A Study of Pain
A well-known psychiatrist, the author of The World Within and Dark Legend, DR. FREDRIC WERTHAM, Director of the Psychiatric Division at Queens GeneraI Hospital in New York, was obliged to undergo a series of painful operations without general anesthetics. In a sense he was his own guinea pig. and the notes he made on pain have proved of professional interest. His article is drawn from the hook When Doctors Are Patients, edited by Max Pinner, M.D., and Benjamin F. Miller. M.D., which Norton will publish in April.
by FREDRIC WERTHAM, M.D.
1
DURING a period of excellent health and activity following a vacation, I developed it thrombophlebitis in the right leg without known cause. Under the treatment of a private physician I followed a course of complete bed-rest for about three weeks. Then what was evidently a small pulmonary embolus was followed within it week by further pulmonary emboli. I developed it high temperature, took sulfa drugs, lost all appetite, became very toxic. When taken to the hospital I was in a critical condition. Within a few hours after reaching the hospital I had an emergency operation, a ligation of the right femoral vein. The same night a course of penicillin was begun. Owing to the fact that the thrombus extended very high and that the blood vessels were deeper than usual and differently placed, the operation, carried out under local anesthesia with scopolamine and morphine, was difficult and lasted longer than usual.
As psychiatric consultant in general hospitals, I have found how essential it is that certain psychopathologic symptoms in physical disease be diagnosed very early. It is sometimes difficult in severe cases or in postoperative cases to distinguish minor transitory mental symptoms from beginning stages of more serious conditions, such as depression or delirium. But from the point of view of prompt and proper therapeutic steps it is very important. I believe my own introspective experiences are significant for the practicing physician.
As far as emotional factors are concerned: before the operation, when one embolus followed the other, during the operation, and immediately after it, I was in danger of death. As a physician I should have known that, merely from objective medical symptoms, which I understood intellectually. It should have been even clearer to me when the director of the surgical service came from some distance to perform the operation as an emergency on a Sunday afternoon; and when the head of a medical service also came. Moreover, I remember the serious faces of some of my medical friends who were there, at the time. But I interpreted their concern as sympathy with my pain, and at no time before, during, or within a few days after the first operation did the idea enter my consciousness that I was critically ill or in danger of dying.
My experiences confirm the generally known psychologic law that one is apt to forget unpleasant experiences and remember pleasant ones. Two factors have become clear to me with regard to this amnesia. In the first place, pleasant or indifferent experiences are also forgotten in circumstances of severe physical disease. Secondly, there are two types of amnesia: forgotten experiences that cannot be recalled even when one’s memory is refreshed, and others that are recalled easily. I have been told of some more or less indifferent things that I said which I have completely forgotten. I have been told of others which I seemed to have forgotten but which I immediately recalled.
For long periods of time during the firs! operation I was in a state of sleep, or at any rate without full consciousness. At other times I was fully awake and clear. Then my main concern was with pain. During the operation it filled my whole mind. There was literally no room for anything else. It is difficult to verbalize these pain experiences. For considerable periods when I was clear there would be no pain at all. Then suddenly it would come. On account of the danger of further emboli, spinal anesthesia was not used. As I understand it, the deeper structures are less accessible to local anesthetics, and certain types of pain, like that of actual ligation, are not susceptible to complete a nest hesia at all.
It is hard to describe one’s emotional reaction to pain. It is partly a fear of more pain to come, of its continuing or getting worst’; partly a hope that pain will cease or lessen.
During the operation I was emotionally reduced to a most primitive level of hope fear. My attention was focused on concern with my body. Freud made a well-known statement about the distribution of “libidinal interest ” in physical illness: “A person suffering organic pain and discomfort relinquishes his interest in the things of the outside world, insofar as they do not concern his suffering, Closer observation teaches us that at the same time he withdraws libidinal interest from his love-objects: so long as he suffers, he ceases to love. . . . The sick man withdraws his libido back upon his own ego, and sends it forth again when he recovers.
It is true, according to my recollection, that my libido certainly was withdrawn to my body and my interest in the outside world was decidedly restricted to what had direct bearing on my immediate situation. But in themidst of the operation, during a period when I was either anticipating pain or enduring it, I asked one of the physicians standing near me to find my wife downstairs and tell her everything was going fine. This preoceupation must have been very strong because sometime after this physician had carried out my request and told me that he had, I asked him the same thing again. This would indicate, in the light of my experience, that Freud’s formulation is an oversimplification of very complicated processes of emotional thinking. One functions on several levels at the same time.
During the periods when I was conscious and there was no pain, my intellectual capacities were greatly reduced. Some medical friends were standing near me during the operation I was separated by a screen from the operating surgeon). On a number of occasions they talked to me in an effort to cheer and encourage me. Most of what they said was over my head. I simply did not understand what they meant, though I heard their voices very clearly and was aware of their words, the finer modulations of their voices, and their friendly intent.
The contrast between my keen awareness of the modulation of voices and my lack of intellectual understanding of what the voices said astonishes me now. At that lime, however, the fact that I did not understand most ol what was said to me caused me neither surprise nor anxiety. I took it for granted that I could not understand and asked no questions. It was as if I were a child or an infant among grownups.
2
I REMEMBER only two factors which alleviated my general feeling of insecurity while on the operating table. One was the voice of the operating surgeon and one was the reassurance derived from definite physical contact.
The surgeon’s voice was deep, calm, and authoritative. It was not raised at any time. One episode was characteristic, of my mental state. I developed a very disagreeable pain in the right calf during the operative procedure. Somehow it seemed to me that this was due to my leg’s “falling asleep, as if it were in an awkward, hanging position from the knee down. (Not true, of course.) I remember that several times I moved the leg, seeking to ease its position — not exactly appropriate behavior in the situation. I recall very distinctly the surgeon’s voire saying quietly bill definitely : “Don’t move your leg, Dr. Wertham.” My emotional response to this remark is difficult to describe. From that moment on, it was unthinkable that I should move my leg, however it felt. The remark had such an authoritative effect on me that — pain or no pain, impulse or no impulse the idea of moving my leg did not come up again. I would venture the speculation that the building-up of the ideal ego in the very young child or infant comes about by a mechanism comparable to this response.
The second fad or alleviating my insecurity was even more unexpected. Words spoken by medical friends present at the operation — even words I understood — had relatively little helping effect, But physical contact did have. One woman physician who assisted at the operation had to lean over me in such a way that she touched my arm. I remember her asking me at one time whether I minded that she had to lean over my arm and my reaction of astonishment at the question. I tried to figure out how to tell her what a great help it was to me. But in my overanxiousness to make it clear to her, I could find no words at all. Much later she asked a second time and then I asked her to stay as she was. (She was actually performing a difficult, prolonged task of retraction.)
Another woman doctor present at the operation touched my forehead once and said something, and I remember her touching me as a soothing event. Evidently friendly physical contact of this primitive type is not sufficiently recognized as a helpful procedure. I have since spoken to physicians who have undergone operations or performed them and they have confirmed my experience.
My general mental condition during the operation and during the next two days and nights was much the same, with very little interest in the outside world. What preoccupied me most was what I would call pressures within the body. I had the typical postoperative difficulty in urination, a great difficulty of peristalsis, with gas formation, and some difficulty in breathing. All these pressures, as far as sensation goes, seemed to combine into one.
At no time during this period was I delirious. But one evening I thought I was confused. When the nurse who had looked after me following the operation came on duty the next day, there seemed to me something strange about her. I was not sure whether she was the same person or not. She looked different, and I remember thinking that maybe I was mixing people up. I asked her. She laughed and said, “I just had a permanent wave.” And so I was reassured.
3
THROMBOPHLEBITIS became manifest in my left leg, and femoral ligation was carried out in that leg, too. I was given scopolamine and morphine. The second operation also presented some complications and lasted longer than usual. My mental state during this operation was so abnormal that it deserves description. While my feeling was one of insecurity, apprehension, and til times great pain, I appeared to be in excellent spirits.
I remember the very beginning of the operation and my general apprehension. But some time later I said to the operating surgeon: “I feel very frivolous, Dr. D. This was a most abnormal statement to make. In the first, place, I had and have the greatest respect for this surgeon and would not address him like that—certainly not during an operation. In the second place, I would say that “frivolous” was about the last word that would describe my mental state at that time.
From then on throughout the operation 1 laughed, told all sorts of funny stories, and made puns. For example, I said, “I am against all isms, especially embolism,” and when during the operation I heard the pathologist ask for a specimen of my vein for biopsy, I asked the surgeon not to give out any “free samples.” A considerable number of my medical friends were present in the operating room. They laughed at my jokes and told funny stories of their own. It all sounded very gay. On many occasions during this operation I suffered terrible pain. I tried not to show it, but could not help contorting my face and exclaiming “Ouch!’ on a number of occasions. Anybody who did not see my face would think I was having a good time.
Toward the operation’s end I suffered particularly severe pain during the ligation of the larger vessels. As I recall it, I was really in agony. At the worst moment, the internist who had been most appreciative of my actual pain, and helpful about it, saw my contorted face and said, “Anybody can tell stories like you did. Now is the time to tell us a really good one, from your life as a psychiatrist.”
If I were asked according to my best psychiatric judgment and according to my best knowledge of myself whether I would have been able to tell a funny story at that time or whether I could have even forced myself to smile at anything then, I would have denied it without hesitation. Yet fully preoccupied as I was with pain, I immediately told a story with great gusto and with all embellishments. This was the story: As a young doctor at Johns Hopkins, I spent a vacation with a psychotic millionaire and his male nurse at a lodge in New Mexico. We had all our meals together in the general dining room. I noticed that when the waitress served us her hands trembled noticeably. After a few days of this, I asked her whether something was wrong. She said, “Well, it’s like this. I know one of you is crazy, but I don’t know which one it is.”
There is evidence here of clear dissociation between actual mood and behavior. In general, my insight into my general condition was very poor. I did not think of my behavior as being caused by a drug, although intellectually I might have guessed that. Yet I evidently had lucid moments with psychological insight. For instance, at one moment I said to the surgeon, as if to excuse my “frivolity": “What I am really doing is whistling in the dark.”
The mental condition during the operation was a form of scopolamine psychosis. It was characterized by a sense of buoyancy, overtalkativeness, general lack of inhibition, misjudgment of the situation, side by side with more or less clear consciousness of apprehension and pain. There were no hallucinations or delirium.
Aclually, the cuphorization of my behavior was a great help. What did it accomplish? it seems to me that it counteracted the anxiety which was undoubtedly present. While telling jokes or listening to them, I was distracted from anxiousness and the strain of experiencing pain. Such a contrast, between euphoria, and anxiety occurs in experimentally induced mescaline psychosis, as shown by the retrospective accounts of subjects.
With regard to the subject of pain and analgesics, some of my observations are significant. I believe that in studies of pain the threshold of pain is too much emphasized. Actually, the quality of pain is very important. I could, after this operation, have enumerated six or eight different kinds of pain, each sharply distinguishable from the others in quality. To express them in words would be impossible. Had I given each of these pains as they occurred a number, I believe an observer would have found that I could identify by its number the special type of procedure by its accompanying kind of pain.
Some of the qualities of pain are: —
1. Localization. Some of the pains I could not have localized at all, some I think I could have indicated exactly.
2. Duration.
3. “ Afterimage effect.” I use this for want of a better term, because some kinds of pain continued even after I knew they were over. This is comparable to the phenomenon of afterimages and eidetic images in visual perception. Such phenomena are easier to investigate in the sphere of vision, but exist also in other forms of sensation. It is possible that this type of pain refers to a more primitive, undifferentiated kind of sensation. Just as in the physiology of the special senses we know that there are phenomena between vision and visualization, so there is an analogous phenomenon in the sphere of pain perception. I call this “eidetic pain” and believe it is of considerable significance in psychosomatic medicine.
4. Special qualities of pain, as when a nerve is touched.
5. Association with fear. Some types of pain seem to be more associated with fear than others.
If psychological factors play a great role in physical disease, as I believe they do, it may well be indicated to stimulate the productive activity of patients in the early stages of their physical disease. I believe that my interest in dictating my observations at the time (they were much more detailed than this paper would indicate, and this paper itself was written during my hospital stay) helped me to rally the recuperative forces of my organism. As Heine said: —
Which gave impulse to my creation.
Creating. I got better.
Creating, I got well.
There are definite and diversified psychiatric aspects of physical disease. Physicians are apt to neglect such experiences, but they are a grim reality. The psychopathological aspects of physical disease demand and deserve attention. They may make the difference between life and death.
Medical and surgical patients need psychological advice about how they should act, what their experiences mean; they need psychological preparation for what to expect; they need guidance so that they can make the best of the possibilities.
4
IT IS now five and a half years since my illness. During all this time I have never had any desire, speaking of operations, to tell anybody the story of mine. But I have in my psychiatric consultations in general hospitals made use of my experiences. I have become more and more aware how much can be done by psychotherapy for patients who have physical diseases. For one thing, the psychiatrist can help to prevent anti-psychotherapeutic actions in a hospital. It isn’t so easy to know what a doctor should or should not say to a very sick patient, especially in the operating room. But it is a safe rule to assume that the patients are apt to take anything wrong. For instance, a postoperative patient recalls: “One doctor said to me, ‘You don’t have a thing to worry about.’ I thought that was silly. I wouldn’t have been there if I wasn’t worried about it, if you get what I mean.” remarks made
Discouraging remarks were made to me by friendly doctors visiting me during my illness.
None of these comments upset me. I evidently was not alert enough to take them in and was reminded of them only when, later, I was dictating my notes. One medical, remark, however, did sink in and stayed with me for a long time. A physician explained to me that phlebitis in the legs is not so bad; but it can happen that the arms also are affected. As a result of this remark, I began to have — or thought I began to have — peculiar feelings in one arm and then the other. I remember that I was very anxiously concerned about this, watched whether the feelings got worse, and thought at times that they did. Actually the position in which one lies in bod for a long time has something to do with it. Here evidently a chance remark inducted a hypochondriacal trend of thought which I would not have had spontaneously.
In psychiatric cases in general hospitals since then I have often noticed that patients were more concerned with something they feared or fancied than with their real illness.
It is probably not easy to prove that a good mental state aids recovery while a bad mental state impedes it. I am sure that especially in old people both chronicity and fatal outcome may be conditioned by an adverse emotional attitude caused by the family or the hospital or both.
The concept of “eidetic pain" — that is, the assumption of a more primitive type of pain not clearly circumscribed or localizable either in space or time —has proved useful to me. It is never superficial, never brief, and is apparently related not only to the deeper structures of the body but also to deeper psychological layers. It may be one of the avenues for understanding certain forms of so-called imaginary pain.
Speaking to many patients with physical illnesses, and comparing their reactions with mine, I have reached the conclusion that organic and neurotic symptoms may be subjectively experienced in the same way. Some men cannot urinate in a public place. Their experience is very much like the organic difficulty following operations. Such a physical difficulty may become easily neurolicized. Appropriate and simple psychological methods which many good nurses know instinctively can make an enormous difference in the course of a physical disease.
Strange though it may seem, we physicians are apt not to acknowledge the tragedy of pain. Even though I no longer remember clearly my pain experiences, I still have with me the realization that it is easier to be philosophical about death than about pain. As scientific physicians we want to find causes, trace processes, cure, and prevent. But every patient who comes to us has at the back of his mind a simple and what you may call primitive or infantile wish: he wants the doctor to alleviate his pain and banish his fear. That is where medicine and psychiatry meet.