme, important for both patients and doctors, that miraculous cures are unlikely to emerge in chronic pain from interventions which cause permanent damage to the nervous system. The inevitable ''re-wiring' may result in worse pain, albeit after a pain-free period. Our ignorance about the mechanisms of treatments which do work is well covered, with an open intellectual curiosity. The sections on complementary medicine are entertaining and fair. The concept of hypnosis underlying acupuncture makes you think. Caveat emptor is an appropriate conclusion.

Towards the end of the book comes the suggestion that the brain representation of pain in common with some other sensations may be as the likely motor response. The distinction drawn is between pain as a signal of a painful stimulus, or pain as a signal of ''the stage reached in a sequence of possible actions'. Here Professor Wall elegantly mops up placebo effects. He argues that if the sensation of pain is associated with a series of potential actions, remove painful stimulus, change posture, seek safety, apply therapy, and my experience is that a particular action is followed by relief, then I achieve relief if I think that action has occurred.

This book is recommended. At one level it should help people with chronic pain to understand that they haven't necessarily gone crazy, and that there may be no simple remedy. For those of us who treat pain it is a necessary and enjoyable read.
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