Pain





Pain, while always a dreaded symptom of disease, seems, with the

increase of comfort and the gradual abolition that has come in our

time of many of the trials of existence, to have had its terrors

increased. Even a slight pain or ache is dreaded, and if continuous or

frequently repeated, becomes for many people a trial that is almost

impossible to bear. This is all the more to be deplored because

ability to stand a certain amount of pain, with reasonable equanimity,

is almost a necessary condition of rapid recovery from disease or

injury. Placidity of mind favors the flow of nerve impulses for

reconstructive purposes, while over-reaction to pain inhibits the

natural processes of repair. According to Shakespeare's heroine:

"There was never yet philosopher that could endure the toothache

patiently." Pain is usually supposed to be an essentially physical

phenomena for which mental influence can be of little, if any,

benefit. As a matter of fact, however, the mental attitude towards

pain modifies it to a considerable degree. I have quoted Hippocrates'

declaration that a greater pain drives out a lesser pain. Any strong

preoccupation of mind will greatly lessen pain at any time.







Pain is not, after all, in the nerves, nor in the central nervous

system, but in the consciousness. Just as there is no sound unless the

waves in the air arouse recognition in the consciousness, so there is

no pain unless the disturbance of nerves finds its way above the

threshold of consciousness. Nerves may be racked, yet no sensation may

be felt. There may be pain in the mind apart from the nerves, and

slight nervous affections may produce severe pains. The whole question

of the treatment of pain involves the individual much more than it

does the affliction which causes the pain. What seems unbearable pain

to many may be little more than a passing annoyance to others. What

would be, under ordinary circumstances, intolerable torture,

especially to sensitive people, may, because of intense preoccupation

of mind, remain absolutely unnoticed. Maniacal patients sometimes

inflict what would normally be extremely severe pain on themselves by

burning or mutilation without any manifestation of pain. In the

excitement of a panic men may suffer what would, under other

circumstances, be excruciating agony, and yet not know that they are

hurt.



To a mind that is without serious interest, even slight pain, if

continuous, soon becomes unbearable. The course of pain, where there

is no diversion of mind, is an interesting study. While suffering, we

seem always able to bear the pain of the present moment, and it is

only the cumulative effect of the pain that is past and the

anticipation of the discomfort to come, that make the pain unbearable.

Nearly, always it is much more the dread of what the pain may mean,

and the lack of power to endure which gradually develops as a

consequence of suffering, that constitute the worst features of pain.

At the beginning of a period of pain we stand it well, as a rule, but

its continual nagging debilitates us and heightens our susceptibility

until we cannot nerve ourselves to further endurance. If our power of

endurance were not thus gradually lessened the pain would not seem

severe. There are many neurotic people whose susceptibility to pain

has been so much increased by their lack of self-control and their

tendency to react easily to pain, that even slight pain becomes a

torment. Psychotherapy should gradually train these people to a power

of endurance.





Pain from Over-Attention.--Much of what is called pain is really due

to such concentration of mind on a particular portion of the body that

the ordinary sensations of that part, usually accomplished quite

unconsciously, become first a source of uneasy discomfort and then an

ache or pain. There may be some slight physical disturbance which

calls attention to the part, but there is no really serious

pathological condition. While such pains are spoken of as imaginary it

must be remembered that this does not mean that they are non-existent.

On the contrary they may be much more real to the patient than

physical ailments. A pain in the mind is a much more serious condition

than having it in the body.



While pain may be thus created by concentration of attention, it must

not be forgotten that what the mind can do in increasing pain is even

more important than in originating it. Slight discomforts by

concentration of attention on them may be made insupportable. It is

this element in pain, above all, that the physician requires skill to

alleviate. Habits of introspection and the lack of serious occupation

of mind of many people leave them the victims of over attention to

themselves. In trying to relieve their pain it may be

comparatively easy to alleviate their physical condition, but the

mental condition, once aroused, may remain, and may easily tempt to

the use of habit-forming drugs or others that may do serious harm. The

story of the evil effects of headache powders in recent years, and of

the opium habits formed in olden times, are a significant commentary

on this fact. It is probable that in most of these cases, the

discomfort for which remedies were frequently taken was of a kind that

should have been treated only partly, if at all, by drugs. It is more

important to lessen susceptibility than to try to cure the pain.



The relation of the mind to what is often considered severe physical

pain, has come to be generally recognized in recent years. Neuralgias,

for instance, have often been reported as recurring after fright, or

strong emotion, or worry. It is at moments when patients are much run

down in health that pains are particularly likely to be unrelievable,

and during periods of emotional strain that anodyne drugs are most

called for and are most likely to be abused.





Rest and Pain.--In any study of pain and its relief, one must always

recur to that classical contribution to medicine, now in the fiftieth

year of its publication and still as important as when it was written,

Hilton's "Rest and Pain." He calls attention to the fact that what he

wrote was only a development of what many practical physicians had

thought long before his time. He quotes a prize essay of the French

surgeon, David, written in 1778. Hilton's development of the idea that

pain is usually a signal on the part of nature for rest, and that rest

will usually enable her to overcome the pathological condition and so

relieve the pain without recourse to drugs, is, and ever must be, the

basic element in the therapeutics of pain. How many forms rest may

take can only be judged by a careful reading of Hilton's book. The

oftener one reads it, the better one realizes how much of precious

common sense and acute clinical observation there is in it. It is

essentially a book of psychotherapy. It treats the patient's mind

first and then through that changes his habits, persuades him of the

need of rest, directs how that rest should be taken and so leads up to

his natural cure.



Every treatment of pain must include rest of mind as well as body.

Hilton has particularly dwelt on the rest of body. Rest of mind is

just as important. Many pains could be easily borne were it not for

the worry that accompanies them. A slight pain becomes greatly

annoying because the patient's general condition makes it impossible

to stand discomfort with equanimity, and there has been no training in

self-control. In spite of all our advance in medicine, we are not

likely ever to make life so free from pain that people can go through

it without needing self-control. Training in self-control is an

important psychotherapeutic prophylactic. If, with a certain amount of

capacity to bear discomfort, there goes such rest of mind as does not

exaggerate or emphasize the condition, then many of the pains of life

lose their power to annoy, all of them are distinctly lessened and the

relief of them by accessory physical methods becomes easier.





Pain in Its Relation to Life.--There is an unfortunate tendency to

exaggerate the significance of pain. We have cultivated irritability

in the physical sense, rather than the power of endurance. Patients

should, as far as possible, be lifted out of this condition of

over-delicate sensitiveness and put into a state where the idea of

pain is not so serious. Only in this way can the more or less

inevitable discomforts of life be borne without such reactions as

seriously interfere with health. It may be said to be other than the

physician's business to secure this magnanimity, but as magnanimity is

needed in our patients, and there is no one else to respond,

physicians must start its cultivation. The necessity for learning to

bear minor discomforts, at least without exaggerated reaction, need

not be presented to the patient directly, but can be gradually made a

part of the system of treatment. By absorption in other interests, the

consciousness of these discomforts disappears without the necessity

for recourse to drugs.





Self-Denial.--Many thoughtful people are sure that what is needed to

make a large number of our generation more happy, or at least less

miserable, is training in self-denial and in self-control. The word

self-denial has come to have a very distant sound for most of our

generation. From early childhood anything that is unpleasant is

shunned and anything that is difficult is likely to be shirked. The

head-master of Eton College has recently insisted that too much is

being done to please young folks and too little to stimulate them to

activity. He declares that, as a rule, any undertaking begins to be

useful just where it ceases to be simply pleasant. Unpleasantness is

avoided to such a degree that the habit of thinking that it has no

part in life comes to be a second nature. As a consequence, the

reaction to any continued unpleasantness is likely to be exaggerated

and make the subject very miserable, and sometimes disturbs and

discourages, whereas it should have the effect of stimulating to

reactive efforts, to bring out the best that is in us.



Hinton emphasizes the fact that an ingredient of pain is necessary to

all health or pleasure. The fatigue and the hardship associated with

mountain climbing is a portion of the essence of the pleasure in it.

All healthy, pleasant exercise has an accompaniment of fatigue and

some aches and pains. What is needed, then, in our time is the

training to do things for the sake of doing them. We should be

neglectful of the discomfort that may be associated with them, or we

should even consciously rejoice in the fact that this very discomfort

is of itself a sign that functions are being used to such an extent,

that their limits are being expanded, their limitations overcome.



It may well be said that it is not the physician who, as a rule,

should do this; it should be accomplished in the early years by the

teachers and trainers of the young. True enough. But physicians can at

least help in reforming the tradition in this matter so as to

neutralize the present state of mind which seems to look upon pain as

an evil. Pain is always either a conservative sensation or an actual

stimulus to function. Besides, many of the present generation who come

to us, having had no training in the precious qualities of self-denial

and self-control under difficulties and discomforts, must have this

knowledge supplied for them as far as possible by suggestions of

various kinds. It is more difficult to accomplish much in this matter

for the adult, but even in apparently hopeless cases of over-attention

to self and incapacity to bear discomfort, much can be accomplished by

patience and persistence.



The common dread of suffering is quite unwarranted by what we know

about the effect of pain. There are many motives that may be adduced

to make it seem less terrifying than it now is to many people. The

effect of pain upon character is always excellent. The difference

between two brothers, as we have said, one of whom has had the

discipline of pain or suffering and the development of sympathy

that comes with it, and the other who has not had the advantage of

this great human experience, is likely to be marked. In the one there

is a depth of human nature that enables him to appreciate and even to

express the meaning of life better than his apparently more fortunate

brother. Practically all the men who have ever got close to the heart

of the mystery of life, and expressed it in poetry or other form of

literature or art, have gone through suffering as a portion of their

training. Even the suffering that comes from ill health is never

wasted. Men have gone through it who have thought that the ecstasy of

relief following it made the experience worth while.



Men are not deterred from action by the prospect of even severe pain.

Probably no greater physical suffering can possibly be invited than is

sure to come to those who go on Arctic expeditions, or who undertake

prospecting in Alaska. Of course, many of the prospectors find

themselves in the bitter cold of the North without having realized

what they would have to stand. But Arctic explorers, as a rule, know

exactly what they have to expect. Most of of them have been through it

all before, yet they deliberately choose to go again for rewards that,

to an average man's eyes, seem trivial. The memory of past pain is

rather pleasant. Virgil's "Perhaps it will be pleasant to recall these

trials at some future time" is not poetic exaggeration.





The Discipline of Pain.--There is only one way to learn how to bear

pain, and that is by practice in it. There might be no necessity for

this in case life were arranged differently. But all men must die, and

death inevitably involves a painful process. Suffering is practically

unavoidable for the majority of men. Even in the midst of every

possible material comfort, cancer may come with all its hideous

connotations. It is important, then, that everyone should be prepared

to stand some pain. Certain suggestions help in bearing special pains.





Pain Diffusion.--Pain along one nerve may readily become diffused.

This diffusion will sometimes cause discomfort, and even tenderness,

at a distance from the original seat of the pain. Such diffusion tends

to produce in the patient's mind the idea that the underlying

pathological condition is spreading, though it is only a sign that the

nervous system is becoming irritable and easily responding to sensory

disturbance. Dr. Head's investigations ("Brain," 1893), should be

known to physicians, and the conclusions that flow from them should be

presented to patients who are sometimes suffering quite as much from

their apprehension of the spread of pain, and its significance, as

from the discomfort itself. Dr. Head says:



If I have an aching tooth, the pain is at first localized to the

tooth affected. The longer the toothache continues the more I become

worn out, and the pain is rapidly accentuated by a "neuralgia," that

is, a pain in the face. The neuralgia is soon accompanied by

distinct cutaneous tenderness over a definite area on the face

corresponding to the tooth affected. If I am anemic, or if the pain

remains untreated until my bodily health is affected, I no longer

have a localized area of tenderness, but the pain, and with it the

tenderness, spreads until the whole of one-half of the head and even

the neck may be intensely tender. Thus at last the pain of an aching

tooth has produced tenderness over areas which bear no relation to

the affected organ.



As pain can be suppressed by diversion of mind, or concentration of

thought on something that creates great preoccupation, it must not be

forgotten that pain may almost be created by concentration of

attention on certain areas of the body, or certain nerve tracts.

Over-attention will actually make sensations intolerable that are at

first quite indifferent, or at least very easy to bear. Sensitive

people, in the ordinary meaning of that term, are those who are much

given to paying attention to their sensations, and who therefore have

much to complain of them. There is much in modern life that has the

tendency to produce this sybaritic condition in which even slight

discomforts become the sources of almost unbearable annoyance.



Even where there is no good physical reason for the occurrence of

pain, thinking may produce discomfort. The one thing that Freud's work

has made clear is that in neurotic persons the memory of a mental

shock or strain may be transferred to some portion of the body related

in some way to the shock, and then prove to be the source of

hysterical pains and also of hysterical palsy. The case told by him in

which the young woman massaging her father's limbs allows them always

to rest on her own lap during the process, and after his death suffers

from an hysterical, painful condition in this region, is a typical

illustration. Her sympathy for her father, accentuated by his

subsequent death, and her sorrow at a time when her nursing efforts

made her particularly susceptible, led to an explosion of nervous

energy along those nerves which had always felt the impress of his

legs. The hysterical condition resulted. This is an extreme case. In

milder forms it would be possible to explain many otherwise

inexplicable pains and aches in sensitive young people along these

same lines.



More than once I have seen young women, who had been asked to rub

father or mother with liniment, complain of tingling pains in their

fingers which were followed by some redness so that one would be

tempted to think of Weir Mitchell's disease, though evidently the

pathological cause at work was the slight disturbance of the vasomotor

system due to the liniment and the rubbing, emphasized by the

sympathetic feelings, and by the over-attention which this brought

about. Whenever women have, for a prolonged period, to nurse others in

whom they are deeply interested, and have to perform some habitual

action that is somewhat fatiguing for them, after the death of the

patient there will not infrequently be the development of hysterical

or neurotic over-sensitiveness in the parts employed. This may give

rise even to an hysterical joint, or to severe neurotic pains. Once

these cases are recognized, the attention can be diverted from

themselves and they can be made to understand that their grief and

sympathy are being concentrated on the part and by transfer are

producing physical manifestations. The pain is not imaginary, but the

condition will improve as soon as the mind is diverted from it.





Neurotic and Organic Pain.--The distinction between pain due to a

neurosis and to a definite lesion is often difficult to make. If there

is a definite localization of pain, it is almost surely not neurotic,

but organic. If there are certain positions in which pain is felt

while it disappears in others, there is some local inflammatory or

congestive condition and not mere hypersensitiveness of nerves at the

bottom of it. These positions of maximum pain are important. When pain

radiates a great deal, even though there may be complaint of a

particular region, it is usually neurotic. If patients are asked to

tell exactly where their pain is, and they indicate its location by a

wave of the hand, it is probable that the condition is neurotic. When

there is a definite localized point of tenderness with the pain,

even though there may be radiations, usually the condition is based

upon some organic trouble. It must not be forgotten, however, that

slight local troubles may by concentration of mind on them, become

exaggerated and that, in spite of the fact that there is or was at the

beginning a definite localization of pain with some tenderness, the

neurotic elements may, after a time, become manifest and prove to be

much more important than the others.



Pain that is definitely influenced by motion, as by the jarring effect

of walking, or by bending and stooping, is practically always organic.

The best differential diagnosis between neurotic abdominal conditions

and organic trouble can be made by the help of information obtained in

this way. If the appendix is inflamed, or the gall bladder infected,

or contains a calculus, or if the kidney has a calculus, these are all

made worse by movements, by jarring, by stooping as in tying the

shoes, by riding on rough roads, and the like. If patients who suffer

from obscure abdominal conditions associated with pain of which they

complain much, can, at certain times, indulge with impunity in these

exercises and motions, it is probable that their attacks are neurotic

in character. Especially is this true if the indulgence in these rides

and motions is without effect when they are in pleasant, agreeable

company, though there may be some complaints when they have to ride

alone, or under conditions that are less pleasant. If a hint of this

distinction by which the physician differentiates one form of pain

from another is given a neurotic patient, the suggestion will serve

the purpose of producing complaints whenever the opportunity presents

itself. Such patients take such suggestions, as a rule, without

wishing to deceive, but they become persuaded that their sufferings

are of the character asked for.





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