Unlocking Pain's Secrets

By Claudia Wallis

COVER STORY

The question for doctors: How do you spell relief?

The alarm rings at 7, and she reaches for the pillbox. It is the first act of her day. Her suffering, like the box itself, is divided into four spaces, each with its allotment of pink, white, brown and blue pills. "The pain is always there," she says; "there are just different levels of it. "First there is the "daily, hard, getting-around pain." This constant pain of rheumatoid arthritis has been with Maureen Hemmis, 37, since she was 18 years old. Then there is the variable pain: spots of acute, stabbing sensations that change location each day. Worst of all are the arthritic flare-ups when each joint rages and burns, hot to the touch. "The pain is everywhere. You can't be moved or touched. It's very much like being on fire."

In one way or another, we have all felt it. If it were a color, we would say it comes in a thousand shades, from vivid reds to somber browns. There is the quick, flashing smart of a ringer scorched by a flame or the grinding torment of the dentist's drill striking close to a nerve. We all know the dull throb of a stubbed toe that sends us hippity-hopping from foot to foot in search of distraction. And many have felt the pain that cuts deeper: the gut-clutching agony that we awaken to after surgery.

Though familiar to us all, pain is mercifully difficult to remember once it has passed (if it were not, it has been observed, every family would have but one child). Doctors refer to the short-lived suffering of childbirth or surgery or even a toothache as "acute pain"; it is terrible at the time, but ultimately it passes. For untold millions, however, pain does not pass. It sings on through the night, month after month, overwhelming sleep, stifling pleasure, shrinking experience, until there is nothing but pain. This is chronic pain, and its sufferers are legion: there are more than 36 million arthritics in the U.S.; there are 70 million with agonizing back pain; about 20 million who suffer from blinding migraines; millions more who are racked by diseases like sciatica and gout. Most feared of all, the pain associated with cancer afflicts some 800,000 Americans and 18 million people worldwide.

All told, nearly one-third of the American population have persistent or recurrent chronic pain, according to Seattle Anesthesiologist John Bonica, founder of the International Association for the Study of Pain and a world-renowned leader in pain research. Of these, he estimates, one-half to two-thirds are partly or totally disabled for periods of days, weeks or months, or for life. "Chronic pain disables more people than cancer or heart disease," says Bonica, "and it costs the American people more money than both." His estimate: $70 billion a year in medical costs, lost working days and compensation. The human cost, of course, cannot be measured. Shingles Sufferer

Mark Metcalf, 35, of Berkeley, Calif., endured weeks of pain that "felt like I had a hot iron held against the side of my neck," and he found himself "considering suicide as a rational alternative." Every year a number of the chronically suffering make that choice. Pain, said Albert Schweitzer, "is a more terrible lord of mankind than even death himself."

It is the single most common reason for seeing a doctor. It is the No. 1 reason people take medication. And yet for a variety of reasons, medical science is ill equipped to deal with pain. While the 20th century has brought remarkable advances in the treatment and in some cases the elimination of disease, doctors' understanding of pain is just beginning to emerge from the dark ages. "Pain is the weak link in modern medicine," says Dr. Josef Wang, director of the pain center at the Mayo Clinic. To begin with, medical students receive only the scantest introduction to the subject. A 1983 survey by Bonica of 17 standard textbooks on surgery, medicine and cancer found that only 54 pages out of a total of 22,000 provided information about pain; half of the books did not discuss it at all. Part of the problem is that there are relatively few known facts to discuss. Pain research is an orphan field that neither anesthesiology, neurology nor psychiatry can entirely claim as its own. As a result, research has been neglected and underfunded. The National Cancer Institute, for instance, spends little more than one-fifth of 1% of its $1.08 billion budget on pain research, even though the dread of terminal-cancer pain has become a national phobia.

The little that is known about pain and how to treat it is often misunderstood or ignored by physicians. A 1973 study by Psychiatrists Richard Marks and Edward Sachar of New York City's Montefiore Hospital found that nearly 75% of hospitalized patients receiving narcotics for moderate to severe pain failed to be relieved by the drugs. A review of their charts showed why. The dosages prescribed by their doctors were 25% to 50% less than what was needed to relieve severe pain. Records showed that nurses had further reduced these dosages substantially. The result: some patients were receiving less than a quarter of the pain medication they needed. According to the study, the problem was largely due to ignorance: most staff physicians simply overestimated the efficacy and duration of painkillers. They also overestimated the risks of narcotics, worrying excessively about the possibility of respiratory problems and addiction. "We've become a nation obsessed with drug addiction," says Bonica, "and this has led to a serious problem with underdosing." Congress is considering legislation to legalize the use of heroin to ease suffering by terminal-cancer patients (see box).

The twelve-year-old boy's sweet smile makes a poignant contrast to his otherwise pitiful appearance. His arms and legs are deformed and bent, as though he had suffered from rickets. Several fingers are missing. A large open wound covers one knee, and the smiling lips are bitten raw. He looks for all the world like a battered child, but only nature is to blame for his condition. He was born with an extremely rare genetic defect that makes him insensitive to pain. His fingers were either crushed or burned because he did not pull his hand away from things that were hot or dangerous. His bones and joints are misshapen because he pounded them too hard when he walked or ran. His knee had ulcerated from crawling over sharp objects that he could not feel. Should he break a bone or dislocate a hip, he would not feel enough to cry out for help.

Pain is the body's alarm system. It alerts us to the fact that something is harming us. It compels us to seek help when we need it. It immobilizes us when we are injured so that healing can occur. Pain has an evolutionary importance, says Anatomist Allan Basbaum, of the University of California, San Francisco. "Not to have pain at all is a disaster." But when the pain alarm fails to shut off, it ceases to serve a useful function. "Uncontrolled pain," Basbaum notes, "is also a disaster." In fact, it can do serious harm. The acute pain that follows surgery can, for example, sometimes interfere with a patient's ability to breathe, as well as contribute to nausea and add to the strain on the heart. Chronic pain often leads to an endless cycle of anxiety, depression, loss of appetite, profound fatigue and sleeplessness, all of which make the pain seem worse. Says Neurologist Kathleen Foley, president of the American Pain Society: "Chronic pain destroys lives."

Thelma Beauregard is a gray-haired, pleasant-faced woman of 67, who awoke one night four years ago at her home in Plymouth, Mass., with tingling and burning sensations running from her left elbow to her hand and down into her fingers. From then on, the slightest touch triggered sharp pain. Tests showed that Beauregard 's ulnar nerve had been damaged at her left elbow. Her right elbow showed the same damage, although for some unknown reason she felt pain only on the left side. She has had three operations on the recalcitrant nerve, but at most these provided only a few months of respite. She has tried acupuncture, hypnosis, narcotics, electrical stimulation, antidepressants, heat therapy, ice-water therapy, all to no avail. Four years of suffering have conditioned her to cradle the stinging limb against her body, as though an invisible sling were holding it in place. The left hand has been used so infrequently that the muscles have visibly wasted away. Although the nails are beautifully manicured, the skin on her hand is paper dry. Daubing on lotion simply hurts too much. She looks weary. It is hard to sleep, she says, when "you feel as if you have a knife slicing into you."

Pain like Beauregard's is still something of a mystery to doctors. What caused it? Why did it arrive one night without warning? Why will it not go away? According to Neurologist Howard Fields of U.C.S.F., there is intriguing evidence that in many cases when pain persists for several months, changes of a relatively permanent nature occur in the nervous system, so that even if the original cause of the pain is removed, the sensation of pain continues. "We don't have any idea how that comes about," he says. Trying to reverse the changes, he observes, "may be something like trying to purge memory."

In simpler times, suffering like Beauregard's would have been attributed to evil influences. While early man had no trouble comprehending acute pain caused by injury, chronic pain was relegated to the occult realm of medicine men, sorcerers and shamans. Ancient Egyptians believed that chronic pain was caused by spirits, gods and the dead, but by the 16th century B.C. they had discovered a corporeal way to treat it. Opium is recommended as an analgesic in the Ebers Papyrus, an early reference work listing nearly a thousand prescriptions used in the times of the Pharaoh Amenhotep. Egyptians and some Eastern cultures believed that the physical locus of pain was the heart. This was debated among the ancient Greeks, until philosophers like Democritus and Plato concluded correctly that the pain-perception center is the brain. Greek scientists found support for this theory by discovering that the brain is connected to a network of two types of nerve fibers, one set controlling motion, the other, sensation. This knowledge was lost in the Middle Ages, and superstition again took hold. Only when taboos against dissection were lifted during the Renaissance did thinkers like Leonardo da Vinci once again understand pain in terms of the nervous system.

Most refinements of this understanding have come about in the past 20 years. Today scientists have a fair idea of what happens physiologically when, for example, the big toe collides with a large, solid object. Not surprisingly, the pain message originates at the point of contact (see diagram). It begins with the release of a number of potent chemicals that are normally stored in or near nerve endings for use on just such clumsy occasions. Among these chemicals are the mysterious substance P (for pain), prostaglandins and bradykinin, probably the most painful substance known to man--just a tiny amount inserted under the skin with a needle causes excruciating pain. These substances sensitize the nerve endings and help transmit the pain message from the injured region toward the brain. Prostaglandins also increase circulation to the damaged area, causing the swelling and redness known as inflammation. The purpose of this is to attract infection-fighting blood cells that will ward off any invading bacteria. Since the days of Hippocrates, doctors have been relieving pain with salicylic acid, a precursor to aspirin that was derived from willow bark, but only in the past 15 years have they understood that it works by inhibiting the production of prostaglandins. Tylenol (the most common brand of acetaminophen) works much the same way, as do popular prescription analgesics like Clinoril (sulindac), Motrin (ibuprofen) and Dolobid (diflunisal), often used to relieve arthritis and severe menstrual cramps.

The pain signal from the stubbing of the toe travels as an electrochemical impulse along the length of the nerve to the dorsal horn of the spinal cord, a region that runs the length of the spine and receives signals from all over the body. In a tall person, the distance from toe to dorsal horn may be more than one meter, and it can take about two seconds for the message to arrive. From there, it is relayed in a bewildering flurry of chemical messages to the brain, first to the thalamus, where sensations like heat, cold, pain and touch first become conscious. Then on to the cerebral cortex, where the intensity and location of pain are recognized. This final stretch of the pathway is the great terra incognita in pain research. Says Fields:

"We can't put an electrode into the consciousness." In any case, it is the cortex that coordinates such highly sophisticated responses to pain as screaming "Ouch!" and rubbing the sore toe.

Toe rubbing, it seems, has its purpose, and one can get considerable relief by massaging or patting a sore area, just as one can relieve itching by scratching or slapping. In 1965 two researchers, Patrick Wall and Ronald Melzack, devised a brilliant theory to explain this effect: the gate-control theory of pain. According to them, only a limited amount of sensory information can be processed by the nervous system at any given moment. When too much information is sent through, certain cells hi the spinal column interrupt the signal, as if closing a gate. Thus, it is reasoned, pain can be prevented from getting through the gate when there is competition from other sensations, like toe rubbing. The theory served as the basis for a now widely used analgesic therapy known as transcutaneous electrical nerve stimulation, or TENS. Electrodes are attached to the skin above a painful area, and a mild current is generated to compete with the pain signals. The stimulation of acupuncture needles is also believed to work, in part, by shutting the pain gate.

The gate-control theory, which has given rise to much new research, has been useful in explaining some of the puzzling psychological aspects of pain. Take for instance the familiar wartime phenomenon of a soldier so immersed in the heat of battle that he does not feel the mine going off beneath his foot. Or the football player so absorbed in making a play that he does not realize he has dislocated a shoulder until the game is over. Neurosurgeon Charles Poletti, of Massachusetts General Hospital, has his own favorite example. As a youth, fresh from the innocence of an all-boys boarding school, Poletti discovered the pleasures of necking with a Wellesley girl one wintry night. Only when he got up off the icy wall where they had been sitting did he feel an excruciating pain in his rump. "I was almost frostbitten," he says. "We must have been sitting there for 45 minutes, and I didn't feel a thing. Something hi my system was suppressing that pain."

About ten years ago, scientists in Scotland discovered what that something might be. Building on the work of American and Swedish researchers, University of Aberdeen Pharmacologists John Hughes and Hans Kosterlitz isolated powerful pain-blocking chemicals that occur naturally in the brain and spinal cord. The substances, called endorphins, switch off the pain alarm, rather like a key fitting into a lock. The locks are receptors on the surface of nerve cells. Opiate drugs like morphine and heroin also fit these locks, activating the body's pain-relief system. "All these years people had been using an extract of the poppy for pain relief," muses Fields. "Finally we have a plausible explanation for how it works."

The endorphin system is just one mechanism that can shut the gate to pain. Since the first endorphin was discovered in 1975, several types of natural opiates have been identified, along with other nonopiates produced in the body that can alter the pain message. Some of these chemicals, called neurotransmitters, not only are associated with pain but are also involved in emotional responses like depression. Doctors have learned that drugs developed to treat depression can also be used, in small doses, as analgesics. Ronald Dubner, of the National Institutes of Health, who spends most of his time trying to unravel the chemistry of pain and analgesia, has come to appreciate the fact that "pain is a complex experience that involves emotions, previous experiences with pain, and what the pain means to us at any given tune." In short, the borderline between the physiology and psychology of pain is a blurry one.

He was a raw recruit from Parris Island, taking a beachhead in the Pacific. He was scared to death. Heavy enemy fire was killing his buddies all around him. When a shell burst near by, he felt an excruciating pain and the sensation of blood pouring down his leg. There was a call for a corpsman, and he was carried to a medical station, where doctors discovered he had indeed been hit--on his canteen. They sent him back out. More shells, more bombs.

Suddenly, he felt a sharp pain in his head, hit the sand, rolled over and ran his hand across his forehead. Sure enough, there was blood. Again they carried him to the medical station. The doctor took some tweezers, picked out a few fragments of metal from his face, slapped on some adhesive bandages and sent him back to fight once more. By then, almost his entire company had been wiped out. For the third time, a shell burst near him. It tore off his leg. He did not feel a thing.

The young G.I. who told this story to Dr. Raymond Houde some 40 years ago declared that the worst pain he had ever felt was when his canteen got hit. The second worst: surface wounds on his face. "What pain signifies makes a big difference in how it is perceived," explains Houde, now chief of pain drug research at New York City's Memorial Sloan-Kettering Cancer Center. Fear, anxiety, stress, the expectation of disaster can make pain seem much worse than it is. For cancer patients, he explains, pain is often magnified because it is interpreted as "a signal of the disease having recurred, or some terrible complication setting in, or worse, that you are dying." Hope and encouragement can, on the other hand, make pain seem less than it is. During World War II, pioneer Pain Researcher Henry Beecher found that soldiers wounded during the bloody battle at Anzio needed far less morphine than did civilians with similar wounds. The presumed reason, now known as the "Anzio effect," was that for civilians the wounds were a source of anxiety; for soldiers they meant going home.

In many cases of chronic pain, the patient has something material or psychological to gain from suffering. Seattle Psychologist Bill Fordyce cites the case of a woman who developed lower-back pain when her physician-husband retired, perhaps so that he would still have someone to treat. Studies have shown that individuals with a pending lawsuit seeking compensation for injuries rarely get better until the suit is settled.

But when there is a powerful motivation to get well, pain can fade into the background. Dr. Jon Levine, of U.C.S.F., describes a woman whose hands and knees are swollen with arthritis but who continues to manage a San Francisco clothing store and has even run in the city's 7.6-mile "Bay-to-Breakers" road race. "I feel sure that she is experiencing the physiological impulses of pain," says Levine. "When you push her, she'll admit that there are certain things she tends not to do; for instance, she can't lift big bundles of clothing any more." But, he says, she refuses to use the word pain.

Some physicians are convinced that there are distinct characteristics that make some people more susceptible to chronic pain. Drs. David Richlin and Leonard Brand of Presbyterian Hospital in New York City list the following traits: low motivation, poor self-image, lack of pride in accomplishments, dependency on others.

Physicians have long known that if a patient is assured that he will recover and is treated with sympathy, his pain will often disappear. In the same way, a simple sugar pill, or placebo, prescribed in place of drugs, can have a curative effect. In fact, before the 20th century, when doctors relied on bleedings and all sorts of dubious nostrums, most of medicine was a type of placebo (Latin for "I will please").

Several studies have documented the efficacy of placebos. In 1955, Harvard Researcher Beecher found that sugar pills work one-third of the time in treating conditions ranging from headache and seasickness to wound pain. Levine and Fields of U.C.S.F. have reported that a placebo was capable of mimicking the effect of four to six milligrams of morphine, a mild dose, in patients suffering the pain of tooth extractions. U.C.S.F. researchers have also shown that the placebo effect is partly due to the stimulation of the body's endorphin system. When the action of endorphins is inhibited (by using a powerful opiate-blocking agent), placebos may not work.

Unfortunately, the psychological element in chronic pain has often led physicians to dismiss their patients' complaints. Says Fields: "Many doctors and nurses believe that if a person responds to a placebo, the pain can't be very bad. This is a terrible mistake." Only about 5% of chronic pain patients are hypochondriacs or hysterics, according to Psychiatrist Anthony Bouckoms of Massachusetts General Hospital. "Pain itself is the reason people suffer; it is not psychopathology," he avers. And yet the most frequent question Bouckoms hears from pain patients is: "Tell me, doctor, is it all in my head?"

She thought she had lifted something too heavy for her during the family's move from South Carolina to New York. But months later, the pain was still getting worse. "Oh, Mama, "her two children would say, "try to forget it." She went to two orthopedic surgeons and a rheumatologist. No one could find anything wrong. "If you get out and run, you'll feel so much better," her husband suggested. But she knew she was unable to run. She began to believe she was making up the pain. "You want to hide your face. Everybody gets tired of people being ill. "After two years, convinced that cancer was the only possible explanation, she persuaded a doctor to take a chest X ray. "That's when they found the whopper, "she recalled recently before her death. The pain had been real, and so was the large tumor in her lung.

People with chronic pain often wind up on a medical merry-go-round: psychiatrists tell them that their problem appears to be physical; internists and surgeons tell them they ought to have their head examined. Western doctors, trained to cure acute illness, are often frustrated by patients with vague pain that refuses to go away. So are the families, who quickly tire of hearing complaints. Dejected, guilt-ridden and increasingly isolated, many pain patients eventually seek care outside standard medicine: herbal treatments, chiropractic, faith healing and, too often, quackery. Says Fields of U.C.S.F.: "They fall through the cracks."

Many of these people are now finding their way to multidisciplinary pain clinics, of which there are about 150 around the world. The idea of combining the skills of doctors in many disciplines to deal with pain was pioneered by Bonica at the University of Washington Medical Center's Clinical Pain Service in Seattle (see box). Treatment at a pain clinic begins with a thorough workup, including physical, psychological, neurologic, orthopedic, radiologic and laboratory examinations. If a physical problem is detected--a tumor pressing on a nerve, a slipped disc--surgery or some other appropriate treatment will be recommended.

However, in general, pain clinic patients have less concrete causes for their suffering. For them, the first step often is to be weaned from whatever narcotics they have been taking for relief, substituting methadone if necessary and offering psychological counseling. Doctors tend to frown upon the use of narcotics and muscle relaxants like Valium because they may add to a pain sufferer's debilitation.

The first line of treatment is the "simple analgesics": usually aspirin and acetaminophen. Even cancer patients can sometimes find relief in a bottle of aspirin. A number of other nonnarcotic drugs have proved useful in treating specific kinds of pain. Migraine Sufferer Elaine Anderson, 31, of San Francisco had tried everything from strong doses of codeine to psychic counseling to relieve pain "that felt like someone was tightening my head in a vise." She finally found relief with calcium channel blockers, originally developed for heart patients. Antidepressive drugs like the tricyclics are frequently recommended for shingles and chronic lower-back pain. Antiseizure medications like Dilantin, commonly used to treat epilepsy, can help calm the spasmlike facial pain of trigeminal neuralgia.

Physical therapies are helpful not only in relieving pain, but in helping patients get on with their lives despite it. Such treatments, including exercise, whirlpool and massage, are particularly useful for back pain, which is often compounded by muscular weakness. Before Maureen Brennan, 37, of Helena, Mont., arrived at the Seattle pain clinic for treatment of her back problem, she was confined to a wheelchair and was spending $180 a week on narcotics, sleeping pills and antidepressants. An accident four years earlier had ruptured five discs in her spine. Seven operations had failed to relieve the pain, and her weight had dropped from 160 lbs. to 81. After Seattle's three-week program of intensive physical therapy and psychological counseling (at a cost of about $10,000), Brennan was walking briskly down the hallways. "I have the same pain I came in with,""she says, "but you're busy here. It's like working an eight-hour day." The hard work makes it easier for her to sleep, and Brennan plans to get a job for the first time since her accident. Observes Clinic Psychologist Fordyce: "People who have something better to do don't hurt as much."

Hypnosis, biofeedback and TENS stimulation, once considered "fringe" methods of treatment, have earned respectable places in the pain clinic arsenal. Acupuncture, which tends to give only temporary analgesia, has a smaller following. According to Bonica, TENS provides significant short-term relief for 65% to 80% of patients and long-term relief for 30% to 35%. The electrical stimulating devices are widely available at costs ranging from $60 to $400. Biofeedback, in which electronic devices are used to teach patients to relieve tension, has proved helpful for a number of ailments, including one of the most perplexing problems in medicine: phantom limb pain, the often agonizing sensations that amputees "feel" in missing limbs. Psychophysiologist Richard Sherman, of Dwight David Eisenhower Army Medical Center in Fort Gordon, Ga., has found that the pain, which afflicts about 80% of amputees at one time or another, is sometimes due to muscle spasms in the stump. When Sherman teaches patients to relax the affected muscles through biofeedback training, the sensations in the phantom limb usually disappear.

For cancer patients, more drastic measures are often needed. According to Kathleen Foley, chief of the pain service at Sloan-Kettering, only about one-third of cancer patients suffer severe pain. With these, the tumor is the cause in 65% of patients, either because it impinges on nerves or because it releases chemicals that affect the nervous system. An additional 30% have pain resulting from the treatment (for example, chemotherapy). Cancer of the pancreas and of bones can be particularly painful because of the sensitive nerves in or near these organs. In the vast majority of cases, cancer pain can be alleviated with drug therapy, including narcotics like morphine or methadone. These may be administered by mouth, by injection into the muscle or directly into the spine via surgically implanted catheters. An implantable morphine pump that provides a continuous infusion of the drug is being tested for use by cancer patients. Unfortunately, patients may develop tolerance to narcotics, and their doctors often fail to provide high enough doses to keep pain at bay.

Surgery is the last recourse of the pain patient. "I spend an awful lot of my time telling people not to have it," says Neurosurgeon Poletti of Massachusetts General Hospital. Although operations to destroy nerves can provide immediate relief, the benefits rarely last more than six months to a year and may be followed by intense, burning pain that is worse than the original complaint. Surgery is often reserved for terminal-cancer patients. For such patients, neurosurgeons have devised delicate operations to cut nerves causing local pain, and even to sever nerve tracts in the spinal cord and brain. In some instances, rather than destroy nerve tissue, doctors can implant electrodes into the spinal cord or brain. The patient can then use an external transmitter to stimulate nerves directly when he feels pain.

Surgery may also be appropriate in cases of the severe facial pain known as trigeminal neuralgia, or tic douloureux. For 16 years, Dr. Mat Boname, 81, of Oxford, N.Y., suffered this excruciating pain, despite the efforts of five doctors. Finally, a delicate operation in which electrically induced heat was used to destroy a facial nerve brought relief. The effect was immediate, he says: "When I came up from the operating room, I had no pain at all."

As the understanding of the pain pathways improves, researchers have great hopes of discovering better methods of analgesia. The search is on for a narcotic that works on the body's opiate receptors without provoking the side effects of morphine. Meptazinol, a drug developed in Britain by Wyeth Laboratories, may be a good candidate. "I think this could be the first in a new generation of opiates," says Sloan-Kettering Neurologist Gavril Pasternak. Scientists elsewhere are experimenting with drugs that activate the body's nonopiate painkilling systems.

Such drugs are needed by patients with diseases like shingles, which does not respond to opiates. Levine at U.C.S.F. is enthusiastic about the analgesic properties of the chili pepper, which, like oil of cloves and ginger, contains a substance that causes sensory nerves to release substance P. Though this causes a burning sensation at first, repeated application produces numbness. Levine believes that capsaicin may eventually prove useful in treating arthritis.

Pain Pioneer Bonica believes that drugs are not the entire answer, and he envisions a day when people will look to their own innate mental powers to relieve suffering. Says he: "I don't think it takes too much scientific license to say that we will discover mental activities that can produce specific analgesia. In ten or 15 years, perhaps we can begin to teach people to control their own pain." The mystical swamis of India have long used what Bonica suspects is "a form of self-hypno sis" to recline peacefully on a bed of nails.

An inner peace can also be induced by music. Lucanne Bailey, who is a music therapist, is using melody and harmony to relieve the suffering of cancer patients at Sloan-Kettering.

Perhaps the only thing worse than having cancer is having it again. As a boy of ten, Charles Lanning fought and won a long, hard battle against Hodgkin's disease. He was free of the disease for years and was beginning to establish himself as a graphics designer in Alaska when, on the eve of his 28th birthday, he learned that he would again have to fight for his life: he had developed another, unrelated form of lymphoma that would prove even more difficult to treat. He returned to Sloan-Kettering six months ago for treatment. When Lucanne Bailey found him, he was in considerable pain, particularly in his back. Says Bailey: "He was very tense and guarded about his feelings, very bottled up. " She offered to play him music and asked him to choose the songs, hoping "to give him a greater sense of being in charge. He was missing a sense of control in his life and over his disease."

Lanning appeared to select songs that reflected his feelings. One favorite: Mr. Bojangles, a song Bailey describes as "sorrowful, about a lonely man, in and out of jail, who loves to dance and drinks a bit. "Seeing that the music seemed to comfort her husband, Lanning's wife Tammy bought him a guitar, which he began to play for the first time in years. "In spite of all the medication, you have to be able to take your mind off pain and on to other things, " Lanning told his mother. "I can lose myself in the music. " He has continued his playing at home, and has begun to sing with his wife.

At a time when she is doing so much for him, Bailey observes, "it is a way for him to give something to her. "

-- By Claudia Wallis. Reported by Ruth Mehrtens Galvin/New York and Dick Thompson/San Francisco

With reporting by Ruth Mehrtens Galvin, Dick Thompson