(This note on the observed effects of pain has been kindly supplied by R. Havard, MD, from clinical experience.)

Pain is a common and definite event which can easily be recognised: but the observation of character or behaviour is less easy, less complete, and less exact, especially in the transient, if intimate, relation of doctor and patient. In spite of this difficulty certain impressions gradually take form in the course of medical practice which are confirmed as experience grows. A short attack of severe physical pain is overwhelming while it lasts. The sufferer is not usually loud in his complaints. He will beg for relief but does not waste his breath on elaborating his troubles. It is unusual for him to lose self-control and to become wild and irrational. It is rare for the severest physical pain to become in this sense unbearable. When short, severe, physical pain passes it leaves no obvious alteration in behaviour. Long-continued pain has more noticeable effects. It is often accepted with little or no complaint and great strength and resignation are developed. Pride is humbled or, at times, results in a determination to conceal suffering. Women with rheumatoid arthritis show a cheerfulness which is so characteristic that it can be compared to the spes phthisica of the consumptive: and is perhaps due more to a slight intoxication of the patient by the infection than to an increased strength of character. Some victims of chronic pain deteriorate. They become querulous and exploit their privileged position as invalids to practise domestic tyranny. But the wonder is that the failures are so few and the heroes so many; there is a challenge in physical pain which most can recognise and answer. On the other hand, a long illness, even without pain, exhausts the mind as well as the body. The invalid gives up the struggle and drifts helplessly and plaintively into a self-pitying despair. Even so, some, in a similar physical state, will preserve their serenity and selflessness to the end. To see it is a rare but moving experience.

Mental pain is less dramatic than physical pain, but it is more common and also more hard to bear. The frequent attempt to conceal mental pain increases the burden: it is easier to say 'My tooth is aching' than to say 'My heart is broken'. Yet if the cause is accepted and faced, the conflict will strengthen and purify the character and in time the pain will usually pass. Sometimes, however, it persists and the effect is devastating; if the cause is not faced or not recognised, it produces the dreary state of the chronic neurotic. But some by heroism overcome even chronic mental pain. They often produce brilliant work and strengthen, harden, and sharpen their characters till they become like tempered steel.

In actual insanity the picture is darker. In the whole realm of medicine there is nothing so terrible to contemplate as a man with chronic melancholia. But most of the insane are not unhappy or, indeed, conscious of their condition. In either case, if they recover, they are surprisingly little changed. Often they remember nothing of their illness.

Pain provides an opportunity for heroism; the opportunity is seized with surprising frequency.

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