An ethical dilemma? Measles vaccine or not?

     Andrew Wakefield is a former British surgeon and medical researcher who published articles which he said related Measles vaccine as a cause of a new form of inflammatory bowel disease he called autistic enterocolitis. Medically there is not such a disease recognized. He also said that the MMR (Measles, Mumps, and Rubella) vaccine may have caused autism in children who received it. There is absolutely no evidence that such is case. Multiple blinded medical studies have been done and there is no evidence of any kind of a causative relationship. Others have suggested that the mercury (thimerosol) used in some vaccines as a preservative and antiseptic could be toxic to infants and might play a role in causing autism. Again multiple studies have been done looking for such a connection. None was found. Now thimerosol is only used in tiny amounts in influenza vaccine. It is not used in an other vaccines that are given routinely to children
     Multiple lawsuits have been filed in all directions. Dr. Wakefield's article which was found to have tampered with results, unethical recruitment of study patients, invasive and harmful tests performed on study patients without approval of ethics committee among other more minor but still significant problems with the data. There was even evidence suggesting that Dr. Wakefield was paid by a legal group to produce this article, that he had applied for a patent for a single Measles vaccine which he stood to make money from should MMR become suspect and be withdrawn, and also a test kit for this supposed new form of inflammatory bowel disease.      .

     Wakefield's conclusions were broadcast in the media worldwide and resulted in fear of children's vaccines and a drop off of the vaccination rates. It is estimated that MMR vaccination rates in Britain dropped from 92% to 73% in the late 1990s after Wakefield's press conference raising the concerns about MMR which he raised in his article in Lancet, the British medical journal. The effect was less in the US but it is still estimated that as many as 125,000 children born in the late 1990s in the US also were not vaccinated due to this scare. Many children therefore got sick and some died from complications of measles. The lawsuits have subsided. Lancet retracted the article and 10 of the 12 coauthors of the original Lancet article withdrew their support for the conclusions. Wakefield left England after losing his medical license to practice there. He is still trying to do research in the US and is still claiming that his research was honest, that there was no deceitful data changes and that there is still a reason to be concerned about the MMR. He still has a small group that supports his conclusions. But the greater medical and scientific community agrees that he is a fraud and there is absolutely nothing to fear with MMR and a bowel disease or autism or any developmental behavioral problems.
     What does all this mean for society? How can one man and at best a very bad medical study, at worst a completely fraudulent publication perpetrated in order to make money have such a broad effect on medical care world over? I recall a few years ago when my grandson started daycare, my daughter in law was concerned. She knew there were some parents of children at the daycare who were not vaccinating their children because of just these fears. She then had concerns about her own infant who would be at this daycare and subjected to exposure to these children and their possible illnesses before our grandson's own vaccinations would have had a chance to take effect. It does become a personal issue when a family member might be involved. This is sort of like the Ponzi scheme of medicine. It doesn't affect people's wealth but instead may affect children's lives. It is true that every area of human endeavor has its bad people who don't care about doing harm to others, whose self interest outweighs any concern for others. However, it is particularly heinous when that person is in the field of medicine. People generally tend to trust their own doctor and by inference the medical profession at large. They would normally believe these allegations coming from a researcher and printed in a prestigious journal like Lancet. Of course, they would react with fear concerning their own children. The legal system and the medical self policing system (British Medical Council, Lancet) and the media itself have more or less shown Wakefield for what he is, but there are still concerned parents out there who don't know the whole story and still wonder. What else could we have done? We are limited in a free and just society in order to protect the rights of the innocent. But I sometimes wonder if the rights of the fraudulent and the criminal are protected too strongly in our Western democracies. What do you think? Send me some comments. Let's get this comment section going!

The Aesclepion, Bergama, Turkey

     Two posts ago you learned what an Aesclepion is. If you missed that post: http://renraeretire.blogspot.com/2011/07/medical-symbol-confusions-cadusis.html
I can show you an Aesclepion first hand. We visited Bergama while traveling in Turkey. In that modern city are the ruins of the ancient city of Pergamon, and in that ancient city is one of the largest if not the largest Aesclepion in the world. This is a fascinating place in Turkey, that was a total surprise to me. Since returning home, I have learned more and found this history even more fascinating.


A drawing of the way the Aesclepion appeared in 2nd century AD.


     For centuries, the Companion Cavalry was a select group of Macedonian soldier/horsemen who served the current Macedonian king both in important battles and as his personal guard. This unit became most know under Alexander the Great. In about 301 BC Lysimachos, one of the successful commanders in this elite Cavalry was assigned by Alexander to deliver 9,000 talents (1 talent + $7500) of war booty to Philiterios, the governor of the small city of Pergamon, located on the coast of Asia Minor and in view of the island of Lesbos. Lysimachos delivered the money and set himself up as ruler of Thrace and Asia Minor. After his death, Philiterios made use of this money to become the first ruler of the Kingdom of Pergamon. He established a Hellenistic dynasty that successfully ruled this small kingdom for 150 years, building a city that rivaled Athens with many structures that were copied directly from Athenian buildings. Eumenes I, Attalos I, and Eumenes II were successive rulers. Successive rulers followed until Attalos III  peacefully signed over his kingdom to the Romans when he died in 133 BC. The city went on to become even more a local capitol under the Romans. Various Roman structures including a Roman theater were added and there were some modifications of Greek structures by the Romans. The Library of Pergamon is famous second only to the Library of Alexandria. It contained 200,000 volumes and under Roman rule, portions of that library were given as a wedding present to Cleopatra by Mark Anthony to help replenish the destroyed Alexandrian Library
      The city's Acropolis rivaled that of Athens and was built on a high promontory over looking the lowlands abutting the Aegean Sea. The Greek Theatre located on the slope of the Acropolis is the steepest theatre known from ancient Greek times. It would house 10,000 people seated on the hillside slope. Greek theatres were always built into a hillside. Whereas Roman theatres usually were constructed on level ground.

Picture taken looking up at the Acropolis of Pergamon from the Aesclepion down below. In the center of the hillside just below the Acropolis, you can see the Greek Theatre. Portions of it have been restored. To the left of the base of the theatre are white columns that remain from the Temple of Dionysius (Bacchus). The columns in the foreground belong to the covered colonnade that completely surrounded the Aesclepion.

     We did not take the time to hike around the Acropolis at Pergamon. I was still limping from a knee sprained while getting into a hot air balloon at Kapadokya. Our guide, knowing that I was a physician, decided to show us the Aesclepion instead. The Aesclepion is a healthspa/ hospital that during Hellenistic times was commonly placed in prominent cities. The patronage of these health facilities carried into Roman times, up to the 6th Century AD. This particular Aesclepion at Pergamon had at least 3 holy springs. It was patronized by the wealthy and the famous including Emperor Hadrian, Marcus Aurelius, and Caracalla. During the 2nd century AD, it reached its peak of influence. The well-known historic anatomist/physician/philosopher, Claude Galen, was born in Pergamon in 129 AD, and schooled in Aristotlean philosophy here. His father, also a learned man, had a dream in which Asclepius, God of Healing told him to educate his son as a physician. Galen studied healing here and then practiced and taught his skills to others, before becoming personal physician to Roman emperors in Rome. He also was famed for attending to gladiators who performed for the High Priest of Asia here at this site. Due to his anatomical and surgical techniques, only 4 gladiators died while under his post, whereas 60 had died the previous year under a different physician. Many of his techniques were used for the next 1500 years and it was not until that long that further anatomical facts disproved some of Galen's ideas. Reluctantly he also became a proponent of bloodletting, a practice that was prominent in our own 18th century. This was perhaps his only major unwitting mistake.

Here are portrayed the sacred serpents of Asclepius on the ancient altar to Asclepius. In the Aesclepion is a Temple to the God of Healing. Several of these sacred serpents were usually kept in the box in this temple. This is thought to be the reason that the mythical Staff of Asclepius has a serpent wound around it.

     This hospital was not intended to treat the deathly ill. In fact at the gate, there was a gatehouse manned by some of the Aesclepiadaie, or physician/priests, who would interview prospective patients to see if they could be helped at the Aesclepion and to turn away those who were ill enough to die, and also pregnant women near term were denied. In fact there is the remains of a pillar at the gate that says, "Death is forbidden to enter in to the Aesclepion as respect for Gods." Treatments consisted of dietary measures, herbs, rest, taking the sun, stress relief, exercise, entertainment at the theatre, reading at the library, massage, mud baths, musical therapy, water baths of all temperatures, bathing in and drinking small doses of the holy water from the springs (which later was discovered to contain a mild radioactive source), dream therapy, because there was a belief that people dreamt of a visit from Asclepius who would prescribe a cure for their illness (before Sigmund Freud), and just sleeping in or near the Temple of Aesclepius, the god of Healing.



In this photo you can see ruins of the Roman Temple at the
 east end of the Acropolis hill. You can see the Via Tecta
 slanting from right to left down the slope.

       The Aeclepion was reached through a half mile long covered and colonnaded walkway down from the Acropolis. As the walkway got close to the entrance, the Monumental Gate, it is called Via Tecta. Along this roadway, many little shops and merchant stalls would have been set up to sell health potions as well as gifts that people going to the Aesclepion would buy to present to the Gods in the Temples of the Aesclepion.
      After entering the courtyard of the Aesclepion, to the right is the Emperor's room, which was later used as a local library. Further along the North Stoia (colonnaded walkway) is the Roman Theatre. This was used to entertain the patients as well as to educate the staff of the Aesclepion. This small theatre could seat 1500 people, has been restored and is now used to present local shows. The stage in Roman times was backed by a 2 story facade, whereas the amphitheatre on the slope of the Acropolis had a stage facade of three stories.

Via Tecta, The Sacred Way (to Aesclepion)

The Library (also called the Emperor's Room)



Northern Stoia with Theatre beyond



Closer view of the Theatre

 

One of the Sacred Springs still flowing with healing waters.

     In the center of the courtyard are the outlets of three springs with adjoining tubs or enclosures to create pools. Also there is an entrance to an underground tunnel which passed from near the theatre diagonally underneath the courtyard to the Temple of Telesphorus. This subterranean and 2 story round building actually housed the patient sleeping rooms and treatment rooms. It is remarkably well preserved. Next to it is the round Temple of  Asclepius which is patterned after the Parthenon in Rome which was only built 20 years before this Temple. All that remains here is the 78 ft diameter circular marble foundation.

The tunnel, to transport patients comfortably from healing springs to the sleeping and treatment rooms.

First floor of the treatment facility (Temple of Telesphorus).



Main floor of the treatment facility.



Marble foundation of the round Temple of Asclepius, adjacent to the Treatment Facility.

     Our guide, Mehmet Tektik, was correct about taking us to see the Aesclepion. If we were younger we probably would have enjoyed traipsing around the Acropolis as well, but I have read that there the ruins are much like other ancient cities in Turkey, and actually the Hellenistic theatre in the hillside of the Acropolis is perhaps more impressive from a distance (though there is a thrill standing at the top and looking down). And I thoroughly enjoyed seeing the Aesclepion and learned even more about its history after researching it when back home.

     Inside the modern city of Bergama, there is the Temple of Serapis, built for the Egyptian Gods in the 2nd c. AD. and called the Red Courtyard by locals. This is a basilica shaped building constructed under the reign of Hadrian. Then, in the 4th century, it was converted into a church dedicated to St. John and became one of the Seven Churches of Christianity (those mentioned by St. John in Revelations).

The Red Courtyard (basilica), in downtown Bergama.





The Hippocratic Oath and the White Coat Ceremony

    Has anyone ever wondered what exactly your doctor has sworn to do? Did he take the Hippocratic Oath? And if he/she did, what exactly is the Hippocratic Oath?

     Well, here are several versions ranging from the original to a much more modern one which has been changed to reflect how medicine is practiced today.
Original, translated into English:[4]
      I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods,  all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement:
     To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art.
     I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.
     I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not give a woman a pessary to cause an abortion.
     But I will preserve the purity of my life and my arts.
     I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art.
     In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves.
     All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal.
     If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot.

     There are several problems with this ancient Oath. First of all, it swears by all the Greek Gods, which most of us don't believe in now. In fact since there are many religious traditions around the world even today, should it swear by a religious tradition at all? The second stanza applies to a time when medicine was learned by serving as an apprentice. Therefore the apprentice would swear great fealty to his mentor and teacher to the point of even swearing to take care of him and/or his family financially in the end. This is usually not done today. There is a statement in the Oath that is usually taken to be anti-abortion, and is now a belief not held by at least a small majority of the population. (We have a law that allows abortion.) The statement about entering a home with purity and against sexual contact with patients, as well as the second to last stanza regarding confidentiality is still applicable today. The final stanza is usually regarded as a little too vengeance oriented. That is if you don't abide by this oath and if you do a bad job, the doctor swears that he/she will have bad outcomes in all of the rest of their life. This is a little too reward and punishment oriented for many people today.

     Here is a more modern oath which takes some of these ideas into consideration:

A widely used modern version of the traditional oath was penned in 1964 by Dr. Louis Lasagna, former Principal of the Sackler School of Graduate Biomedical Sciences and Academic Dean of the School of Medicine at Tufts University.

     I swear to fulfill, to the best of my ability and judgment, this covenant:

     I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow.

     I will apply, for the benefit of the sick, all measures [that] are required, avoiding those twin traps of overtreatment and therapeutic nihilism.

     I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.

     I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the skills of another are needed for a patient's recovery.

     I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given to me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play at God.

     I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.

     I will prevent disease whenever I can, for prevention is preferable to cure.
     I  will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.
     If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.

     Some medical schools use the Oath of Maimonides, a Jewish scholar, as their Oath at graduation. It appears below:
     "The eternal providence has appointed me to watch over the life and health of Thy creatures. May the love for my art actuate me at all time; may neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind; for the enemies of truth and philanthropy could easily deceive me and make me forgetful of my lofty aim of doing good to Thy children.
     May I never see in the patient anything but a fellow creature in pain.
     Grant me the strength, time and opportunity always to correct what I have acquired, always to extend its domain; for knowledge is immense and the spirit of man can extend indefinitely to enrich itself daily with new requirements.
     Today he can discover his errors of yesterday and tomorrow he can obtain a new light on what he thinks himself sure of today. Oh, God, Thou has appointed me to watch over the life and death of Thy creatures; here am I ready for my vocation and now I turn unto my calling."

     Others use the Oath of Physicians as outlined below:
From Wikipedia, the free encyclopedia: The Physician's Oath was codified in the Declaration of Geneva (1948) by the World Medical Association. It was adopted by the General Assembly of the World Medical Association, Geneva, Switzerland, September 1948 and amended by the 22nd World Medical Assembly, Sydney, Australia, August 1968.

     I solemnly pledge myself to consecrate my life to the service of humanity;
     I will give to my teachers the respect and gratitude which is their due;
     I will practice my profession with conscience and dignity; the health of my patient will be my first consideration;
     I will maintain by all the means in my power, the honour and the noble traditions of the medical profession; my colleagues will be my brothers;
     I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient;
     I will maintain the utmost respect for human life from the time of conception, even under threat, I will not use my medical knowledge contrary to the laws of humanity;
     I make these promises solemnly, freely and upon my honour.

     So your physician may have sworn to any of the above, or to any of several others written by individual medical schools, or by graduating student classes. Or they may not have sworn to any Oath at all. I did not! We didn't have any ceremony to take this oath. I graduated from UW Medical School in 1970. At that time, graduation took place with all the undergraduates and all the graduate students in Camp Randall Stadium. There were different times assigned by the graduating school, and for the different post graduate schools. We were called across the stage just like law students and all the graduate students. The only difference was that we were to invite some doctor (MD or PhD) who was supposed to be our mentor to escort us across the stage. (Could have been a respected teacher or mentor or a member of our family if they were a doctor.) But there was no general administration of any oath as part of this ceremony.

     Some years later, when my son graduated from Medical School at UW, the medical graduates participated in another ceremony that preceded the general graduation. This ceremony was only for the MDs, attended by friends and family, and faculty. This ceremony is called the hooding ceremony. Some of you may or you may not know that in the United States of America academic regalia has a hood that is worn over the graduation robes. Each hood has characteristic colors for the degree and for the school which grants the degree. You can therefore recognize where a person graduated from, what degree they have and in what field by their hood. The hood’s length signifies the degree level -- 4 foot long for a doctorate degree; with the institution's colors in the lining and a velvet trim in a color that represents the field of study (Link:  standardized color that signifies the scholar’s field, green for medicine). Many schools include the administrations of the Hippocratic Oath or its replacement at the hooding ceremony.

The 4 foot hood with black and red lining of UW and the green border for Medicine.

     I of course had the same hood that I wore to graduate from Medical School, but we had no hooding ceremony. But there is one other time that I remember wearing that hood just like it was yesterday. That event is pictured below. It is the day my son graduated from UW Medical School and I escorted him across the podium to receive his degree. I had told him early in his medical school days that he better not think of asking anyone else to escort him; I don't care how close he was to other teachers during his medical school days. He said, "Mom, you don't have to tell me this. I know it." That was the proudest day of my life. My oldest son following in my footsteps. Of course, my youngest son also graduated from college and with a Masters and there was great pride there. He followed in his father's footsteps, becoming an engineer. I think it is the greatest statement of respect for your parent to follow the same occupation or profession as mom or dad.

Proud Mom and her graduating son

     Now, most medical students take the Hippocratic Oath or its equivalent which has sometimes been written by their own mentors at their medical school, while participating in the White Coat Ceremony. This is a "robing" or "cloaking" ceremony that usually precedes the beginning of clinical work when there will be patient contact, after the basic medical sciences have been mastered. The origin of this ceremony is  quite recent. In 1989 at the University of Chicago, it was noted that medical students were coming to their first class in interviewing patients in which they would have face to face contact with these patients wearing shorts and baseball caps. It was decided that year to try using a "white coat ceremony" to transition these students into clinical care, to demonstrate to them and the observers that they had a professionalism to uphold and to impress upon them how they appeared to their patients. This idea was kicked around for a few years and then in 1993 at Columbia University the first full fledged White Coat Ceremony was held, in which family and friends were invited. The class took the Hippocratic Oath (or another oath) together and they received their White Coat. It was impressed upon them that from that point on they would always need to "look the part" of doctor whenever they were likely to see patients. Originally medical students didn't start seeing patients until their clinical years of medical school, i.e. junior year. But these clinical contacts were gradually moved backwards to the sophomore year and then even in the freshman year as an emphasis on starting interviewing instructions and face to face patient contact occurred early in medical school. That emphasis of course has many good aspects but it also has some controversial aspects for the White Coat Ceremony. In many medical schools, the White Coat Ceremony is now done in the first days of medical school. This necessitates that the medical school class takes an oath that they have not read before, that they have not contemplated, that promises things that they don't even understand at that point in their education. These oaths would have much more meaning to someone who has actually participated as a team member in the care of at least a few patients providing ethical experience that would clarify some of  the things to which the student is swearing.

      I don't know what the answer is. I didn't have a White Coat Ceremony nor a Hooding Ceremony and yet I think I practiced medicine with the ethical tenets strong in my mind. It seems a little extreme to institute a whole new procedure just because some students wore shorts and baseball caps to their patient interviews. Faculty should have prepared these students beforehand and told them about the requirements in dress. I will never forget a Professor of Medicine that I had at UW. Dr. Middleton had a black derby hat that he carried to all the medical lectures. If someone nodded off, which medical students so deprived of sleep often did, they had the ignominious reception of that derby hat flung across the lecture room like a frisbee, striking their nodding head. I was once on Dr. Middleton's teaching rounds. We were standing in the hallway discussing the next patient we would be seeing on rounds. Dr. Middleton looked us over. One student had his hands in his pockets. Unprofessional! Dr. Middleton chastised him. Another was leaning against the wall. Dr. Middleton's words straightened him up. He told me that it looked like I had slept wrong on my hair. Another male student had a yellow short sleeved shirt under his white coat. Dr. Middleton told him he looked like a bartender; he'd better invest in some white shirts. We didn't need a White Coat Ceremony. We had Dr. Middleton.

     I am retired now, and I have found the following oath for Retired Physicians. I like this one: it applies to me in that I am trying to use my medical knowledge and even more my life experience to write this blog and to give public talks about various topics to groups that want to listen. Here is that Oath for Retired Physicians. I never took the Hippocratic Oath officially, so I tell you here that I have taken this one.

•Recognizing that a life well lived is a debt well paid, there is yet a time for direct accounting. On my inner sense of rightness, expressed as a sacred honor, I retire from active medical practice, solemnly pledging my continuing strength of mind, body, and resources toward repaying real and current debts accrued in the course of a full and rewarding physician's life

•To my family, I owe years of time they granted with forbearance and understanding while sustaining me in patience and affection despite my absences in mind and body
•To my teachers, I acknowledge an obligation of knowledge and skill that calls for return, however modest, through continuing teaching and reflection. Their wisdom in showing me how the art and science of medicine are never connected by “either or” but always by “both and” is treasure beyond recompense
•To my community, for directly and indirectly providing for my medical education, I owe considerable sums only partially repaid through charity services to the poor and duty to the nation in time of war and peace. Greater than money has been society's gift of personal respect bestowed on me and my profession with generous allowance for more than life's necessities
•To organized medicine, I am indebted for warm welcome in foreign lands, unexpected honors, and the opportunity to share in making a difference, measured in diminished human suffering
•To patients, I owe countless debts for transgressions of time, ignorance, and inadvertent arrogance. But most important, the balance is wanting in matching patients' abiding trust in sharing their pain, suffering, and their very lives, to the secrets of their hearts
•With keen awareness that remaining life is short and time is precious, as mind and body permit, I dedicate myself to a sustained sense of humanity expressed through the spirit of medicine. Though I can never repay my accumulated debt, I am proud to be known by it.

COOL!

Medical Symbol Confusions: Caduceus versus Staff of Asclepius

    Many posts ago (11/10/10 -- Obituary Tells a Story http://renraeretire.blogspot.com/2010/11/obituary-tells-story.html), I promised you an explanation of the origin of the symbol of Medicine, the Caduceus. There is only one problem: I had the Caduceus mixed up with another symbol, the Staff of Asclepius which is the true symbol of Medicine. So if a doctor doesn't even know the symbol of her own profession, I thought that this might be an opportunity for education, as I educate myself. 

                                                                               
                                                                                 OR

     Which is the symbol of medical care? Confused. Don't feel bad. I am a doctor and I didn't know the answer. I have certainly seen the first used to symbolize different forms of medical care, but had only a vague recollection of seeing the second symbol. The origin and use of these two symbols is quite interesting. Like most things that are very old, their story is long and convoluted, and many beliefs contribute to what is now accepted in the modern world.
     The first symbol above, two serpents wound around a staff with wings at the top is the caduceus or magical Staff of Hermes who was a Greek god, messenger of the gods, inventor of (magical) incantations, conductor of the dead and protector of merchants and thieves. It is derived from the Greek karykeion = "herald's staff", itself based on the word "eruko" meaning restrain, control. It was a symbol for the Phoenician god of Wisdom. Later the Roman god, Mercury replaced Hermes. The wings on top of the short rod may represent the wings that were often attached to the heels of Mercury, messenger of the Gods, signifying speed.
     The mythical origin of this rod is said to have occurred when Poulenc, in "Les Mamelles de Tiresias" (The Breasts of Tiresias) tells how Tiresias--the seer who was so unhelpful to Oepidus and Family- found two snakes copulating, and to separate them stuck his staff between them. Immediately he was turned into a woman, and remained so for seven years, until he was able to repeat his action, and change back to male. The transformative power in this story, strong enough to completely reverse even physical polarities of male and female, comes from the union of the two serpents, passed on by the wand. Tiresias' staff, complete with serpents, was later passed on to Hermes.
     So how did this symbol become associated with medicine? After all, Hermes is the god of commerce, eloquence, invention, travel and theft, and so was a symbol of heralds and commerce, not medicine. The words caduity and caducous imply temporality, perishableness and senility, while the medical profession espouses renewal, vitality and health. So what happened? Well, probably the use of this staff of Hermes came about because by the seventh century AD, Hermes was associated with alchemy. What is alchemy? Alchemy is an ancient tradition, the primary objective of which was the creation of the mythical "philosopher's stone" which was thought to be able to turn base metals into gold, and also act as an magic potion that would confer youth and immortality upon its user. Those who studied and knew alchemy were said to practice the Hermetic Arts. Initially alchemy preceded modern science and chemistry. However, alchemy also included various non-scientific mystical and occult concepts, theories and practices. Then gradually alchemy came to mean not only chemical processes but medical and pharmaceutical procedures, as well.as even metallurgy and mining.  The staff of Hermes represented these processes as well as Mercury's messenger functions. Therefore it also became a symbol for the printing trade when it first advanced in the 14th and 15th century, because the printers liked to think of themselves as disseminators of knowledge (messages). By the 17th century and 18th century this symbol was used for all alchemical processes in all of these fields. Into the modern arena, the staff of Hermes began to represent many occult practices as well. To this day a form of the staff of Hermes, called the Caduceus Power Wand can be purchased from occult, new age, and witchcraft stores.

    Pictured left is this modern occult use of the staff of Hermes. The central phallic rod is said to represent the masculine and it is wrapped by a twisting and turning shakti (female) energy of two coupling serpents. Also occult explanations say that the rod is the spine and the tapes represent the serpents which conduct spiritual currents in a double helix pattern from the chakra at the base of the spine to the pineal gland in the brain.
     But the great mistake that sealed the Staff of Hermes' use in medicine came when the United States Army began using it to represent its medical corps in 1902. World War I guaranteed that this insignia was well disseminated. Since that time, many medical organizations, large clinics, as well as pharmaceutical companies have used this symbol in their logos.
     Walter Friedlander performed a study of 242 logos of American medical organizations. He found that typically the Caduceus was used most commonly by medical organizations that are commercial, such as large commercial hospitals and clinics, drug companies, etc. Medical organizations that are professional such as the Canadian Medical Association, the New Zealand Medical Association, and the World Health Organization are more likely to use the second symbol above, the Staff of Asclepius, perhaps because they are often organizations of doctors and perhaps have better knowledge about the origin of both symbols.


     So what is the origin of that second symbol, the Staff of Asclepius? Aescepius is described in Homer's Iliad as a healer or physician who practiced in Greece probably about 1200 BC. He was so respected that he was sometime later turned into the God of Healing. He is usually pictured as bearded, dressed in a robe that does not cover his chest, holding a staff, that is a rough hewn piece of tree limb, with a single serpent wrapped around the wood, head at the top. A similar symbol appears on a known Sumerian vase from about 2000 BC thought to represent the Sumerian God of Healing Ningishita.
     The mythical origin of Asclepius is as follows:
 Asclepius is the god of Healing. He is the son of Apollo and the nymph, Coronis. While pregnant with Asclepius, Coronis secretly took a second, mortal lover. When Apollo found out, he sent Artemis to kill her. While burning on the funeral pyre, Apollo felt pity and rescued the unborn child from the corpse. Asclepius was taught about medicine and healing by the wise centaur, Cheiron, and became so skilled in it that he succeeded in bringing one of his patients back from the dead. Zeus felt that the immortality of the Gods was threatened and killed the healer with a thunderbolt. At Apollo's request, Asclepius was placed among the stars as Ophiuchus, the serpent-bearer. The children of Asclepius included his daughters Meditrina, Hygeia and Panacea who were symbols of medicine, hygiene and healing (literally, "all healing") respectively. Two of the sons of Asclepius appeared in Homer's Illiad as physicians in the Greek army (Machaon and Podalirius).

     Medical schools developed in Greece and later spread to Rome. These locations, called Asclepions (Asclepiae) usually included a temple from which to worship Asclepius, as well as buildings to house the priests/physicians, called Asclepiadae; and buildings to house the patients. People came to believe that just by sleeping in an Asclepion, they could be healed. The practices of the local priests added an additional attraction. The people who came to these places were usually well off and offered gifts and sacrifices to the God Asclepius as well as gifts to the priests. Snakes in honor of the God were kept here. They were harmless, usually the species called Elaphe longissima. Many escaped and still thrive in the locations of the ruins of these Asclepions. There were active Asclepions under Roman rule as late as the 6th century AD.

    The staff of Asclepius was also used as a printers symbol, often used on the frontispiece of pharmacopoeia that date to the 15th and 16th century. The Caduceus and the staff of Asclepiu were used interchangeably for this purpose and that may explain some of the confusion. Many people still today (me included) use the word Caduceus to indicate both symbols.

     The actual medical origin of the staff of Asclepius is quite interesting. This may be the practical meaning of the "serpent" wound around a stick. In tropical areas, there is a parasite known as the guinea worm, Dracunculus medinensis, also called "the fiery serpent"  or the dragon of Medina. Infestation with this worm is called dracunculiasis. The life cycle of this worm involves only the human and a small water flea or crustacean. The water flea ingests the smaller larvae of the roundworm. People ingest the water flea when they drink contaminated water. The water flea is digested releasing the roundworm larva which migrates through the body, maturing and then migrating subcutaneously and growing quite long. The male is the size of spaghetti and can grow to 2 to 3 feet long. Eventually by gravity it usually moves to the lower extremities leading to inflammation and pain. Eventually they would grow to maturity and emerge from the host by eating a hole in the skin. The whole process especially the latter caused a fierce burning pain that disabled the victim from work until finally the worm would emerge and the track and emerging hole would heal up. The pain is so great in the end that people would go into the cool water of ponds or streams to relieve the pain. The water then triggers the female roundworm to release her larva into the water, contaminating it and beginning the worm's life cycle all over again. Though not life threatening, a sufferer from dracunculiasis would lose a lot of days of productive life and the emergence was often timed during the key farming season. Where endemic, so many people were infected that sometimes the harvest could not be completed contributing to hunger and societal disruption. Hence if people could afford it they went to physicians who would treat this worm. The treatment consisted of making an incision in the skin just ahead of the progress of the worm. When the worm began to emerge, the physician would wind it around a stick and exert slow tension (over days' time) and gradually wind the worm up until it was removed from the skin. If too much or rapid tension was applied, the worm would break and removal would be much more difficult and painful. The worm was very common so physicians who were knowledgeable in this procedure hung an image of the worm wound around the stick in front of their place of business.
     Interestingly, the current National Geographic Magazine has a one page article demonstrating that through education alone, the guinea worm is going the way of smallpox. People in endemic areas have been taught to drink water through a simple straining straw, or to filter it, or add an larvacide to the water before drinking. Also people who have guinea worm emerging have been taught not to go into the water to relieve pain but instead to take some anti inflammatory medications and/or seek medical treatment. Since we humans are the only hosts for this worm to mature, these two practices are eliminating the worm. Now only 4 African countries continue to see guinea worm and even those infections have become much less significant. This is the only time that a disease will likely be totally eliminated without the use of vaccines or antibiotics.

     So now you know the difference between the Caduceus and the Staff of Asclepius. You know that the true medical symbol should be the Staff of Aesclepius, though an insignia that champions Hermes, the god of commerce, might symbolize portions of the practice of medicine today. Following is a frieze that depicts the confusion between these two symbols.

Hermes (Mercury) and a merchant approach a disapproving Asclepius (Physician) and  his daughters, the naked Graces (Meditrine, Hygeia and Panacea)
[Engraved from an original in the then Museum Pio Clemens in Rome
Galerie Mythologique, Recueil de Monuments by Aubin Louis Millin, Paris 1811.]

Asclepius dealt with patients - merchants make deals with clients

Asclepius is linked with a constellation of idealistic medical ideas

Hermes is linked with hermetic occultism

Mercury is identified with mercantile mercenary views

Physical Therapy

     As my readers can see, I have not posted a new article for over a month. Yet I am looking over the new flags that made hits on my website and also where some of these viewers came from. I feel I owe you a posting, so I decided to write a little about why I have been delinquent.

     I have been accessing the medical profession again from the consumer side of the desk. My elbow has been continuing to have daily pain from my melanoma surgery. I have had various types of strange pains starting about 2 weeks after the surgery. At first it was, I think, a nerve pain with hyperesthesias (extreme sensitivity to normal touch) over the area, and allodynia, which is accentuated pain from stimuli over the area. I saw a physical therapist at the Hand Clinic at the Medical College of Wisconsin. But she really didn't have much to suggest and showed me a couple exercises to try to stretch the nerves, and slapped some corticosteroids cream on the site and gave me an ultrasound treatment. But she said she was not allowed to get the ultrasound head very close to the relatively new incision so she couldn't really get to the area that was bothering. Even so I found the vibration of the ultrasound to be very annoying, accentuating the pain.

     This was very similar to therapy years ago for my knee and mostly what was done was modalities ie ultrasound, and electrical stimulation. That time zapping my quadriceps muscles with electrical stimulus while I was voluntarily contracting them was I thought extreme torture. And I did not complete that session. My knee slowly got better on its own.

     Since my pain is persisting and some of that hyperesthesia is better, but now I am having deep pain with motion and with hanging my arm down, I have decided to try therapy again. It is after all three months since my surgery. A friend from my Spirit Mind Body group gave me a name of a therapist at the Sports Therapy clinic near my home. After the first visit with him, I was very optimistic. I now think there are therapists and then there are therapists. He was great, treating my whole body, found some things that I didn't know could cause me trouble. Very thorough. and astute at picking up on what I told him about the nature of my pain. He found a lot of tightness in my neck and shoulder, and at the acromioclavicular joint in the shoulder. He also said I was lacking about 40% motion when turning my head toward the surgical arm. He said one of my vertebrae was turned on the other because of that muscle tension. so he took it upon himself to strengthen this out and release those tight muscles. Just with the first two sessions I was felling somewhat better in the arm.

     But then he started working on my surgical site and that elbow. He was probably too vigorous that first time. Within a day or two I began to recognize the pain; it was no longer strange or a stranger to me. I now had lateral epicondylitis, or tennis elbow. Somehow all that manipulation of the elbow had centered the pain and inflammation right on that lateral epicondyle. I had experienced tennis elbow before from playing tennis, but this one was created with the help of a surgeon and a physical therapist and it was a wing-dinger. But at least I knew what to do for this. I purchased a fresh new tennis elbow band and wearing it brought some relief. I have been wearing it much of the time since. My physical therapist was bummed out that he had caused a lateral epicondylitis, and stayed away from the elbow until about my 7th or 8th session. He continued to work on my neck and shoulder girdle. He is good, he identifies the muscles and performs maneuvers and asks me to move certain ways against resistance while he is isolating those muscles. My grip strength is lagging and seems to have plateaued at about 30% down from normal. We are able to record increases in neck range of motion, and arm range of motion after these sessions.  But then the next session, I have lost all that range of motion and everything is all tightened up again.  I have learned that therapy is an example of the cliche: Two steps forward, one step backwards. In fact it may sometimes be one step forward, two steps backward. Once I seemed to get a flare up of the arm pain after attending an Imax movie -- looking up. Once when I seemed to have moved backwards, the therapist took a history of my activities and we decided it might be me working a lot on my laptop, writing blogs and, -- I admit it, playing solitaire, or mahjong on line. So I have limited my computer time or else tried to steal the desktop machine which is more ergonomic from my husband, which is not always easy. So, indeed, you have not seen any blogs for a whole month.

     I am still occasionally taking steps backwards. I went to water aerobics on Saturday and had a different and very young teacher. Of course, the moves were different because of the different teacher and she did a lot of arm work with buoys in the water. I stopped using my bad arm about 2/3 of the way through when I saw this, and I iced it after, but still I was pretty sore the next day. My therapist says I must stay positive, so I will try. Thank goodness for tennis elbow bands! And I will get better; I know it. It is just a slow process.

     In the middle of this whole therapy thing, I did go back to see the plastic surgeon who operated on my arm. First let me go against rules and generalize that I think many surgeons (my son excepted) do not deal well with postoperative pain, particularly the pain that is different or more than expected.  He was not very interested in the neuropathic pain I was reporting to him when I returned to get the sutures out. This 3 month follow up was just as disappointing. He really didn't address the location, nature or degree of my pain. He put his finger on a spot on my forearm which was slightly tender, and brought up a diagnosis that I had never even heard of, called a radial tunnel syndrome, and he suggested I was creating it by wearing my tennis elbow band too tightly. He also criticized my therapist implying he was treating me appropriately.  He was otherwise showing off for the medical student that was with him. He also was critical of the report that my oncologist had sent him because she had decided that the total depth of my melanoma was only 0.48 mm which is very superficial. This depth would probably not justify as wide an excision as I had and would not justify a sentinel node biopsy. So he told me that we still do not know the depth. He still said we can't be sure and add up the depths, which of course would be 0.48 mm and 0 since nothing was found in the wide excision specimen. Just to make sure his student knew the degree of surgery was justified, he told me that we still had to be paranoid about this melanoma, that it could come back. Then he said,"Now, if you ask me do I think it has spread, I would say 'No.' but I do think we will never know the depth of this lesion, so I would class it as more advanced class of tumor than your oncologist did." OK, that's going to make me feel good and confident. Needless to say, I found this appointment very disappointing.

     In an unrelated experience, I wanted to write another tale of a medical interaction. Amazingly, my husband had a nevus removed from the bottom of his foot about a week after I had my melanoma surgery. A dermatologist in my clinic had been watching this lesion on the bottom of hubby's foot for about 6 months and just could not live with it there anymore. He was going to do a very shallow biopsy of it, but knowing how my depth was disturbed by the shave biopsy, my husband insisted that at least 1 mm of tissue be removed in the biopsy. The dermatologist said he was uncomfortable about doing this and so wanted to send my husband to a surgeon. He called me into the exam room to explain this to both my husband and me at the same time. But then he began speaking to me about my amelanotic melanoma. He related that he made the same "mistake" that my dermatologist made and shave biopsied an amelanotic melanoma on a young woman. He felt bad about this, but then he said: "But it really didn't matter, because her melanoma had already metastasized and she died of a brain met." Yes, he said that to me and I was still wearing the big bandage on my arm from having my melanoma removed. This was an example of the doctor talking with the doctor and his being unable to view me as a patient. He was in truth not very sensitive to the situation. I told this story to my water aerobic lady buddies, and they thought it was terrible. They wanted to know his name, but I refused to give it to them, because this dermatologitst was a good doctor. He was just having trouble telling between the patient and the doctor.

Bathroom Wars

     The proverbial war of the toilet seat up or down goes on.
      Our war has some extras that add fuel to the fire. Our large house has 5 bathrooms, 3 of them downstairs where we live most of the time. The one that is part of the master bedroom suite has always more or less been mine so I would usually find the toilet seat down. My husband when he got up to go at night would usually walk to the other end of the house and use the back powder room near the laundry. I don't know why he always walked so far--maybe because he usually left that seat up and so it was ready for him. There is the guest powderroom that is right outside his bedroom door, but that one is special. It contains my Kohler :Wildflowers of the Prairie pedestal sink. Also both of us got in the habit of not flushing because we didn't want to wake the other person, but then we would forget the next day and this is not good for the porcelain toilet bowl or for the welcoming odor of the home. Finally we both agreed to flush even at the risk of waking the spouse. But this still leaves us with the "seat up or down" battle.
     As time as gone on and we have both aged, various things have happened to our bladder musculature. My husband has had prostate issues and subsequent radiation treatment that leaves him with nocturia (medical term for getting up at night to urinate too often). He may also have some urgency, I don't know. (Term that means you have to rush to urinate to avoid an accident). I have definite urgency to a significant degree and perhaps some degree of overactive bladder in addition to the sinking musculature that contributes to this. Both of these factors in the two of us sometimes necessitate us using the other's designated bathrooms. For example, I come home and have that urgency the minute I step in the door that leads me to use the back powder room near the laundry. Hence, seat stays down on husband's bathroom. My husband again avoiding the "special" guest powder room , uses the one in the master suite. Hence I find the seat up and I am having urgency. Those few seconds needed to put the seat down in the middle of the night might be all it takes to prompt an accident. Neither one of us have commented to each other about these issues because they are beneath civilized conversation in the living room or over coffee in the morning.
     What do we do? Write Ann Landers? I think she is no longer doing a column. I think her sister is, but should either of us communicate with her? See our respective doctors and medicate ourselves further than we already are medicated? I for one don't want any more medication. Wear one of the several brands of panty liners and/or with time a Depends type of product? I have already tried the former and it helps, but I doubt I could get my husband to do this. Anyway how would this help under dire circumstances? What should we do, just let it rip? Fill the product, so to speak. Seems rather uncouth, don't you think? I did do some research on the Internet on this issue. Some suggestions for toilet bowl etiquette suggested that both parties lower the seat and the lid each time. Then both parties would be equal when they approach the toilet bowl and can choose which way they want the set up. Each would be subject to the same delay -- certainly an equitable solution. There is also the question of closing that lid on germs and just the general site of the open toilet while washing your hands or brushing your teeth. Before we have company, I always go around and close all the toilet lids, so there is something in me that thinks the closed seat and lid is more esthetic.

     To add further analysis to this question access the following website. You will see an analysis on work units starting with two different schemes pertaining to the position of the toilet seat after use. Convincingly there is less work if the toilet seat is simply left in the position in which it is found. But the level of kindness to the female is at least perceived to be higher if the seat is left down even though it takes more work units to accomplish this. Access this website to see the statistical analysis: funny!  http://www.speech.sri.com/people/anand/toiletseat/index.h  Or google toilet seat up or down etiquette and you will find this site listed.

     I guess after my husband's encounter with prostate neoplasm and mine with melanoma, the urgency and nocturia problems as medical problems go are rather diminutive. Just another sign of aging and another deficiency to deal with. Maybe some day there will be a toilet seat reader that reads an implanted chip on the butt of the urinator and automatically raises or lowers the lid. Wouldn't that be something?

Post surgical stories

     I have to write one more story about my little surgical/medical excursion with melanoma. And there is a chance for you to tell me about your surgical pain experiences. Below is a neuropathic pain scale to use to assess your own pain levels at various times of the day. This might be useful to your medical care team. Read on below to learn more about my experiences and medical studies that sometimes document poor postsurgical pain control.

I did absolutely great after the surgery; took oxycodone doses on time for the first day, and by the second morning home, I changed to Tylenol. Even the Tylenol, I only took for that second day. By the third day I was on nothing for pain and feeling fine. I was limited because I was instructed to keep my arm up most of the time but that was my only limitation. Then about 10 days after the surgery I started getting strange sensations in the arm, in a several inch circle around the lower half of the incision. I couldn't keep my arm down at all because I started feeling pressure and tightness, and heat, and a sense of strong discomfort in this area. Slowly these sensations became worse so that I had to sit with my arm up again and I became more uncomfortable and more limited in what I could do than I was several days after the surgery. I tried an ace wrap and that helped some but it would slide around and pull on the arm tissues and make the symptoms more noticeable. I went back at 3 weeks to get the sutures taken out. I told the surgeon about my symptoms in detail trying to describe them as I have above. I told him that I had a similar pain syndrome occur after a breast biopsy many years ago and a nerve drug called Tegretol took it away in a few days. He said that my symptoms were probably just due to swelling, but he suggested I get to see a therapist at the hand clinic. He wrote "scar mobilization and desensitization" as the orders on the slip to the therapist. But when I described where it hurt to her and showed her how I could move the scar itself around and rub on the scar without any problem, she didn't know exactly what to do for me. She tried some ultrasound therapy which in one area irritated the arm more. She did give me some silicone gel sheets to put on the scar to soften and flatten it and that worked well. Also she gave me an elastic sleeve to wear on the arm over the scar and that did help me keep the arm down a little longer before it would start to burn. But the desensitization rituals she showed me of massage, rubbing with a towel and vibrator use over the sensitive area didn't do anything to help and was quite uncomfortable though I was a good patient and did try them. Meanwhile I had spoken with my general surgeon son, and he asked if I was on either of two drugs that he uses for just this purpose: Lyrica (pragbolin) or Neurontin (gabapentin). He said he uses these drugs quite often to treat these types of nerve damage symptoms. He said that some of his surgical partners even use the medication preventatively right from the time of surgery with good success.
     I researched on the Internet and found articles that support the use of these drugs for postoperative neuropathic pain and proof that they reduce narcotic use and seem to prevent this type of pain development. There are all kinds of elaborate theories for why these pain syndromes develop. One postulates that the nerve firings recruit more pain nerves in the spinal cord and even the brain until there is a distribution of the pain even to more distant points from the surgical injury. Many people then go on to develop chronic pain syndromes that become more and more difficult to treat. I could identify with that myself both times I have had this problem. With the strange discomforts in the arm or chest wall like last time, I would catch myself grimacing with my face. Similar muscle contractions were occurring in my shoulder and neck muscles and then pretty soon the muscles are aching just from being tightened in discomfort for long periods of time. Now pain messages are coming from sites distant from those touched by the surgeon. Tense shoulders and neck muscles lead to headaches. A general sense of hopelessness and depression creates an inability to move, exercise, eat, or take an interest in usually pleasurable activities. Then sleep disturbance can enter the picture worsening all of the above. I could see this cascade starting to develop in my own situation. Therefore, the idea is to catch the neuropathic pain early before this cascade of events has gotten started and becomes habitual.
     I called the surgeon 1 week after the sutures were removed and told him I was no better, perhaps even slightly worse. I received a messsage back that as far as he was concerned I could go on a Tegretol like medication but I should call my primary care doctor to get the prescription. Apparently he was not comfortable prescribing these kind of drugs. So I made an appointment with my primary care doctor and saw her today. Indeed she was willing to prescribe a newer version of the Tegretol that had worked for me, one with fewer side effects. So I started this medication today. We will soon see if it worked as well as last time.
     All of this led me to research several medical articles on the Internet about treating post surgical pain. First I learned that several medical articles indicate that acute postoperative pain and then persistent pain after the acute pain should have remitted occur and are inadequately treated. An article in May, 2006 Lancet quoted that between 10-50% of post surgical patients have persistent pain beyond that of the acute surgical injury. And in 2-10% of those people, the pain is severe. These persistent pains are attributed to neuropathic pain with mechanisms similar to that I have described above.
     Another large (1299 patients) and well conducted survey following hysterectomy found that 1 year after surgery 32% of the patients were still experiencing (chronic ) pain and of these 15% did not have any pain beforehand. Of patients receiving spinal anesthesia, 15% had pain at 1 year compared with 37% receiving general anesthesia. Using a pain relieving model that extends for 2 weeks after the surgery, this incidence of chronic pain was reduced from 7% to 1% of patients in another study. So chronic pain after surgery is a common problem. It seems to be influenced by the type of surgery, whether there was pain before the surgery or not, presence of other risk factors such as diabetes, and other history of neuropathic pain, and even genetics. There seems to be a gene which codes for a lower tolerance of pain and having that gene allows manifestation of surgical pain to become expressed to a greater degree in those individuals.
         One other interesting question arose in my mind during my surgical experience and since. Many of you readers may have been asked by various members of the medical profession to rate the level of your pain on a scale from 1 to 10. Most of us whether with medical background or not have no idea what these different numbers might mean. I would venture to guess that if there were a way to measure objectively that pain, individuals would still cite a range of numbers for that same level of pain even if their pain tolerance were the same. So I researched the pain scales being used and found that there are indeed ways to make these scales more representative of the actual pain being experienced. Following are two methods to make these pain scales representative of the pain being felt. The first is descriptions of each pain level on a 1 to 10 scale. The second pain scale gets away from using word descriptions and uses simple facial features that might show the level of pain and would ask the pain victim to point out the face that represents his/her pain. Using this 1 to 10 scale I would say that my current chronic pain is mostly in the 2 and 3 level. Occasionally after having my arm down for a while, it reaches 4. When I am sitting with my arm propped up on pillows level with or higher than my heart, the pain level is usually 1. So not severe, but enough that my quality of life is affected and my daily activities are reduced.
    
The Pain Scale in words:
0 -- Pain Free
     Mild Pain - Nagging, annoying, but doesn't really interfere with daily living activities.
1 -- Pain is very mild, barely noticeable. Most of the time you don't think about it.
2 -- Minor pain. Annoying and may have occasional stronger twinges.
3 -- Pain is noticeable and distracting, however, you can get used to it and adapt.
     Moderate Pain - Interferes significantly with daily living activities.
4 -- Moderate pain. If you are deeply involved in an activity, it can be ignored for a period of time, but is still distracting.
5 -- Moderately strong pain. It can't be ignored for more than a few minutes, but with effort you still can manage to work or participate in some social activities.
6 -- Moderately strong pain that interferes with normal daily activities. Difficulty concentrating.
     Severe Pain - Disabling, unable to perform daily living activities.
7 -- Severe pain that dominates your senses and significantly limits your ability to perform normal daily activities or maintain social relationships. Interferes with sleep.
8 -- Intense pain. Physical activity is severely limited. Conversation requires great effort.
9 -- Excruciating pain. Unable to converse. Crying out and/or moaning uncontrollably
10 -- Unspeakable pain. Bedridden and possibly delirious. Very few people will ever experience this level of pain. It may cause unconsciousness.

The face pain scale.

     It is interesting to read all about these items while being affected by the problem oneself. We will see if the Tegretol nerve drug does anything for me this time. I am hopeful it will act like it did in the past.

     I am very interested in any of you who have experienced persistent post surgical pain extending out beyond 14 to 21 days after surgery. I would like to know if it had the characteristics of neuropathic pain that I described. And I am interested in how it was managed by your doctors. Send me some comments.