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| EXPRESSIONS
OF PAIN
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| There is one surefire way to stop that head-splitting toothache of yours—relocate it by singeing a fingertip. The only way you can erase that searing headache right now is by lopping it off—the head, that is. The only basis for the existence of human rights organizations whose global influence can alter, even dictate, methods of governance and the reign of governments: the infliction of pain. Pain isn't just the most effective weapon of control: it's the only one. Tradition says that your are halfway up the path to enlightenment the moment you stop feeling pain. The first signpost to transcendence is the cessation of pain. Sheer physical pain is killing more people around the world than all known disease put together. If the sound bites above don't provide you with a clue to what pain is—well, welcome to the ranks of the unenlightened majority. When God made a provision for bliss, He made it somewhat complicated; you could get it, but only after the complete elimination of pain—unfortunately the most easily manufactured, widely distributed, difficult to pacify and most intense sensation known to humankind. Befriending it is like willing to sip at the fount of treachery: the sheer brute power of pain makes it the ultimate leveler of all social hierarchies, a juggernaut that supersedes all priorities, flattens all feeling and emotions, tramples reason and loyalty into an unrecognizable mess. | |||||||
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| This was invented by an American teaching at a hospital, the highest notch (10) is that of death, followed closely (09) by childbirth. So far, most evidence seems to point at pain being monochromatic, varying not in kind but in degree. Most evidence couldn't be more wrong. Pain is among the most complex of physiological phenomena, but it defies definition. Even the working dictionary of the International Association for the Study of Pain in the USA is entirely inadequate: "An unpleasant, sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." You can use up every language's entire vocabulary and still not be able to put a finger on the tiniest ant nip, leave alone the howling agony of kidney stones. Confronted with this pantheon of pain, all that you can do is either grin and bear it or pray and plunge into the huge corpus of remedies: herbs and shamanism, chemistry and hypnosis, faith and placebos, invasive excision and psychic surgery. Pain provided fodder for Nietzsche's withering contempt of social conventions. "The preponderance of pain over pleasure," he said, "is the cause of our fictitious morality and religion." Its dubious attractions kept the notorious Marquis de Sade fruitfully occupied for the 27 years he spent in the Bastille, devising innovative ways of inflicting pain that have yet to be bettered. As for its redeeming side, it was the sight of pain that jolted the Buddha out of royal complacence and set him off on one of history's greatest spiritual journeys. And this is what the Buddha observed: "Birth is attended with pain, decay is pain, disease is painful, death is painful; Union with the unpleasant is painful, painful is separation from the pleasant an any craving that is satisfied, that, too, is painful." | |||||||
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HOW
TO COPE WITH PAIN
Sauresh Mehta was plagued by dental rot: but his bigger problem was that he was pumped so full of Novocain during his weekly visits to the dentist that mandibular pain became chronic. It was only after years of hopping from physician to physician that he met his tooth fairy, a dentist whose bark was worse than his bite. Dr Jagadish Prasad has made a unique career using his considerable skill as a raconteur to divert the attention of his patients from the agony of the drill. Wartime legends are replete with soldiers who have extracted bullets or shrapnel from their bodies with no anesthesia but willpower. And you don't need a doctor to tell you that there is no better antidote to pain than the will to live. The enemy here has origins as elusive as they were at Avicenna's time, 1000 years ago. He described the cause of 15 different 'types' of pain and recommended exercise and massage, and snorts of opium, for relief. Defining pain has been painful. Says Dr Akhilesh Sharma, an ayurveda physician: "Ayurveda understands pain as a problem in vayu (air, one of the personality types according to ayurveda), which deals with the nervous system. Pain follows the ingestion of anything that creates imbalance in the vayu dosha." Traditional acupuncture believes that pain is directly related to zhu (loss of energy: chronic pain) and shi (excess energy: acute pain). | ||||||
| Sounds uncomplicated. Before pain became the subject of serious study, it was thought of as different not so much in kind as in degree. (Physical torture, an outdated and inaccurate benchmark still adopted by the Geneva Convention on the rules of war, ranges from the first to the third degree.) A rudimentary scale is the 'Visual Analog Scale' essentially a rod marked from I (painlessness) to 10 (unbearable trauma). "Pain is a complex bioelectrochemical process which is still not fully understood," says Dr Sanjay Wadhwa of the Department of Physical Medicine and Rehabilitation in New Delhi's All India Institute of Medical Sciences. "The management of the two types of pain-somatic (external source) and visceral (internal)—are different." | |||||||
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Time
was when the treatment of pain was cursory, based largely on strength
of pain, pharmaceutical dosage and depth and duration of psychotherapeutic
input. Today, treatment begins with the theory that physical pain is more
than just a matter of intensity and area of influence.
Marking the intensity of pain on a 'wince scale' is a shot in the dark because it vacillates according to personality, intelligence and culture. Each individual's threshold of pain is unique. When Anita Saluja, 45, had a head-on collision with 19-year-old Sanjay's car, it was he who writhed in unbearable agony. Later, when they reached a hospital, it was discovered that Sanjay had nothing more than a hairline fracture on his ankle while Anita's right hand was smashed in three places. And she didn't even whimper. Says Indian psychiatrist Sharad Chandra: "People often come to me with vague, anatomically unrelated aches and pains. The pains shoot up during periods of stress and responds not to analgesics but to antidepressants. Anxiety, a useful emotion up to a point, begins to bite back and spark off tension and headaches. Their severity makes it difficult to believe that they have no physical basis. Fortunately, molecular biology has established that the mere absence of any negative finding through Computer Tomography or Magnetic Resonance Imaging doesn't mean that there is no source of pain." But, says Dr Prem Bajaj, one of India's few pain management specialists: "If the patient says he has a pain, then it should be accepted. We call it non-organic. The snowball effect is that anxiety and stress lead to pain, which then adds to anxiety and stress, resulting in more pain, and so on." Dr L.N. Kothari, who runs the Multi-disciplinary Pain Relief Research Center in Nagpur, India, adds: "Migraine headaches and back aches do not cause any tissue damage and are often psychological." |
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| Somatic pains start at nerve endings and arrive at the brain's decoding centers through the body's information superhighway, the spinal cord. A response immediately bounces back to the nerve endings, telling them to withdraw from the source. But as for visceral pain: where would you retract to from internal discomfort? "It is important to recognize and know enough about the most serious pains," says Dr Wadhwa. "Different conditions cause pains of different intensity, with visceral pains usually the most severe." Fortunately, no other known malady is as susceptible to placebos and autosuggestion and prayer. | |||||||
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Contrary
to all indications, there is a positive side to pain: its function as
a (somatic) burglar alarm or (visceral) fire sensor. The human body cannot
do without its nervy tics and twinges, its itches and throbs, its grinding
migraines and sinus detonations. Pain is the body's riot alarm. Without
its warning signals, we would succumb to the mildest of maladies.
The value of pain is evident when you think of diseases like leprosy. Its major symptom is dead nerves. With its messengers knocked out of commission, the brain has no intimation of the rampaging leprosy bacillus and cannot mobilize its defenses and take reflexive action. Unfelt and ignored, burns don't heal, infection runs uninterrupted, scabs rip and turn ulcerous. Even one of the most devastating diseases known to humankind, cancer, makes its conquests on light feet. Despite early warning systems—palpitating of breasts, outcrop of warts, agony in the bones, skin rash, sub dermal nodes—many cancer patients realize their predicament and seek help only when it is too late. | ||||||
| Pain management is a hybrid of psychology, instinct, counseling, medication, and empathy. Although its extreme subjectivity begs for quackery, it also leaves it open. "Some of the simplest and time tested ways of checking pain," says naturopath Kashinath Panda, "include therapeutic heat, cold, and massage. The application of heat to affected parts has a soothing effect when the hurt is of muscular or skeletal origin. It is also helpful during back sprain and spasms. Spine baths-immersing the spine in an inch of warm water-for 20 to 30 minutes helps keep the spine in working order." Naturopathy believes that pain is the result of toxin accumulation, and recommends enemas, abdominal packs for 20 minutes three hours after dinner, excreting regularly, and frequent massages. | |||||||
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The
body also reacts positively to bearable extremes of heat and cold ice.
A constrictor is a good analgesic, effective after even deep invasive
trauma. Hot fomentation prevents spasms by relaxing the muscles. Among
other methods, paraffin wax contains swollen joints from further inflammation,
a contemporary version of the poultices that our grandmothers perfected.
The electric form of thermal treatment—infrared lamps—says Dr Wadhwa, "helps in relieving subsurface pain. For deep-seated pangs, short-wave diathermy is a popular method." Uncomfortable though it may look, "traction helps a stiff lower back or neck, the result of spondylosis or disc problems. State-of-the art therapy for near-surface, concentrated pain employs low-energy soft lasers which have few contraindications: they catalyzes the regeneration of affected tissues," Dr Wadhwa adds. "Allopathic medicines act fast, but they come with contraindications," warns Bangalore-based pain specialist Dr Ratnakant Patil. Analgesics can cause gastric irritation. Many potent painkillers are camouflaged in medication for other maladies: tricycles antidepressants, effective with acute pain caused by damaged nerves in herpes zoster and diabetes, are said to be addictive; and opium, originally a Chinese mediation, sparked off the infamous mid-18th century Opium Wars and continues to turn millions of addicts into soggy vegetables. It is an irony that from the country which had a tradition of subjecting its women to the lifelong agony of foot binding came the most benign of invasive treatments: acupuncture, which sees health as a matter of energy harmony between yin and yang. Dr Raman Kapur, acupuncture specialist, says: "When the needles are inserted and twirled, the inter-neurons are stimulated, leading to the release of endorphins (the body's self-manufactured intoxicant)." Dr Bajaj adds: "Acupuncture also has a hypnotic effect: it distracts the patient." Hypnosis itself can help direct the anatomy's sensory traffic. Says Indian hypnotist Santosh Babu: "Through autosuggestion, pain can be changed into some other feeling or shifted from one location to another." Creative visualization can be added to hypnotherapy to make it more effective. The mind works by relocating itself: while your body is stretched out on a municipal hospital gurney, your mind could be trained to take a walk along the talcum powder beaches of Hawaii. Dreaming of a cure is the next best thing to an actual cure. |
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| Ayurveda claims traditional expertise in "pain management". A more contemporary concept in acute pain management, for distress such as postoperative or cancer pain, is Patient Controlled Analgesia (PCA), based on the premise that the patient is the best judge of his degree of pain and thus of dosage. PCA is little more than an uncomplicated, user-friendly, shoulder-strapped electronic digital pump connected to a catheter. While doctors set a ceiling on the amount of the drug that can enter the body, the precise dosages are controlled by the patient. Cancer patients in the advanced stages can use PCAs even at home. Doctors found that small amounts of morphine applied epidurally to treat cancer are just as effective, if not more, than larger amounts ingested orally. Epidurals are commonly used after knee surgery and are also a part of the home care regimen of acutely ill patients. | |||||||
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General
and local anesthesia earlier applied exclusively and separately, are today
being used in conjunction, on the grounds that mixing and matching reduces
the quantity and side effects of both.
Not even the smallest dose of morphine is free of contraindications; its current blending with local anesthesia, the consequent reduction in the volume and increase in efficacy of the latter, and the minimizing of side-effects such as nausea and hallucinations has the medical world beaming. But taken without supervision, the brew can still kill as surely as an overdose of morphine. Fortunately, technology constantly comes up with novel pain-obviating methods: one is fentanyl, a highly soluble opiate, which is available as a stick-on patch. The medicine soaks through a special membrane, lining a thin adhesive bandage, and enters the body through the skin at a steady rate. In India, however, chronic pain is rarely viewed as a complete condition by itself, demanding its own exclusive range of therapies, and pain clinics are yet to be established as part of the medical mainstream. Says Dr Bajaj: "In the West, there is a multidisciplinary approach to pain, a single clinic offering various therapies under one roof, which might range from Transcutameous Electric Nerve Stimulation (TENS) and intraspinal pumps for neuropathic pains to treating neuromas (outgrowths at the end of nerves) and phantoms pains which ostensibly have no cure. | ||||||
"Pain
management is not part of the regular curricula in most medical courses
and orthopedics tend to take a limited anatomical and surgical view of
patients. Pain alleviation is not possible through the usual outpatient
departments because there has to be patient-doctor interaction at least
four to five days a week."
There is no way you can paint a pretty picture of pain. It both creates and thrives in a devastated landscape. All your life, you walk through its domain, more and more gingerly as you get older and less able to emerge whole at the other side. The irony is that it is not pain itself that shadows you doggedly—it is the fear of pain, a terror that transcends all other fears. But again, like all fears, it can occasionally be cunningly put to use-as a warning beep of more pain to follow if you don't repair the breach. And even if the most you do is bang the lid on loose talk of the "spiritual and metaphysical aspects of pain" and concentrate on how to rid yourself of that pulled nerve in the lower back—well, you are halfway to heaven. | |||||||
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