204 



Dr. H. Head. 



occurs, depends more on the temperamental condition of the patient than on 

 the intensity of the painful irritation. 



A sudden rise of temperature is also a frequent cause of " generalisation " of 

 pain. Follicular tonsillitis or any parenchymatous affection of the tonsils may 

 be directly associated with superficial tenderness on the same side, extending 

 from the lower part of the mastoid almost to the middle line in front : the 

 so-called " hyoid " area. Suppose, however, that the onset is sudden and is 

 associated with fever, we may now discover pain and tenderness on both 

 sides of the neck, over the forehead, occipital region, and even in the back or 

 other parts of the body and limbs. 



Anaemia is another fruitful cause of " generalisation." A patient may be 

 profoundly anaemic, and yet suffer from no pain or tenderness. But, as soon 

 as some source for pain is present, it at once begins to spread. Toothache in 

 an anaemic patient is a diffuse affection, extending far beyond the segmental 

 areas connected in any way with the irritated organ. If the local cause is 

 removed, the pain does not cease, at any rate immediately : for when central 

 resistance has once broken down, control is recovered with difficulty. 



In all such cases, the pain originated in some definite and recognisable 

 cause ; it spreads widely because of the severity or long duration of the 

 stimulus, or in consequence of the relaxation of central control, which may 

 accompany menstruation, pyrexia, or anaemia. But sometimes pain and 

 tenderness of this order may become widely diffused in consequence of some 

 debilitating psychical state, such as anxiety or emotional shock. Neuralgia 

 and superficial tenderness of dental origin not uncommonly assume undue 

 proportions owing to insomnia and worry, and the mental state of the patient 

 has a profound influence over pains originating in the pelvic viscera. 



Occasionally the central resistance to potentially disagreeable impulses is 

 temperamentally so low that pain may appear without any obvious cause for 

 peripheral irritation. Some women are rarely free from tender spots in 

 various parts of the body, representing the maxima of one or more of these 

 tender areas ; they form foci from which pain may generalise widely under 

 the influence of emotion or other conditions which lessen the dominant • 

 power of higher centres. No gross visceral stimulus is required ; the central 

 apparatus is already in an explosive condition, and any relaxation of physio- 

 logical control leads to an outburst of energy manifested in widespread 

 discomfort. In such cases the order in which the phenomena appear does not 

 follow the rules that can be laid down for pain of visceral origin. Severe 

 pain over the lower part of the abdomen and back may be accompanied by 

 headache and tenderness situated over the forehead ; the trunk can be widely 

 affected without the head and neck or vice versd. Such want of harmonious 



