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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

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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