Ontology of Pain

 The ontology of pain.

          I was operating on this patient today. He was suffering from the most excruciating pain for the last 8 years. The pain was in the lower half of his face on the right side. In medical parlance he was suffering from Trigeminal Neuralgia. He could not even drink water from the right side, slightest touch or exposure to innocuous stimuli like mild breeze on the affected part, would cause intractable, paroxysmal pain. His plight was really very pathetic. 

  After retracting the top of cerebellar hemisphere through a small opening made in the cranium just behind the right ear, the trigeminal nerve was brought into view. After separating the arachnoid coverings on the nerve, I was looking down on that rogue nerve through the microscope.

There was a normal artery that was impinging on the nerve, and with each pulsation, it was triggering that lancinating pain along the distribution of that nerve. 

  There was really nothing abnormal. Just a normal anatomical variation, that resulted in this intriguing disorder. The treatment involved interposing a piece of Teflon between the artery and the nerve, that insulated the nerve from the pulsatile impulses of the artery. After ensuring proper placement of the Teflon piece, closure was done. 

When the patient woke up from anaesthesia, miraculously,his pain was gone. By the time of the evening round, the patient was sitting comfortably in his bed, with a beaming smile, the surest testimony to the efficacy of the surgical intervention. 

     The pain was due to irritation of the nerve. The trigeminal nerve was conveying the sensation of pain despite absence of any injury or problem from the part of the face, from which it was meant to carry the touch sensation. Virtual pain?

Academic pain? Illegitimate pain?

        Pain of somatic origin is mediated through the  impulses from nociceptors.

Nociception is the sensory process that generates signals that lead to pain. Nociceptors, primary sensory neurons are activated by stimuli that cause tissue damage. Stimuli can include tissue injury, extremes of heat and noxious chemicals.

Somatic pain has very specific pathways traveling through the sensory nerves, spinal cord and finally to the sensory cortex in the brain. 

     The illegitimacy of trigeminal neuralgic pain was very intriguing. It was in the absence of any tissue damage, without the mediation of the nociceptors. The abutting of the artery was supposedly causing demyelination of the nerve at the site of impingement. This psuedo pain got me wondering about the other more ubiquitous pain. Emotional Pain. 

Physical pain and emotional pain are different, but there is research that suggests that both types of pain may share some neurological similarities.Both emotional and physical pain are linked to changes in the prefrontal cortex and cingulate cortex.Rather than viewing emotional pain and physical pain as fundamentally different, they should be conceptualized as both being part of a broader pain continuum. Some types of pain are purely physical while others are purely emotional; but many times, pain lies somewhere in the middle.

What might be the pathways of Emotional pain? Are there any specific receptors for emotional pain? These perhaps could be the Sensitivity,  nociceptors. Isn't emotional pain also virtual? Illegitimate ? Academic? What propose does it serve? It lies in the domain of a wide cognitive spectrum ranging from indifferent insensitivity to an intense hypersensitivity that could even self destruct. 

     The images of Meena Kumari languishing in pathos and convulsing with torturous emotional spasms rush to the mind. If this pain too was virtual like the Trigeminal Neuralgic pain, it ought to also have some Teflon patch, that could stop the propagation of pain impulses.

Could there ever be this proverbial  Emotional Teflon patch, that can be interposed between the stimulus and the pathways carrying the sensation? It could be the epiphany of  realisation of our true self, and interposing it between the perceived sufferings and our Ego, or assumed identity.  Or then one can choose the masochistic path of languishing eternally and wallowing in self pity, a la Meena Kumari?

Dr. Deepak Ranade.