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SOME PAINS I HAVE KNOWN
1133
Personal
Paper
SOME PAINS I HAVE KNOWN ROY SWARTOUT 416 West Las Tunas Drive, Suite 304, San
Gabriel,
California 91776, USA "The art of the practice of medicine is to be learned only by experience." (ref 1: no 264: p 125). OVER the years I have, rather unusually, experienced almost all the epigastric and precordial pains it is possible to have-angina pectoris stable and unstable (proved by angiography), pericarditis (which followed five-vessel bypass surgery), pneumonia with pleurisy, bronchial asthma (both recurrent problems), hiatus hernia, peptic ulcer disease (both proved by X-ray and endoscopy), acute pancreatitis (proved by appropriate laboratory tests), and acute cholecystitis with cholelithiasis (proved by a surgical
specimen). Now that I have reached the winter of my years, even a restrained look backwards must appear hyperbolic. There is odd temptation simply not to believe the record of one’s recollection. Implausible as it may seem, however, in the winter’s quiet that affects many of us, this is the way it is remembered and the way it truly was. Having experienced all of these disorders I know there are different and distinctive qualities to each of their pains. I am therefore sure that a thorough history can be as accurate as any known graph, serum level, or technetium scintigram. This is not to say that the diagnosis should not be verified before treatment by the appropriate test. However, an hour spent taking a history is a lot cheaper than compiling computer printout sheets of drafts and graphs. It is also much more satisfying. an
"Angina pectoris
may be
precipitated by: muscular exertion, or cold weather." (ref 1: no
violent mental states, stomach upsets
315: p 137). The pain of angina is not only more complex than other pains but it is also by far the most variable in my experience,
described because of that be so mild that it is times variability. Angina may manifested only by an unconscious rubbing of the wrist. This action seems almost like a habit, is unaccompanied by any chest pain, and is not at all severe; usually I was unaware I was doing it. Interestingly, it is usually the right wrist that is involved. If you want to experience severe anginal pain yourself, place a blood-pressure cuff on your upper arm, pump it up to 300 mm Hg, and occlude the tubing with a towel clip so there is no slippage. After 5 minutes, work your fist. The feeling in your forearm is the same as that in your chest in severe angina. The angina also makes you seem breathless. In my experience, anginal pain does not run into the jaws or ears. Severe angina is not as severe as some other pains-for and it is the most
poorly at
example, gallbladder pain, colic, or pancreatitis-but it is by
far the most frightening. It is the only one I have had that makes me afraid I am going to die or, if severe enough, that I am not going to die. Angina is a peculiar disorder in that its timing is often absolutely predictable. Usually, it is worst in the morning. If I parked my car in its usual spot then walked into the hospital in the morning, I knew by the time I had reached
the steps I would need a glyceryl trinitrate tablet, by the time I reached the record room I would need another, and so on, until by the time I reached my office, I would have taken five tablets-each day, in the same spot, always. On returning from lunch and parking in the same area in the afternoon, I often would need none and rarely one tablet, never two. In other words, as the day goes on and the weather and your body warm up, you can do things without pain that in the
morning are impossible. Glyceryl trinitrate is a fine drug and relieves pain completely. Its only drawback is that tolerance to it develops very rapidly. Nitrodiscs and ointment work well at first. But if it is used to go to bed every night, within a few days it will have ceased to work completely. It really does not matter much where the ointment is applied. A person with intermittent claudication in the legs and angina may even have relief from both disorders simultaneously by applying it to the legs. I find that the best glyeryl trinitrate preparation is ’Nitrogard’ (Parke Davis), whereas I find isosorbide dinitrate, in all of its sizes, strengths, and varieties, ineffective. I have no personal experience of calcium blockers and beta-adrenergic blockers. In angina using the arms over the head, sweeping, and making beds can be very aggravating. But by far the worst inciting factor in my experience is sudden inhalation of cold air, particularly in the morining. "All writers agree that there is in asthma a strong neurotic element."
majority of cases of bronchial (ref 2: p 497).
a
Bronchial asthma is also precipitated by inhaling cold air and it also causes me chest pain. There is a substantial difference, however; the angina comes almost instantly after cold inhalation, whereas I can usually walk about quarter of a mile in freezing weather before the asthma begins. The substernal pressure caused by asthma comes only after I have had severe bronchitis or status asthmaticus. The pain is very similar to angina, in that it feels like an elephant is sitting on my chest. It is not as severe as severe angina, and it is never associated with angor animi. The distress, to me at least, seems to be caused by mucous plugs, because it subsides only after I can start coughing these up. Steam inhalation and a saturated solution of potassium iodide seem to be of some help. This pain does not seem to be mentioned in modern medical texts but Osler described it2 (p 499). "Pericarditis is diagnosed in proportion examination." (ref 1: no 330: p 141).
to
the
care
of the
The pain of pericarditis is boring and continuous but it is also positional; it did not make me breathless. Complete relief can almost always be had by finding the proper position to lie in. Similarly, it can always be started by inadvertently rolling into the wrong position while asleep.
"Keep an open mind toward pneumonia." (ref 2: The
p
323).
of
pain pleurisy is similarly positional, but is not It boring. actually feels like a rub, and you can often feel it with your fingers yourself before the doctor can hear it. As well as being relieved by a change in position, it can also be relieved by pressure. Coughing may be an exquisite experience with a good pleurodynia, but it may be made almost tolerable by holding a sandbag or rolled-up firm towel to the area before starting to cough. Whether or not you feel winded depends on the size of the region involved. is sometimes "Spasm of the oesophagous (oesophagismus) associated with the lodgement of foreign bodies ... In elderly ...
1134
patients oesophagismus is almost always connected with hypochondriasis but great care must be taken to exclude cancer." (ref 2: p 340). Several years ago while in an upper berth in a train in the middle of Russia, I tried to swallow an aspirin without liquid. The aspirin stuck about halfway down and caused an oesophageal spasm. Now that is a pain. It was really very different from angina. It was deeper and more intense than the average angina but was not associated with angor animi. It didn’t make me breathless, but it did make me sit up. I don’t think there is any way a person with oesophageal spasm could stay lying down. In angina and asthma, of course, you may feel better sitting up, but the feeling does not have the same imperative quality. Interestingly, the oesophageal pain radiated to my ears and never down my arms, whereas angina has never radiated to my ears. The presence of this condition must be pancreatitis considered in all abdominal cases which come on suddenly with intense pain in the epigastric region, vomiting and distention of the abdomen." (ref 2: p 458).
"Acute
...
relieved by any change in position. I felt better, however, curled up and splinting the right side. "Medicine is learned by the bedside and not in the classroom."
"Observe, record, tabulate, communicate. Use your five senses." (ref 1: p 200-01).
Having experienced over the years several of the disorders causing precordial and/or epigastric distress, I have become convinced that there are enough differences among them that the diagnosis can almost always be made by means of an adequate history and physical examination. After that, confirmation should be sought in the laboratory with one or two well-aimed tests. Sometimes letting a patient talk for a few minutes will save many minutes of mulling over conflicting computer reports. REFERENCES 1. Bean WB, ed. Osler’s
2. Osler
Aphorisms. New York: Henry Schuman, Inc, 1950. W. The principles and practice of medicine, 1st ed. New York: Appleton, 1892.
Point of View
I have had one attack of mild pancreatitis. This pain also radiated to the ears. It is lower in the epigastrium than any of the others and was also relieved by sitting up and forward. It also was oppressive and, unlike angina and the others, caused pronounced perspiration. "Gastric ulcer seldom has classical
symptoms." (ref 2: p 307).
Acute ulcer disease also causes pain in the epigastrium but it is nowhere near as severe as the others. It becomes intolerable because you know that (untreated) you will have the pain again and again and again. It is usually aching in character. Depending on location, it may be relieved by position (for example, if it is pointing backwards, it may be relieved by leaning forward). It is characterised by its absolute rhythmicity; the ulcer starts to hurt at exactly the same times every day. Only someone who has never had an untreated ulcer will tell you it doesn’t matter what you eat. Probably today’s liberal diet is related to the efficacy of ulcer treatment. However, a person with an untreated ulcer would as soon take hemlock as coffee, straight whisky, aspirin, or hot peppers. Having had both gastric and dudodenal ulcers, the only difference I have ever noticed is that sometimes I could delay the pain of the gastric ulcer by omitting
breakfast. "Bitter fluids may be brought up. In other instances a clear watery fluid is ejected (pyrosis or water brash). (ref 2: p 317).
In my experience of diaphragmatic hernia real pain occurs only if there is associated oesophageal spasm or peptic ulcer. Pyrosis or heartburn, which may be associated with a hiatus hernia, is not a real pain but is usually a mild burning anywhere from the back of the throat to the epigastrium. Isosorbide dinitrate, as well as being useless in angina, is the only substance that inevitably gives me pyrosis. Neither Russian vodka with pepper nor Mexican jalapeno liquor caused me pyrosis anywhere near as severe as that caused by isosorbide dinitrate. "The best thing nature can do with gall stones is to close the stone quarry.
(ref 2: p 317).
The pain of acute cholecystitis is not relevant to a discussion of precordial and epigastric pains because, in my experience, it is in the region of the gallbladder. I should say, however, that it is as severe as severe angina but is not associated with angor animi. It radiates to an area below the right shoulder blade in my experience, and it is not totally
QUALMS ABOUT QALYs ALWYN SMITH
Department of Epidemiology and Social Oncology, University of Manchester, Christie Hospital and Holt Radium Institute, Kinnaird Road, Manchester M20 9QL
THE
QALY (quality-adjusted life-year) is an index designed to take account of the quality as well as the duration of survival in assessing the outcome of health-care procedures or services. It was first proposed in the United States and has been developed in this country by Professor Alan Williams and his colleagues at York University. The apparent simplicity of the technique has commended it to many. I join in the general respect for those who have developed it but believe that there are many grounds for caution in its general adoption. Not the least important of these is the widespread lack of understanding of the technique and its implications and limitations. This paper is offered as both an exposition and a critique of the QALY. The QALY is derived from a modification of standard life-table procedures. Doctors will probably be most familiar with the use of these procedures in the comparative of treatments for chronic disorders-and for especially malignant disorders. In this application the life-table is a way of presenting data on the survival of patients who may have been followed up for varying times since the start of treatment. Their observed mortality is used to calculate the proportional attenuation of a treated population at defined times after the start of treatment. In reports of survival after treatment for cancer it used to be common to summarise the life-table by quoting the proportion surviving at 5 years. It is more informative to calculate the mean survival time of those who have survived to some specified point after the beginning of treatment. Standard life-table procedures deal with simple duration of survival. Williams and his colleagues have proposed that each year of life contributing to the life-table should be multiplied by a fraction expressing the impairment of the quality of life experienced by survivors. A summary measure is then calculated just as in an unadjusted life-table. From this value and from the cost of a treatment or assessment
Personal
Paper
SOME PAINS I HAVE KNOWN ROY SWARTOUT 416 West Las Tunas Drive, Suite 304, San
Gabriel,
California 91776, USA "The art of the practice of medicine is to be learned only by experience." (ref 1: no 264: p 125). OVER the years I have, rather unusually, experienced almost all the epigastric and precordial pains it is possible to have-angina pectoris stable and unstable (proved by angiography), pericarditis (which followed five-vessel bypass surgery), pneumonia with pleurisy, bronchial asthma (both recurrent problems), hiatus hernia, peptic ulcer disease (both proved by X-ray and endoscopy), acute pancreatitis (proved by appropriate laboratory tests), and acute cholecystitis with cholelithiasis (proved by a surgical
specimen). Now that I have reached the winter of my years, even a restrained look backwards must appear hyperbolic. There is odd temptation simply not to believe the record of one’s recollection. Implausible as it may seem, however, in the winter’s quiet that affects many of us, this is the way it is remembered and the way it truly was. Having experienced all of these disorders I know there are different and distinctive qualities to each of their pains. I am therefore sure that a thorough history can be as accurate as any known graph, serum level, or technetium scintigram. This is not to say that the diagnosis should not be verified before treatment by the appropriate test. However, an hour spent taking a history is a lot cheaper than compiling computer printout sheets of drafts and graphs. It is also much more satisfying. an
"Angina pectoris
may be
precipitated by: muscular exertion, or cold weather." (ref 1: no
violent mental states, stomach upsets
315: p 137). The pain of angina is not only more complex than other pains but it is also by far the most variable in my experience,
described because of that be so mild that it is times variability. Angina may manifested only by an unconscious rubbing of the wrist. This action seems almost like a habit, is unaccompanied by any chest pain, and is not at all severe; usually I was unaware I was doing it. Interestingly, it is usually the right wrist that is involved. If you want to experience severe anginal pain yourself, place a blood-pressure cuff on your upper arm, pump it up to 300 mm Hg, and occlude the tubing with a towel clip so there is no slippage. After 5 minutes, work your fist. The feeling in your forearm is the same as that in your chest in severe angina. The angina also makes you seem breathless. In my experience, anginal pain does not run into the jaws or ears. Severe angina is not as severe as some other pains-for and it is the most
poorly at
example, gallbladder pain, colic, or pancreatitis-but it is by
far the most frightening. It is the only one I have had that makes me afraid I am going to die or, if severe enough, that I am not going to die. Angina is a peculiar disorder in that its timing is often absolutely predictable. Usually, it is worst in the morning. If I parked my car in its usual spot then walked into the hospital in the morning, I knew by the time I had reached
the steps I would need a glyceryl trinitrate tablet, by the time I reached the record room I would need another, and so on, until by the time I reached my office, I would have taken five tablets-each day, in the same spot, always. On returning from lunch and parking in the same area in the afternoon, I often would need none and rarely one tablet, never two. In other words, as the day goes on and the weather and your body warm up, you can do things without pain that in the
morning are impossible. Glyceryl trinitrate is a fine drug and relieves pain completely. Its only drawback is that tolerance to it develops very rapidly. Nitrodiscs and ointment work well at first. But if it is used to go to bed every night, within a few days it will have ceased to work completely. It really does not matter much where the ointment is applied. A person with intermittent claudication in the legs and angina may even have relief from both disorders simultaneously by applying it to the legs. I find that the best glyeryl trinitrate preparation is ’Nitrogard’ (Parke Davis), whereas I find isosorbide dinitrate, in all of its sizes, strengths, and varieties, ineffective. I have no personal experience of calcium blockers and beta-adrenergic blockers. In angina using the arms over the head, sweeping, and making beds can be very aggravating. But by far the worst inciting factor in my experience is sudden inhalation of cold air, particularly in the morining. "All writers agree that there is in asthma a strong neurotic element."
majority of cases of bronchial (ref 2: p 497).
a
Bronchial asthma is also precipitated by inhaling cold air and it also causes me chest pain. There is a substantial difference, however; the angina comes almost instantly after cold inhalation, whereas I can usually walk about quarter of a mile in freezing weather before the asthma begins. The substernal pressure caused by asthma comes only after I have had severe bronchitis or status asthmaticus. The pain is very similar to angina, in that it feels like an elephant is sitting on my chest. It is not as severe as severe angina, and it is never associated with angor animi. The distress, to me at least, seems to be caused by mucous plugs, because it subsides only after I can start coughing these up. Steam inhalation and a saturated solution of potassium iodide seem to be of some help. This pain does not seem to be mentioned in modern medical texts but Osler described it2 (p 499). "Pericarditis is diagnosed in proportion examination." (ref 1: no 330: p 141).
to
the
care
of the
The pain of pericarditis is boring and continuous but it is also positional; it did not make me breathless. Complete relief can almost always be had by finding the proper position to lie in. Similarly, it can always be started by inadvertently rolling into the wrong position while asleep.
"Keep an open mind toward pneumonia." (ref 2: The
p
323).
of
pain pleurisy is similarly positional, but is not It boring. actually feels like a rub, and you can often feel it with your fingers yourself before the doctor can hear it. As well as being relieved by a change in position, it can also be relieved by pressure. Coughing may be an exquisite experience with a good pleurodynia, but it may be made almost tolerable by holding a sandbag or rolled-up firm towel to the area before starting to cough. Whether or not you feel winded depends on the size of the region involved. is sometimes "Spasm of the oesophagous (oesophagismus) associated with the lodgement of foreign bodies ... In elderly ...
1134
patients oesophagismus is almost always connected with hypochondriasis but great care must be taken to exclude cancer." (ref 2: p 340). Several years ago while in an upper berth in a train in the middle of Russia, I tried to swallow an aspirin without liquid. The aspirin stuck about halfway down and caused an oesophageal spasm. Now that is a pain. It was really very different from angina. It was deeper and more intense than the average angina but was not associated with angor animi. It didn’t make me breathless, but it did make me sit up. I don’t think there is any way a person with oesophageal spasm could stay lying down. In angina and asthma, of course, you may feel better sitting up, but the feeling does not have the same imperative quality. Interestingly, the oesophageal pain radiated to my ears and never down my arms, whereas angina has never radiated to my ears. The presence of this condition must be pancreatitis considered in all abdominal cases which come on suddenly with intense pain in the epigastric region, vomiting and distention of the abdomen." (ref 2: p 458).
"Acute
...
relieved by any change in position. I felt better, however, curled up and splinting the right side. "Medicine is learned by the bedside and not in the classroom."
"Observe, record, tabulate, communicate. Use your five senses." (ref 1: p 200-01).
Having experienced over the years several of the disorders causing precordial and/or epigastric distress, I have become convinced that there are enough differences among them that the diagnosis can almost always be made by means of an adequate history and physical examination. After that, confirmation should be sought in the laboratory with one or two well-aimed tests. Sometimes letting a patient talk for a few minutes will save many minutes of mulling over conflicting computer reports. REFERENCES 1. Bean WB, ed. Osler’s
2. Osler
Aphorisms. New York: Henry Schuman, Inc, 1950. W. The principles and practice of medicine, 1st ed. New York: Appleton, 1892.
Point of View
I have had one attack of mild pancreatitis. This pain also radiated to the ears. It is lower in the epigastrium than any of the others and was also relieved by sitting up and forward. It also was oppressive and, unlike angina and the others, caused pronounced perspiration. "Gastric ulcer seldom has classical
symptoms." (ref 2: p 307).
Acute ulcer disease also causes pain in the epigastrium but it is nowhere near as severe as the others. It becomes intolerable because you know that (untreated) you will have the pain again and again and again. It is usually aching in character. Depending on location, it may be relieved by position (for example, if it is pointing backwards, it may be relieved by leaning forward). It is characterised by its absolute rhythmicity; the ulcer starts to hurt at exactly the same times every day. Only someone who has never had an untreated ulcer will tell you it doesn’t matter what you eat. Probably today’s liberal diet is related to the efficacy of ulcer treatment. However, a person with an untreated ulcer would as soon take hemlock as coffee, straight whisky, aspirin, or hot peppers. Having had both gastric and dudodenal ulcers, the only difference I have ever noticed is that sometimes I could delay the pain of the gastric ulcer by omitting
breakfast. "Bitter fluids may be brought up. In other instances a clear watery fluid is ejected (pyrosis or water brash). (ref 2: p 317).
In my experience of diaphragmatic hernia real pain occurs only if there is associated oesophageal spasm or peptic ulcer. Pyrosis or heartburn, which may be associated with a hiatus hernia, is not a real pain but is usually a mild burning anywhere from the back of the throat to the epigastrium. Isosorbide dinitrate, as well as being useless in angina, is the only substance that inevitably gives me pyrosis. Neither Russian vodka with pepper nor Mexican jalapeno liquor caused me pyrosis anywhere near as severe as that caused by isosorbide dinitrate. "The best thing nature can do with gall stones is to close the stone quarry.
(ref 2: p 317).
The pain of acute cholecystitis is not relevant to a discussion of precordial and epigastric pains because, in my experience, it is in the region of the gallbladder. I should say, however, that it is as severe as severe angina but is not associated with angor animi. It radiates to an area below the right shoulder blade in my experience, and it is not totally
QUALMS ABOUT QALYs ALWYN SMITH
Department of Epidemiology and Social Oncology, University of Manchester, Christie Hospital and Holt Radium Institute, Kinnaird Road, Manchester M20 9QL
THE
QALY (quality-adjusted life-year) is an index designed to take account of the quality as well as the duration of survival in assessing the outcome of health-care procedures or services. It was first proposed in the United States and has been developed in this country by Professor Alan Williams and his colleagues at York University. The apparent simplicity of the technique has commended it to many. I join in the general respect for those who have developed it but believe that there are many grounds for caution in its general adoption. Not the least important of these is the widespread lack of understanding of the technique and its implications and limitations. This paper is offered as both an exposition and a critique of the QALY. The QALY is derived from a modification of standard life-table procedures. Doctors will probably be most familiar with the use of these procedures in the comparative of treatments for chronic disorders-and for especially malignant disorders. In this application the life-table is a way of presenting data on the survival of patients who may have been followed up for varying times since the start of treatment. Their observed mortality is used to calculate the proportional attenuation of a treated population at defined times after the start of treatment. In reports of survival after treatment for cancer it used to be common to summarise the life-table by quoting the proportion surviving at 5 years. It is more informative to calculate the mean survival time of those who have survived to some specified point after the beginning of treatment. Standard life-table procedures deal with simple duration of survival. Williams and his colleagues have proposed that each year of life contributing to the life-table should be multiplied by a fraction expressing the impairment of the quality of life experienced by survivors. A summary measure is then calculated just as in an unadjusted life-table. From this value and from the cost of a treatment or assessment