What they don’t teach you in medical school about pain (and some of what they do)

Patients always complain of backache. Nobody ever tells you they’ve got frontache.

Harold Ellis, Professor of Surgery, Westminster Medical School

When I was a student the emphasis was on the diagnostic information that you could get from pain. Where is it? What brings it on? Is it sharp or dull? Is it constant or does it come and go? When I first started practising it became apparent that it seldom fits into these simple categories, and as I grew older and experienced various pains for myself I came to realise the importance of remembering that whatever they teach you it ain’t necessarily so.

A doctor questioning someone about their pain is trying to work out what is causing it. To the patient, however, this approach can give the impression that they are not being taken seriously, and they tend to be much more interested in conveying the severity of their pain, even if it isn’t particularly useful from a diagnostic viewpoint. I saw endless Indian ladies with not much English coming through the doors of Watford General Hospital, and the only history I could get from them was “Too much pain, Doctor”. I used to wonder how much pain was enough until I discovered that in Hindi “a lot” and “too much” were the same word.

My grandfather’s reminiscences were my first introduction to the different priorities of doctors and their patients. He was a pilot in both World Wars, in the Royal Flying Corps and later the RAF. During the former he was unfortunate enough to be shot down (he always maintained) by Hermann Göring (this is certainly plausible, as Göring’s triplane was distinctive and his many air victories in the air are a matter of record). Fortuitously he landed in the grounds of a hospital and with his leg broken in fifteen places he was taken to see a surgeon who,so the story goes, had already been operating continuously for 24 hours. The easiest thing would have been to amputate, but according to my grandfather the surgeon rose to the challenge and said “I am going to save that leg”. While recovering from the surgery my grandfather was not particularly troubled by post-operative pain except in his hallux, where it was agonizing. (For non-medics this is the big toe. It is important to have a clear and unambiguous naming system for parts of the body, and every bump, hollow and crease has an anatomical name. When it comes to the extremities, to avoid confusion between thumb and four fingers vs. digits 1, 2, 3, 4, 5 they are all named. The thumb is the pollex (or just the thumb) and the great toe is the hallux. The fingers are usually known by their English names, index, middle, ring and little, or pinky in the US, which was also the name of my brother’s teddy bear. In Latin, index, medius, annulus and minimus. Similarly for the toes – market, home, roastbeef, none, wee-wee.) With his more serious injuries nobody took much notice of this and it was several days before a piece of shrapnel was found there.

There’s another thing they always say: “It was like a hot wire going through me, Doctor”. Then one day I saw a factory worker who was impaled on a hot wire in an industrial accident. My curiosity aroused, I asker her what it felt like.

“The funny thing is, Doctor, I never felt a thing.”

Harold Ellis, Professor of Surgery, Westminster Medical School

They say that if a man complains of his heart, examine his stomach, and vice versa. Certainly pain is often felt somewhere other than the site of pathology. It isn’t very useful, for instance, to be able to scratch your gall-bladder or your colon if there is something irritating it, so we have never evolved any good way of localising pain except on the surface. On the other hand, if there are two inflamed surfaces rubbing against each other (e.g. pleurisy, pericarditis, appendicitis) then there is a clear relationship to breathing and movement, particularly if one of the surfaces is parietal rather than visceral (the lining of a body cavity rather than its contents). Another useful rule of thumb is that pain (and sometimes even tenderness) radiates distally. Pain from a sore hip is often felt in the knee, and nerve root irritation in the spine causes pain anywhere in the territory of the nerve (e.g. sciatica).

If there are two pathologies affecting a nerve, for instance cervical spondylosis and carpal tunnel syndrome, or neuropathy plus a disc, the pain can multiply, which is worth bearing in mind if it seems worse than you are expecting.

Old-fashined neurologists are very good at working out this sort of thing. They can examine the patient with feathers, pins, tuning forks and the keys to their Bentley (back when consultants earned more than footballers; those were the days…) and tell you exactly where the lesion is, though to some extent this is all a bit redundant now we have MRI scans. I worked for a neurologist once who paged his Registrar to come to his office and bring some GTN (this is medical terminology for nitroglycerine, which as well as being the main ingredient in dynamite is also a potent vasodilator). When she arrived he was pale and sweaty,

“You look terrible. What’s the matter?”

“I’m having an inferior infarct.”

Trust a neurologist to identify which coronary artery was blocked purely on the basis of how he felt.

Doctor, Every time I have a heart attack I go yellow.

Attributed to a patient, as told by Harold Ellis

One type of pain we learn about is colic, which is a poorly-localised but particularly distressing pain involving smooth muscle contraction in the wall of a hollow viscus (for non-medics this is the singular of viscera). We have all experienced bowel colic from gastrointestinal infections, in the mid-abdomen for small bowel and the lower abdomen for large bowel so you should know what I mean. We are taught that renal (strictly uereteric) colic due to the ureter being blocked by a stone, starts in the loin (this is where your thumb is when you are akimbo; if you don’t know what akimbo means then look it up in the dictionary) and radiates into the groin and finally the testicle, though nobody has ever told me where the pain ends up in women. We are also taught about iliary colic and that it can be distinguished by being continuous rather than intermittent, and although the level of pain can vary, it never goes away.

My first introduction to biliary colic was my first night on-call as a surgical house officer. I received a call from a GP:

“I’m phoning from the kitchen because I don’t want her to hear me. Im sending in a lady with tummy ache. She’s fat, female and forty, all the F’s, so it’s got to be gall stones.”

Although male I can nevertheless attest to the pain of biliary colic. It superficially ressembles that of a stomach upset, but it is higher up in the abdomen and much more severe, and is accompanied by a sensation technically referred to as bloating, though it put me more in mind of Sigourney Weaver’s hapless crewmates. It is impossible to do anything else during an attack (except maybe vomit); you just have to forgo the New Year glass of champagne, cancel the clinic or stop the car as the case may be. In my case it always lasted four hours, though I eventually discovered that diclofenac will reduce this to two. It is supposed to be triggered by fatty food, and what confused me initially is that there was a 12-hour gap between ingesting fat and the onset of the pain. Once I had made the connection, of course, it was easy to prevent by knowing what to avoid (in my case lamb, cheese, butter, creamy French sauces and fois gras; with hindsight if I had avoided them for longer maybe the stones would never have formed in the first place).

Having formed my suspicions and convinced a radiologist colleague to confirm the diagnosis on ultrasound (a nice fat stone), I knew I had to have a cholecystectomy, which will bring me on to another type of pain shortly. From my days as a surgical house officer I remember long sessions in the operating theatre pulling on a retractor to enable the surgeon to see what he was doing in that fiddly space under the liver, and the patient eventually coming back to the ward with a very long scar and a T-tube poking out of their side to drain the bile until the internal wounds had healed. I also remember when it leaked and the resultant biliary peritonitis and other horrible complications. I remember one poor chap who was on the ward for the full three months of my appointment (he did go home eventually). Watching all this I thought nothing would convince me to submit to this barbarism myself, but then I had never had biliary colic.

By now I was a consultant oncologist in the same hospital, and one of the juniors I had worked with back then was the hepatobiliary surgeon, so I entrusted myself to his hands. Surgery had moved on a lot since 1986 and cholecystectomies were now laparoscopic. I woke up after the operation with four small stab wounds instead of a long slice, and although I was given a couple of co-codamol tablets I didn’t really need them. I went home the following day and the colic was no more.

The post-operative pain, though mild, was nevertheless quite interesting. I am sure you will remember the mnemonic that we all learnt for the innervation of the diaphragm (and the levator ani). Imagine a football crowd chanting:

C 3, 4 and 5! Keep your diaphragm alive! S 2, 3 and 4! Keep your a**ehole off the floor!

So you can deduce that diaphragmatic pain is felt in the shoulder, also innervated by C3, 4 and 5. What they don’t tell you, however, is that it is indistinguishable from the pain of a stiff neck from sleeping awkwardly.

This brings me on to another personal observation, which is that the character of a pain seems to have much more to do with where it is felt than by what is causing it, completely the opposite of what we were taught. A headache is always a headache, whether it is muscle spasm in the neck (the commonest cause), new glasses, ‘flu, sinusitis or walking into a door. The position may vary and the intensity, but they all feel basically the same. Similarly abdominal pain. The colic of gastroenteritis feels the same as the pain in the abdominal wall from doing too many sit-ups, and the same as the pain I felt in the T12 dermatome after I collapsed my T12 vertebra three years ago from undiagnosed multiple myeloma (rather dramatically as I was squatting with a 70Kg barbell on my shoulders at the time).

(For those afflicted by tension headache, and effective treatment is an orthopaedic pillow, made from heavy memory foam and sold by Marks & Spencer, John Lewis and others. Make sure you find the most comfortable position in which to use it).

I have also started to wonder about the truth of colic always being smooth muscle spasm (or alternatively stretching of the visceral wall) as I have also been taught. I am now significantly immunosuppressed by my myeloma (I have no immunoglobulins – antibodies – in my blood at all, and one of the drugs I am on also suppresses white blood cells). This has made me very susceptible to gastrointestinal infections of all kinds, and of course increases their severity and duration (as an example my wife and I both had a runny tummy after a dodgy curry once, but she was back to normal in 12 hours, whereas 24 hours later I had lost 4Kg and I was on a drip for 3 days to correct the dehydration and electrolyte imbalance). But although I have had diarrhoea, vomiting and extreme fatigue now on many occasions in the past three years I have never had significant abdominal pain with them. If this is because I am no longer able to mount the normal inflammatory response, then there must be more to the pain then simply stretching and contracting. I don’t know, and I would be very interested to find out what is going on.

Then there is the pain that nobody ever talks about. This is the pain in the proverbial, proctalgia fugax. Almost everybody I have asked admits to getting it from time to time, including me. It is a severe, poorly-localised pain centred in the vicinity of the anal sphincter, but with no obvious associated spasm or tenderness. I don’t think anybody really knows what causes it, but I have occasionally had it so badly as to almost lose consciousness from the vasovagal reaction to it. It lasts 10 – 20 minutes, which means that oral painkillers are useless as it is gone before they can take effect. I read a paper once suggesting that salbutamol inhalers can be helpful, but they have never worked for me. It doesn’t seem to be associated with any serious underlying problem, however.

Oh the pain! The pain! It was terrible, it was. I said to my friend, I said, I’ve never felt anything like it, I said. It was so bad I could hardly eat my chocolates…

Harold Ellis

One thing all oncologists worry about is incident pain. This is pain in a band around the chest or abdomen which is severe and affected by movement and posture. It is very often due to a tumour in the spine eroding a vertebra and compressing the spinal cord, and if ignored it can progress rapidly to complete and permanent paraplegia. This is particularly bad news for cancer patients who don’t usually rehabilitate very well from paraplegia or indeed live very long afterwards. So if anybody complains of incident pain, particularly if they have any neurological or sphincter disturbance, take note. They require immediate bedrest, MRI scan of the spine and specialist assessment.

Any cancer can cause pain, and cancer pain in many ways is different from other kinds of pain. One key feature is that until you do something about them tumours keep growing, which means that symptoms will steadily get worse. As an oncologist I don’t care how severe a pain might be if it is gone again within a day or two (I mean from a diagnostic standpoint; I’m not gratuitously cruel). But anything progressive (pain, weight loss…) will grab my attention.

Actually there is a malignant pain that only lasts a short time, which is often misdiagnosed, and that is hepatic capsular pain. It can occur when there are liver metastases present, and it seems what happens is that sudden bleeding into one of the deposits can stretch the membrane covering the surface of the liver. This is very painful indeed, and the patient will lie very still, with shallow bleeding. The right upper quadrant of the liver is tender but there is no guarding, rigidity or other features to suggest peritonitis. It generally resolves after 48 hours or so but requires strong analgesia in the meantime.

Another distinguishing characteristic of malignant pain is that it is not eased by rest. Most pains improve considerably when you lie down, and you can nearly always find a comfortable position to get off to sleep. You might be really stiff in the morning, but once you get up you can generally get going again. But malignant pain really gets going at night, and gnaws away at you so that you can’t sleep and you can’t find the right position. Even if it isn’t severe it still does this. This is a very reliable symptom – if you can’t sleep due to pain it is malignant. If it eases when you go to bed it is benign.

“Please take off all your clothes, except your underpants, and lie down on your back.”

(Irish builder removes his best suit, worn out of respect for the medical profession, and lies down on his stomach)

“Good. Now turn onto your front.”

Derrick Brewerton, Professor of Rheumatology, Westminster Medical School

I can think of one possible exception, which is polymyalgia rheumatica, a common condition, particularly in the elderly, and very important to diagnose and treat promptly because if it is left alone it can result in sudden and permanent loss of sight in one eye (and then maybe the other). The patient very commonly feels non-specifically unwell, with pains in multiple joints but particularly around the shoulder girdle. This pain prevents them from turning over in bed at night, and there are few other conditions that will do this. Sometimes it is accompanied by temporal or cranial arteritis (hence the risk of blindness due to retinal artery occlusion), so also ask about headache, amaurosis fugax (showers of stars in the vision or transient blindness in one eye) and jaw claudication (ache on chewing). The ESR is usually very high and you should insist on getting it back the same day. Don’t let the patient leave your clinic without starting steroids (prednisolone 30mg daily will do), and their effect is so dramatic that all symptoms will resolve withing 24 hours. The patient has probably been unwell for months so they will be very pleased with you for this. You need to refer them back to their GP for further management at that point.

I have only once been caught out by nocturnal pain, and that was from my own collapsed T12. The pain was keeping me awake and I couldn’t understand why because at the time I thought it was osteoporosis. Once the malignant cells were seen in my bone marrow all became clear and I could breathe a sigh of relief that my diagnostic skills were undimmed.

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