NERVOUS SYSTEM PAIN

Among the most severe of all chronic pain syndromes is trigeminal neuralgia or tic douloureux. This condition, known in some alarmist literature as ‘suicide pain’, is an affliction of a sensory nerve in the face.

Even a puff of wind, or a slight brushing touch, can set off a bout of severe pain. The pain is classically described as being fleeting in nature, occurring like lightning strikes — each one being as agonising as the others.

Although its cause is as yet unknown, it has been treated in the past by neurosurgical procedures which include lifting the nerve off from the artery thought to be causing compression on the nerve.

More damaging procedures such as alcohol injections of the nerve and a collection of nerve cells which control it, have been used, sometimes effectively, but sometimes leaving one side of the face totally numb.

Treatments Medications include the anti-epileptic drugs Tegretol and Dilantin. More recently, another anti-epilepsy medication, Ri-votril, has been successfully used in pain clinics in Australia and throughout the world.

Antidepressant drugs such as Prothiaden, Anafranil and Tolvon have also been used to modify the pain experience and to control the understandable depression that is caused by this most devastating of pain problems.

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CULTURAL ASPECTS OF PAIN: LOOK BEFORE YOU LEAP

Surgeons also sometimes play a game which is seemingly interminable: ‘If in doubt, cut it out’. Alternatively: ‘A chance to cut is a chance to cure’.But, there are also many surgeons who agree with those medical schools that teach that surgery is an admission of defeat and should only be seen as a last resort.

Before submitting to the knife, you should be certain the doctor has satisfactorily answered the following questions:

1. Why is the operation necessary?

2. What are the risks of complications, including death?

3. What are the risks without surgery? Are there alternative methods of treatment?

4. What are the chances that the surgery will achieve its aim? Surgery can never be undone. While a surgeon may cite a 75 per cent success rate, the other 25 per cent of failures sometimes develop long-standing problems that did not exist before!

The following poem is taken from The Pain Game by Dr C. Norman Shealy: There was a crooked man Who walked a crooked style He saw an orthopaedist Who sinisterly smiled. Ahah! I have the answer, Your problem is quite clear I diagnose a bulging disc We’ll remove it, have no fear. The surgery was ended The doctor got his fee And now the disc that was removed Is causing pain around the knee. So that crooked man who still had Pain and strife

Became another victim of a well-intended knife.

Information important for understanding

Closely allied with the ‘It’s all in your head!’ game is the implication, sometimes spoken quite frankly: ‘You’re too stupid to understand!’ Trading on this basis, doctors can excuse many of their own failures. They will fail to explain to a patient the risks of surgery or any other treatment, or the alternatives available.

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PHYSICAL EXAMINATION

Physical examination, and further questioning, usually leads to the impression that the complaint of pain is excessive compared with the physical findings and that emotional factors have significantly contributed to the pain — the presence of which medical treatment cannot offer a reasonable expectation of cure.

Common denominators are often lack of relief from medication and often depression, addiction and decreased ability to function normally as a result of over-medication. Frequently, there is also disability beyond that justified by the physical findings and the contribution of psychological and social factors for the reinforcement and perpetuation of pain behaviour is overlooked.

People often tend to over-value their pain. That is, the pain plays a central part in how they relate to themselves or others. In such cases, the pain controls the person rather than the reverse! Manipulation of others happens more often than most doctors would like to admit. Histories reveal that the patient has often succeeded in manoeuvring physicians into attempting ill-advised medical treatments or surgical procedures.

All this can be very tricky for the physician trying to make a diagnosis and decide the correct treatment. Often the presence of medical illness unrelated to pain is overlooked because of the patient’s restricted focus on the pain complaint. Most patients convey a sense of urgency, complain of distress and disability, and expect that the illness will be named and a definitive treatment started. Little pain management can be achieved until both patient and physician exchange the patient’s expectations, or desires for pain relief, for that of a mutual goal of rehabilitation.

After all, effective pain management involves an unwritten contract between patient and therapist.

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THE ESSENTIAL BACKGROUND — THE HISTORY OF PAIN

.fain exists in all age groups and is common to almost all humanity — affecting the psyche or mind as well as the soma or body.

It cuts across the boundaries of culture, heritage, socio-econom-ics and language. Pain has always been attended by controversy as it is symptomatic of many diseases and its problems involve many disciplines in medicine and philosophy. Its presence or absence has formed the basis for some philosophic systems, and has been the inspiration for much of the world’s literature.

Many penal codes are based on the notion of inflicting pain, both mental and physical on the transgressor. Even the word ‘pain’ has similar roots to the Greek word for penalty.

Pain is no ordinary sensory experience. It has several attributes which differentiate it from the sensations of touch, smell, taste, etc.

One is the emotional aspect of real or threatened pain; another is the subjective experience of pain, which makes it a unique experience different for each individual.

Pain is not always experienced as noxious, and in some aberrant behaviours it is sought for pleasure and recreation. Pain is a perceptual behaviourial state of the whole animal.

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CLASSICAL ALLERGIC DISEASES: ASTHMA WITHOUT ALLERGENS

Asthmatics who are constantly exposed to their allergen – as is the case with house-dust sensitivity – are likely to have bronchi that are highly ‘irritable’, because of the inflammation in the membranous linings. The late-phase reaction, described in the box below, plays a large part in producing this state of chronic sensitivity. Once it has developed, all sorts of irritating stimuli can then spark off an asthma attack. Common irritants include smoke (cigarettes, bonfires etc), factory fumes, infections, very cold air and sulphur dioxide.

Becoming emotional or afraid can have the same effect as these airborne irritants, as can strenuous exercise. It was the ability of the emotions to bring on an asthmatic attack that led to the idea of asthma being largely ‘psychosomatic’.

Eating large amounts of the food additive monosodium glutamate, can also provoke an asthma attack, according to Dr David Allen, a respiratory specialist from Royal North Shore Hospital in Sydney, Australia. He believes that MSG -common in Chinese cooking, packet soups and other convenience foods – has an effect on the central nervous system which triggers off the attack. Similar claims have been made for diets that are high in salt, although how salt in food might contribute to asthma is unknown.

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