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Chronic Pain
Management in General
and Hospital Practice

Koki Shimoji
Antoun Nader
Wolfgang Hamann
Editors

123
Chronic Pain Management in General
and Hospital Practice
Koki Shimoji • Antoun Nader
Wolfgang Hamann
Editors

Chronic Pain Management

in General and Hospital
Practice
Editors
Koki Shimoji Antoun Nader
Pain Control Institute Feinberg School of Medicine
Shinjyuku Northwestern University Feinberg
Tokyo School of Medicine
Japan Chicago
IL
Wolfgang Hamann USA
Guy’s and St Thomas’ Hospital,
Pain Management Centre
London
UK

ISBN 978-981-15-2932-0    ISBN 978-981-15-2933-7 (eBook)

https://doi.org/10.1007/978-981-15-2933-7

© Springer Nature Singapore Pte Ltd. 2021

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
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Contents

Part I Basic Considerations

1 History of Pain������������������������������������������������������������������������������������������    3
W. Hamann
2 Theories of Pain����������������������������������������������������������������������������������������   11
Koki Shimoji and Yoshiyuki Yokota
3 Anatomical Physiology of Pain ��������������������������������������������������������������   21
Koki Shimoji and Satoshi Kurokawa
4 Pathophysiology of Pain��������������������������������������������������������������������������   43
W. Hamann
5 Pharmacology of Analgesics��������������������������������������������������������������������   55
Koki Shimoji and Hitoshi Fujioka
6 Investigation of the Chronic Pain Patient����������������������������������������������   87
Nicholas Padfield
7 Interventional Treatment of Chronic Pain�������������������������������������������� 113
Thomas E. Smith
8 Nerve Blocks �������������������������������������������������������������������������������������������� 129
Ryan Zaglama and Antoun Nader
9 Other Methods: Minimally Invasive
Techniques in Pain Clinic������������������������������������������������������������������������ 141
Koki Shimoji and Tatsuhiko Kano
10 Pain Measurements���������������������������������������������������������������������������������� 173
Koki Shimoji and Sumihisa Aida

v
vi Contents

Part II Pain Management Techniques

11 Back Pain�������������������������������������������������������������������������������������������������� 203
Pierluigi di Vadi
12 Postherpetic Neuralgia���������������������������������������������������������������������������� 219
Christine El-Yahchouchi and Antoun Nader
13 Neuropathic Pain: Complex Regional Pain
Syndrome (CRPS)������������������������������������������������������������������������������������ 225
Mansoor M. Aman, Ammar Mahmoud,
and Taruna Waghray-Penmetcha
14 Neuropathic Pain Syndrome: Diabetic
and Other Neuropathies�������������������������������������������������������������������������� 249
Atsushi Sawada and Michiaki Yamakage
15 Phantom Limb Pain�������������������������������������������������������������������������������� 261
Luminita M. Tureanu and Ljuba Stojiljkovic
16 Neuropathic Pain Syndromes. 5: Other
Neurological Conditions�������������������������������������������������������������������������� 279
Soshi Iwasaki and Michiaki Yamakage
17 Psychological and Psychiatric Pain Conditions������������������������������������ 291
Yukari Shindo and Michiaki Yamakage
18 Headache�������������������������������������������������������������������������������������������������� 303
Oluseyi Fadayomi and Antoun Nader
19 Trigeminal Neuralgia������������������������������������������������������������������������������ 323
Kim Nguyen
20 Orofacial Pain������������������������������������������������������������������������������������������ 341
Maxim S. Eckmann and Antoun Nader
21 Myofascial Pain Syndrome and Fibromyalgia�������������������������������������� 355
Maria M. Cristancho, Gunar B. Subieta, and Maria L. Torres
22 Urogenital Pain Including Pelvic Pain �������������������������������������������������� 373
Maged Mina, Jonathan Benfield, Sylvia Botros-Brey,
and Cyril Mina
23 Chest Pain ������������������������������������������������������������������������������������������������ 389
Ju Mizuno and Kazuo Hanaoka
24 Upper Abdominal Pain���������������������������������������������������������������������������� 425
Ju Mizuno and Kazuo Hanaoka
25 Central Pain���������������������������������������������������������������������������������������������� 443
Marc Korn, Mary Leemputte, and Dost Khan
Contents vii

26 Management of Cancer Pain in Primary, Secondary,

and Palliative Care���������������������������������������������������������������������������������� 455
Emma Whitehouse and Nick Dando
27 Arthritis Pain; Rheumatoid Arthritis, Osteoarthritis,
and Fibromyalgia ������������������������������������������������������������������������������������ 483
Afsha Khan, João Calinas Correia, and David Andrew Walsh
28 Vascular Pain�������������������������������������������������������������������������������������������� 517
Kellie Gates and Pegah Safaeian

Index������������������������������������������������������������������������������������������������������������������ 535
 Part I
Basic Considerations
Chapter 1
History of Pain

W. Hamann

This summary of the history of pain focusses on its relevance to pain management.
It is self-restricting, aiming to tease out the development of the subject pain towards
the present situation of the history of medicine.
At the beginning, it is worthwhile to summarize our current understanding of the
pain pathway, and then go through history bearing in mind what research tools were
actually available to clinicians and researchers at particular points in times, and
what relevant religious faiths and philosophies influenced the thinking about the
nature of pain. One also needs to be aware that pathology can occur at any level of
the pain pathway from peripheral receptors right up to relevant connections in the
brain. Central pain, e.g., which may be excruciatingly debilitating, occurs without
any peripheral origin but may be projected to peripheral parts of the body.
Rey [1] emphasizes the importance of discriminating between perception of pain
and the ensuing suffering. Both aspects are of course therapeutic targets for the pain
physician. Without alleviation of suffering there can be no effective pain manage-
ment. It is therefore now generally accepted that pain management has to be holistic.
Historically, pain medicine concentrated on acute pain conditions. This may par-
tially be due to the much shorter life expectancy in historic times. Many people did
not live long enough to experience the full effects of degenerative diseases. Among
the Graeco-Roman minor deities there are many gods specifically concerned with
acute pain conditions and hardly any focussed on chronic pain. Similarly, among the
catholic saints, there are only Milian, Saint Marcus and James the Great, whose
remit is rheumatism. There are many more saints one can appeal to for help with
acute pain.
Every civilization does have its own medicine experts with specific views on the
significance of pain and how to deal with it. Commonly, sophisticated systems of

W. Hamann (*)
Guy’s and St Thomas’ Hospital, Pain Management Centre, London, UK
e-mail: wolfgang.hamann@doctors.org.uk

© Springer Nature Singapore Pte Ltd. 2021 3

K. Shimoji et al. (eds.), Chronic Pain Management in General and Hospital
Practice, https://doi.org/10.1007/978-981-15-2933-7_1
4 W. Hamann

herbal medicine were part of the treatments employed, and frequently, the same
plants were used for similar indications.
This summary focusses on a few major instalments in the history of medicine
preceding and during the recent scientific approach to pain and its management
of pain.
The earliest written records mentioning opium date back 3000 years, on Sumerian
clay tablets [2]. It is not clear whether this document refers to the use of the drug for
pain control or as a narcotic. Thompson [2] also reported on Assyrian clay tablets
recommending the use of ointments containing mandrake together with the use of
charms for the control of toothache.
In parallel, medicine developed separately in Egypt, China, the Indian subconti-
nent in the form of Ayurvedic medicine and later further west in the Greco-Roman-­
Arabic sphere. Many aspects of pain management originating from these cultures
have survived either in mainstream practice or in the form of alternative medicine.
Egyptian pain treatment was often combined with a Charm [3]. The Ebers
Papyrus [3] reports use of the yeast of the opium drink, the willow tree, poppy plant,
berries and seeds accompanied by chanting of a charm for pain control.
In Indian (Ayurveda) and Chinese (Tao) medicines an individual’s good health
was dependent on complying with conditions maintaining well-balanced relation-
ship and heaven and earth.
The authoritative historical reference to Chinese medicine is the Yellow emper-
ors Huang Ti’s Classic of Internal Medicine (Nei Ching) dated 2697 B.C. which
catalogues the knowledge current at his time. However, over the years the original
information will have been added to. Analysis of style of the text available now
indicates that the present text was written approximately at 1000 B.C.
The Nei Ching is a Chinese philosophical compendium on preventative medi-
cine. It is not a medical textbook in the modern sense. It quotes the old sages [4] as
saying that “they will not treat those who were already ill; they instructed those who
were not ill”.
Tao, which means “the way”, expresses itself in the human body through the
opposing concepts of Yin and Yang, which need to be kept in balance for good
health and longevity. Diagnosis and treatment is based on a structured system
around the five viscera, five elements as well as the seasons. Severe pain ensues
when the spirit is hurt [4].
Acupuncture was introduced as a technique that can control the flow of vital
forces including Yin and Yang.
It is surprising that surgical techniques do not figure highly in the Nei Ching. For
this, Veith [4] gives two reasons. Firstly, the very high esteem for Chinese internal
medicine hindered the development of surgery. Secondly, because of the Confucian
tenet of the sacredness of the human body surgery appeared an inappropriate form
of treatment.
However, two surgeons Pien Ch’iao and Hua T’o achieved prominence around
190 A.D. [4]. Apart from excellent surgical skills their success was based on the
introduction of effective anaesthesia. All Hua T’o’s records were unfortunately
burned, and no record exists today of either his or Pien’s methods of pain control.
1 History of Pain 5

Four Sanskrit Vedas (Rigveda, Samaveda, Yajurveda and Atharvaveda) date

back to between 4500 and 1600 B.C. [5]. They form the basis of the Indian Ayurveda
medical practice.
The Egyptian compendium of medicine, the Ebers Papyrus [6] was written about
1500 B.C. and refers back to data collected as early as 3500 B.C.
Historic approaches to medicine and by implication pain management were
often holistic in one way or another. They went beyond solely targeting the assumed
somatic mechanism. Treatment of the assumed pathology was complemented by a
psychological or spiritual component. Plato [7] succinctly expressed this as follows
“For this is the greatest error of our day; in the treatment of the human body the
physicians first separate the soul from the body”.
During Antiquity important strives were made in the development of medicine.
The Hippocratic collection [1], mostly written between 430 and 380 B.C. is a col-
lection of medical knowledge and thought available at that time. It drew both on
practices at the Cosian as well as Cnidian school. Although it subscribed to the
concept of humorism (black bile, yellow bile, phlegm and blood), it introduced the
concept of rationalization in medicine. Hippocrates furthermore postulated the sep-
aration of medical doctrine from philosophy. At his time, medical doctrines were
most or part based on philosophy about nature’s origin and composition. Pain itself
had no utility, but nevertheless needed to be controlled.
In the text of Epidermis V it is recommended to match like with like. One pain
may calm another simultaneous one, anticipating the diffuse non-specific inhibitory
control (DNIC) described by Le Bar in 1979 [8].
For gynaecological pains, the use of mandrake, a nightshade and poppy is
recommended.
Alexandria with its large library was a centre for medical research in the third
century B.C. Eristrasus [1] described motor and sensory nerves using vivisection on
criminals, which was later forbidden by the authorities.
Roman medicine was built on the foundation of Greek knowledge and experi-
ence. In his book De Re Medicinae written about 30 A.D., Celsus [9] who was prob-
ably not a doctor himself, stated that pain was mainly useful for prognostic purposes,
and that seasonal aspects, different periods in life, individual temperament and gen-
der were important factors affecting the presentation of pain. Pain itself had no
conceivable positive value. In terms of medical methodology, he discriminated
between diagnosticians who tried to understand the pathophysiology of a condition,
empiricists who relied on their clinical experience and methodists who were relying
on common traits evident between specific disorders.
The most prominent physician during Roman times living in the second century
was Galen [vide ref 1] a real celebrity physician. The emperors Marcus Aurelius,
Commodus and Septimius Severus were among his patients. He published some
500 titles. For him, pain was important as a symptom to be treated, but also helpful
for the understanding of the pathophysiology and prognosis of a condition.
Dissection was for him an important tool for the understanding of underlying mech-
anisms of a disease. Pain was regarded as excessive mechanical stimulation in anal-
ogy to excessive brightness harming vision and sound that is too loud damaging
6 W. Hamann

hearing. Galen’s pathophysiological model about good health depending on balance

between black bile, yellow bile, phlegm and blood was finally abandoned only dur-
ing the nineteenth century.
Galen’s writings, the Hippocratic corpus and De Materia Medica by Dioscorides
[10] have remained required reading for doctors until the mid-nineteenth century.
The Materia Medica is a compendium of 800 plants described to very high botanical
standards. Side effects and efficacy are described in detailed terms. The book men-
tions opium poppy, field poppy, lettuce, belladonna, hyoscine and black nightshade
for pain control.
As part of these developments, herbal medicine advanced on an empirical basis
with the detailed Materia Medica by Dioscorides surviving [10]. Willow bark as an
analgesic reminds us that the first known non-steroidal anti-inflammatory has been
in use for a very long time.
During medieval times in Europe, the understanding of medical matters was
strongly interwoven with religious thought.
The concept of pain as punishment by God for the original sin or other sins often
entailed that pain had to be endured. Consequently, there was little advance in pain
management during this time. The power of a strong faith in controlling the sensa-
tion of pain is well documented by the absence of signs of suffering in artwork of
the time depicting torture of saints.
Many of the Greek manuscripts only survived in Arabic translation.
With the advent of the age of Enlightenment in Europe, modern scientific method
established itself gradually, and has since remained the driving force for development.
Based on anatomical knowledge, Descartes [11] proposed a dualistic system for
the perception of pain that separated the sensing of pain from its emotive compo-
nent. This deviated from the holistic approach towards pain management that had
prevailed hitherto. The impact of his model of pain perception on the one hand had
a stimulating effect on further scientific research. On the other hand, it engendered
a somewhat mechanistic approach towards perception and control of pain, which
has only been overcome recently with the introduction of cognitive behavioural
treatment into pain management and more recently with the emphasis on mindful-
ness. It is significant that early modern pain centres often called themselves pain
relief clinics. Unfortunately, pain relief is not always attainable in chronic pain con-
ditions. Most pain clinics have since redefined themselves as pain management
establishments.
In conclusion, over the centuries and millennia pain management has been
shaped by the prevailing understanding of the underlying mechanisms as well as by
culture and religion.
During the middle ages, between 500 and 1500 A.D., the concepts about the
meaning and control of pain understanding of pain diverged between Europe on one
side and Arabia and Persia on the other. The latter two areas became centres of high
learning, building on the knowledge of Greek and Roman experts and translations
of their writings.
In Europe, the largely scholastic approach towards medicine precluded any fur-
ther development in the understanding of the physiology of pain. In addition,
1 History of Pain 7

r­eligion had a profound effect on the appreciation and contemporary meaning of

pain. Either as a divine punishment by God or as redemption by suffering in a way
Christ did were probably important ways to accept pain as deserving. Pain was
sanctified, because it brought sufferers closer to the pain experienced by Christ [1].
For non-­believers this type of reasoning is difficult to agree with. Indirectly, the
religious understanding of pain amplified the inhibition of development inherent in
the scholastic approach.
Renaissance and the age of enlightenment brought a change towards a more
­scientific approach towards medicine and biology.
In 1586 Fernel [vide Rey 1] applied Galen’s concept of overstimulation to the
understanding of pain. He introduced tissue damage as the common denominator
for the sensation of pain. However, perception of pain was only caused by the sub-
sequent appreciation of the injury.
During the middle of the seventeenth century, Descartes developed the dualistic
system of sensory perception [12]. He accepted phantom limb pain in an arm ampu-
tee as a real phenomenon and not as an aberration of the mind. His model of nervous
conduction was that of a mechanical pulley, which could be tugged at any position
on its course to the brain. Interpretation of the message took place in the soul, which
was supposed to reside in the pineal gland.
During the eighteenth and nineteenth century, although not universally accepted,
views were held that the sentience for pain was a function of the perceived level of
civilization as well as cultural and intellectual development of an individual. It was
this type of thinking that led to the appalling conditions associated with ­slavery [13].
During the nineteenth century, there were major advances in anaesthesia and
analgesia. In parallel, hypotheses and theories and factual observations about the
organization of the pain pathway became increasingly detailed. Perl has provided a
comprehensive time line of the development during the nineteenth and twentieth
centuries [14].
Based on the study of cross-sectional spinal lesions in patients, Brown-Sequard
[15] established the contralateral anterolateral tract in man as essential for the
­transmission of nociceptive information.
Anatomically, Edinger [16] identified the spinothalamic tract in 1890.
At the beginning of the nineteenth century Johannes Mueller [17] developed the
concept of specific peripheral receptors for each individual sense, a concept previ-
ously held by Avicenna. Muellers law of “law of specific nerve energies” stated that
there were specific receptors for each of the senses. However, he attributed their
sensitivity to unique Vitalism based qualities of energy in the afferent nerve fibres.
He came to this conclusion, because specific sensory experiences could be elicited
by non-physiological excitation with electrical stimuli or, e.g., excessive pressure
on the eyeball. It was Adrian’s discovery of the action potential as the uniform mode
of nervous conduction which disproved the hypothesis of a unique sense specific to
nervous energy in primary afferent fibres.
On the basis of finely discriminating sensory testing of the skin in combination
with histological investigations, von Frey [18] developed the specificity hypothesis
of the senses. The test of this theory ultimately depended on electrophysiological
8 W. Hamann

primary afferent and postsynaptic single unit recordings. Initially only few nocicep-
tor primary afferents were identified by Zottermann [19] the A delta fibres and by
Iggo [20] among C-fibres.
During the nineteenth and twentieth century, several hypotheses were proposed
discussing the issue whether pain is a specific or non-specific sensation gaining its
unique properties not on the basis of specific receptors in the periphery, but solely
by central nervous processing.
The debate became even more intense after it became possible to record from
single postsynaptic cells in the spinal cord. Initially, only wide dynamic range units
were encountered, receiving excitatory input from a wide range of nociceptive as
well as non-nociceptive primary afferents. It was not clear, how the nervous system
could disentangle such messages. On the basis of the electrophysiological evidence
available in 1965, Melzack and Wall [21] developed the gate theory, postulating that
the gate to the perception of pain was opened by discharge in primary afferent
C-fibres and that it was under control of descending and segmental modulation.
Since then electrophysiological recording techniques have improved. A large
proportion of primary afferent C-fibres does not subserve nociception [22], how-
ever, many do. Postsynaptically, there are neurones solely responsive to noxious
stimuli [23].
In 1897, Sherrington [24] introduced the concept of the synapse into neurophysi-
ology, allowing for modulation of information along the pathway from the periph-
ery to the brain. The concept of integration along sensory pathways from the
periphery to the ultimate termination in the brain was a considerable advancement
on Descartes’ “bell pulley” mechanism eliciting the sensation of pain in the soul. It
was also more specific than the forces of vitalism to which Mueller still subscribed.
In modern medicine, artificial activation of segmental and descending inhibition is
activated by transcutaneous nerve stimulators, acupuncture, spinal cord stimulators
and peripheral nerve stimulators.
Mersky’s 1979 [25] definition of “Pain as an unpleasant sensory and emotional
experience associated with actual or potential tissue damage, or described in terms
of such damage” was adopted by the International Association for the study of pain.
This definition clearly differentiates between the perceived sensory event and its
emotional impact.
Until sometime during the nineteenth century, Western clinicians still discrimi-
nated between personality types on the basis of the Hippocratic philosophy of the
predominant effect of one of the four humours (phlegm, black bile, yellow bile and
blood). According to this classification, there were phlegmatics, cholerics, melan-
cholics and sanguins. Pain was experienced according to one’s type of personality.
Since the nineteenth century, in parallel with sensory neurophysiology, clinical
and behavioural observations have served as influential tools investigating the whole
breadth of pain perception as outlined in Mersky’s definition.
Clinical and behavioural hypotheses and theories were reported in depth by
Bourke [13]. Observations by Leriche [vide 13] during World War 1 and Beecher
[26] during World War 2 described substantial injuries being sustained by soldiers
without any pain being reported.
1 History of Pain 9

Among civilians, pain sentience was said to depend on race, personal character-
istics or traits shared by individuals grouped according to class or occupation [13].
Phrenology was also of some importance. Organs of destructiveness, and an organ
for fighting were supposedly identified, the location of these centres can still be
found in phrenology maps sometimes sold in curiosity shops.
Whilst much of this evidence is anecdotal or of prejudicial nature, it points
towards differences between individuals in central nervous processing of painful
events. In other words, it became clear that there must be modulation on the passage
of messages along the pain pathway.
During the second half of the twentieth century, psychological techniques of pain
management became increasingly Important. In the first wave, operant conditioning
based on the concept of Pavlovian reflexes were tried for a variety of medical condi-
tions. The second wave in the form of cognitive behavioural treatment (CBT) was
introduced to many pain management establishments. Courses were either residen-
tial or on an out- patient basis. They consisted of a combination between explana-
tions of the current medical understanding of patient’s pain conditions, reduction in
medication and fitness training, often resulting in improvement in quality of life that
mattered. More recently, the third phase has become widely accepted in the form of
mindfulness training Kabat-Zinn [27], which is in essence a form of meditation
without the teachings of Buddhism.

References

1. Rey R. History of pain. Paris: Editions La Decouverte; 1993. p. 11. ISBN 2-7071-2256-4, Ibid
pp. 26–32, Ibid pp. 32–35, Ibid pp. 60–66, Ibid p. 72, ref 27.
2. Thompson. Proc. Roy. Soc. Med. Sect. Hist. Med. 1926;19:69–78. Quoted from Sigchrist
HE. Primitive and archaic medicine. Oxford Univ. Press; 1967.
3. Ebers G. The Papyrus Ebers: translated from the German version by Cyril P. Brian. London:
Geoffrey Bles; 1930. p. 24–30.
4. Veith I. The Yellow Emperor’s classic of internal medicine. Berkeley: University of California
Press; 1970. p. 2–3. ISBN 0-520-01296-8, p.53, Ibid p 117, Ibid p 3, Ibid.
5. Mishra LC. Scientific basis for Ayurvedic therapies. Boca Raton: CRC Press; 2004.
0-8493-1366-X. Introduction.
6. The Ebers Papyrus (trans: Ryan CP). Letchworth: The Garden City Press LTD; 1930. Royal
Soc Med.
7. Stempsey WE. Plato and holistic medicine. Med Health Care Philos. 2001;4(2):201–9.
8. Le Bars D, Dickenson AH, Besson JM. Diffuse noxious inhibitory controls (DNIC). I. Effects
on dorsal horn convergent neurones in the rat. Pain. 1979;6:283–304.
9. Celsus De Re Medicinae AD. 30 (quoted from Douglas Guthrie. Edinburgh: Thomas Nelson
and Sons LTD; 1958. p. 72–75). Ibid pp. 74–82.
10. De Materia Medica D. Being an herbal with many other medicinal materials (trans: Osbaldeston
TA). Johannesburg: Ibidis Press; 2000.
11. Descartes R. Dioptrique, Discourse Quatrieme. In: Oevres et lettres. Paris, Gallimard; 1637.
[La Pleiade (1953) p. 203].
12. Descartes R. Principia Philosophica. Amsterdam: Lois Elzevir; 1644.
13. Bourke J. The story of pain. Oxford: Oxford University Press; 2014. p. 195.
ISBN978-0-19-96843-9. Ibid pp. 193–268, Ibid p. 224, Ibid. p. 209.
10 W. Hamann

14. Perl E. Ideas about pain, a historical view. Nat Rev Neurosci. 2007;8:71–80.
15. Brown-Sequard CE. Course of lectures on the physiology and pathology of the central nervous
system. Philadelphia: Collins; 1860.
16. Edinger L. Zwolf Vorlesungen uber den Bau der Nervosen Centralorgane Fur Arzte and
Studierende. Leipzig: F.C.W. Vogel; 1892. p. 150–3.
17. Müller J. Handbuch der Physiologie des Menschen fur Vorlesungen, vol. 2. Coblenz: Verlag
von J. Holscher; 1837–1840.
18. von Frey M. Beitrage zur Sinnesphysiologie der Haut. Dritte Mitteilung, Konigl Sachs Ges
Wiss Math Phys, Classe 48; 1895. p. 166–184.
19. Zottermann Y. Touch Pain and Tickling and electrophysiological investigation on cutaneous
sensory nerves. J Physiol. 1939;95:1–28.
20. Iggo A. Cutaneous heat and cold receptors with slowly conducting © afferent fibres. Quart J
Exp Physiol. 1959;44:362–70.
21. Melzack R, Wall PD. Pain mechanisms a new theory. Science. 1965;150:971–9.
22. Walker SC, Trotter PD, Swaney WT, Marshall A, Mcglone FP. C-tactile afferents: cutane-
ous mediators of oxytocin release during affiliative tactile interactions? Neuropeptides.
2017;64:27–38.
23. Christensen BN, Perl ER. Spinal neurons specifically excited noxious or thermal stimuli: mar-
ginal zone of the dorsal horn. J Neurophysiol. 1970;33:293–307.
24. Sherrington CS. The integrative action of the nervous system. New York: Charles Scribner’s
Sons; 1906.
25. Mersky H, Bogduk N. Classification of chronic pain. Seattle: IASP Press; 1994.
26. Beecher HK. Pain in man wounded in battle. Ann Surg. 1946;123(1):96–105.
27. Kabat-Zinn J. Mindfulness with Jon Kabat-Zinn. 2007. YouTube. https://www.youtube.com/
watch?v=3nwwKbM_vJc.
Chapter 2
Theories of Pain

Koki Shimoji and Yoshiyuki Yokota

2.1 Specificity Theory

Specific theory of pain states that each modality of sense, touch or pain, is encoded
in separate pathways. For instance, touch and pain stimuli are received by special-
ized sense organs. Impulses of each sensory modality are conducted along the
­distinct pathways and projected to the touch and pain centers in the brain, respec-
tively. Thus, its fundamental thought is that each sense of modality has a specific
receptor and associated sensory fiber sensitive to only one specific ­stimulus [1].
Aelius Galen, a prominent Greek physician, demonstrated that spinal cord sec-
tion caused sensory (including pain) as well as motor deficits cited by Ochs [2, 3].
Vesalius, Belgium anatomist, in the middle of seventeenth century, also confirmed
the findings by Galen [2, 3].
Descartes was believed to be the first philosopher who described the hypothesis
on pain pathway in man in 1662 (Fig. 2.1). He described pain as a perception that
exists in the brain and is distinct difference between neuronal phenomenon of
­sensory transduction and the perception of pain. Descartes perceived the nerves as
hollow tubules that conduct both sensory and motor activities.
Descartes claimed that the heat of flame near the foot activates a fiber within the
nerve tubule that travels up to the leg, to the spinal cord, and finally to the brain
center. Descartes postulated proverbial bells which are the pores lining along the
cord and brain ventricles. When pores open in response to the sensory stimulus “the

K. Shimoji (*)
Niigata University Graduate School of Medicine, Niigata, Japan
Pain Control Institute, Tokyo, Japan
e-mail: koki-shimoji@nifty.com
Y. Yokota
Department of Anesthesiology, Ariake Hospital, Cancer Foundation, Koto City, Japan
e-mail: yokota@jfcr.or.jp

© Springer Nature Singapore Pte Ltd. 2021 11

K. Shimoji et al. (eds.), Chronic Pain Management in General and Hospital
Practice, https://doi.org/10.1007/978-981-15-2933-7_2
24 K. Shimoji and S. Kurokawa

Table 3.1 Characteristics and functions of A-delta and C fibers

A-delta fibers C fibers
Characteristics
 • Primary afferent fibers  • Primary afferent fibers
 • Larger diameter  • Small diameter
 • Myelinated  • Unmyelinated
 • Fast conducting  • Slow conducting
Receptor type
 • High-threshold mechanoreceptors responding to  • P
 olymodal receptor responding to more
mechanical stimuli over a certain intensity than one type of noxious stimuli:
 • Thermal
 • Chemical
 • Mechanical
Pain quality
 • Well-localized  • Diffuse
 • Sharp  • Dull
 • Stinging  • Burning
 • Pricking  • Aching
 • Referred to as fast or first pain  • Referred to as slow or second pain

hot and cold) stimuli. These nociceptors have small-diameter, nonmyelinated C

fibers that conduct slowly, generally at velocities of 0.5–2.0 m/s (Table 3.1).
The cause of stimulation may be internal, such as pressure exerted by a tumor or
external excessive stimuli such as trauma or burn. These noxious stimulations cause
a release of chemical mediators from the damaged cells including: prostaglandin,
bradykinin, serotonin, substance P, potassium, histamine, etc. (Fig. 3.1).
These chemical mediators activate and/or sensitize the nociceptors to the nox-
ious stimuli. In order for a pain impulse to be generated, an exchange of sodium and
potassium ions (depolarization and repolarization) occurs at the cell membranes.
This results in an action potential and generation of a pain impulse (Fig. 3.2).

Fig. 3.2 Propagation of action potentials in sensory fibers results in the perception of pain.
(Modified from Fields HL, Basbaum AI, Heinricher MM, 2005) [3]. (a) This electrical recording
from a whole nerve shows a compound action potential representing the summated action poten-
tials of all the component axons in the nerve. Even though the nerve contains mostly nonmyelin-
ated axons, the major voltage deflections are produced by the relatively small number of myelinated
axons. This is because action potentials in the population of more slowly conducting axons are
dispersed in time, and the extracellular current generated by an action potential in a nonmyelinated
axon is smaller than the current generated in myelinated axons. (b) First and second pain are car-
ried by two different primary afferent axons. First pain is abolished by selective blockade of Aδ
myelinated axons (middle) and second pain by blocking C fibers (bottom)
Another random document with
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certitude que mon mari n’était pas un assassin ? Car c’était pour
cela… seulement pour cela… Je ne savais plus maintenant ce
qu’avaient pu être mes craintes… — mes espérances !… — Je ne
savais plus si ma vie se nourrissait depuis quelques semaines
d’imaginations absurdes ou des plus profondes et poignantes
réalités sentimentales. Le fait seul m’apparaissait dans son
évidence, brutal et nu comme la lumière de cette lampe ; et ma
douleur devant lui ne pouvait être que grotesque ou que
monstrueuse. Je le compris… il ne me fut plus possible de
comprendre autre chose. Et, voulant me défendre de moi-même et
de tout ce que j’éprouvais d’effrayant, je criai presque :
— Triste ! moi !… après ce que tu viens de me dire !… Triste !…
ah ! par exemple !…
Et voici que, soudain, je me mis à rire. C’était un rire terrible et
violent qui ne pouvait plus s’apaiser. Je riais sur Fabien et sur son
visage satisfait. Je riais plus encore sur moi-même et sur mes
grandes émotions. Et ce rire, qui secouait convulsivement mes
épaules, faisait monter à mes yeux des larmes brûlantes tandis que
le spasme du sanglot serrait dans ma gorge son nœud dur et
douloureux.
— A la bonne heure, s’exclama Fabien tout épanoui. Vois-tu…
J’ai été comme toi d’abord… Le contentement semblait m’abrutir. Je
n’ai bien compris qu’au bout d’un instant. Mais alors, dame, j’ai été
pris d’une espèce de folie. Comme toi, vois-tu… tout à fait comme
toi.

*
* *

… Je ne sais plus le nom de ce restaurant vers lequel nous

allions par les petites rues obscures, ni tout ce que Fabien me
racontait de sa vieille renommée et des personnages importants de
la ville qui ont coutume d’y fréquenter. Mais je me rappelle bien
l’entrée dans la salle basse, pleine et chaude, le gros tapage des
voix et des vaisselles, l’odeur des nourritures dans laquelle se mêlait
à l’acidité des plats vinaigrés, le relent de l’huile bouillante et le
fumet lourd des gibiers. Je me rappelle cette vapeur qui flottait, faite
de l’exhalaison des plats et des haleines et de la fumée du tabac,
cette vapeur embuant aux murs les grandes glaces encadrées de
guirlandes peintes, de fruits, de jeunes femmes coiffées du ruban
provençal, et qui noyait également dans son opacité les figures
décoratives, aux couleurs crues, et les visages vivants, enluminés
avec violence. Et je me rappelle le soin que prit Fabien de choisir,
pour nous y installer, une table qui fût bien en vue, au beau milieu de
la salle.
Il appela le garçon ; il lui donna ses ordres à voix très haute,
satisfait de voir que la plupart des dîneurs se retournaient vers lui ; et
le regard qu’il promena sur tous, quand il fut assis, était un regard
triomphal. En ce moment il était plus heureux encore qu’il n’avait pu
l’être en recevant la lettre de Fardier, et plus heureux que tout à
l’heure, en me faisant son récit haletant de fièvre et de joie.
Véritablement son apparence était celle de la résurrection. Il
semblait de minute en minute s’épanouir davantage. Il prenait sa
revanche de ces quelques semaines pendant lesquelles il avait
vécu, terré, caché, se mourant de honte et de peur, à imaginer
autour de lui le sourire et la raillerie des hommes ; il la prenait avec
éclat, sans mesure et presque insolemment.
Je m’étais assise de façon à tourner le dos à la salle. Parmi tant
de visages qui nous entouraient je ne voyais devant moi que le
visage de Fabien ; parmi tant de gestes qui s’accomplissaient, je ne
voyais que ses gestes. Chacun exprimait l’orgueil, la satisfaction
absolue, la suffisance mesquine et profonde. La manière qu’il avait
de trancher son pain, d’attirer à lui la salière, de reposer fortement
son verre sur la table, révélait, me semblait-il, mieux qu’aucune
parole, de quelle étoffe grossière était faite sa joie… Et je pensais
que, dans la même étoffe, avait été taillé et façonné son désespoir,
ce désespoir sur lequel je m’étais penchée et dont j’avais nourri ma
vie la plus frémissante et la meilleure pendant tant d’heures qui me
paraissaient belles.
 Je commençais maintenant à me rappeler ces heures-là. Je ne
faisais que commencer… Dans cette salle bruyante et chaude, dont
l’air s’épaississait d’odeurs désagréables, je les retrouvais l’une
après l’autre, ces heures d’angoisse et de tourment, redoutées
d’abord, et qui peu à peu m’étaient devenues si chères… Je n’avais
devant moi que le visage de Fabien, mais quand il avançait ou
tournait la tête, ce qui, dans son agitation, lui arrivait à tout moment,
un autre visage m’apparaissait dans la glace étroite, gravée d’étoiles
mates, qui décorait derrière lui le pilier octogone, un visage pâle,
avec des yeux un peu élargis et fixes. Ces yeux, qui étaient les
miens, étaient aussi les yeux de maman que je croyais revoir. Ils
contenaient ma vie tout entière, ils l’expliquaient toute. Ils étaient à la
fois avides et résignés, exigeants et craintifs. Et je n’avais jamais su
voir comme aujourd’hui qu’à leur humilité soumise pouvait se mêler
un désarroi infini et qu’ils se troublaient à la fois des plus étroits
scrupules et de passionnées inquiétudes.
La tête de Fabien, se tournant et s’agitant sans repos, me cachait
ces yeux un instant, et puis de nouveau, je les voyais m’apparaître
confusément dans l’eau de la glace obscurcie de vapeurs et de
fumées. Et ce qui vivait en eux maintenant, ce n’étaient plus que ces
dernières semaines, ce n’étaient que ces dernières heures de mon
existence… Un temps bien court, plus vaste cependant que tout le
reste des jours où j’avais respiré sur la terre. Je me souvenais… je
continuais de me souvenir… Il y avait eu cette nuit à Lagarde…
l’horreur de cette nuit ! Il y avait eu, mystérieuses, menant mes
gestes, dictant mes paroles et cependant comme inconnues à moi-
même, ma résolution soudaine de ne pas abandonner Fabien, ma
volonté de le suivre. Il y avait eu… Mais tant de choses
aboutissaient à une seule… — et c’est une pensée unique à présent
qui me torturait, c’est parmi tous ces souvenirs le souvenir d’une
seule minute — il y avait eu, devant cette douleur que je voyais si
grande, si absolue, capable d’enrichir de ses tourments l’âme la plus
misérable, il y avait eu mon amour, l’élan merveilleux de mon amour.
— Et maintenant il y avait cela seulement ; la révélation que cette
âme n’avait pas changé, la certitude qu’elle ne changerait pas. Il y
avait cela… rien que cela.
« Ah ! peut-être j’aurais préféré qu’il tuât réellement… qu’il tuât…
et qu’il ne fût pas ce qu’il est… »
A ce moment Fabien se redressa, et je ne vis plus mes yeux
dans la glace ; je n’eus plus devant moi que son regard à lui, un peu
vague et tout chavirant d’excitation et de plaisir.
— Garçon ! appela-t-il… Et jetant son ordre avant que l’autre fût
tout près de lui… Du châteauneuf des papes… Une bonne bouteille.
Il se pencha vers moi, ricanant et confidentiel :
— Ça va me coûter cher, ce petit dîner… Mais puisque ce sont
eux qui paient.
— Qui cela ? demandai-je.
— Mais, dit-il, les clients du père Fardier. D’où sors-tu donc ?…
Depuis une demi-heure, nous ne parlons pas d’autre chose.
Il disait : « nous ne parlons », sans remarquer qu’avant cette
brève question je n’avais encore prononcé aucune parole. Ma
distraction, qu’il crut soudaine, l’égaya. Il se servit pour la deuxième
fois des cailles placées devant nous, qui dressaient et
recroquevillaient sur des croûtons de pain gras leurs petites pattes
noires et métalliques, et il reprit cet entretien que je n’entendais pas.
Ne cessant de parler et de manger avec une égale abondance, il ne
cessait non plus de s’avancer de droite et de gauche, de se dresser,
de se pencher, d’observer qui le regardait. Et revoyant à tous
moments derrière lui, dans la glace, ces yeux qui me regardaient, je
continuais, tout éperdue, de leur répondre et de les interroger.
« N’eût-il pas mieux valu qu’il tuât réellement… qu’il tuât ?…
L’être est-il plus avili par l’acte passionné d’une seule minute, que
peuvent essayer de racheter tous les repentirs, ou par la continuité
paisible de la médiocrité et de la platitude ?… »
Mais de cette même façon réelle dont je voyais Fabien couper sa
viande et se verser du vin rouge, je voyais maintenant que le crime
même, s’il eût été commis, n’eût éveillé dans cette âme qu’un ennui,
qu’un repentir et que des craintes à sa taille. Et désespérément
alors, pour ne plus rien voir de lui ni de moi-même, me détournant
moins de ces deux visages dressés devant moi que de l’âme secrète
et trop douloureuse à connaître dont s’animait chacun d’eux, je
regardais la salle, moi aussi, j’attachais mon attention, toute mon
attention, au chapeau extravagant d’une jeune femme, aux
remarques faites par nos voisins, deux couples brésiliens, dans le
plus divertissant langage, aux courses des garçons glissant
prestement au milieu des tables serrées, à la caissière ronde et
brune qui paraissait tant s’ennuyer derrière son haut bureau fleuri de
roses. Je m’appliquais à écouter jusqu’au petit bruit de la monnaie
tombant dans les plateaux de métal, et j’entendais venir de la salle
voisine, où trois billards étalaient sous les lampes leurs tapis d’un
vert éclatant, le choc léger des boules d’ivoire, les voix des joueurs
annonçant les points, et quelquefois aussi s’élevant avec violence
pour discuter d’un « coulé » douteux ou pour applaudir un coup
difficile.
Dans un de ces moments où tous les secours m’étaient bons
pour échapper à moi-même, regardant une fois de plus, pour
regarder le plus loin qu’il me fût possible, dans cette salle où
s’agitaient les joueurs de billard, je vis un homme qui venait sur le
seuil, le chapeau sur la tête, boutonnant son pardessus, prêt à sortir,
un vieil homme robuste et grand dont l’aimable visage était tout
rayonnant sous d’épais cheveux blancs ; et je le reconnus
brusquement… Alors, me penchant vers Fabien, je me mis tout à
coup à répondre à chacune de ses phrases, à lui demander de petits
détails, à l’entretenir avec une animation fébrile de toutes ces
questions qui l’intéressaient. Il fallait que sa pensée en ce moment
s’attachât à moi seule, que son regard se fixât sur moi seule, car je
ne voulais pas qu’il vît cet homme à son tour et qu’il le reconnût, je
ne le voulais pas… Mais il ne remarqua pas plus mon attention qu’il
ne s’était inquiété de mon indifférence. Et malgré mes pressantes
paroles, mon visage tendu vers lui, mes yeux qui cherchaient les
siens, se tournant de tous les côtés comme il continuait de le faire, il
fallut bien enfin qu’il se tournât de ce côté.
 Aussitôt une rougeur plus violente monta à son visage déjà
empourpré. Il s’exclama ; il frappa joyeusement sur la table, et d’une
voix forte, à travers tout ce monde, il cria :
— Fabréjol !
Je vis le petit mouvement surpris de M. Fabréjol, je vis son
regard se promener de table en table, cherchant avec étonnement
qui pouvait l’interpeller ainsi, et je vis son sourire qui n’était peut-être
pas seulement de cordialité, tandis qu’ayant aperçu Fabien qui
s’était levé et lui faisait de grands gestes, il prenait le parti de venir
nous rejoindre. Aussitôt mon mari donna l’ordre que l’on apportât
des liqueurs, bouscula nos voisins afin de placer une chaise de plus
entre leur table et la nôtre, rappela le garçon pour demander des
cigarettes, et attira sur nous de telle sorte l’attention générale que M.
Fabréjol me parut un peu gêné.
— Mais je vous en prie, ne cessait-il de répéter, ne vous donnez
pas tant de mal… Ne dérangez pas ainsi tout le monde…
— Laissez donc, disait Fabien… laissez !… Ah ! mon ami, mon
cher ami, je suis si heureux de vous revoir… Quelle chance que
cette rencontre ! Justement, figurez-vous, je quitte Avignon demain.
M. Fabréjol m’avait saluée avec cette cordialité amicale, cette
bonté affectueuse et presque paternelle qu’il m’avait témoignées
déjà en me recevant chez lui. Et il allait me parler. Fabien ne lui en
laissa pas le temps.
— Hé ! oui, reprit-il, demain. Je ne pensais pas partir aussi
brusquement, mais que voulez-vous ! Les malades me réclament…
Les confrères aussi. C’est à croire vraiment qu’à Lagarde on ne peut
plus vivre — ni mourir, ajouta-t-il plaisamment — sans que je sois là.
Alors je repars, je sacrifie ma santé… mon repos… Il le faut bien.
— Votre santé, me semble-t-il, est meilleure maintenant,
remarqua M. Fabréjol.
— Meilleure, déclara Fabien, oh ! certes, et même aujourd’hui
tout à fait bonne. Ce n’est pas comme le jour où je vous ai rencontré,
Fabréjol, — avouez, mon ami, que j’avais une tête à faire peur — ni
comme cet autre jour où j’ai eu le grand regret de ne pouvoir
accompagner ma femme à votre déjeuner. Ah ! j’ai été vraiment très
mal… Mais c’est fini, bien fini… De la chartreuse, Fabréjol, ou de la
fine ?…
Jamais il n’avait parlé aussi familièrement à M. Fabréjol. Même
quand nous étions seuls et qu’il m’entretenait de lui, il le faisait avec
plus de déférence. Mais il se sentait aujourd’hui tout magnifique, il
était tout hors de lui-même, et je crois bien qu’il n’eût pas imaginé
sur la terre entière quelqu’un à qui il ne pût s’égaler.
— L’une et l’autre, ajouta-t-il en débouchant les flacons de
liqueurs. Et je vous ferai raison.
— Ni l’une ni l’autre, dit M. Fabréjol couvrant son verre de sa
main. Je vous remercie. D’ailleurs je vais être obligé de vous quitter.
Il est bien tard. J’ai six kilomètres à faire pour rentrer chez moi. Un
vieux cheval… un vieux cocher. Ma sœur qui s’inquiète et veille en
m’attendant. Mais j’ai voulu ce soir prendre congé de quelques amis.
— Allons donc !… s’exclama Fabien, vous repartez déjà ! Moi qui
comptais vous demander de venir nous voir un de ces jours à
Lagarde.
Il prononça ces derniers mots avec désinvolture. D’un trait il vida
son verre qu’il avait rempli de chartreuse. Et il éprouva le besoin
d’ajouter, important et confidentiel :
— Ma situation là-bas, vous savez, est en train de devenir
considérable !
Il répéta, tapotant la table de sa main ouverte, comme pour bien
pénétrer de ce mot le marbre lui-même :
— Considérable.
— Je n’en doute pas, dit M. Fabréjol avec politesse. J’ai toujours
pensé qu’il en serait ainsi. Et je vous félicite bien sincèrement.
Autant qu’il m’était en ce moment possible de remarquer quelque
chose, je remarquai que le ton de Fabien le surprenait ce soir, et
peut-être même l’agaçait un peu. Ce fut vers moi qu’il se tourna pour
ajouter :
 — J’ai conservé de Lagarde le meilleur souvenir… Et j’aurais eu
grand plaisir, madame, à vous y rendre de nouveau visite.
Malheureusement, je vous le répète, je pars, ou plutôt nous partons,
mon fils et moi.
J’acquiesçai de la tête. Je crois même que je souris. J’avais
tremblé en apercevant M. Fabréjol. J’avais souhaité qu’il ne nous vît
pas ce soir, qu’il ne vînt pas auprès de nous. Mais je ne savais plus
d’où m’était venue cette frayeur ; je ne me représentais pas bien en
ce moment ce fils qui devait partir avec lui ; je ne souffrais pas en
l’écoutant.
— Philippe, continua M. Fabréjol, était un peu hésitant. Il avait, je
crois, l’intention de prolonger son séjour en France d’un ou deux
mois. Et sa tante, ma pauvre vieille sœur, en eût été bien heureuse.
Mais vous savez comme sont les jeunes gens. Il a maintenant
changé d’avis. Et tout à l’heure même, il vient de me déclarer que sa
résolution était enfin prise et qu’il préférait m’accompagner.
— Quand partez-vous ? demanda Fabien.
— Le douze, dit Fabréjol.
— Le douze, répéta mon mari d’une façon machinale.
Ce fut ce petit mot qui réveilla tout. A cause de cette date qu’il
avait prononcée au musée Calvet et que j’avais répétée comme
Fabien venait de le faire, je revis le musée et Philippe devant moi.
J’entendis sa demande et mon refus. J’entendis ma voix sourde et
sincère qui prononçait : « J’ai l’amour… » Et voici que de nouveau,
comme tout à l’heure, rue des Trois-Faucons, dans la chambre
vilainement éclairée par la lumière nue de la lampe, j’éclatai de rire.
Et c’était comme tout à l’heure, un rire terrible, violent, qui ne cessait
plus de secouer mes épaules et faisait monter à mes yeux des
larmes brûlantes, tandis que le spasme du sanglot serrait dans ma
gorge son nœud dur et douloureux.
M. Fabréjol me considérait, étonné ; mais Fabien expliqua avec
une grande indulgence :
— Elle est très gaie… Que voulez-vous ! — (Et j’avais
l’impression précise que chacune de ses paroles serait répétée à
Philippe, et chacune de ses paroles me déchirait comme une lame
grinçante et froide.) — C’est que la journée d’aujourd’hui a été pour
elle une bonne journée.

*
* *

… Sur le toit de tuiles rousses que je vois de ma fenêtre, une

fumée voudrait monter, que rabat le grand vent. Elle bouillonne au
sortir de la cheminée comme un jet d’eau sans force ; elle se couche
et s’échevèle, et, comme le soir va venir, elle est blanche sur le ciel
gris.
Nous sommes en hiver, maintenant. Nous approchons de la
Noël. C’est le temps, à Lagarde, où l’on se rend des visites. J’ai été
très occupée à en faire, à en recevoir aussi. Et j’ai dû m’interrompre
souvent d’écrire, si souvent que quelquefois je ne savais vraiment
plus bien pourquoi j’avais entrepris de conter toutes ces choses…
A quoi bon l’avoir fait ? C’est fini d’ailleurs, c’est fini. Je n’ai plus
rien à dire. Je fréquente beaucoup de monde maintenant. Cela est
naturel. Je donne à goûter et quelquefois à dîner. La situation de
Fabien m’impose ces obligations, qui ne sont pas désagréables. Ce
dernier soir en Avignon, dont j’ai parlé pour finir, il avait bien raison
d’être si content. Tout s’est parfaitement arrangé. Le vieux Fardier a
commencé déjà de lui passer la plus grande partie de sa clientèle.
Nous le voyons assez souvent. Il dîne ici demain avec Romain de
Buires, qui est maintenant tout à fait de nos amis.
Bien entendu, on ne parlera de rien. Je veux dire : on ne parlera
pas de toute cette histoire. On n’en parle jamais. Elle est vieille
d’ailleurs : un an déjà. Personne n’y pense plus. Moi-même, bien
souvent, je crois l’avoir oubliée.
Quelquefois cependant… oui, quelquefois… je me rappelle. Cela
me vient tout à coup, d’une manière brusque que rien ne prépare et
qui me surprend. Cela me vient quand je suis seule dans ma
chambre ou bien assise près de Guicharde à coudre devant le feu,
ou encore, ce qui est plus singulier, quand je fais quelque visite
d’importance, au beau milieu d’une conversation, alors que je
m’applique à me tenir avec élégance et que je suis toute contente de
mon chapeau avec une plume brune qui vient de Paris, ou de mes
gants montant un peu haut et brodés de baguettes noires, à la
dernière mode. Je me rappelle…
Il semble que mon cœur tout à coup se réveille et supplie, qu’il
grandit et qu’il souffre. Ma gorge se serre. Je ne sais plus que dire.
Mes mains deviennent un peu froides. Et si j’ai une glace devant
moi, j’y vois aussitôt se lever ces yeux qui me regardèrent tout un
soir, du fond de la glace trouble, gravée d’étoiles mates, ces yeux
résignés et tout remplis cependant d’inquiètes exigences…
Mais ces moments tourmentés sont assez rares maintenant.
Peut-être vont-ils encore le devenir davantage. La vie passe. Elle
ordonne. J’ai toujours été pliée à l’obéissance et je ne fais que
continuer. J’accepte ce qu’elle entend faire de mon être soumis. Je
souris à la forme du visage qu’elle tourne vers moi. Oui, je souris…
Je suis heureuse. — Pourquoi pas ? La considération dont nous
entoure tout le pays est chaque jour plus grande. Mon mari chaque
jour gagne plus d’argent et la tendresse qu’il me témoigne est
raisonnable et fidèle. C’est Guicharde qui a raison. Il ne faut
considérer que l’apparence des choses et quand elle est excellente,
il est inutile et peut-être ridicule de rien chercher au delà.
C’est fini. Je vais faire un grand feu avec tous ces feuillets. Le
soir vient. Des femmes dans la rue vont à la fontaine. J’entends le
grincement de la pompe, le bruit sonore d’une anse retombant
contre un seau vide. Et j’entends au-dessous de moi tous les bruits
de ma maison : Guicharde met la table avec vivacité, Adélaïde fend
du bois dans la souillarde. Tout à l’heure, Fabien va rentrer dans sa
voiture grise et basse, pareille à quelque gros cloporte roulé dans la
poussière.
La vie est régulière, abondante et tranquille. Elle est bonne pour
moi en somme. Elle est très bonne. Je suis heureuse. Je puis l’être.
Je le serais tout à fait s’il n’y avait pas encore ces moments, tous
ces moments où il me semble que je m’éveille, et où je pense que
ces minutes paisibles et satisfaites sont peut-être les pires de
toutes…
 PARIS
IMPRIMERIE GAMBART & Cie
52, avenue du Maine, 52
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