A painful understanding ======================= * Meredith B. Marks **Pain: the science and culture of why we hurt** Marni Jackson Toronto: Vintage Canada; 2003 366 pp $22.95 ISBN 0-679-31190-4 ![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/169/10/1055/F1.medium.gif) [Figure1](http://www.cmaj.ca/content/169/10/1055/F1) Figure. This exploration of the expansive topic of pain is written not by a physician, scientist or disenchanted patient, but by a journalist. I was intrigued that a journalist with no scientific background would take on the challenge of trying to understand pain: people who have devoted their lives to its management will be quick to admit that they still have trouble understanding the phenomenon of pain. But Jackson's goal is not to assist in the diagnosis and management of pain; it is to “describe pain in the round, from as many sides as possible.” Her aim is to understand how people experience pain, and how those with a professional interest in the subject consider pain and its management. Although Jackson states that her book is not comprehensive, it covers an amazing breadth of material. The origin of the word “pain,” the social history of pain, the genetics of pain, the emotional aspects of pain and those who deal with pain as patients, scientists and health care professionals are all considered. The pain-inducing conditions that Jackson considers range from bee stings to chronic neuropathy to heartbreak. Similarly, the treatments discussed range from narcotic analgesia to meditation. Occasional factual errors do not detract from Jackson's real purpose of presenting a qualitative enquiry regarding pain. The fact that phantom pain is extremely rare among children as opposed to adult amputees, or that Tylenol 2 contains codeine as well as caffeine, is really not so important. The stories she presents are what make this book worth reading. Whether the experience is of a patient, a physician, a scientist, or the author herself, it is described in a concise, vivid and realistic manner that draws the reader in. From the beginning Jackson indicates that “pain” is difficult to define. She spends time discussing physical versus mental pain. Returning to this theme through the book, she clearly favours the concept that the two cannot be separated: that is, pain involves an emotional component no matter what its source. She argues convincingly that there is more to pain than a physical stimulus. Otherwise, why would patients experience phantom pain after an amputation? And why would two people react differently to the same pain stimulus? Other than discussing physical versus mental pain, which she prefers not to differentiate, Jackson does not attempt to further categorize different types of pain. Pain of any source, quality and chronicity is presented simply as pain. As a result, we go from reading about the challenges a patient faces in coping with chronic low back pain in one chapter to the voluntarily inflicted pain of sadomasochism in another, to the short-lived experience of dental pain in a third. At times I was left wondering if Jackson confuses pain with suffering, as it seems that she considers almost any negative emotion as a type of pain. Without a means to organize these observations, the reader may at times be left with an unwieldy set of ideas related to pain. Dichotomous positions related to pain management are presented throughout the book. The first is that doctors do not adequately consider the emotional component of pain and, by relying solely on medications in treating pain, have limited success in helping their patients. The second position is that doctors do not adequately medicate for pain. In short, according to Jackson, doctors are usually not their patients' allies in pain management. Although I do not disagree with her criticisms, Jackson does not seem to have come to terms with the fact that not all pain requires analgesics and that some pain can be managed adequately with limited emotional support. Of course, it is this variability in pain management that makes it so challenging for everyone involved. It is unfortunate that, in spite of the comprehensive nature of this book, the views of a key group of informants — the front-line physicians who work with patients to manage pain — were not considered. The challenges that physicians face in identifying the cause of pain, reading their patients' unspoken messages, individualizing and optimizing medication and trying to help people who are reluctant to accept help are never addressed. These ideas might have provided Jackson and others with a clearer view of the complexities inherent in pain management. Physician readers can add this perspective themselves, but not all general readers will be similarly informed. Despite the evident gaps in Jackson's attempt to “view pain from the round,” this book is worth reading. Even experienced physicians are likely to see pain from a new vantage. And it is always interesting to see how others view both physicians and patients. Clinicians will not find answers to pain management dilemmas in this book, but reading it will make them reflect on their practice, stimulate new insights, and pose even more questions about the definition of pain and its management. **Meridith B. Marks** Associate Professor Physical Medicine and Rehabilitation University of Ottawa Ottawa, Ont.