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Pain, Che and the forthcoming revolution

By David Butler Pain awareness 14 Sep 2018

I saw this photograph in an exhibition in Havana. It’s a class of medical students in the faculty of anatomy in Buenos Aires in 1948.

Click for full image *WARNING* contains graphic image of a human dissection.

I noted the predominance of males, with all females to the front. I observed the symbolism of white coat power and primacy over the cadaver, and the lack of dignity for the deceased. All with due respect that the event was around 70 years ago.

The student in the back row on the 6th from your right, is Ernesto Che Guevara – the only one of the whole group who is smiling!  Is he aware of something that the others aren’t? Aficionados of Che’s memoir The Motorcycle Diaries will be familiar with this image.

Looking at this image I couldn’t help but sense the pain revolution brewing right now. Useless and deadly drugs, excessive surgery, so much bullshit and so much money spent for nothing in return.

Do others sense a change?


– David Butler


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  1. jqu33431quintner

    Wishful thinking? I would prefer to reserve judgment.

    1. davidbutler0noi

      Of course you would John! And how long will you reserve judgement for before you decide if you are giving up or helping?

      Not wishful thinking in my view. I note change happening at multiple levels and opportunities arising – here’s one…. The medical profession has provided an abysmal and negligent line of public defence from Purdue, Mundipharma and others. Our species is in trouble. We are yet to see apologies from medical societies, something which would powerfully contribute to revolutionary change. Too much reserved judgement out there for me.

      Best wishes

      1. jqu33431quintner

        David, when I look at the same picture taken 70 years ago, I do not share your sense that a pain revolution is brewing.

        Sure, there is a growing disenchantment with interventional medical pain management, with medicine’s apparent inability to curb the inappropriate prescribing of opioid medications, and its promotion of surgical cures for those with spinal pain.

        Some members of the pharmaceutical industry (“Big Pharma”) have facilitated the creation of the massive opioid problem in our society.

        However, physical therapists have also been guilty of promoting useless treatment, as exemplified by “dry needling” and “myofascial release” of “trigger points”.

        The list of our sins of commission and omission is a long one.

        Nonetheless, you can rest assured that I have neither given up nor ceased in my attempts to improve the lot of suffering humanity.

        But I do not look to Dr Che Guevara for inspiration. His legacy as a revolutionary leader is a rather mixed one:

        1. I’d be willing to teach you about trigger points if you are open to learning – I could send a reading list.

          1. davidbutler0noi

            Hi Richard,
            Thanks for your offer. I know the author (jqu33431quintner) has read all there is on trigger points.

          2. He/she SEEMS to have disguised it well in his/her/their first piece .. way too many ironically-laden “parentheses”.

          3. jqu33431quintner

            Richard, the day may yet come when I would happily remove what you correctly regard as the ironically-laden parentheses. However, I have yet to read a study that did not beg the question as to the existence of myofascial trigger points as primary sources of nociception.

            But even if they do exist, as was postulated by the late Drs Travell & Simons, the rationale of attempting to destroy them with needles or a variety of other instruments escapes me.

            In my opinion, the failure of the MPS/trigger point theorists to mount a scientifically credible response to our 1994 paper has ultimately condemned them to the same cult status as other quacks.

          4. I just read this paper again … not a bad effort, brings up some pertinent points WITHOUT unnecessary anger, name-calling or ironic “. “. This a much better approach ~ as the great Louis Gifford used to say “if you are trying to persuade, much better not to get people’s back up”

            A critical evaluation of the trigger point phenomenon
            John L. Quintner Geoffrey M. Bove Milton L. Cohen
            Rheumatology, Volume 54, Issue 3, 1 March 2015, Pages 392–399,
            Published: 03 December 2014

          5. jqu33431quintner

            Richard, sometimes “getting people’s back up” is the only way to gain their attention.

            For nearly 25 years, the MPS/TrP enthusiasts have by and large been totally deaf to our criticism.

            Johann Wolfgang von Goethe [1749-1832] neatly explains their selective hearing loss:

            “Thus I saw that most men only care for science so far as they get a living by it, and that they worship even error when it affords them a subsistence.”

            Quoted by Johann Peter Eckermann in “Conversations with Goethe” October 15, 1825 (tr. by J Oxenford).

        2. davidbutler0noi

          Hi John,

          Well I am pleased to hear that you haven’t given up and I am going to follow up on that.

          The medical profession needs more than growing disenchantment. I think you need to be more outspoken about your own profession ( or elements within it)

          1. Big pharma make the stuff, but they do not prescribe it.
          2. Defending medical clinical behaviours by suggesting PTs are also guilty via promoting dry needling/ myofascial releases wears thin. I am with you on the uselessness of these interventions but they are not killing and maiming people as long term opioids and inappropriate surgery can. And there are therapists who use these techniques as part of a bigger functional movement enhancement treatment package.



          PS I sense you could be quite a revolutionary with a bit of a push!

          1. jqu33431quintner

            David, I have been regarded by my rheumatological colleagues as a “revolutionary” medico since 1985.

      2. As a chronic pelvic pain physician specialist I base my program on a bio-psychosocial and “Explain Pain” approach. I reacted to David’s article earlier today on my Facebook post:
        Robert Echenberg, MD, FACOG

        “My thoughts of the day were stimulated by a provocative article from one of my most inspirational “heroes” in the world of pain. David Butler from Australia posted his thoughts on a rare medical school anatomy class picture from Argentina in 1948.


        I have mixed feelings about David’s comments. For those of you who have taken a look at his post, entitled “Pain, Che and the forthcoming revolution”, you will see that he points out that Che Guevara is in that group of medical students and can be seen smiling.

        David also commented that he “observed the symbolism of white coat power and primacy over the cadaver”. Although I almost completely agree with his final paragraph about “deadly drugs, excessive surgery, so much BS and so much money spent for nothing in return”, I think that the connection between those thoughts and the picture he depicts, however, is quite a stretch.

        My father was no Che Guevara but I can point him out as the 4th man from the left in this picture of his anatomy class in 1932, 16 years before Che’s picture.

        See on DropBox:…/Max%20Echenberg%201932%20Anatomy%…

        You will see two cadavers and not even one female in all of the students or faculty on my father’s picture taken at Queen’s University Medical School in Ontario, Canada. Fast forward to 1962 when I actually won the anatomy prize at Jefferson Medical College in Philadelphia. Our class was the first class ever at Jeff to accept women students (6 out of about 160). Today, women outnumber men in many specialties.

        There was never a group picture taken with the cadavers we worked with in 1962. And I agree that the previous pictures can be looked at as quite appalling today. Nonetheless, those human bodies were respected and honored, and we were told that these were people with life histories that we could only imagine by seeing some of the pathologies exhibited as we went through tedious and difficult dissections.

        As a specialist now in chronic pelvic, genital and sexual pain disorders, I tell many of my patients how I did win that anatomy prize 56 years ago, then practiced Ob/Gyn for over 35 years and “forgot” during all those clinical years that there were muscles, nerves, fascia, bones, joints, ligaments, skin and other anatomic entities in the pelvic region – not just a uterus, tubes, ovaries and a vulva and vagina.

        Therein lies the real issue: Clinical medicine has gotten so reductionist over the last century or more. Where would the masters of art in the Renaissance have been if they hadn’t studied contraband bodies stolen from pauper’s graves in order to accurately depict “the whole person”.

        Where, in our current system, are the clinicians who look at the entire bio-psychosocial aspects of people with chronic illness? “the whole person”?

        I do not believe the problem has been medical student’s disrespect for the dead, but much more a disrespect and dismissal of living breathing human beings trying to explain their pain and suffering to many graduate medical practitioners.

        There are more layers of thoughts that could be debated about those pictures, but that is for another day.”

        1. davidbutler0noi

          Many thanks for those thoughts and reflections Robert,

          There are so many layers for discussion here. One thing that stands out for me is just how many thoughts and memories the image has evoked and in so many people.

          Best wishes


    1. davidbutler0noi

      Hi David,

      Yes, not pretty! Recently I have been experiencing a different kind of shiver down my spine when talking to some rural physiotherapists in Australia and realising what a brilliant and very special job they are doing with pain treatments for people where once there was nothing or addiction. True revolutionaries!


  2. Maggie Jeans

    Brilliant observations. We need you to come to the Sultanate of Oman where I am working on the introduction of palliative care!

    1. davidbutler0noi

      Hi Maggie – I’d love to come to the Sultanate of Oman, but you don’t need me! The new and liberating modern pain knowledge is out there for all. And it has a special and perhaps not appreciated place in palliative care. Good luck with your work!

      Best wishes


    1. davidbutler0noi

      Hi Koen, I hope you are talking about changes in pain treatment and not the latest Belgian beer !


  3. As our physical world in a crescendo of upheaval and change so is the passe methods of treating pain with the BS surgeries and overuse of drugs. You have created an army of revolutionaries David, and we are unstoppable. I recently wrote an eBook, re.lieve Solutions for Chronic Pain,
    lead my pelvic PT staff to change how they explain their treatments from ” this manual therapy will lengthen the pelvic floor muscles” to “this technique will fine tune the firing of your pelvic floor neurons in your sensorimotor cortex and help your brain send pain relieving chemicals”

    “The true revolutionary is guided by a great feeling of love. It is impossible to think of a genuine revolutionary lacking this quality” Che Guevara

    Evelyn Hecht PT, ATC (from Brooklyn!)

    1. davidbutler0noi

      I love that quote too Evelyn! And there is is a lot of leadership from the pelvic world.


  4. I agree with you, David. I have been a physical therapist for nearly 30 years and more and more patients are coming to me for something different. They are tired of the drugs and I am alarmed at the number of “procedures” (injections, nerve ablations and surgeries)never mind the number of MRIs that are performed at our small rural hospital. For some patients in the USA the quick fix is what they seek. I feel that they have been trained to expect this. We are trying at our humble clinic to slowly adjust the mindset of “fix me” and help others to see health in another way and take responsibility. We desperately need to start training physicians and other health care providers (including PTs) in more current concepts and leave the old, tired approach to pain behind.

    It is a daunting task…

    1. davidbutler0noi

      Hi Katherine,

      Good to hear. It is beginning to happen in hundreds of “humble clinics” in many parts of the world and in most professions. Many great revolutions have started in the country too. It’s not easy , there is a long long way to go, but for the first time for many years, I can sense change at patient, professional and policy levels. Hang in!

      All the best


  5. Frank

    PT’s are leading the pain revolution. Sometimes, without a doubt. I feel like a guerrilla, but my weapon is education and knowledge, my tactics empathy and my ideal altruism.

    Saludos de Chile

    1. davidbutler0noi

      Hey Frank,

      That is an intriguing quote from Che ! I think the entire quote starts with “Let me say, at the risk of sounding ridiculous….

      Some PTS are pushing the revolution, there are many holding it back.

      Go for it!


  6. don smith

    Che and love? I don’t think so. Che lacks human compassion and unable to differentiate right from wrong. Astounding observations and most excellent conferences with writings Mr. Butler.

  7. Mel Parker

    Definitely sensing the change but behaviour pretty entrenched, will take time. Reverse education. Educate the people and they will help educate the health professionals. Enable and empower the people to self treat and heal (with HP support as needed). We need to avoid casting ourselves as the fixers and saviours.
    From the photo I notice that the woman near the torso is as far back as possible. I love how Che is smiling!

    1. davidbutler0noi

      Hi there Mel,
      Yep – this will have to be a people led change – too entrenched at the top. That photo is so evocative!



  8. Can the pain revolution succeed in the US? I hope so, but the medical reimbursement system here doesn’t encourage it – not enough money to spend time with people or for communication and a lot of money for procedures/surgeries. Many patients also need a “quick fix” – they just don’t have enough time off to cover cutting back a bit at work (here many people work a lot more than 40 hours a week). As a Rolfer (i.e. someone off the medical/insurance industry grid) I have the luxury of spending time with people over multiple sessions. It can take a lot of talking, repetition, questions, personal stories, encouragement, gradually experiencing movement without pain to bring people over, but once they get it it’s wonderful – it’s a really empowering thing to understand your body and know that you can manage it yourself. I hope there will be more and more physicians and PTs on board, but where I see the most change here is with manual and movement therapists – we’re also in the pain revolution movement!

    1. davidbutler0noi

      Thanks Anne,

      Knowing that this shift is happening is happening in most professions is cause for optimism. Revel in the luxury of time!


  9. Drew Canoe

    Hey David,

    I don’t know if Che was right or wrong, but he certainly was passionate about whatever he was fighting for. I have watched the movies, read some of the books, but I still don’t really know what to make of the guy… I wasn’t there. From what I do know, in some ways I feel like I can relate to him with his passion and his love for humanity, and also his errors and madness. Maybe you can relate too?

    I am a pain self-management co-ordinator in rural Nova Scotia, Canada. I’ve been a physiotherapist for about 15 years now, and I met you once in Thunder Bay, Ontario, years ago, we had a beer together, and you confirmed a lot of stuff I already knew intuitively, but essentially you revolutionized my practice and are a big part of the reason why I am doing what I am doing now. I went back to school and got a Masters in Counselling so I could support people better in the psychosocial aspect of their chronic pain along with the physio. I run groups now and work with people individually, covering all dimensions of the bio-psychosocial model, which feels incredibly “right”. I am going to a physicians network meeting within the next month to explain what I do, as they are slowly getting on board in this area of health care.

    The point of writing this, is that I do certainly sense a revolution… I do believe that is the right word. However, it is a very different revolution than Che’s, and far less questionable. Though there may be a little madness and error involved, I think the bulk of this revolution is really based on passion and love for humanity, and it’s super exciting, and I’m thrilled to be a part of it! I think this post was to get people revved up?… and obviously to keep people thinking and critically using their brains!

    Fight on!

    Drew Canoe

  10. Mel Macoun

    Wow! A great response to this topic. I was just thinking about this very topic, on a much smaller (and far less philosophical) scale, the other day. The Pain Revolution – is it working?

    Yes, David, it is. Inch by inch. Slowly, slowly. More and more health professionals are starting to understand the science and to change the way that they conceptualize pain themselves, and hence how to explain it to their clients. And, as someone above said, lead with the people. People are educating themselves and seeking more information from professionals, rather than hearing it from professionals for the first time.

    I have noticed that people are more likely to come to my practice “primed” with an awareness of pain science, and are not nearly as resistant to hearing me talk about it as they used to be. I used to think when I struggled to get someone to “get it”, that “maybe I’ve at least planted a seed”, thinking they might “get it” from somewhere else, sometime down the track. But now I have patients coming in with seeds already planted and ready to grow.

    It’s getting easier, it’s getting out there. There is still a long way to go, but I will never give up!

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