It was the first time that Mattie had ever written to him, and the possession of the paper gave him a strange new sense of her nearness; yet it deepened his anguish by reminding him that henceforth they would have no other way of communicating with each other.
There are no more uses of "anguish" in the book.
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I felt unbearable anguish when my 4-year-old child died from brain cancer.
Her guilt led to anguish until she committed her life to good.