118 years of trust

Wednesday, December 30, 1998

  Understanding nuances of pain
by Dr K.C. Kanwar
AIN, by and large, is a localised sensation of discomfort. It is a sensory experience which emanates from excessive stimulation of specialised nerve-endings.

HIV: a seamless approach — II
by Jaya Shreedhar

IVA, a sex broker who began by bringing his employees and their friends to the hospital for free medical care, is now a full-time CHES worker. “I did not think I would stay on, but I have,” he said.

Giggling in quest of health
By Sarat Chandra Das

ELHI: Every afternoon, a continuous ripple of laughter rises like an orchestral crescendo through the glass windows of one of Delhi’s largest hospitals.

Pure water through ozone
Y using ozone, French researchers have developed a safe way to disinfect water, treat wastewater and bleach paper-making pulp.



Understanding nuances of pain

PAIN, by and large, is a localised sensation of discomfort. It is a sensory experience which emanates from excessive stimulation of specialised nerve-endings.

Pain results as a consequence of injury to body tissues. It compels the individual to react through reflex to avoid the stimulus. Many a time, perhaps always, pains are protective. They forewarn the sufferer about the impending danger and caution him for action to avoid further harm. Many a time, it facilitates diagnosis by the doctor.

Without pain one would not know enough about the inflamed appendix which, if left unattended, could burst and prove fatal. The ability to perceive pain is critical to our survival. " Pain-blind" individuals, though rarely born, tend to die at a young age because they have no way of knowing when and where they are hurt. Interestingly, the perception of pain ( as well its intensity) differs in different subjects.

Pain, in fact, represents a threshold of awareness which approximately is the same in different persons but the degree to which each one reacts to it varies tremendously. The same injury in two individuals is differently felt depending upon the threshold of tolerance. Stoical persons react far less intensely than more emotional ones do.

Pain's threshold of tolerance in children is lower than in adults. We lose sensitivity ( or become more tolerant) to pain as we age. Aged persons, who frequently complain of pain, suffer most often from psychosomatic aches -- the imaginary pains where doctors fail to attribute any organic cause for the discomfort.

How do we perceive pain ? The stimulus of pain is carried by nerve fibres which enter the spinal cord and move upwards to the centre of consciousness in the brain-thalamus. The thalamus registers signals from pain receptors and labels them painful before transmitting them on to the cerebral cortex the thinking part of the brain. It is the cortex which determines the intensity and the specific location. The perception may be subdivided into two phases -- the initial sensation and the reaction that follows. There are two main nerve pathways available to the signals originating from the pain site. One pathway sends signals quickly and the other slowly. Sudden encounters require fast reactions for speedy safety reflexes. The express route is made up of large nerve fibres that allow the messages to be transmitted at about 220 miles per hour -- a speed that covers the distance from the foot to the head in the less than one hundredth of a second.

A message of burnt finger travels quickly to trigger instantaneous reflex action to move the finger away. Thereafter, the pain of the burn is replaced by a dull throbbing sensation indicating that pain receptors are now sending messages to the brain along the body's slower pathway which is made up of small nerve fibres. Whether the pain travels using fast or slow routes, the final destination is the same, i.e. the thalamus.

How is pain suppressed? The feeling of pain is somewhat a chemical process. Certain parts of the brain (notably the hypothalamus and the pituitary) manufacture chemicals called endorphins -- the body's natural but transient pain suppressants which act like opiate morphine and deaden pain. Both opiates and endorphins act by making the brain send messages that halt further messages. However, endorphins can provide only temporary relief and therefore, the need for exogenous painkillers or analgesics in the management of pain. Stressed persons and chronic suffers have a low amount of endorphins and hence are more sensitive to pain.

What analgesics really do : Analgesics or painkillers relieve pain without blocking nerve impulses. There is a wide variety of these available over the counter. These are basically of two types -- (1) non-narcotic and (11) narcotic or opiates. Strictly speaking, both types are injurious. Too much of either can be harmful. The indiscriminate use of painkillers needs to be curbed. Non-narcotic analgesics comprise aspirin, ibuprofen, paracetamol (all sold under various brand names and in different combinations). All these relieve pain of mild to moderate intensity and are also antipyretic (used to bring down the body temperature in case of high fever). Aspirin and ibuprofen, in addition, are anti-inflammatory too and, therefore, more suitable for arthritic or joint pains in general. Ibuprofen is more effective against soft tissue injury such as sprained tendons and strained muscles and also better suited against menstrual camps. Both of these are gastric irritants and should never be taken on an empty stomach or by those suffering from peptic or intestinal ulcers. Avoid aspirin before surgery; it thins the blood and encourages haemorrhages. Watch out if someone is allergic to aspirin. He is likely to be so for ibuprofen. Paracetamol is a relatively safe and mild painkiller but it is contraindicated for those who suffer from liver or kidney ailments.

Narcotics or opiates are very potent painkillers but are addictive. These are sparingly used -- only if the pain is unusually severe and piercing as in the case of angina or a coronary heart attack, for example. These are also commonly prescribed to terminal cancer patients to alleviate their agonising pains. These relieve pain by altering the brain perception of it. Pain is felt but is not appreciated as being painful. Morphine is one of the strongest painkillers falling in this category.

Different parts of the body are varyingly sensitive. A needle inserted into the skin evokes more intense pain than if the muscle is probed similarly. Whereas an arterial injury is painful, a venous maceration is painless. Pain is perceived through millions of pain receptors ( nerve-endings) varyingly distributed in the skin, muscles, bones and internal organs. Some of these special nerve-endings are more sensitive to pain than others.

The cornea of the eye, the thin transparent layer that covers the pupil, is the most pain sensitive part of the body. Skin in general is sensitive. Thick skin, as of the foot sole, has fewer nerve endings and so it is less sensitive. Internal organs like the lung, the liver and the spleen, on the other hand, are not painful even when inflamed since these are sparsely supplied with nerve-endings. However, the internal organs are very sensitive to distensions and obstructions. Internal tumours are not intrinsically painful but become so when they grow large enough to exert pressure on the adjoining organs. Curiously, the least pain sensitive organ of the body is the brain itself even though it processes all its pain signals. The meninges, the non-nervous membranous sacs that enclose the brain tissue, however, are highly sensitive to pressure pain. When the flow of blood to a tissue gets curtailed by any reason, it becomes very painful within a few minutes. The greater the rate of metabolism in a tissue, the more rapidly the pain appears when subjected to infarction. Muscle spasm or muscle ischaemia is a frequent cause of pain as in the case of angina. As to why ischaemia is painful is not precisely known.

Whereas the flow of unoxygenated blood to the affected tissue does not relieve the pain, it is promptly relieved when oxygen is supplied to the ischaemic tissue. Diminished blood flow to the muscle, combined with the increased metabolic need of the muscle for the nutrients, seemingly combine to cause ischaemia which results in severe pain. The same is the cause of pain in the spasm of the gut, the gall bladder, the bile duct or the ureter . Extreme over-filling of the hollow viscus also results in pain. Some workers feel that ischaemic pains could result on account of excessive accumulation of lactic acid -- the end-product of anaerobic metabolism, which in itself is irritating and painful to the affected tissue. Other tissue-degenerative chemicals like histamine and bradykinin, when formed, reportedly stimulate the nerve endings and cause pain.

(The above write-up is an attempt to understand pain and not to suggest its management.)

(Prof K C Kanwar is a former Chairman of the Department of Biophysics, Panjab University, Chandigarh.)


HIV: a seamless approach — II
by Jaya Shreedhar

Siva, a sex broker who began by bringing his employees and their friends to the hospital for free medical care, is now a full-time CHES worker. “I did not think I would stay on, but I have,” he said.

His change of heart came when Siva was entrusted with the task of nursing 27-year-old Veni, a sex worker from the neighbouring state of Andhra Pradesh. Veni was bedridden due to weight loss, had herpes zoster (shingles) and could not speak. “I used to talk to her every day and she would seem to understand,” Siva said. “She would refuse food and eat only if I fed her.

“Her death affected me greatly,” he continued. “I have risked getting HIV-infected hundreds of times in the course of my job but have been spared. But what about the innumerable girls I procured for the profession?”

Condom use in the project area increased to 63 per cent in October 1997 from a baseline of 7 per cent two years earlier. During 1997 alone, Thozhi reached some 700 new entrants to sex work, 150 brokers and 2,400 clients, and peer educators distributed 288,150 free condoms. The project also improved its STI care facility with financial support from the US Agency for International Development’s (USAID’s) AIDS Prevention and Control (APAC) Project through the NGO Voluntary Health Services.

Reaching men: Dusk had already fallen over the narrow paths dissecting the slums into myriad patches of tiny houses when CHES field workers Raju and Muthupandian swung into action. Watched by a straggly group of adolescent boys, Raju spread a large blanket on the mud path to demarcate the dance floor. As the lyrics about AIDS set to hit film tunes pulsed out from a tape recorder, a crowd of mostly teenage boys and men collected. Male dancers from CHES’s student volunteer corps, each made up to impersonate a popular film star, began dancing, accompanied by much cheering and clapping from the audience.

Between the dances, Muthupandian seized the mike to talk to the audience about STIs and HIV/AIDS, and a boisterous interaction followed. “What are the ways you can protect yourself from AIDS?” he yelled, and was answered correctly by a chorus of voices. The show usually ends with a quiz on AIDS. Prizes are handed out to the winners, and they are invited to come to CHES for further information.

Those who accept this invitation — and many do — receive counselling on safer sex and condom use and are trained as peer educators for Project Velicham (light). CHES developed this project for men with funding from the Tamil Nadu State AIDS Society following complaints from the sex workers that they were often forced to agree to unprotected sex because clients refused to use condoms. Velicham staff have staged over 300 such programmes in the slums and reached an estimated 40,000 people along the coastal areas of South Chennai.

Reuniting families: After reading newspaper reports that CHES was taking in people living with HIV/AIDS, a family of four from a remote district in Tamil Nadu arrived at the NGO’s doorstep in early 1995. They had fled their village, following a relative’s attempt to poison them.

Raghu, his wife Mala and their elder son, barely aged 3, were HIV-positive. Their 2-year-old son was uninfected. “Mala, who was found to have genital warts during a routine antenatal checkup, was tested for HIV first,” says Dr Venkateshwar K. Rammohan Rao, CHES medical officer. “We counselled them and gave Raghu the job of the office assistant. Mala was extremely depressed, and we got help from psychotherapists from the Institute of Mental Health to help her handle her feelings better.”

The couple’s relatives visited regularly and were counselled by CHES. After a year, their families wanted the couple and their children back home.

“They saw us eating and working with them every day and realised that their fears of contagion on casual contact were baseless,” now explains the thoughtful Dr Pinagapany. “For them, seeing was believing.”

The family subsequently visited CHES twice for checkups. Raghu got a job selling cloth in Wyzag, a coastal town. Mala began to neglect her health and eventually succumbed to tuberculosis. In a letter to the CHES staff, she wrote that she would not forget CHES until her last breath.

When they received news of Mala’s death, two CHES workers, Siva and Vetri, went to her village to attend the funeral. Although relatives were at the funeral in large numbers, nobody wanted to be a pallbearer. It was only when Siva and Vetri started performing the last rites without hesitation that other family members followed suit.

(To be concluded)


Giggling in quest of health
By Sarat Chandra Das

DELHI: Every afternoon, a continuous ripple of laughter rises like an orchestral crescendo through the glass windows of one of Delhi’s largest hospitals.

The pitch of the laughter varies like jazz music on a free scale. A curious crowd gathers below in the under-nurtured garden. One new visitor believes the burst of laughter comes from a hideous asylum, where the mentally ill are going through electroshock therapy.

The reality is as far removed from that image as it could be. Perched on a rectangular carpet in a hospital hallway, a group of people cross their legs and raise their arms, looking almost as if they are at prayer. Through the control of their breathing, they slowly stoke their energy up to the top of their spines. Storms seem to gather on their faces, and eventually they open their mouth and let go. This is how they learn to laugh.

The man behind this show is Dr S C Sethi, a middle-aged paediatrician. He is inspired by Norman Cousin’s book, Anatomy of Illness, which says the absence of the laughter and of vitamin C are the two primary causes of illness.

“I picked laughter because it is easy on the system,” said Sethi. “I practised all by myself before encouraging the crowd to laugh.”

Sethi arranges a daily gathering in the hospital from 3 to 4 pm, an unofficial club whose participants are mainly hospital employees. Laughing is part of their yoga curriculum.

“Initially it was not easy as people felt they were to put on a show, but when it became a regular exercise they were completely at ease,” Sethi said.

In Delhi’s public parks, people gather to laugh every morning and evening. Janakpuri, a residential pocket of West Delhi, regularly hosts an early morning laughing gathering. Participants come from all walks of life — doctors, government officials, school teachers, even security officers who have been taught to stiffen their face like granite for their job and find it difficult to relax and laugh.

“It’s hard to believe that people who look morose the previous afternoon laugh so heartily and for so long,” says J. Kumar Arora, a retired senior civil servant and participant in the laugh-in.

Laughing is already a mass movement in many cities of western India. It may have originated in the Lokhandwala Park in Mumbai’s Andheri suburb, where Dr Madan Kataria, a local physician, began a course of laughter with a handful of people. The movement then crossed Thane Creek to tickle the sides of smaller and more sedate cities like Pune, Nasik, Ahmednagar, Indore, Baroda and Ahmedabad.

“They were hesitant and shy about laughing in the open, but gradually picked up the chorus,” Kataria said.

Kataria added that they initially believed no one other than a circus clown could made them laugh. He kept his sessions going with a stock of jokes heavily borrowed from the Reader’s Digest. “Initially, I had to try hard to make people laugh but now no more, since people have realised the physical benefits of laughter.”

Today they laugh almost at everything, wisecracks or shaggy dog stories, irreverent anecdotes and anti-climactic punchlines.

Today there are more than two dozen laughing clubs around Mumbai, with more than 3,000 participants. The membership is free. The clubs observe a somewhat strict protocol: men and women stand in parallel rows, like a co-educational school during morning prayers. The tutor stands solemnly in front of the crowd before he keys them up to laugh. The laughter takes its course through routine breaks for jokes and temporary letups when the participants feel the laughing is becoming too heavy on their stomachs.

“That is only a small cost you pay to ease out your stress,” says Kataria.

The Indian Yoga Institute, with 450 centres across the country, is responsible for bringing laughter into the hospital and elsewhere. It circulates literature that says laughing helps the abdominal muscles flex and contract, giving a mild massage. “As you laugh, you inhale and exhale more deeply,” says its brochure. “More oxygen, the vital force of existence, enters the body and toxins automatically get thrown out.” — Gemini


Pure water through ozone

BY using ozone, French researchers have developed a safe way to disinfect water, treat wastewater and bleach paper-making pulp.

Ozone in the upper layers of the atmosphere filters out the ultraviolet radiation from the sun.

But when injected into water, ozone destroys all microorganisms with formidable efficiency. It also removes any discolouration and eliminates manganese and iron.

Since ozone is very unstable and easily destroyed, it leaves no traces of its presence in the water. There is no irritation, no smell and no taste.

Though the traditional way to disinfect water is chlorination which is cheaper, there are a number of disadvantages associated with it, including unpleasant taste.

Chlorine produces organochloride by products of the trihalo-methane type, which are suspected cancer-causing compounds, reports Newsletter France Technologies.

To solve the problem, two French companies, Ozonia and Trailigaz, with the assistance of the Institute of Hydrological Research in France, developed the new ozone-based technology to disinfect water.

As this gas is too unstable to be transported, it is produced on site within the water treatment plants by means of an ozonator.

These units use oxygen from the atmosphere or pure oxygen to produce as much as 315 kg of ozone per hour from oxygen.

The oxygen atoms are ionised between two capacitor plates though a continuous and controlled electrical discharge at a frequency 600 and 1000 Hz. This produces a gas mixture containing three to ten per cent ozone, which is mixed with water using porous diffusers, turbines or static mixers.

To reduce bacteria by 99.9 percent, as little as 0.1 to 0.2 mg/litre of ozone for around five minutes needs to be maintained.

A full installation includes an electric oven or catalyst downstream which removes and destroys the remaining ozone, since most national regulations prohibit the release of more than 0.1 parts per million of ozone into the atmosphere.


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