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Pain
776
EDITORIALS
these complicated procedures are chiefly destruction of tissue. To ignore pain is successful in the hands of those who are to display either stoicism or such a con continually performing major surgical op dition of mental exaltation that pain is erations. temporarily thrust into the subconscious. There was much talk of medical eco Vivid experience of pain occurs in all nomics and ophthalmo-optometric rela the higher animals. It is probably shared tionships outside of the meetings, but in by the lower animal orders, although lack executive session the only action taken of voice, or of voice such as reaches was to authorize the appointment of a human ears, renders us less directly aware committee of five to consider these mat of such pain. Questions have been raised ters. It was understood that plans might as to the existence of something analogous be presented soon to the membership for to pain in the vegetable world. Plants their consideration at the next meeting certainly display protective reactions to of the Section. injurious influences, but the problem whether they have what we call feeling is Dr. Frederick C. Cordes was elected somewhat metaphysical. chairman, and Dr. Grady E. Clay, vicechairman for the coming year. Most human beings are relatively lack Although protests are frequently voiced ing in sympathy with regard to pain in against the holding of scientific meetings the animal world below man, although during this period of essential heavy the reality of such sympathy is vouched travel and overcrowding of hotels which for by many passages in ancient and mod are understaffed and which suffer from ern literature, as well as in laws and food and drink shortages, the majority of organizations whose purpose is to prevent physicians support the idea that these or punish cruelty to animals. scientific meetings are of sufficient value Sympathy with pain in others depends to justify them. Certainly, they are more fundamentally upon our own experience important than are a host of other meet in suffering, and our visualization of what ings that keep the hotels in the large might happen to ourselves under similar cities constantly crowded. It is obvious circumstances. Capacity for such sym that unessential travel has never been pathy must therefore be bounded on the seriously curtailed. It is equally certain one hand by the degree of our own sensi that the Government is not vitally con bility, and on the other hand by the ex cerned in the matter, otherwise it would tent of our own experience, or at least by not wink at the holding of conventions, the scope of our imagination in regard to which could easily be discouraged by a what we have learned of the experience of simple prohibition, if they were thought others. to be really derogative to the war effort. It is impossible for each one of us to They do serve a good scientific purpose know with certainty just what are the and afford the doctor opportunity of get sensations of others under given circum ting a little release from the enormous stances. Those sensations may be much strain under which he is working. more severe, or conceivably much less severe, than we should have to face, or Lawrence T. Post. ever have faced, under apparently similar conditions. PAIN It is likely that the greater intensity of Pain is essentially a warning of injury pain expressed by a few individuals in or of impending injury, or of threatened the presence of what most of us regard as
EDITORIALS mild disturbances is not purely imaginary but real, its exaggerations depending upon a pathologic sensibility. A patient usually tolerant to his daily experiences, even to such circumstances as may be capable of causing mental distress, may shriek and writhe during the use of a hypodermic needle, whereas other individuals, far from robust, show themselves quite phlegmatic to so trivial an injury. At such a moment the more sensitive individual may actually sustain a torture beyond his power of philosophic endur ance. In other persons there is no phi losophy of endurance, but a riotous and unreasoning fear and imagination of ' physical torment. As to the sensation of pain, just as in many other phases of life, certain persons never grow out of their childhood. On the other hand, some adults who have never ceased being chil dren in other respects will display re markable fortitude with regard to pain. It must be remembered that two indi viduals, apparently intelligent, healthy, and vigorous, may vary greatly as to in nate sensibility. Even in the presence of equally excellent visual acuity, one person may show a surprising sharpness of re sponse to tests for minute fractions of astigmatism, while another person may prove tantalizingly incapable of discrimi nating as to astigmatic fractions quite readily apprehended by the ordinary run of patients. In like fashion, it is probably true that some patients are definitely made more comfortable by correction of astigma tism down to eighth-of-a-diopter differ ences, especially where the balance be tween the two eyes is concerned, although other patients may be utterly insensitive to uncorrected errors of a half diopter or more. It is even conceivable that very rare individuals are capable of experienc ing eyestrain from astigmatic differences of less than an eighth diopter. Who shall
777
venture to set arbitrary limits to sen sibility? Variations in sensibility are well illustrated in the field of aniseikonia, where small size differences are ap parently much more important to some patients than are much larger size dif ferences to others. To the physician the significance of pain is most widely found in the field of diagnosis. Much has been written on this subject from a more or less philosophic point of view. The course of lectures first published three quarters of a century ago by Mr. John Hilton, Clinician at Guy's Hospital, London, under the title of "Rest and pain" is rightly regarded as a medical classic. Another book combin ing wide experience with the shrewd ob servations and intuition of a medical mas ter mind is that recently issued from the pen of Walter C. Alvarez, of the Uni versity of Minnesota and the Mayo Clinic, entitled "Nervousness, Indiges tion, and pain." Hilton's famous work was designed es pecially to give his surgical students and other readers an understanding of the relationship between anatomic details and symptomatology. Alvarez' volume is de scribed by the author in his preface as "a different sort of book—one which deals more with sick unhappy persons than with their diseases . . . more with the handling of patients than with the giving of medicines . . ." In the daily practice of ophthalmology, the greatest amount of time is commonly devoted to the measurement of refractive errors. The patient may complain merely of poor vision, but in many cases the history includes complaint of pain or dis comfort. The ophthalmologist does well to ob tain and record personally the history of the patient, for only in this way can he establish that personal relation between physician and patient which is the basis
m
EDITORIALS
of good medical practice. By cross-exami nation he may learn important details as to the patient's daily activities, including the time of day at which the pain or dis comfort usually develops. He will at times suspect that headache is not ocular in origin. Headache in the early hours of the morning, for example, may occasionally depend upon use of the eyes during the evening hours, but it is sometimes due to vasomotor reactions in the nose and ac cessory sinuses, and these reactions may be connected with draughts or changes of temperature in the sleeping quarters toward morning. One should carefully investigate symp toms of an apparently migrainous charac ter, bearing in mind that headache may have a migrainous basis without manifest ing all the typical elements of the migraine syndrome. Instead of presenting the pre liminary scotoma scintillans, followed by headache, dizziness, nausea, and vomit ing, a migrainous patient may experience only a scotoma, or may have the scotoma followed by headache, or headache with out scotoma or nausea, or headache and nausea without other symptoms. Migraine commonly represents an in herited nervous tendency for which there is no complete and final cure. Yet in some patients it may either be cured, or at least greatly lessened in frequency and severity, by removal of an important ex citing cause. Some very definite cases of migraine are actually cured by an ac curate refractive correction, while in others the refractive correction gives the patient some, although incomplete, relief from the attacks. When dealing with a history of mi graine, the ophthalmologist may often render valuable service as a psychoana lyst. The migrainous patient is usually a person with keen sense of responsibility, whose busy days are crowded with many tasks, each of which is a "trouble met halfway." The patient needs to learn that
to undertake these successive tasks and responsibilities with the greatest pos sible efficiency and the least possible waste of nervous energy he should devote him self to the thing in hand without worried consciousness of what has already been done or of the mountain of jobs that re main to be accomplished. It is also useful to suggest a general attitude of muscular relaxation of those parts of the body not concerned in the activity of the moment. The patient may need to be advised of the destructive effect of that form of men tal perturbation which arises from irri tation against the task, against other per sons, or against the patient himself on ac count of dissatisfaction as to the degree of his own efficiency in action or in per sonal relationships. In other words he must cultivate concentration without ten sion. The lesson will of course be more effective if the physician himself displays the attitude which he seeks to inculcate in his patient. Even the ophthalmologist, puzzled by neuro-ocular symptomatology for which he has found apparently inadequate ex planation, may profit at times by realiz ing the expediency of inquiring delicately into the existence of secret problems which more than physical causes plague the life of his patient. While in many of our nervous patients the necessity for working without tension, and without emotional frictions, is of great significance, we ought never to over look the fundamental importance of rest. Many ocular irritations are decidedly in creased by lack of sufficient sleep. The senile or presinile patient who believes himself capable of working just as hard and just as continuously as he did many years ago will last longer and accomplish more if he learns to go more slowly and to rest from his labors more frequently than was perhaps necessary in his earlier days. Balanced judgment as to the meaning
BOOK NOTICE of the pain symptom is of particular im portance in dealing with malingering. In a case of injury where insurance or in dustrial compensation is involved, a com plaint of pain exaggerated beyond the evidence of actual damage to the organ of vision is always suggestive of intent to deceive. The workman who shows no inflammation or destruction in the an terior segment of the eye, yet persistently complains of pain and distress on expo sure to light, and insists on squeezing the eyelids together during examination, is wholly or partly malingering. As opposed to the general fact that pain is a warning, we are faced by a group of conditions in which pain is entirely ab sent, at least in the earlier stages of the disease. This is true of some malignant tumors, whether superficial or deep. The pain produced by deep-set conditions is commonly reflex in character, the deeper tissues being relatively poor in direct sen sibility. Pain gives us no direct warning at all with regard to changes in the optic nerve, retina, or choroid. The most tragic example of this absence of warning is simple glaucoma, in which the patient may go along for years without pain and perhaps regarding his gradual loss of sight as something proper to his declining years and in which no treatment is indi cated or would avail. In some surgical cases our estimate of the importance of pain or its absence will depend partly upon our previous experi ence of the individual, partly upon other ocular symptoms. To the patient who has an exaggerated sensibility we must often make light of his pain. But some patients must be coaxed to acknowledge pain, and we must occasionally be on our guard against trusting the phlegmatic patient
779
who confesses no pain, for the lack of this symptom may serve to mislead us. W. H. Crisp.
BOOK NOTICE YOUR EYES. By Sidney Fox, Sc.M. (Ophth.), M.D. Clothbound, 191 pages exclusive of index; illustrated. New York, Alfred A. Knopf, 1944. Price $2.75. This book is the best of recent publica tions about the eye for laymen. It has the double virtue of being informative and interesting. The material is well ar ranged and handled with a light touch. Starting with some physiology, the author progresses through Causes for poor vision, Presbyopia, and History of eye glasses. The subject of Color vision is treated in an entertaining manner. This leads naturally to comments on Color lenses. The Eye muscles come in for a brief chapter, the Eye in traffic occupy ing somewhat more space. An attempt is made to take the head ache out of the ophthalmologist-optome trist relationship. To one who has had to explain the differences between ocu list, optician, and optometrist daily for 30 years there seems little hope that the public, no matter how well approached, will ever make the discrimination. Quackery is discussed in a short chap ter. A consideration of the eye of youth and of old age finishes a book that may suitably be recommended for lay con sumption. There is not much material that will be new to the ophthalmologist, al though he will have an enjoyable hour in glancing through it. Lawrence T. Post.
EDITORIALS
these complicated procedures are chiefly destruction of tissue. To ignore pain is successful in the hands of those who are to display either stoicism or such a con continually performing major surgical op dition of mental exaltation that pain is erations. temporarily thrust into the subconscious. There was much talk of medical eco Vivid experience of pain occurs in all nomics and ophthalmo-optometric rela the higher animals. It is probably shared tionships outside of the meetings, but in by the lower animal orders, although lack executive session the only action taken of voice, or of voice such as reaches was to authorize the appointment of a human ears, renders us less directly aware committee of five to consider these mat of such pain. Questions have been raised ters. It was understood that plans might as to the existence of something analogous be presented soon to the membership for to pain in the vegetable world. Plants their consideration at the next meeting certainly display protective reactions to of the Section. injurious influences, but the problem whether they have what we call feeling is Dr. Frederick C. Cordes was elected somewhat metaphysical. chairman, and Dr. Grady E. Clay, vicechairman for the coming year. Most human beings are relatively lack Although protests are frequently voiced ing in sympathy with regard to pain in against the holding of scientific meetings the animal world below man, although during this period of essential heavy the reality of such sympathy is vouched travel and overcrowding of hotels which for by many passages in ancient and mod are understaffed and which suffer from ern literature, as well as in laws and food and drink shortages, the majority of organizations whose purpose is to prevent physicians support the idea that these or punish cruelty to animals. scientific meetings are of sufficient value Sympathy with pain in others depends to justify them. Certainly, they are more fundamentally upon our own experience important than are a host of other meet in suffering, and our visualization of what ings that keep the hotels in the large might happen to ourselves under similar cities constantly crowded. It is obvious circumstances. Capacity for such sym that unessential travel has never been pathy must therefore be bounded on the seriously curtailed. It is equally certain one hand by the degree of our own sensi that the Government is not vitally con bility, and on the other hand by the ex cerned in the matter, otherwise it would tent of our own experience, or at least by not wink at the holding of conventions, the scope of our imagination in regard to which could easily be discouraged by a what we have learned of the experience of simple prohibition, if they were thought others. to be really derogative to the war effort. It is impossible for each one of us to They do serve a good scientific purpose know with certainty just what are the and afford the doctor opportunity of get sensations of others under given circum ting a little release from the enormous stances. Those sensations may be much strain under which he is working. more severe, or conceivably much less severe, than we should have to face, or Lawrence T. Post. ever have faced, under apparently similar conditions. PAIN It is likely that the greater intensity of Pain is essentially a warning of injury pain expressed by a few individuals in or of impending injury, or of threatened the presence of what most of us regard as
EDITORIALS mild disturbances is not purely imaginary but real, its exaggerations depending upon a pathologic sensibility. A patient usually tolerant to his daily experiences, even to such circumstances as may be capable of causing mental distress, may shriek and writhe during the use of a hypodermic needle, whereas other individuals, far from robust, show themselves quite phlegmatic to so trivial an injury. At such a moment the more sensitive individual may actually sustain a torture beyond his power of philosophic endur ance. In other persons there is no phi losophy of endurance, but a riotous and unreasoning fear and imagination of ' physical torment. As to the sensation of pain, just as in many other phases of life, certain persons never grow out of their childhood. On the other hand, some adults who have never ceased being chil dren in other respects will display re markable fortitude with regard to pain. It must be remembered that two indi viduals, apparently intelligent, healthy, and vigorous, may vary greatly as to in nate sensibility. Even in the presence of equally excellent visual acuity, one person may show a surprising sharpness of re sponse to tests for minute fractions of astigmatism, while another person may prove tantalizingly incapable of discrimi nating as to astigmatic fractions quite readily apprehended by the ordinary run of patients. In like fashion, it is probably true that some patients are definitely made more comfortable by correction of astigma tism down to eighth-of-a-diopter differ ences, especially where the balance be tween the two eyes is concerned, although other patients may be utterly insensitive to uncorrected errors of a half diopter or more. It is even conceivable that very rare individuals are capable of experienc ing eyestrain from astigmatic differences of less than an eighth diopter. Who shall
777
venture to set arbitrary limits to sen sibility? Variations in sensibility are well illustrated in the field of aniseikonia, where small size differences are ap parently much more important to some patients than are much larger size dif ferences to others. To the physician the significance of pain is most widely found in the field of diagnosis. Much has been written on this subject from a more or less philosophic point of view. The course of lectures first published three quarters of a century ago by Mr. John Hilton, Clinician at Guy's Hospital, London, under the title of "Rest and pain" is rightly regarded as a medical classic. Another book combin ing wide experience with the shrewd ob servations and intuition of a medical mas ter mind is that recently issued from the pen of Walter C. Alvarez, of the Uni versity of Minnesota and the Mayo Clinic, entitled "Nervousness, Indiges tion, and pain." Hilton's famous work was designed es pecially to give his surgical students and other readers an understanding of the relationship between anatomic details and symptomatology. Alvarez' volume is de scribed by the author in his preface as "a different sort of book—one which deals more with sick unhappy persons than with their diseases . . . more with the handling of patients than with the giving of medicines . . ." In the daily practice of ophthalmology, the greatest amount of time is commonly devoted to the measurement of refractive errors. The patient may complain merely of poor vision, but in many cases the history includes complaint of pain or dis comfort. The ophthalmologist does well to ob tain and record personally the history of the patient, for only in this way can he establish that personal relation between physician and patient which is the basis
m
EDITORIALS
of good medical practice. By cross-exami nation he may learn important details as to the patient's daily activities, including the time of day at which the pain or dis comfort usually develops. He will at times suspect that headache is not ocular in origin. Headache in the early hours of the morning, for example, may occasionally depend upon use of the eyes during the evening hours, but it is sometimes due to vasomotor reactions in the nose and ac cessory sinuses, and these reactions may be connected with draughts or changes of temperature in the sleeping quarters toward morning. One should carefully investigate symp toms of an apparently migrainous charac ter, bearing in mind that headache may have a migrainous basis without manifest ing all the typical elements of the migraine syndrome. Instead of presenting the pre liminary scotoma scintillans, followed by headache, dizziness, nausea, and vomit ing, a migrainous patient may experience only a scotoma, or may have the scotoma followed by headache, or headache with out scotoma or nausea, or headache and nausea without other symptoms. Migraine commonly represents an in herited nervous tendency for which there is no complete and final cure. Yet in some patients it may either be cured, or at least greatly lessened in frequency and severity, by removal of an important ex citing cause. Some very definite cases of migraine are actually cured by an ac curate refractive correction, while in others the refractive correction gives the patient some, although incomplete, relief from the attacks. When dealing with a history of mi graine, the ophthalmologist may often render valuable service as a psychoana lyst. The migrainous patient is usually a person with keen sense of responsibility, whose busy days are crowded with many tasks, each of which is a "trouble met halfway." The patient needs to learn that
to undertake these successive tasks and responsibilities with the greatest pos sible efficiency and the least possible waste of nervous energy he should devote him self to the thing in hand without worried consciousness of what has already been done or of the mountain of jobs that re main to be accomplished. It is also useful to suggest a general attitude of muscular relaxation of those parts of the body not concerned in the activity of the moment. The patient may need to be advised of the destructive effect of that form of men tal perturbation which arises from irri tation against the task, against other per sons, or against the patient himself on ac count of dissatisfaction as to the degree of his own efficiency in action or in per sonal relationships. In other words he must cultivate concentration without ten sion. The lesson will of course be more effective if the physician himself displays the attitude which he seeks to inculcate in his patient. Even the ophthalmologist, puzzled by neuro-ocular symptomatology for which he has found apparently inadequate ex planation, may profit at times by realiz ing the expediency of inquiring delicately into the existence of secret problems which more than physical causes plague the life of his patient. While in many of our nervous patients the necessity for working without tension, and without emotional frictions, is of great significance, we ought never to over look the fundamental importance of rest. Many ocular irritations are decidedly in creased by lack of sufficient sleep. The senile or presinile patient who believes himself capable of working just as hard and just as continuously as he did many years ago will last longer and accomplish more if he learns to go more slowly and to rest from his labors more frequently than was perhaps necessary in his earlier days. Balanced judgment as to the meaning
BOOK NOTICE of the pain symptom is of particular im portance in dealing with malingering. In a case of injury where insurance or in dustrial compensation is involved, a com plaint of pain exaggerated beyond the evidence of actual damage to the organ of vision is always suggestive of intent to deceive. The workman who shows no inflammation or destruction in the an terior segment of the eye, yet persistently complains of pain and distress on expo sure to light, and insists on squeezing the eyelids together during examination, is wholly or partly malingering. As opposed to the general fact that pain is a warning, we are faced by a group of conditions in which pain is entirely ab sent, at least in the earlier stages of the disease. This is true of some malignant tumors, whether superficial or deep. The pain produced by deep-set conditions is commonly reflex in character, the deeper tissues being relatively poor in direct sen sibility. Pain gives us no direct warning at all with regard to changes in the optic nerve, retina, or choroid. The most tragic example of this absence of warning is simple glaucoma, in which the patient may go along for years without pain and perhaps regarding his gradual loss of sight as something proper to his declining years and in which no treatment is indi cated or would avail. In some surgical cases our estimate of the importance of pain or its absence will depend partly upon our previous experi ence of the individual, partly upon other ocular symptoms. To the patient who has an exaggerated sensibility we must often make light of his pain. But some patients must be coaxed to acknowledge pain, and we must occasionally be on our guard against trusting the phlegmatic patient
779
who confesses no pain, for the lack of this symptom may serve to mislead us. W. H. Crisp.
BOOK NOTICE YOUR EYES. By Sidney Fox, Sc.M. (Ophth.), M.D. Clothbound, 191 pages exclusive of index; illustrated. New York, Alfred A. Knopf, 1944. Price $2.75. This book is the best of recent publica tions about the eye for laymen. It has the double virtue of being informative and interesting. The material is well ar ranged and handled with a light touch. Starting with some physiology, the author progresses through Causes for poor vision, Presbyopia, and History of eye glasses. The subject of Color vision is treated in an entertaining manner. This leads naturally to comments on Color lenses. The Eye muscles come in for a brief chapter, the Eye in traffic occupy ing somewhat more space. An attempt is made to take the head ache out of the ophthalmologist-optome trist relationship. To one who has had to explain the differences between ocu list, optician, and optometrist daily for 30 years there seems little hope that the public, no matter how well approached, will ever make the discrimination. Quackery is discussed in a short chap ter. A consideration of the eye of youth and of old age finishes a book that may suitably be recommended for lay con sumption. There is not much material that will be new to the ophthalmologist, al though he will have an enjoyable hour in glancing through it. Lawrence T. Post.