We all have a personal interest in pain: we have all experienced it; we have all inflicted it; and some of us spend much of our time trying to prevent and treat it. Few of the latter group will be unfamiliar with the name of Patrick Wall, who has been a giant in this field for 40 years. The co-originator with Ron Melzack of the gate control theory of pain (which explains why we rub an injured body part to make it hurt less); the inventor of transcutaneous electrical nerve stimulation (TENS); the founding editor of the journal Pain; the author of countless articles and books including the pain bible (Textbook of Pain, co-edited with Melzack); and recipient this year of a Royal Society Royal Medal: Professor Wall has better credentials than anyone else to write a monograph about pain and what it is (and isn’t). Pain—the Science of Suffering is the first in a series of Maps of the Mind which aims to cover various themes in the function of the brain and mind. Omnicef 125 5 mg/ML

In the introduction, Wall tells of his early experiences as a medical student and his encounters with patients in pain. He reminds us of the indiscriminate universality of pain when he matter-of-factly mentions his apprehensions about his own future experience of pain relating to his (currently responsive) metastatic cancer. Thus the scene is set for a personalized account of what we mean when we talk about pain, why we sometimes feel it and sometimes don’t, and what we can do about it. The book is liberally sprinkled with anecdotes, analogies ranging from chess to fishing, and throw-away lines including sideswipes at fellow academics trying to stave off impending dementia and assorted other professional groups. buy Levaquin 500 mg

I could not decide at first who the target readership was. The fly-leaf states that the aim is to ‘enable us to control and understand our own pain as well as that of others’ whilst we are warned later ‘this is no mere self-help volume’. The text contains a lot of technical jargon and there are some complex (and rather poor-quality) diagrams. On the other hand, the style is very easy to read: cells ‘fall to bits’, tissues become ‘poorly’ and tissue reaction to injury is likened to a three-part opera. The mix was quite acceptable to me but I wonder how it would be received by someone who knows either a lot more or a lot less than I do about the topic. There are no references—a pity since I would have liked to check authors’ names, or study dates at least. There is, however, an index. buy Strattera 25 mg

The first third of the book discusses what pain is and how it is experienced. Wall explains why the traditional view of pain, as merely a sensation that we interpret like any other, is wrong: pain is an experience in itself. Similarly, there is no single ‘pain centre’ in the brain as there is for visual and auditory processing, say. An account of the philosophy of pain leads into a discussion of whether the mind is separate from the body or part and parcel of a single entity. As Wall explains, how we react to pain is affected by our immediate circumstances, and we ‘deal’ with pain at the time of injury or later depending on other urgent priorities (thus soldiers fight on with limbs blown off; footballers play on with broken ribs; and horses race on despite fractured legs). This phenomenon, embodied in our image of the hero, is reinforced on-screen and in print. Other factors are also important: labouring women in Naples apparently shout more loudly than those in Oslo; men are wimps even though everyone pretends they aren’t; how other people around us react to our injury makes a difference; and the consequence of the injury may affect the degree of suffering experienced more than the pain itself does. buy Celebrex 200 mg

The middle third of the book covers painful conditions both with and without known causes. Wall describes eloquently the twisted ankle with its immediate flash of pain, slower excruciating deep-seated pain, and subsequent spread of pain and immobility to the whole of the lower leg. He uses several examples to illustrate how the pattern of tissue damage, local reaction and altered central sensation is common to painful conditions. I was looking forward to this part of the book but a little disappointed; my own areas of interest (pain in obstetrics and postoperative pain) were rather briefly discussed and the whole section was repetitive. Postoperative patient-controlled analgesia (PCA), in which the patient presses a button and self-administers a bolus of analgesic (usually morphine), is deemed a huge advance; but in reality, studies show that opioid requirements are no different from those with intramuscular administration by a nurse, and that the most important factor in providing effective postoperative pain relief is regular assessment of patients’ pain and appropriate analgesic regimens. It is in this area that the greatest advances in postoperative pain have been brought about. Some have wondered whether the more costly PC A is advocated for the benefit of the patient or for the convenience of medical and nursing staff. buy Sumatriptan 50 mg

Wall describes some chronic pain states and the development of allodynia, when a normally non-painful stimulus becomes painful, and hyperalgesia, when a painful stimulus becomes even more painful. However, there is little on why this should happen in some people. He goes on to describe the various treatments available for pain, obviously aiming this part at the non-medical reader. The point is made that we do not need to understand how a treatment works for it to be useful. However, many (like me) will be disappointed by his lack of enthusiasm for acupuncture. In a list of stimulatory therapies, the paragraph under ‘Gentle massage’ contains the single word ‘delightful’. The section on epidural and spinal opioids claims that they are free of side effects—not so. However, the chapter on the placebo response I thought terrific; it is clearly set out and full of interesting information for both lay and medical readers. Here, though, I found the lack of references frustrating; for example, some of the studies referred to appear to be of dubious quality: a trial in which patients with headache were randomized to receive ketorolac, pethidine or placebo apparently showed no difference between the groups, but with only 10 patients per group this is hardly surprising. Skelaxin 400 mg online

The final few chapters seemed to be in the wrong place. ‘Your pain’ repeats many of the points made earlier and finally makes clear a specific aim of the book—to help sufferers of pain reduce their anxiety about pain and so help themselves. My feeling is that Pain—the Science of Suffering may well do that, especially the parts that describe how patients react to medical staff when standard treatments fail, and the methods and aims of chronic pain clinics. Rather confusingly, this is largely discussed in the chapter ‘Other people’s pain’. At last, anaesthetists get a mention (and the praise they—we—deserve) for recognizing the importance of preoperative visits in reducing anxiety and thus pain, and for improving the safety of anaesthesia and surgery (but surprisingly, not for improving postoperative analgesia). An important hypothesis surfaces here too, that sensation is analysed by the brain in the context of the motor response that is required to deal with the original stimulus. For example, acute injury to a limb requires the muscles to immobilize it to allow recovery. An undercurrent of frustration and almost bitterness surfaces occasionally and is expressed by rather a lot of doctor-bashing. Much of it is justifiable, I suppose, in view of the reluctance of some doctors to accept that pain can exist without evidence of organic disease, although I did feel Wall was too harsh at times. Surgeons who continue to operate when the patient clearly derives no benefit; doctors who blame the patient when their treatments don’t work; medical schools that do not give enough time over to discussing pain; schools for not teaching first aid; drug companies and research institutions for not investigating new analgesics: nobody escapes Professor Wall’s criticisms. Have we really done so badly? Perhaps my impressions of great advances in both the understanding and resources for treatment of pain (much of them the result of Professor Wall’s work) are unfounded. If, as Wall suggests, doctors and others still have such a long way to go then this book may well be the ideal travelling companion. Buy canadian Celebrex

Books on pain are pretty painful to read, in my experience. This one, in contrast, is the most enjoyable book on pain I have read in the last five years. In fact it is the only one I have read from cover to cover, which is itself perhaps an indication of its appeal and relevance. It contains much that is positive for both sufferers and carers. Wall puts pain in perspective as an awareness of a required action, much like hunger or thirst, and one that cannot be assessed or managed out of context. Not only will Pain— Science of Suffering help those caring for patients; it may well affect the attitudes of sufferers themselves and help them to help themselves. canadian pharmacy Levaquin