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A Thousand Deaths

copyright 2001, by bloodandivory

Disclaimer:    The characters Dr. Hannibal Lecter and Clarice Starling were created by Thomas Harris.  They are used herein without permission, but in the spirit of admiration and respect.  No infringement of copyright is intended, and no profit, of any kind, is made by the creator, maintainer or contributors to this site.

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She sleeps.

Infamous guard down, each recent line, and every shadowed hollow shows.  Yet the worst marks are not on her face. 

Beyond mere physical remembrance, the months since Muskrat Farm have cut of scars crueler than all the losses in her life.  Now she hurts in deeper places. 

Many fretful shifts mar this unsound slumber.  Lying open across her lap, a magazine slips.  A glaring neon Post-It marks her place, glaring against subtle blues and grays.  Red felt tip lines scream attention to certain passages.  These forceful marks bite into the quality paper, but they jag, as though the hand that made them was unsteady. 

The publication, a prestigious medical journal, ends it short journey, settling across her knees.  The binding is stubborn and in a wistful fan, a page turns over backward.

Overview

Commonly seen in amputees (patients that have lost an arm or a leg due to reasons such as surgery, trauma, etc.), Phantom limb pain syndrome has long perplexed medical science.  It is defined as a chronic pain occurring in some smaller subset of amputees.  In this article, the syndrome is discussed and new research is examined that now sheds some light on the problem and may lead to new treatment options. 

Phantom limb pain was described as far back as 1871 - the sensation of a limb that was no longer present was thought back then to be due to a ghost, hallucination, disturbance of body image, etc.  As time went on, studies into the origin of this pain led to many theories as to the cause of this problem (see sidebar “Theories of Cause” at left), although it remains unclear as to the exact etiology of the problem. 

The actual incidence of the syndrome is unclear - the problem may be drastically underreported due to the strange nature of the symptoms - patients know that they have no limb to attribute the symptoms to.  Therefore they may be reluctant to raise the issue - fearing that they will be thought of as unstable, irrational, etc.  These factors make the syndrome even more difficult to treat.

She dreams.  

For seven years she wandered the corridors of her mind at night, reprising games of cat and mouse.  Without the maddening protection of Plexiglas, without the tyranny of her contentious conscience, all the possibilities played out.  Oh, how they troubled her, these private excursions where, again and again, she took everything she coveted.  

Whatever joy there was, she steadfastly refused, except in guilty dreams.  And now she lacks even this small comfort.  Her night world no longer brings her pleasure and release.  

Sidebar – Theories of Cause 

There are several theories as to the pathophysiology of phantom limb pain. These are not widely agreed upon and all have some supporting data. The theories are divided into peripheral causes (those that happen at the nerves around the injury), spinal causes (changes in the spinal cord causing the sensation) and central causes (those that are due to some mechanism in the brain).

Here are some examples of possible and popular theories:

  • peripheral cause - sensation due to a loss of previously present peripheral nerve activity
  • peripheral cause - regeneration of the nerves that were injured/cut
  • peripheral cause - neuroma formation with resulting painful nerve activity
  • peripheral cause - alteration in ion channel activity at the site of injury
  • spinal cause - due to the loss of previous inputs to the spine. This is known as deafferentation
  • central cause - due to changes in parts of the brain known as the cortex and thalamus
  • psychological cause - not usually regarded as the primary cause but stress, depression, feelings of mourning, loss and rage may contribute to the syndrome

It is likely that the cause is multifactorial - that is, similar symptoms may be seen from a variety of causes.  This also explains why treatment is so difficult - one technique that works for a given patient may be an utter failure in another.  Aside from purely physical considerations, treatment of any peripheral psychological issues is strictly indicated.

She grieves. 

Finding him was difficult, but it has been the work of a lifetime, and she managed.  Such determination always bears fruit.  

Sometimes it is very bitter. 

She’d sat before her costly laptop for an eternity.  Bargaining, hoping, trying to find the scenario that would make it work.  But there is no undoing her monstrous folly. 

No welcome, no forgiveness waits for her in his eyes.  Once she’d have seen herself there, with a terrifying clarity.  Then she had been safe; his interest was enough.  How can she forget she’d looked into his eyes and watched it die? 

Symptoms 

Interestingly, in patients that report this problem the "phantom limb" is often said to be in a contorted or abnormal position - one that would be painful if the actual limb were in that posture - distorted, grotesque or in an abnormal posture which in an intact limb would be painful.  In addition, stretching of the limb or uncontrollable movements of the phantom limb are often reported. 

Other symptoms of this syndrome include stabbing, shooting, and burning of the phantom limb. 

Many patients report that fatigue, anxiety, depression and changes in weather seem to make the condition worse. 

She aches. 

The connection between them was vital and the place it lived is hollow and filled with nettles.  

It will never heal.  And pain, whether real or imagined, is still pain. 

Each day she pushes at her burden, and each day it eats her whole. 

Treatment 

Treatment of phantom limb pain is difficult - but should be undertaken as quickly as possible to prevent further changes to the nervous system (note that all the prevailing theories are based on some abnormal alteration of normal nervous system activity).   

Medications often used include non-steroidal anti-inflammatories, narcotics, anticonvulsant medication, and antidepressants.  Each of these have some reports of effectiveness - as well as reports of failures - in the literature. Each of these medications also has its own set of side effects.  It is vital to keep abreast of new treatments, however.  See sidebar “New Researches” at right.  There is no single technique that works all the time or even most of the time. 

Lastly, it is important to recognize the importance of psychological assistance in many cases. 

She exists. 

There was little outcry when she did not return to the institution she’d thought so long would shelter her.  They want as little to do with her as she with them.  She was, and always has been, unclean in their eyes.  She is no longer surprised at how little this matters.  Like the orphanage, she has outgrown them.   

There is work, of course, to occupy and recompense.  She is a master handgun instructor at an expensive private gun club just outside the Beltway.  It is a haven of unrepentant political incorrectness where people learn to kill efficiently.  Even on her bleakest days, this still amuses her. 

But in the gray and haunted shadows, pain is the only living thing that touches her. 

Sidebar – New Researches 

Researchers at Vanderbilt University recently reported findings that show that phantom limb pain seems to result from the brain's attempt to reorganize itself after an injury.  When an injury such as amputation occurs, this results in a major interruption or loss of sensory input from the peripheral limb to the brain.  As a result, the brain seems to grow new nerve cells in an attempt to "re-wire" its existing pathways of nerve transmission. This builds on recent discoveries in neuroscience that show adult mammalian brains can grow new brain cells - something that was once thought impossible after early childhood.

This evidence was interpreted as showing that the brain, lacking normal sensory input for missing hand, for example, re-routes the pathways to new areas of the brain.  This then, seems to be an attempt by the brain to heal itself or to "re-connect" broken pathways in some way.

She dies. 

Each day, she succumbs to the slow poison of regret, bleeding from the thousand wounds she cannot see. 

Each night, she holds out a single, bleeding hand against the death she owes.  There are a thousand variants, but the blade always falls.  There is no mercy. 

She is smart enough to know that nothing can be undone.  But destiny does not acknowledge error and she is very tired.

Someday, she will go to him.

FIN

copyright 2001, by bloodandivory

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