Sunday, June 7, 2009

The Ambiguity of Pain and Disease

I write as a physician, one who attempts to heal disease.

Virtually all who have sought my ministrations have done so because they were in pain. Indeed, they have generally regarded pain and disease as synonymous. This is natural. Does not the very word dis-ease equate with dis-comfort, with pain and suffering?

Yet a major part of my patients' predicament has frequently been a misunderstanding of the nature of disease. The fact is that pain and disease are seldom identical. In other words, the ignorance of this fact - ignorance of the reality of disease-is itself a frequent cause of disease. Healing, therefore (particularly in the case of emotional and social disorders), usually requires education concerning the distinction between disease and suffering. So it is for the serious cultural 'illness' of which that 1990 Dun & Bradstreet advertisement was a symptom.

When I was seven years old, a Boy Scout handbook happened to fall into my hands. Instantly the deepest desire of my life was to become a Scout, only I was five years too young. But in the back of the handbook was an advertise­ment for the official Boy Scout hatchet. The notion came to me that if I could just lay my hands on that hatchet, then I could begin my career as a Scout on my own. There was but one thing I asked of my parents for my eighth birthday.

They gave it to me. It was beautiful, its sharp blade protected by a sweet-smelling, fresh leather snap-on sheath. In anticipation of that birthday morning I had my target picked out for weeks: a small birch tree with a four ­inch-thick trunk on the edge of our rural property. At the first possible opportunity I escaped from the house, un­sheathed my lovely present, and went to work.

It is surprisingly difficult to chop down even a small tree with a hatchet. Halfway through the job I stopped to rest. At that moment I was horrified to notice blood streaming down my right leg. Somehow-either because the blade was so sharp or my concentration so intense-I had managed, without any awareness, to hatchet a two-inch-long gash in my right knee. Grabbing tool and sheath, I ran home crying.

The doctor was called. They made house calls in those days. To the best of my recollection novocaine was not yet routinely available. So the three stitches he took to close the wound hurt like hell-although not much more than injections of local anesthetic would have.

My parents took away my hatchet. I was not old enough for it, they said. Maybe in a couple of years they would give it back to me. I was heartbroken. Over the next few days the skin surrounding my stitched gash became reddened, slightly swollen, and tender to the touch. It was several weeks-well after the stitches were removed-before this mild inflammation went away, before the skin returned to its normal color and I could press on the' area without pain.

In terms of pain, the injury-the disease, if you will - caused me no hurt whatsoever. I would not even have known about it had it not been for the frightening sight of blood. What did hurt, however, was the medical intervention taken to repair the disease. And what hurt far more, on an emotional level, was the preventive medicine of my parents taking the hatchet away from me so that such an injury was much less likely to happen again in the future.

Then there was the mild inflammation. While it was the least of my pains, it is the most instructive of all. At the time-and for years thereafter-I considered inflammation a disease. But one of the very first things we learned about in medical school was ' the inflammatory response,' which, we were taught, is the essential part of the healing process.

The body in its wisdom (through mechanisms we still do not completely understand) responds to an injury or infection with a dilatation of the little blood vessels, or capillaries, in the vicinity of the disease. This dilatation, or engorgement, of the tiny blood vessels in the skin around the wound is what causes the skin to look so red; the fiery redness (from which we get the term inflammation) is a result of an increased blood flow to the area of the disease.

Not only do these little blood vessels dilate but their walls become more porous to allow the escape of blood plasma (or transudate) into the surrounding tissues. This is what causes the swelling. The blood vessel porosity also allows the selective escape of white blood cells (but not the more passive red cells). Moving through the transudate, the white blood cells (often called phagocytes or, literally, `eating cells') go to the diseased spot and gobble up dead cells, bacteria, dirt, and other debris. They actually digest this debris and then return through the transudate into the blood vessels. It is a remarkably efficient, microscopic garbage collection and removal service.

The transudate, by surrounding the minute nerve endings in the skin and putting increased pressure upon them, has the effect of making these nerves more sensitive. Hence the increased tenderness of inflamed tissue. But the result of this tenderness is to encourage the individual to protect the area from unusual pressure or activity so as to prevent any interference with the healing process.

Finally, because it so dramatically increases the blood supply to the diseased area, inflammation provides an increased amount of oxygen and other nutrients essential to the rapid growth of new cells-new skin cells if it is a simple scrape or, in the case of a deeper cut like mine, new connective tissue cells that form the scar. Once the debris has been carted away and the damage repaired, the dilatation of the vessels ceases and the blood supply returns to normal. The inflammation is over because the disease has been healed.


There are, of course, a few morals to the story.

The first is that health is a process. If a physician had examined me at any time during the three weeks between when the gash in my knee was sutured and when the last vestiges of inflammation had vanished, she would have pronounced me a perfectly healthy eight-year-old. Not in spite of the inflammation, but because of it. A reason I was perfectly healthy was precisely because the inflammatory response was proceeding well.

We creatures are always being subjected to little nicks and bruises, pimples and bug bites, and besieged by hordes of alien bacteria and viruses. Some part of us is always in the process of healing. Consequently, the condition of health is not a static state of perfect wellness; it is, among other things, a condition of ongoing healing. For example, a possible explanation for the cause of cancer is referred to as the 'scanner theory.' This theory holds that various cells in the healthy body routinely become cancerous; but the body remains healthy because within it there is some not-quite-yet identified mechanism that scans the body for such malignant cells, spies them out, and proceeds to kill them before they multiply into a growing tumor. What causes cancer then, according to the theory, is not a cancerous cell but rather the failure of the 'scanner' to detect it. While there are some suggestions, we do not yet know why such a defensive healing mechanism ceases to operate effectively. The theory is offered not because it is proven, but because it demonstrates the way in which physicians are increasingly coming to think about disease: that most disease may best be defined as a failure of the healing process.

Please do not think of this theory as some harebrained speculation cooked up by a wild-eyed scientist in his isolated laboratory. There is much to support it. If we physicians know anything at all, it is the reality of what we call the ''immune system.' The immune system is an extremely complex, multifaceted orchestration of various blood cells and antibody-producing mechanisms that elegantly serves as the body's defense system against disease. The inflammatory response itself is but one example of the immune system in action.

The point that health is not so much the absence of dis­ease as it is the presence of an optimal healing process is crucial for understanding our lives. It is crucial because the principle applies not only to our physical health but also to our mental health and to the health of our organizations and institutions. A healthy organization-whether a marriage, a family, or a business corporation-is not one with an absence of problems, but one that is actively and effectively addressing or healing its problems.

Perhaps the most dreaded disease of all history has been leprosy. What made it so dreaded were the ghastly deformities it caused: twisted joints, amputated toes and fingers, chronic ulcers. But few today realize the reason for most of these dreadful effects. The primary way in which the causative agent, Hansen's bacillus, wreaks its havoc is its affinity for settling along those nerve fibers that carry the sensation of pain and then destroying them. It thereby creates a condition of painlessness. A leper who broke his ankle would continue to walk on it, unaware that anything had happened to him. Or severely burn her fingers while not realizing she had placed them too close to the flame. Pain is a signal of disease, not the disease itself. Indeed, it is primarily a disease-preventing mechanism. Without it we would all quickly become crippled. So a second moral is that we need to experience pain for our healing and health.

Since physical pain is so often either a disease-preventing mechanism or a normal part of the healing process, we obviously cannot define disease as the presence of pain, nor health as its absence. Then how do we define these conditions?

Simply, health is an ongoing process, often painful, of an organism becoming the most the best-it can be. And disease is anything, sometimes painful, often painless, that interferes with the process of health.

I use the word organism to signify that these definitions apply not only to individual creatures but also to organiza­tions. The similarity between the words organism and organization is no accident. Any organized system, whether an individual or a group, is an organism. Schools, churches, businesses, government agencies, and entire nations are organisms as well, and each may also be healthy or diseased.

These definitions further apply not only to physical health and disease but also to psychological and spiritual health and disease. As in my previous books, I make no distinction between the psychological and the spiritual, so will hence­forth use the word psychospiritual. The words health and healing come from the same Anglo-Saxon root as whole and holy. The leper does not have a whole nervous system. The man who will not face certain obvious issues is not using his whole mind. A corporation that is blind to its own problems cannot be healthy. Mental health-the ongoing process of becoming the most that we can be psychospiritually-is the ongoing process of becoming whole and holy.

Becoming the most that we can be is also the definition of salvation. The term literally means 'healing.' As we apply `salve' to our skin to heal it, so we can learn to apply the principles of mental health in our lives to heal, to make us whole, to save our souls, individually and collectively.

Extracted from M Scott Peck's A World Waiting To Be Born.

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