published 10/14/06

Review of Pain: The science and culture of why we hurt, a book by Marni Jackson

A fascinating but insubstantive tour of the weird world of pain science

by Paul Ingraham, Vancouver, Canada MORE

Credentials and qualifications

I am a writer and retired Registered Massage Therapist (unusually well-trained for a massage therapist, a 3000-hour program). I’m almost done with a Bachelor of Health Sciences degree. I am a peer reviewer for The Natural Standard, and a copyeditor for Science-Based Medicine. My most important qualification is more than a decade of workaholic post-graduate study, clinical experience, and constant conversations with readers from around the world, including many experts who have provided countless suggestions and criticisms.

For more information, see: Who Am I to Say? More information about my qualifications, credentials and professional experiences for my readers and customers.

Marni Jackson. Pain: The science and culture of why we hurt. Random House, 2002.

Marni Jackson’s book is probably the perfect book for thoughtful, liberal, middle-aged women in pain. Others may find it frustrating, overtly poetical and coquettish, neither rigorous enough for the science-minded, nor explanatory enough for the layperson seeking a better understanding of either “the science or the culture of why we hurt.”

Pain certainly does offer many interesting and creatively presented perspectives on pain: historical gee whiz facts, nuggets of science, and seemingly endless miscellany, curiosities and anecdotes from the subject.

Jackson’s thesis never coalesces — unless her thesis is that pain is hard to define or explain. On almost every page of her book, Jackson calls for a more nuanced definition of pain, and bemoans the failure of medical science to place pain in a cultural context. Unfortunately, after a few chapters of artful and entertaining meandering, it becomes clear that whatever greater definition there might be of pain, Marni Jackson is not writer enough to supply it. The reader is left agreeing but unsatisfied.

Whatever greater definition there might be of pain, Marni Jackson is simply not writer enough to supply it.

Again and again Jackson tells us that pain is not “just” the Cartesian cliché, that it is more than just a signal from insulted tissues, but Jackson never tells us: more what? Other than constantly cribbing from the great pain neurologist V.S. Ramachandran — that the mind is involved, that “pain is an opinion” — Jackson seems unable to say what pain is, only what it is now understood not to be.

Still, most of this probably won’t (and shouldn’t) concern readers less curmudgeonly than myself. And, to be fair, Jackson undoubtedly fails simply because everyone else has — it really is a fiendishly difficult subject to talk about. As with any phenomenon that gets too tangled up in “the mind,” science simply does not yet have the relevant vocabularly. Trying to discuss the True Meaning of Pain in the early 21st Century is like talking about quantum physics before Einstein. We are probably at least two or three scientific paradigms away from some good answers on this subject.

A final word of warning: Jackon’s chapter about her sister’s bout of acute back pain is pretty much overflowing with amateurish misconceptions and contradictions. Even after quoting sensible back pain experts warning against the conventional wisdom in previous chapters, she still charges carelessly ahead and puts her stamp of approval on several chestnuts of erroneus but popular back pain faith. Only at the end of the chapter does she redeem herself somewhat with a few more level-headed assertions about back pain, namely that bed rest is not supported by the evidence, and most back pain heals regardless of what you do. Otherwise, the chapter is just the usual back pain nonsense.

For better information back pain, see Save Yourself from Low Back Pain!).

Excerpts from Pain: The science and culture of why we hurt

Why do we persist in this distinction between mental and physical pain when pain is always an emotional experience? What explains the fact that something as universal as pain is so poorly understood, especially in a century of self-scrutiny? Has nobody noticed the embarrassing fact that science is about to clone a human being, but it still can’t cure the pain of a bad back? Americans consumer four tons of aspirin a year, while chronic pain is on the rise. It’s almost as if pain flourishes on our diet of analgesics.

Many medical students receive no more than one hour of instruction in pain management. Some schools don’t even have pain on curriculum, even though pain is the number one reason that sends people to their GPs ... It’s not the fault of physicians — this is how we teach them.

Why are we, the most medicalized of societies, a culture in pain?
p5

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In this passage, Marni Jackson is quoting and paraphrasing Nikolai Bogduk’s opinions, as expressed at the Ninth World Congress of the International Association for the Study of Pain.

Although [Nikolai] Bogduk has a reputation for having all the answers and being a bit of a ‘needle jockey’ who travels everywhere with his little vial of painkilling bivucaine, his presentation in Vienna surprised his colleagues. Instead of talking up the latest surgical intervention, he spoke about addressing the patients’ fears and anxieties, and ‘getting inside their heads.’ He emphasized that what was most important was to first eliminate ‘red-flag conditions’ that might be (but probably weren’t) causing the back pain, and then to reassure the patient that the back would most probably get better and not worse. He still believed in judicious painkilling, but what was more important in treating back pain, he had found, was communication and reassurance. Preventing acute [back] pain from turning into chronic pain was often a matter of ‘treating the patient nice and convincing him that there is nothing so horribly wrong.’
pp120–1

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This excerpt is best understood in context. Gordon Waddell, the respected Scottish orthopedic surgeon and back pain expert, is commenting on a debate between back pain experts at the Ninth World Congress of the International Association for the Study of Pain. The debate had an unusual premise: “You’re on a desert island with severe back pain, you do not know what you know now, and you want some advice to help you cope with the pain. A hot-air balloon is being sent to help you. There is only so much room in the hot-air balloon, and a whole spectrum of back experts to choose from. So who would you allow on board?”

Surgery is not the answer for back pain, and it doesn’t work. So I’m now going to jump out of this hot-air balloon and leave the other two hot-air experts to battle it out. But the trouble is, it’s very easy for back specialists to set themselves up as experts. Beware of amateur experts who step out with their own speciality. Beware of high-tech experts who blind you with science or pseudoscience. And beware most of all of the bullshit artist who can sell the idea to you and convince you that their treatment is better than everyone else’s — odds are, they’re wrong. So throw out the experts and fill up the balloon with malt whisky, which will probably do your back more good than the experts.
p121

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Marni Jackson, quoting Nikolai Bogduk on the subject of low back pain, an Australian physician, at the Ninth World Congress of the International Association for the Study of Pain in Vienna.

Simple intervention — the time spent with a patient — is a very powerful ingredient of the patient-doctor contract. The evidence is against the traditions such as surgery [for back pain] being true — the evidence says it doesn’t work.
p122

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Hasn’t anyone thought to look at outcomes as a logical way to figure out what really works? Not until recently. That tells you how far out of the picture the patient has been.
p122

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These doctors [a panel of medical back pain experts at the Ninth World Congress of the International Association for the Study of Pain], who had long experience with people in pain in addition to their traditional training and schooling, had discovered that nothing happens without communication, treatment based on evidence of outcome, and what used to be called a good bedside manner.
p122

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Given the … multidisciplinary philosophy [of The Ninth World Congress of the International Association for the Study of Pain], I was surprised by the absence of alternative pain approaches — the whole spectrum of cranial-sacral massage [sic], healing-touch therapy, and other hands-on skills that are a lifeline to many people with chronic pain. Alternative therapie are hard to evaluate, but that’s no reason not to explore them.
p130

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[Bill] Livingston described a lumberjack, a timber feller, who had cut off the tip of his left thumb with an axe. The wound healed, but the scar remained so sensitive that he couldn’t work. Another operation removed a chunk of the remaining thumb, after which the stump was even more painful. Doctors were at a loss to treat him. Livingston took the caseon, hoping to at least ease the man’s pain for brief periods with a local anaesthetic. he found that when he injected the man’s thumb with a local anesthetic, he suddenly felt his arm “relax” for the first time since the accident. After a series of injections, the lumberjack found he could finally put on a glove and eventually use an axe. Livingston felt it wasn’t the procaine that had “cured” his condition, but the interruption and reorganization of the stimulus in the area. The injections seemed to reboot a nervous system that had become stuck in an old modality.
p212

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This is an amazing anecdote about the power of perception!

“There are psychic factors involved in every patient’s complaint of pain,” [Bill Livingston] wrote. He tells a story of one midnight emergency to illustrate his point.

A woman called him to report that her husband had just had a “massive bowl hemorrhage and was in a state of collapse.” Just before bed, he had felt some cramping pains and hurried to the bathroom. Then she heard him calling her name, followed by the thud of him falling to the floor. She found him unconscious, white-faced, and covered in sweat. And in the toilet there was a quantity of bright red blood.

Livingston told her not to flush the toilet and rushed over. He found the man lying on the bed, conscious, but in pain. Where does it hurt the worst, Livingston asked. “All over,” the man whispered. He went on groaning as his wife said that he had been in fine spirits and food health, until he had gone to the bathroom.

Livingston examined him, to no avail. Then he went into the bathroom and inspected the alarm-looking contents of the toilet. Beets. Lots of beet fragments. It turned out that her husband had eaten beets for lunch, and little else. Livingston decided that this accounted for the “hemorrhage” and that the man’s state — the pallor, the sweating, and the “all over” pain — had been entirely caused by fright.

The two of them walked back into the bedroom with smiles on their faces, which annoyed the husband, who was languishing on the bed. But when Livingston gave him his diagnosis, the man’s condition improved rapidly. “Within half an hour he was moving about in his usual energetic fashion and offering to pour me a drink if I would stay and chat.”
p213

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In neuroscience, the homunculus has big gorilla hands, a giant toe, looming genitals, and huge lips and tongue; these brain-areas lie close together, or even overlap. Anything that happens to the mouth might as well be happening to the genitals, too, which is why kissing is integral to sex. By this logic, and according to the homunculus, dentistry could be considered the antikiss. If there is incest or other dark sexual trauma in someone’s past, dental work can stir up those memories, too.
p241

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… the more we learn about the placebo effect, the more ammunition it gives to the pharmaceutical companies. They now have evidence that round white pills are less effective than a colored tablet with corners, and that certain colors have more powerful associations. Red suggests power, green and blue are associated with calm, and the most promising pill is a capsule with lots of colored beads inside. (With doctors with feather anklets may have the right idea.) Also, a patient is more likely to respond to an injected placebo than to a pill, because we have learned that injections are serious medicine. And an intravenous placebo, with a nice little hanging bag attached, is the best of all.
p278

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If Jeff Mogil and Ron Melzack are right [about genetics and pain], fifty years from now, generic Tylenol tablets will seem as quaint to us as a bottle of sarsaparilla tonic. Instead, we’ll take our genotype ID bracely to the local genopharmacologist to order some bespoke pharmaceuticals. Or we may rise at four A.M. to meditate on the part of our nature that is painful and feel better for it. Along with social insurance, we’ll carry geno-cards that list our predispositions: photosensitivity, osteoporosis, and poor response to codeine.

Addiction might be redefined not as a character flaw but as a “biochemical deficit management.” Our emotional habits will become an accepted factor of good health, along with slogans like “Heartache can be harmful to your unborn children.”
p348