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A Method of Quick Relief of Pain Due to Renal Colic
Tim
.ToUR~AL OF CROLOGY
Vol. 78, No. 6, December 1957 Printed in U.S.A.
A METHOD OF
RELIEF OF PAIN DUE TO RE~AL COLIC PETER VAN DOOREN
From the Department of Urology, Charlotte Memorial Hospital, Charlotte, N. C.
The purpose of this paper is to contribute a simple method for quick relief of one of the most severe pains known; namely, renal colic. The results are so constant and gratifying that the method may be helpful to others who hrwe faced the same problem of handling patients suffering frorn this condition. The standard treatment ,vith demerol or morphine with or without atrophine requires considerable time to take effect, and during that time it is also frequently impossible to obtain a good history or to do an adequate physical examination on the patient. It is not the intention of this paper to claim originality for this method, sincEi the struggle of man against pain probably started shortly after the creation of Homo sapiens. Old and almost forgotten remedies have been rediscovered and perfected as far as the progress of science permitted at that particular time, or they have been again in the dust of history, Looking back at the history of pain control, we have to go back to the most primitive tribes; for instance, in Asia and Africa, one will find the most primitive form,; of medicine practiced by a medicine man, who usually has an extraordinary ability to combine his knowledge of herb extracts with a fair amount of psychology and a large dose of hocus-pocus. A man in the agony of renal colic turns to him for the same reasons that our patients come to us; namely, for relief of his pain. The medicine man lrnmn very well that a renal colic usually lasts a short time, but that it also may last for hours. He therefore bringR forth a small statuette or fetish, and after having questioned his patient about the character and location of his pain, he will drive pins or nails into the corresponding site of the fetish. With prayers, magic dances, and sufficient noise to suppress the cries and lamentations of his patient, he will carry on his "treatment" until the pain subsides and everybody ,vill go home convinced of the magic healing powers of this great medicine man. In the next step of the evolution of medicine, the pins are not inserted in the fetish but in the skin of the patient, followed usually the same or similar rites . A widespread cure for ailments as pneumonia, abdominal pains, and colics is cauterization of the skin over the area where the pain is felt. In Saudi Arabia for instance, I have seen this done by contact with the heated head of a large nail; in remote areas of Canada, electric cautcrizers are m,ed. This treatment is so effective that magic dances are no longer necessary. These methods I am sure will be rn.et by the physicians of this era with smile, but it is wise not to push aside the knowledge of the primitive people because essential drugs such as opium, digitalis, curare, etc. were long used people before their oc:currence in our pharmacopoeia. It is a well noted fact that visceral organs can be handled and cut, crushed, or burned without causing any pain, as long as traction on the mesentery or Accepted for publication .June 3, 1957. 727
728
PETER VAN DOOREN
stimulation of the abdominal wall is avoided. Indeed, viscera are sparsely innervated. Kinsella has shown that the viscera are definitely sensitive if adequate stimulus is applied, and the threshold of pain fibers may have been lowered by the pathological state. The adequate stimuli for visceral afferents are those arising from their own environment and especially from their own activities and pathological state. For instance, 1) spasms or strong contractions especially when accompanied by ischemia, 2) sudden distention against resistance, 3) chemical irritants, 4) mechanical stimulation, especially when the organ is hyperemic. While the organic sensations and visceral reflexes are served by afferents in the parasympathetic nerves, the impulses serving visceral pain are conducted in the sympathetic nerves, except for the viscera in the pelvic region, the esophagus and trachea. Impulses arising in visceral structures give rise to pain frequently localized in superficial structures at a considerable distance from the disturbed organ. Such pain is known as referred pain. The referred pain follows the dermatomal rule, namely, it is referred to the dermatomes supplied by the posterior roots through ·which the visceral afferent impulses reach the spinal cord. Visceral irritation by pathological process may be manifested in a) pain or b) hyperalgesia, hyperesthesia, or tenderness c) autonomic reflexes and d) somatic reflexes. The first two manifestations are of most interest to us in this particular pathological condition. An explanation of this referred pain is that some visceral afferents converge with cutaneous pain afferents to end upon the same neuron at some point in the sensory spinothalamic or cortical pathway and these systems of fibers are organized in such a manner that the dermatomal reference is provided. The impulses coming from the spino-thalamic tract are interpreted by the brain as coming from the skin. To say it in the words of Wolff and Hardy as they describe it in their article "On the Nature of Pain": "Referred pain may be accentuated in intensity by virtue of effects of ordinarily non-noxious stimuli from
hypersens. area.
Fm. 1. Skin cleansed with alcohol or methiolate. With 5 cc syringe filled with 1 per cent solution of procaine or novocain, and using No. 24 hypodermic needle, multiple intracutaneous injections of approximately one- or two-tenths of cubic centimeter are given (*). Injections are evenly spaced in hypersensitive area, but pattern is not important.
QUICK RF;LIEF OF PAIN DUE TO RENAL COLlC
729
zones of reference. Impulses from such sources, normally inadequate to produce pain, may do so upon reaching the cord in a segment involved in central of excitation." .i\1cC1ellan and Goodell experimenting ·with the ureter of a female patient, faradic stimulation of the ureter high up near the kidney, found the pain referred along the border of the rectus muscle approximately at the level of the umbilicus. This pain disappeared quickly, and was followed in half an hour by a dull ache in the flank. This ache increased gradually and lasted six hours. Most of the pain Yrns found in the costovertebral angle. The tenderness of the back muscles most likely was due to skeletal muscle contraction. In acute appendicitis in the early stage there is a similar area of pain around the umbilicus which later on shifts down to .1frBurney's point. There is a definite area of hypersensitivity which can be demonstrated by scratching a pin over the skin. An ice bag applied to the skin of the right lower quadrant will reduce pain. In renal colic we have an area of hyperesthesia in the flank running from the eostovertebral angle dmvn to the groin. This area can easily be located scratching the skin with a pin or needle and subsequently marking the area with ink. Multiple intracutaneous injections of a tenth of a cc of a 1 per cent procaine solution in this hypersensitive area (fig. 1) produce instant disappearance of the sharp colicky pain. Patients who are rolling and tossing in agony, become quiet and relaxed. There remains a dull ache which is very mild in com parison with the acute pain and is comparable to the soreness of muscle spasm. It is nuw possible to examine the patient properly. One can make him lie still on the x-ray holding his breath ·while the pictures are taken. The spasm originating in the ureter or the pelvifi around the irritating stone is not now felt the patient. Antispac1modics can be given to relieve the spasm of the ureter and further conservative treatment or surgical intervention naturally follows. This very interesting subject of referred pain is still wide open for scientific research, but it was believed that the results of this method of treatment were dramatic enough to justify its presentation to the profession. STJMi\L\.RY
A simple method for quick pain relief in renal colic has been described. The mechanism of referred ·with superficial and/or deep hyperalgesia has been discu:c;secl REFERENCES V. J.: The l\Icclrnnism of Abdominal Pain. Sydney, Australia: Angus and RobertHl4i( son, M ..rnn GoonwELL, H.: Res. Pub. Assn. Nerv. }\Jent. Dis., 23: 252-262, J\lcCLELLAN, HJ4:3. R1:ca, T. C.: In. Textbook of Physiology, edited by Fulton, 17th eel. Philadelphia.: W. B. Saunders 1955. WHITE, .J.C. AND W. H.: Pain, Its Mechanism and Neurosurgical Control. Springfield, Ill.: Charles C. Thomas, publisher, 1955. WoLFF, H. C. AKD H1HDY, ,) . D.: On the nature of pain. Physiol. Rev., 27: 167-UJO, Hl47.
.ToUR~AL OF CROLOGY
Vol. 78, No. 6, December 1957 Printed in U.S.A.
A METHOD OF
RELIEF OF PAIN DUE TO RE~AL COLIC PETER VAN DOOREN
From the Department of Urology, Charlotte Memorial Hospital, Charlotte, N. C.
The purpose of this paper is to contribute a simple method for quick relief of one of the most severe pains known; namely, renal colic. The results are so constant and gratifying that the method may be helpful to others who hrwe faced the same problem of handling patients suffering frorn this condition. The standard treatment ,vith demerol or morphine with or without atrophine requires considerable time to take effect, and during that time it is also frequently impossible to obtain a good history or to do an adequate physical examination on the patient. It is not the intention of this paper to claim originality for this method, sincEi the struggle of man against pain probably started shortly after the creation of Homo sapiens. Old and almost forgotten remedies have been rediscovered and perfected as far as the progress of science permitted at that particular time, or they have been again in the dust of history, Looking back at the history of pain control, we have to go back to the most primitive tribes; for instance, in Asia and Africa, one will find the most primitive form,; of medicine practiced by a medicine man, who usually has an extraordinary ability to combine his knowledge of herb extracts with a fair amount of psychology and a large dose of hocus-pocus. A man in the agony of renal colic turns to him for the same reasons that our patients come to us; namely, for relief of his pain. The medicine man lrnmn very well that a renal colic usually lasts a short time, but that it also may last for hours. He therefore bringR forth a small statuette or fetish, and after having questioned his patient about the character and location of his pain, he will drive pins or nails into the corresponding site of the fetish. With prayers, magic dances, and sufficient noise to suppress the cries and lamentations of his patient, he will carry on his "treatment" until the pain subsides and everybody ,vill go home convinced of the magic healing powers of this great medicine man. In the next step of the evolution of medicine, the pins are not inserted in the fetish but in the skin of the patient, followed usually the same or similar rites . A widespread cure for ailments as pneumonia, abdominal pains, and colics is cauterization of the skin over the area where the pain is felt. In Saudi Arabia for instance, I have seen this done by contact with the heated head of a large nail; in remote areas of Canada, electric cautcrizers are m,ed. This treatment is so effective that magic dances are no longer necessary. These methods I am sure will be rn.et by the physicians of this era with smile, but it is wise not to push aside the knowledge of the primitive people because essential drugs such as opium, digitalis, curare, etc. were long used people before their oc:currence in our pharmacopoeia. It is a well noted fact that visceral organs can be handled and cut, crushed, or burned without causing any pain, as long as traction on the mesentery or Accepted for publication .June 3, 1957. 727
728
PETER VAN DOOREN
stimulation of the abdominal wall is avoided. Indeed, viscera are sparsely innervated. Kinsella has shown that the viscera are definitely sensitive if adequate stimulus is applied, and the threshold of pain fibers may have been lowered by the pathological state. The adequate stimuli for visceral afferents are those arising from their own environment and especially from their own activities and pathological state. For instance, 1) spasms or strong contractions especially when accompanied by ischemia, 2) sudden distention against resistance, 3) chemical irritants, 4) mechanical stimulation, especially when the organ is hyperemic. While the organic sensations and visceral reflexes are served by afferents in the parasympathetic nerves, the impulses serving visceral pain are conducted in the sympathetic nerves, except for the viscera in the pelvic region, the esophagus and trachea. Impulses arising in visceral structures give rise to pain frequently localized in superficial structures at a considerable distance from the disturbed organ. Such pain is known as referred pain. The referred pain follows the dermatomal rule, namely, it is referred to the dermatomes supplied by the posterior roots through ·which the visceral afferent impulses reach the spinal cord. Visceral irritation by pathological process may be manifested in a) pain or b) hyperalgesia, hyperesthesia, or tenderness c) autonomic reflexes and d) somatic reflexes. The first two manifestations are of most interest to us in this particular pathological condition. An explanation of this referred pain is that some visceral afferents converge with cutaneous pain afferents to end upon the same neuron at some point in the sensory spinothalamic or cortical pathway and these systems of fibers are organized in such a manner that the dermatomal reference is provided. The impulses coming from the spino-thalamic tract are interpreted by the brain as coming from the skin. To say it in the words of Wolff and Hardy as they describe it in their article "On the Nature of Pain": "Referred pain may be accentuated in intensity by virtue of effects of ordinarily non-noxious stimuli from
hypersens. area.
Fm. 1. Skin cleansed with alcohol or methiolate. With 5 cc syringe filled with 1 per cent solution of procaine or novocain, and using No. 24 hypodermic needle, multiple intracutaneous injections of approximately one- or two-tenths of cubic centimeter are given (*). Injections are evenly spaced in hypersensitive area, but pattern is not important.
QUICK RF;LIEF OF PAIN DUE TO RENAL COLlC
729
zones of reference. Impulses from such sources, normally inadequate to produce pain, may do so upon reaching the cord in a segment involved in central of excitation." .i\1cC1ellan and Goodell experimenting ·with the ureter of a female patient, faradic stimulation of the ureter high up near the kidney, found the pain referred along the border of the rectus muscle approximately at the level of the umbilicus. This pain disappeared quickly, and was followed in half an hour by a dull ache in the flank. This ache increased gradually and lasted six hours. Most of the pain Yrns found in the costovertebral angle. The tenderness of the back muscles most likely was due to skeletal muscle contraction. In acute appendicitis in the early stage there is a similar area of pain around the umbilicus which later on shifts down to .1frBurney's point. There is a definite area of hypersensitivity which can be demonstrated by scratching a pin over the skin. An ice bag applied to the skin of the right lower quadrant will reduce pain. In renal colic we have an area of hyperesthesia in the flank running from the eostovertebral angle dmvn to the groin. This area can easily be located scratching the skin with a pin or needle and subsequently marking the area with ink. Multiple intracutaneous injections of a tenth of a cc of a 1 per cent procaine solution in this hypersensitive area (fig. 1) produce instant disappearance of the sharp colicky pain. Patients who are rolling and tossing in agony, become quiet and relaxed. There remains a dull ache which is very mild in com parison with the acute pain and is comparable to the soreness of muscle spasm. It is nuw possible to examine the patient properly. One can make him lie still on the x-ray holding his breath ·while the pictures are taken. The spasm originating in the ureter or the pelvifi around the irritating stone is not now felt the patient. Antispac1modics can be given to relieve the spasm of the ureter and further conservative treatment or surgical intervention naturally follows. This very interesting subject of referred pain is still wide open for scientific research, but it was believed that the results of this method of treatment were dramatic enough to justify its presentation to the profession. STJMi\L\.RY
A simple method for quick pain relief in renal colic has been described. The mechanism of referred ·with superficial and/or deep hyperalgesia has been discu:c;secl REFERENCES V. J.: The l\Icclrnnism of Abdominal Pain. Sydney, Australia: Angus and RobertHl4i( son, M ..rnn GoonwELL, H.: Res. Pub. Assn. Nerv. }\Jent. Dis., 23: 252-262, J\lcCLELLAN, HJ4:3. R1:ca, T. C.: In. Textbook of Physiology, edited by Fulton, 17th eel. Philadelphia.: W. B. Saunders 1955. WHITE, .J.C. AND W. H.: Pain, Its Mechanism and Neurosurgical Control. Springfield, Ill.: Charles C. Thomas, publisher, 1955. WoLFF, H. C. AKD H1HDY, ,) . D.: On the nature of pain. Physiol. Rev., 27: 167-UJO, Hl47.