I have deliberately described pain in a standard way without dwelling on the huge variations. It is, of course, a complete myth that a standard cause produces a standard pain. However, the myth affects the reactions of patients, medical staff and friends alike.

If you walk into an accident and emergency department with a broken wrist, you are matching the pain you feel with the pain you expect to feel with a broken wrist. They rarely match. You may be astonished if it does not hurt. You feel additionally miserable if your pain reduces you to a helpless, weeping wretch. The nurses and doctors instantly spot that you have a wrist at a strange angle, make a diagnosis and assign you to a category. For them, a broken wrist comes with an appropriate package of pain and deserves a fixed protocol of action. You as an individual may be anxious, terrified, drunk or sad, but for them you become 'the broken wrist in cubicle 6'. When your friends turn up, they too add to this porridge of disparate expected, 'appropriate' behaviours. They may act relieved that it is 'only' a broken wrist. They may complicate your sadness by weeping with you. Their sympathy and care help or hinder your own progression of feelings, assessment and worries. It is all a genuine drama with each actor seeking their appropriate role in the play entitled 'The Man with the Broken Wrist'. Some people are wonderful in such a situation, some are paralyzed and others hopeless. Everyone influences the patient's pain.

Emergency situations are a problem but the real challenge occurs when pain persists beyond the 'appropriate' time. Medical personnel can become grossly dismissive and switch their attitude to suspicion that this is no longer a 'proper' patient. They may act as though pain is an option, especially when the initial pathology has gone but the pain continues. The doctor becomes uneasy when patients fail to respond to their treatment and this discomfort of the doctors may escalate into irritation, guilt, anger and withdrawal. Friends who are not doctors play their role with sympathy, support, shelter and care, but these too wear thin if the patient's pain fails to diminish along the expected path. As this situation advances, all players including the patient begin to share guilt, anxiety and depression with major scenes of pity and self-pity, defiance and resignation. A very different reaction is needed by all involved in this chronic phase than during the early reactions to the beginning of pain.

In this chapter we have seen that the location of most pains caused by obvious damage coincide with the area of damage but then extend as a result of the spread of inflammation and the raised excitability of spinal-cord cells. When the damage occurs in deep organs, such as the heart or uterus, the pain is not located in the damaged organ but is referred to a distant zone on the surface of the body. When nerve fibres are cut across, there is a particular danger that the spinal-cord cells on which these fibres terminate react to the loss of input by becoming hyperexcitable. Cancer pains are a special case because the body does not recognize cancer cells as being foreign and so the cancer grows without pain and inflammation until the cancer has grown to such a size that it produces mechanical damage and the consequent inflammation or nerve damage.

In all of these instances, the nature of the pain is influenced by the patient's attitude and that of their friends and doctors. If the pain persists, the attitudes of patients, doctors and friends are tried progressively more severly.

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Pain Relief