Pain Analysis

A Guide to Diagnosis

Rudolph Janzen

• Publisher: Butterworth-Heinemann
• Year: 2013
• ISBN:
  9781483183350
• Topic: Medicine
• Subtopic: Clinical Medicine

Pain Analysis: A Guide to Diagnosis describes the morphology of pain receptors. This book is composed of 12 chapters that discuss the triggering and conduction of the pain stimulus. Some of the topics covered in the book are the localization, different types, development and course of stimulus, and characteristics of pain, as well as the conditions that produce the stimulus. Other chapters deal with the diagnosis of head and facial pain, neuralgia, cephalalgia, trunk and extremities pain, thoracic and acute abdominal pain, and colic. The discussion then shifts to the role of acute abdomen situation in metabolic diseases, the pain analysis in diseases in the retroperitoneal space, and lower abdomen that generates the feeling of pain. A chapter is devoted to the pain due to peripheral arterial occlusion. The final chapters focus on the special pain analysis in the newborn and infants. The book can provide useful information to doctors, students, and researchers.

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PAIN

R. JANZEN

Publisher Summary

Theology, philosophy, psychology, anthropology, and psychiatry have frequently viewed the problem of pain in its psychophysical context and produced thoughtful contributions. However, the study of the structural and physiological basic phenomena requires urgent and renewed efforts. Pain is neither a quality of the object nor it can be reproduced in the imagination. This chapter describes pain as a sensation that only exists in an abstract situation, that is, during examination. A sensation must inform one about the nature of the environment, but the information must be precise. A sensation shows no tendency to irradiation, that is, it does not spread to regions of the nervous system. Sensations only release to a small extent phenomena of summation, tracking, inhibition, or change. Change, inhibition, and tracking are, however, aroused by feeling. In an animal or infant, pain stimuli are followed by elementary or complicated defence reactions, together with movements of expression. Movements of expression and emotion correspond to each other as soon as the brain matures. However, there is no psychic correlation to the movement of expression in an infant.

Pain—is for the doctor a principium cognoscendi.

Pain—is for the patient a principium agendi.

The doctor must interest himself in pain, as he is called on to ease it. The thinking doctor recognizes in pain a ‘limit of human behaviour’ (Plessner), which has fundamental significance for all kinds of anthropology. Heidegger saw in pain ‘an access to the blueprint of being’. Whilst pleasurable sensations are mostly experienced as unproblematical, ‘being impotently delivered to pain causes in man its reflexive effect, the separation of the ego and the body’.

Theology, philosophy, psychology, anthropology, and psychiatry have frequently viewed the problem of pain in its psychophysical context and produced thoughtful contributions. However, the study of the structural and physiological basic phenomena requires urgent and renewed efforts.

We doctors can, as a result of information communicated to us and our own experience, ‘deal with pain’, especially when there are other important symptoms which indicate the nature of the illness.

If, however, pain is the ‘presenting symptom’, if, in other words, no other indication is available as to the nature of the disease, the gaps in our systematic knowledge of pain quickly become apparent.

Anatomy, physiology, and pathophysiology endeavour to explain the functional structure of the nervous system under normal and abnormal conditions. Schemata and models may be of heuristic value, but cannot explain. Von Uexküll has described as biology, as opposed to physiology, those images, which make comprehensible or explain to us the manner of reaction of a living being, but do not explain this scientifically. Interpretations and images intrude if the doctor uses the phenomena of pain to deepen understanding of anthropology. At the same time, however, sometimes a limit is passed unconsciously, because a subject dwells within the object (von Weizsäcker). The doctor will consider the manner of reaction of the person in his analysis of pain phenomena carefully, and include it within his plan of therapy. In this sector of his art he carries out what Paracelsus expressed in the sentence ‘the physician is the medicine’. But this process is carried out on a different plane from that of scentific medicine. ‘From all branches of knowledge and skill we borrow the means to be adequate to our tasks’ (von Leyden). Scientifically one should, however, always be conscious of the plane on which the respective thought or action is carried out.

Whilst so-called academic medicine is accused of having badly neglected the subject, the danger exists at the same time of overvaluing it. In the case of a patient with pain which cannot be explained by physical findings in a routine examination, one is nowadays inclined to ascribe the manner of reaction to personality abnormalities or to peculiarities of the ‘biographical situation’. Only when pain analysis has failed to indicate the nature of the illness and physical examination also has not led any further, should a psychogenesis of pain be considered. That does not mean that a psychogenesis should only be diagnosed by exclusion: it must always be positively founded. The premature diagnosis of psychogenic pain is just as bad as repeated and useless laboratory examinations and different attempts at therapy, if expert examination reveals a psychologically caused disturbance.

To clarify this, an excursion into the physiology of senses is necessary. A sensation (e.g., sound, light) informs us of our environment; a sensation can be reproduced in the imagination. Pain however is not a quality of the object (Achelis), pain cannot be reproduced in the imagination.

A sensation of pain thus only exists in an abstract situation, that is, at the examination.

Thus, pain is not specific sensory awareness. What do we understand by a sensory awareness? Johannes von Müller, the founder of modern physiology and a teacher of eminent doctors considered the following experiment: if it were possible to cut through the optic and the auditory nerves, to stitch them up crossways, and heal them, then acoustic stimuli would result in a sensation of light, and optic stimuli would result i n a sensation of sound—the law of specific sense energies.

Receptors are provisions of the organ for the reception of specific stimuli from the environment: they are specifically constructed transformers. Pain is released by various stimuli and, what is more, by stimuli of an intensity which approaches tissue damage. Free nerve-endings, which until now have been regarded as pain receptors, can also receive other qualities of sensation. We have only limited knowledge of receptors for pain in internal organs (see p. 12). The fact that the viscera and the brain do not feel pain in operations from thermic or electric stimuli, only proves that these stimuli, which cause pain on the skin, are not adequate for brain or viscera.

A simple experiment by Ebbecke may take us farther. A narrow elastic band is laid against the lower arm, stretched, and released. It whips against the skin. Immediately a sharp, precisely localized pain occurs, transmitted to the central organ through nerve-fibres which have a high speed of conductivity. After a brief interval a dull, burning, deep, but no longer precisely localized pain arises and lasts longer. It is passed on to the central organ by slowly conducting fibres (see p. 9). With that, the pain sensations after the irritation by the elastic band come to an end. Observation of the section of skin whipped by the elastic band (that is, the injured section) shows, however, an increasing reddening in the shape of a stripe, around which a white area is an indication of the reaction introduced through the finest branches of the capillary system. Finally, a swelling occurs as a sign of the reparative inflammation. What is being repaired is the consequence of mechanical tissue damage. All these processes continue regardless of consciousness; the initial sensation of pain appears, as it were, superfluous –an ‘epiphenomenon’. Much has been cleverly thought and written concerning the meaninglessness of pain. These considerations may be summed up in a sentence by Bloy: ‘souffrir passe, avoir souffert ne passe jamais’, i.e., pain itself passes, but the traumatic experience of having been delivered to pain remains in the memory and acquires influence on the attitude of man. Pain is not pure sensation. Johannes von Müller in his Handbuch der Physiologie in 1837 first used the expression ‘feeling-sensation’.

What is the difference between sensation and feeling? A sensation must inform us about the nature of the environment, the information must be precise. A sensation shows no tendency to irradiation, i.e., spreading into further regions of the nervous system. Sensations only release to a small extent phenomena of summation, tracking, inhibition, or change. Change, inhibition, and tracking are, however, aroused by feeling.

Pain is not only sensation and feeling, pain is also affect. In an animal or infant, pain stimuli are followed by elementary or complicated defence reactions, together with movements of expression. Movements of expression and emotion correspond to each other as soon as the brain has matured. In the infant, however, there is no psychic correlation to the movement of expression. Emotions could therefore be described also as luxury phenomena, as meaningless epiphenomena.

Let us now ask, on the contrary: How does the content of consciousness influence the reaction to pain? Here too, popular language has formulated the expression ‘crazy with pain’. This means that the emotion of pain can effect a change in consciousness. On the other hand, experience and training, the basic attitudes, influence the primitive defence and instinct reactions. When consciousness is limited, e.g., in a state of intoxication or semiconsciousness, a pain stimulus can release a primitive reaction, an unrestrained emotional reaction, an unbridled defence expressed in blindly raging attack. Not all parts of the organism are capable of experiencing pain. Internal organs are experienced as immediately painful. We often localize inaccurately into the cavities of the body. Irritations of the internal organs either remain quiescent, are only imprecisely recognized, or are ‘transferred’ to other regions of the experienced physical scheme. Thus, the patient reports a pain at a site which is not identical with the site of irritation. The body schema is a function of the central nervous system, and matures autonomously; for its manifestation it only requires stimulation by a sense quality (Poeck and Orgass). The experienced body schema is comprised of those parts which are in immediate relationship with the environment.

If the skin has been directly irritated, the pain zone is identical with the zone where the pain is felt. The skin possesses the facilities for local defence. Independently of that, it passes on to the central organs information which we experience as localized pain.

Even the decerebrate animal possesses very complicated defence mechanisms. If dilute acetic acid is placed on to the big toe of a spinal frog, the leg is immediately withdrawn. If a small cotton-wool swab with dilute acetic acid is put on the skin of the belly, the leg on the same side is immediately used to remove the source of irritation. If this leg is tied, the other leg is used. If this leg too is tied, the front legs will remove the source of irritation.

Complicated defence reactions and expressive movements, as well as instinctive actions, are regulated by the brain-stem which is fully developed and functional in the infant. Ebbecke objects that Schiller, in his verses on the function of hunger and love in the world, had omitted a vital circle–he had not added the vital circle of self-defence to the vital circles self-nourishment and self-reproduction. Pain, too, can effect something that belongs to the basic qualities of instincts; for instincts can conflict with each other, restrain each other. Thus when animals are on heat, mechanisms are suppressed which would at other times lead to the avoidance of pain. However, in man, instinctive actions resulting from pain can limit consciousness and will. On the other hand, will and attitude can influence the expression of the pain emotion and the instinctive actions consequent to it.

The animal is protected in its environment now and for the future by genetically-etermined demotional and instinctive actions. Man has lost this protection; he is a biologically vulnerable being. But through consciousness, memory, experience, and tradition he has acquired a new protection within a greater freedom. Memory provides him with a reminder of pain. From experience, man can avoid foreseeable pain. Experience, tradition, and degree of maturity also determine the degree of his reaction to pain. The pain which precedes a pleasurable experience, e.g., the pain of setting a dislocation or labour pains, can be borne ...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• PREFACE
• CONTRIBUTORS
• PUBLISHER’S NOTES
• Chapter 1: PAIN
• Chapter 2: MORPHOLOGY OF PAIN RECEPTORS
• Chapter 3: SUPERFICIAL AND DEEP PAIN: TRIGGERING AND CONDUCTION OF THE STIMULUS
• Chapter 4: ELUCIDATION OF SOME TERMS
• Chapter 5: PRINCIPLES OF CLINICAL PAIN ANALYSIS
• Chapter 6: HEAD AND FACIAL PAIN
• Chapter 7: PAIN IN THE TRUNK AND EXTREMITIES
• Chapter 8: THORACIC PAIN
• Chapter 9: ANALYSIS OF ACUTE UPPER ABDOMINAL PAIN AND COLIC
• Chapter 10: LOWER ABDOMINAL PAIN
• Chapter 11: CARDIAC AND VASCULAR PAIN
• Chapter 12: PAIN ANALYSIS IN CHILDHOOD
• INDEX