DIFFERENTIATION OF PAIN
The Problem of Pain
Pain, even more than fever, is probably the main complaint that sends people hurrying to see a doctor. A vast multitude of diseases and conditions have some form of pain, in some part or parts of the body, as part of the overall clinical picture. Many diseases and disorders can be tolerated for many years, but when the pain gets too severe, the sufferer goes running to the doctor to seek relief.
Pain, and in a broader sense suffering, is, according to many traditional medical systems, the very nature and essence of disease, or dis-ease. The problem of pain, its causes and origins, and how and why we get it, is the concern not only of physicians, but of philosophers and metaphysicians as well.
Why is there pain, and why would a supposedly loving and benevolent Creator permit it to exist? Philosophers of a more stoic, ascetic bent may claim that pain is the very nature of phenomenal existence in a world of duality and conflicting opposites. Others take pain to be a dire message of warning from the body and mind that something is drastically wrong or out of order. Many times, only the severe scourge of pain will get the sufferer to mend his ways and return to the path of health, harmony and balance.
To Kill the Messenger - Or Treat the Cause?
Too many people, when pain arrives with its dire warning, simply kill the messenger by popping a painkiller. But this is at best only a temporary, short term, stopgap measure, and one that is unfortunately too heavily relied on by the medical profession today.
Traditional holistic healing systems like Greek Medicine maintain that the best way to obtain permanent, lasting relief from pain is to treat its root cause. As we shall see, there are several different types of pain, each with a different kind of cause.
And so, the physician's question is whether to kill the messenger by desensitizing the nervous system with painkillers, or to treat the cause. This question is not always so simple to resolve.
Severe pain can be very devitalizing and disabling, and can even disrupt the normal physiological functions of the body. In these cases, it's often wise, compassionate and expedient to administer some type of painkiller, to provide immediate, necessary relief for the stress, tension and dysfunction of pain, allowing the organism to return to some semblance of normalcy.
But at the same time, the physician must do his utmost to treat the root cause of the pain. To ignore this imperative is to sell short and betray the highest principles of holistic healing. Relying exclusively on painkillers is simply not practicing good medicine.
In premodern times, the most powerful herbs and medicines in the physician's arsenal of natural painkillers were mainly strong narcotics that were potent and toxic, often addictive, and with negative side effects. These included Opium and various opiates, as well as Nightshades like Belladonna and Henbane.
Galen was fully aware of these dangers and drawbacks, and cautioned his fellow physicians against over-reliance on these potent painkillers and opiates. Herbs and medicines that focused on treating the root cause of the pain tended to be gentler and safer to use. Designing an effective treatment strategy and deciding which medicines to use, and how much of each, can be a tricky judgment call.
Pain and Discontinuity
The concept of discontinuity is central to Greek Medicine's understanding of pain. Greek Medicine sees pain, in all its myriad forms, as resulting from some kind of discontinuity.
In our dualistic world of opposing forces and qualities, conflict and disharmony are often inevitable. When this conflict or clash of opposing forces or qualities occurs somewhere within the human body, the host will experience pain. And the point where the pain is most keenly felt is often, but not always, the focal point of the conflict or discontinuity of qualities and/or forces.
The most obvious kind of discontinuity as a source and cause of pain is the actual physical or structural discontinuity of the body and its tissues resulting from injury or trauma. Severed or ruptured nerve endings naturally and obviously feel pain, which sends the dire message: Fix me!
But beyond this gross, obvious structural discontinuity, Greek Medicine sees the subtler, less visible forms of pain as being due mainly to a discontinuity of humor and/or temperament that is stressing or irritating some organ, tissue or part of the body.
Greek Medicine, through the concept of discontinuity, sees pain primarily as an acute phenomenon. By acute, I mean sharp, and not in the chronological sense, as many types of chronic pain can also be quite acute, or sharp and severe. The sharper the battle lines of conflict between opposing forces and/or qualities are drawn, the more acute and severe will be the pain.
It's a common clinical observance that pain that's felt quite sharply and acutely at the initial onset will often become dulled or obscured with the passage of time. The conventional neurological explanation of modern medicine is that the brain and central nervous system gradually desensitize themselves to the repeated influx of pain stimuli.
But Greek Medicine, while not denying the existence of these neurological factors, maintains that the conflict or discontinuity between an invading dystemper or humoral disharmony and the righteous physiology and homeostatic forces of the organism will be more acutely felt in the initial stages. With the passage of time, the organism will gradually acclimatize itself to the imbalance or disorder, and therefore will feel the initial conflict or discontinuity less acutely.
Sometimes, the conflict or discontinuity will be between the natural impetus of a fluid, humor or vital principle to flow in a certain direction and factors, either energetic or humoral, that are obstructing or stagnating its flow. And so, Chinese medicine has a maxim: "Where there is stagnation, there will be pain; remove the stagnation, and you remove the pain."
A parallel could be drawn here between pain and fever: Obstructions that are more subtle and energetic in nature, involving the vital principles, could be called ephemeral; these ephemeral types of pain would include mainly nervous, colicky or spasmodic types of pain. Obstructions that are more humoral or substantial in nature will produce pain that also feels more solid and substantial.
Regarding this ephemeral aspect of pain, it's undeniable that there's a strong correlation between one's spiritual, mental and emotional state and how one feels pain. Joyful, positive, outgoing psychic states tend to reduce or mitigate the perception of pain, whereas negative, stressful, anxious or apprehensive states will heighten it. Pain can often be ignored by singleminded concentration on some other focal point or activity. This is true especially for the more ephemeral types of pain, but it can also apply to other types of pain as well.
Pain, Qualities and Dystempers
We've all experienced waking up with a stiff, painful neck or shoulder after catching a chilly draft by sleeping all night with the window open. This would be an example of pain due to a cold dystemper. Exogenous cold has entered the shoulder muscles, cramping and constricting them. Or, one can get a headache by staying too long in an air conditioned theater without warm or protective clothing.
Each one of the Four Basic Qualities can produce certain types or qualities of pain. The astute physician can, by analyzing the quality of pain felt by the patient, determine which of the Four Basic Qualities is causing the discontinuity, which gives rise to the pain.
Heat can generate pain directly by roasting or burning the tissues, as in sunburn. But by far, most heat-related pain involves the process of inflammation.
Galen identified the four main signs of inflammation as being Rubor (redness), Calor (heat), Turgor (swelling) and Dolor (pain). The redness is indicative of the heat, which causes the tissues to swell, which then causes the pain. Inflammation can be a natural immune response to sepsis and infection, or it may be generated by chronic or repetitive stress and irritation to the tissues, which can be either humoral or physical/mechanical in origin, as in overwork or trauma.
The most distinctive feature of inflammatory pain is its throbbing, pulsating quality. According to Avicenna, this is because the inflammatory swelling of the tissues presses against a nearby artery, making its pulsations felt.
Humoral irritation is generally caused by humors or secretions that are too sharp, acidic, ulcerative or caustic. Gastritis or stomach pain caused by a Choleric excess of caustic stomach acid would be a good example.
Cold is a terrible culprit when it comes to generating pain, and one that is greatly underappreciated by modern man. Extremes and discontinuities of cold cause pain because cold is basically inimical to life.
Cold cramps and constricts, impeding proper circulation and metabolism. Cold congeals and thickens the humors, causing pain by obstructing the flow of the humors, fluids and vital principles. Mild or moderate cold, often in conjunction with dampness, produces a dull ache, sometimes with a heavy, bearing down sensation. Rheumatic aches and pains are a good example. Extreme cold can cause a numbing pain, as well as cramping, colic and spasm. Other types of pain commonly caused by cold include headache, stomachache, rheumatism, menstrual pains and toothache.
By far, the most active qualities in the generation of pain are the two primary or active qualities of Hot and Cold.
Dryness is often seen in conjunction with, or as the result of, excess heat. It can generate pain through a tightening, shrinking or fissuring of the tissues.
Wetness is often seen in conjunction with Cold. Its distinctive feature is a feeling of bloating, distension or heaviness, as moisture descends.
In addition, wind can also play an active role in generating pain, usually in combination with one or more of the other Four Basic Qualities. Wind generated pain will often be light, mobile or spasmodic, as in ephemeral shooting pains, or cramps and spasms.
Avicenna's Fifteen Types of Pain
In Avicenna's Canon of Medicine, he lists fifteen different types of pain, with a different causative factor for each. Here is that list, with a brief description of the causative mechanisms behind them:
1) Itching Pain - A humor of a pungent or sour quality.
2) Rough Pain - A humor of a rough, caustic, sour quality.
3) Stabbing Pain - A humor entering and separating membranes in a transverse direction.
4) Stretching Pain - A gas or humor stretching nerves and/or muscles.
5) Compressing Pain - Some matter or humor surrounding, confining and compressing an organ.
6) Corrosive Pain - Irritating matter trapped in between muscle fibers and their sheaths.
7) Tearing Pain - A humor or gas entering between the bones and the periosteum, or when cold compresses the periosteum.
8) Loose Pain - Some matter extending and relaxing the flesh of a muscle, but not its tendons.
9) Boring Pain - Some thick matter or gas trapped within the folds of a hard organ like the colon, and boring into it.
10) Piercing Pain - Like Boring Pain, but matter pierces all the way through.
11) Dull Pain - An excess of cold temperament blocking passages of sensation, or sensitive pneuma; repletion or blockage of vessels by cold, thick humors.
12) Throbbing Pain - Due to a hot swelling or inflammation.
13) Heavy Pain - The swelling of an insensitive organ like the lung, kidney or spleen - surrounding tissues feel heaviness, pressure.
14) Fatigue Pain - Physical exertion; wear and tear (labor fatigue)
Humor causing distension (tension fatigue)
Gases (flatulent fatigue)
An irritating humor (ulcerative fatigue)
15) Irritative Pain - A humor with a sharp, caustic quality.
Get what you will from these fifteen different types of pain and their causes. Some of these types of pain and their causative mechanisms I have discussed already, some I haven't. Some you will find more understandable and relevant, some less so.
Avicenna, to sum things up, goes on to explain how three different things are behind most kinds of pain:
Excessive movement causes pain through distension, contusion or laceration. In other words, this is excessive wear and tear, as in the first type of Fatigue Pain.
Abnormal humors cause pain in two ways. First, their excessive quantity can distend, stretch, compress or pierce an organ or tissue. Secondly, their sharp, caustic quality can irritate, corrode or inflame tissues with which they come into contact.
Gases cause pain mainly through distension. Everyone is familiar with the pain of gas and bloating in the GI tract. But, according to Avicenna, gas doesn't just accumulate and get trapped in the gastrointestinal cavities; it can penetrate into many places - between the fibers of internal organs, muscles, bones, periosteum, flesh or even skin. In short, gas can go virtually anywhere to cause distension and pain.
Pain and the Four Humors
Wherever the Four Humors get critically congested, stagnant or obstructed, they can generate pain. The nature or character of the pain will vary, according to which humor is involved.
Stagnant or congealed blood will generate a sharp, stabbing pain. Menstruating women often get such sharp, stabbing pains, which are usually relieved once the clot is passed. Angina, or blood stagnation in the heart and chest, also produces sharp pains. Milder states of blood congestion and stagnation can generate itching or prickly pain; the tingling of "pins and needles" from impaired blood circulation to an extremity is a good example.
Morbid excesses and congestions of the Phlegmatic humor often produce dull, heavy aches and pains, especially in conjunction with excess cold. The aches and pains of rheumatism are a good example; they tend to have their onset or get worse in cold, damp weather. Signs of pallor, puffiness, swelling or edema may also be present.
Choleric in nature and temperament are pains caused by humoral accumulations of a sharp, acidic, pungent, caustic or irritating quality. In terms of Avicenna's fifteen types, this would be: Itching Pain, Rough Pain, Corrosive Pain, Irritative Pain and Ulcerative Fatigue Pain. Choleric aggravations also aggravate inflammation, which generates Throbbing Pain.
Melancholic pains tend to be colicky, spasmodic or neuralgic in nature. They are often associated with frayed nerves and neuraesthenia, which is a severe exhaustion or fatigue of the nervous system, as well as with neuromuscular disorders. In the GI tract, accumulations of morbid black bile will produce flatulent colic, stomach pains, or even the severe pain of chronic constipation or intestinal obstruction. The areas affected by Melancholic pain may also have a withered, atrophied appearance.
Pain and Pneuma
Pain, in its various forms, will, to a greater or lesser extent, compromise or constrict the flow of pneuma, or the vital breath, through the body. As evidence of this fact, intense pain will often inhibit our breathing, making it constricted and shallow.
In the Vital Faculty, pain can not only inhibit respiration, but it can also constrict and inhibit the free flow of the Vital Force and disturb the vital spirits. Pains caused by the stagnation and obstruction of blood will also affect the Vital Force, since blood is its humoral vehicle, or medium.
In the Natural Faculty, pain will both be caused by stagnations or obstructions of the Natural Force, as well as aggravate them, in a kind of vicious circle; such is the nature of colic. The normal, righteous flow of peristalsis through the GI tract, which is mediated by the Natural Force, working through the Four Administering Virtues, wants to flow downwards; milder blockages will produce burping, belching and various reflux symptoms, whereas severe obstructions will produce pain. Excess or aggravation of the Retentive Force, associated with black bile, is most often involved in these obstructions. Colic can also be generated by digestive wind, also known as gas, or flatulence.
In the Psychic Faculty, pain is often associated with Melancholic obstructions of coldness and dryness. Colicky and spasmodic pains are generally the most ephemeral and energetic in nature, directly involving the Psychic Force. Neuralgic pains are often caused by Melancholic conditions involving the wasting, pinching or constriction of a nerve. The synapse or junction between nerve and muscle is the focal point for neuromuscular pain. Wind can disturb or obstruct the free, orderly flow of the Psychic Force, causing spasmodic or shooting pains.
All types of pneumatic pain, whether they involve the Vital Force, Natural Force or Psychic Force, are basically energetic or ephemeral in nature. More than other types of pain, pneumatic pains can be greatly aggravated by negative or apprehensive psychic states, or ameliorated by positive, joyful ones. Since pneuma, in its various forms, motivates all the physiological functions of the body, pneumatic pains will profoundly affect and influence these functions.
Treatment of Pain in Greek Medicine
Traditionally, the powerful painkillers used in Greek Medicine were either powerful intoxicants which, through generating moisture, produced sleep or unconsciousness. Or, they could be strong analgesics which, through an extremely cold nature and temperament, numbed the nerves. Some analgesics, like Clove oil, however, numb the nerves through extreme heat.
Heating or warming medicines, many of them strongly aromatic in nature, improve circulation and disperse the obstructions and blockages that cause pain. Anodynes, through their warming, relaxing qualities, soothe and ease cold, constricting pains. Counterirritants draw congested heat or cold away from the focal site of the pain by creating their own heat and irritation. Many of these medicines are applied topically in the form of liniments, balms, compresses and medicated oils.
In his Canon of Medicine, Avicenna recommends the topical application of a paste made from Dill seeds and Flax seeds mashed together with water for pain. The Dill seed is a warming anodyne, and the Flax seeds are a soothing demulcent.
Antiinflammatories are the natural course of treatment for throbbing, inflammatory pain. In modern medicine, the main treatment options are NSAIDs (Non-Steroid Anti-Inflammatory Drugs) or steroids, but the herbal kingdom offers a very rich diversity of antiinflammatories. They address all levels and types of inflammation, in every organ, tissue or part of the body, and have no negative side effects.
If the pain is caused by a localized buildup or accumulation of morbid matter in a certain spot, then Greek Medicine will often use hygienic purification treatments to eliminate the congestion or draw it out. And so, enemas are used to relieve the pain of intestinal obstruction. Vesicant plasters are applied topically to draw morbid toxins out of a painful arthritic joint.
If colic and spasm is the cause of the pain, then powerful antispasmodics are used to relieve it. Perhaps the most commonly used pain relieving antispasmodics in traditional Greek Medicine were Rue and Henbane, which were used, in the appropriate dosages, both internally as well as topically. Since these herbs, especially the latter, are extremely potent, they are to be used under professional supervision only.
And so, the most effective way to treat pain is to treat its cause. Wherever the painful conflict or discontinuity exists, it must be resolved and harmonized.