copyright 2001, by
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
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Infamous guard down, each recent line,
and every shadowed hollow shows. Yet the worst marks are not on
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.
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.
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
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.
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?
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
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 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
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.
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
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.
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
Someday, she will go to him.
copyright 2001, by
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