A Country Doctor Writes:

Doug Leland is no stranger to back pain. After two failed back surgeries he is on long-acting narcotics in addition to high doses of seizure medications to dull the relentless nerve pain that burns day and night like an eternal fire deep inside his left leg.

A few weeks ago Doug went to the emergency room several days after slipping on his icy front steps. I read the report with some surprise. He had caught himself, and didn’t actually fall. He didn’t have broken ribs or any other serious injury, but was experiencing so much pain under his right shoulder blade that the ER doctor had decided to give him two intravenous injections of hydromorphone, a very strong, fast-acting opioid, plus high doses of a muscle relaxant and an anti-inflammatory medication.

When I saw him last week he was miserable. Every little movement of his upper body bothered him. His pain covered an area under his shoulder blade about the size of one of his large hands. Dead center in this area was an exquisitely sore spot with a palpable knot in the upper portion of his latissimus dorsi muscle. Even mild pressure on this tender spot caused a burning pain that radiated down the back of his right arm. This didn’t fit with the anatomy of any cervical or thoracic nerve.

I didn’t want to continue increasing his narcotics as they clearly weren’t providing him relief. With Doug’s ulcer history, he wasn’t a good candidate for continued anti-inflammatory drugs.

I decided to offer him something I haven’t done for a few years – a trigger point injection. They were common twenty years ago, but seem to have somewhat fallen out of fashion.

Doug was game: “Anything, Doc. Anything that might help, I’ll try it!

I mixed lidocaine and saline in a 3 cc syringe and attached a 25G 1½ inch needle. I localized the tender spot again and circled it with a ballpoint pen. I cleaned his skin with iodine and inserted the injection needle into the trigger point I had marked. I aspirated the syringe to make sure the needle wasn’t in a blood vessel.

“You’re in the right spot, Doc!” Doug groaned.

“Okay, Doug, here we go…” I told him.

A few minutes later Doug was moving his shoulders around, bending his back comfortably in all directions.

“The pain’s gone…”

“The Novocain is in the right spot, then,” I explained. “We’ll have to see if there is a lasting effect. Come back after the weekend and let me see how you’re doing.”

Doug came back, still smiling. There was a small area of tenderness several inches above where I had put the needle, but his pain was essentially gone. Doug was grateful.

“You’re a magician, Doc!”

“It’s an old trick I had almost forgotten,” I confessed.

“I’m sure glad you thought of it, Doc!”

That evening I thought more about trigger point injections. I don’t remember hearing about them in medical school or my internship in Sweden. I heard of them soon after I came to this country, thirty years ago.

I decided to do some research.

Trigger points were first described in 1942 by Janet Travell, MD. She became the personal physician to President John F Kennedy, who suffered from chronic back pain. Her first edition of “The Trigger Point Manual” was published in 1983 when I was a Family Practice resident here in the United States. I learned to inject trigger points in patients with myofascial syndrome in my residency, but this is not something all physicians learn today. Other modalities, from manual pressure to laser therapy, are now sometimes applied to trigger points.

Trigger points are thought to relate to dysfunctional end plates within the sympathetic nervous system. Acetylcholine levels and pH are thought to be important factors in myofascial pain.

The effect of trigger point injections can be reversed with naloxone, an opiate antidote. This suggests that the release of endorphins may be partly responsible for the effect of trigger point injections.

Very few articles have been published on this topic in recent years. There are few randomized controlled trials, and not all of them have found trigger point injections to be effective. One recent study found similar results for trigger point injections and acupuncture.

There are many similarities between trigger points and acupuncture points, but they have been viewed as very different in how they work. Trigger point injections, regardless of which chemical is used, are thought to cause physical changes at the injection site. Some clinicians even do “dry needling” of trigger points with the same results. The insertion of an acupuncture needle is generally thought to affect energy flow in predetermined meridians.

Intentional or accidental trigger point pressure can cause referred pain in other locations, similar to the correlation between acupuncture points and meridians. In fact, a 2006 study shows that of 255 trigger points with referred pain patterns described by Janet Travell and her collaborator, David Simons, 170 correspond to classic and 64 to newer acupuncture points and their meridians. This raises the question of whether the 70-year-old trigger point theory isn’t just Western medicine’s rediscovery of an ancient form of energy medicine. Doug’s pain pattern, radiating from the tip of she shoulder blade to the back of the arm, fits one described by Travell. It also closely follows one of the large acupuncture meridians.

What I did in the case of Doug Leland the other day may not just date back to 1942, but three or four thousand years.

“Tell me about the day you passed out,” I asked the middle-aged woman in Room 4 the other morning. “How did you feel?”

“We were up early, my husband and I, because Debbie – that’s our daughter – was coming home for Easter break. She’s on the dean’s list at Swartham College. She wants to be a civil engineer with a double in business administration. She’s so talented…”

“Were you feeling okay when you woke up?” I tried to redirect her.

“Well, Gordon looked at me kind of funny and asked if I was feeling all right…”

“Were you?”

“He didn’t think I looked well. Pasty, he said my face was… Pasty-looking!” She sighed. “I didn’t finish my toast or my bran flakes, and I usually gulp my breakfast before Gordon even gets back in the house with the morning paper.”

“Did you feel nauseous?”

“I didn’t throw up, if that’s what you mean. Gordon asked me the same thing. He felt my forehead and said I was clammy.”

“Then, what happened?”

“We got ready to go to the airport to pick Debbie up. On the way, I asked Gordon to stop at Dunkin’ Donuts and get me some Munchkins, but he was worried we’d be too late, so he talked me out of it.”

I started to be increasingly aware of the time.

“Do you remember the moments before you passed out? What did you feel?” I asked.

“I remember thinking it was hot in the luggage hall, and I remember Debbie talking about her new roommate. Then Gordon said he should have stopped for Munchkins after all, because we had had plenty of time and I was probably getting a low blood sugar…”

I changed my strategy and asked several more directed, yes-or-no questions. I formulated a plan for what kind of workup to do.

The rest of the day I kept thinking about that encounter. Over the years I have seen so many patients who don’t seem to be able to describe or even recognize their own feelings, but instead tell me what other people notice about how they appear to them. I have often wondered if there was a name and a psychological profile for people like that. They are a challenge to take a medical history from, but they must also be challenged themselves by never really knowing how or what they feel.

Last night after supper, my brother-in-law called from the west coast. While my wife talked with him, I Googled my question.

“Inability to describe own feelings, relying on other people’s description” I typed.

The third link on my search gave me the word I needed: “What is alexithymia?” The literal meaning of a-lexi-thymia is “lack of words (for) emotion”. I searched for “alexithymia” and a half-dozen articles completely captured my attention while my wife and her brother continued their telephone conversation.

What I read resonated with my own observations. Curiously, the first website I looked at had been posted or updated the day before my search and the original article by P.E. Sifneos, introducing the word and describing the phenomenon, was published in 1973 – the year before I started medical school. It took me this long to “discover” it myself!

Alexithymia is not classified as a disease in DSM-IV, the psychiatric book of diagnostic definitions. It is rather more like a personality type. What I found fascinating as I read along is the link between alexithymia and psychosomatic illness.

People with alexithymia can’t tell if their bodily sensations represent physical or emotional phenomena, because they have trouble registering their emotions. They are likely to look for physical illness as an explanation for sensations others may easily recognize as related to strong emotions. An extreme example from one of the websites I read was that a crying alexithymic might worry about having a blocked tear duct instead of registering their sadness. A person with little insight into how upset, sad or anxious he or she might be would not have any ability to judge whether they might feel bad, be it headache, chest pain or belly cramps, for emotional reasons.

One article suggested up to 10% of people have some degree of alexithymia.

Those impromptu few minutes on the computer made me a wiser clinician. I will be more tenderhearted with patients who have trouble describing their feelings in a fifteen-minute visit, and I will look harder for that trait in patients whose symptoms baffle me.

Talking with my wife on the phone at lunch today, I asked in my usual manner:

“Was there anything interesting in the mail?”

She hesitated for a moment before answering:

“There’s a letter from the Board of Medicine.”

My mind switched into a higher gear.

“A letter? Not a mass mailing?”

“No, it’s a regular, business-sized envelope.”

“Does my name look typed, or is it a mailing label?”

“It looks typed.”

I have had a couple of letters from the Board before. Many years ago two disgruntled patients complained about me. One wasn’t happy that I stopped prescribing pain pills, and another wanted me to provide care via email. Both times all I had to do was give my side of the story, and the complaint was dismissed without merit.

“Was this a letter about a complaint against me?” I thought to myself. I didn’t know if such letters came registered mail or not.

“Do you want me to open the letter?” my wife asked.

“No, save it for me to open when I get home.”

I had arranged to be off this afternoon in preparation for a weekend trip. A surprise April snowstorm thwarted our travel plans, so we had changed our plans to include a nice, early Friday dinner and a classic movie by the fireplace.

“Would the letter from the Board change the mood of our Friday evening and quiet weekend at home?” I wondered to myself. It had already made me feel a little uneasy the moment I heard about it. It could be a simple announcement of some type; it wasn’t necessarily something unpleasant, although I supposed it might be.

As a physician in America, I work very hard. I strive to do what is medically correct and also to take care of each patient’s need to understand and take responsibility for his or her condition. Sometimes when you read the headlines, it feels as if doctors are never safe from criticism and litigation for being humanly fallible.

“Was it my turn now to be called before the Board of Medicine because I had failed in someone’s eyes, or offended someone inadvertently? My mind wandered as I drove through town to do a few errands on my way home. “How bad could it be?” I tried not to worry.

It had already started snowing by the time I got home. The letter waited for me on the dining room table. I opened it quickly.

With a feeling of relief I read the first few words. The letter was addressed to all physicians with licenses coming up for renewal after May 1 this year:

“Written Exam Required at Renewal” it began.

When I renew my license next time, I will have to take an exam about the Board’s guidelines regarding Informed Consent.

One more hoop to jump through to prove myself worthy of continuing to practice medicine, nothing personal…

Edgar Bowler relies on his much younger wife, who sees one of my partners, to help him keep track of his appointments and drive him to the office. Both of them have multiple medical problems and between them they take well over a dozen different medications. She usually handles their prescription refills and pill minders. Some of their medications are quite expensive and not all of them are covered by their insurance, so our office sometimes helps them out with samples.

Recently, Jane Bowler had eye surgery and Edgar had to step in with the help of his son-in-law, Jonathan, and take care of their medications. They came in to pick up a bag of several kinds of medication samples we had saved for them.

A few days ago, Edgar made an urgent appointment for hives. He was literally covered with them. Fortunately, he didn’t have any trouble with his breathing, but I did prescribe both steroids and antihistamines for him. At first, he had no idea what had caused the hives, but as I went down the usual list of considerations, he exclaimed:

“New medications, yes, there was a new one in the bag Jonathan and I picked up a while ago, that might have been it!”

“But I haven’t prescribed anything new for you,” I protested.

“You didn’t?”

“I think we need to take a look at those pills, Edgar. Could you bring them in for us to look at later on?”

Edgar left with his allergy medication prescriptions. Later the same day he returned with all his pills, neatly laid out in his two-week pill-minder.

The ones that seemed to have caused his hives were off-white, oblong, and imprinted with “LILLY 4165”.

The offending drug turned out to be Evista, a selective estrogen receptor modulator, used occasionally for postmenopausal women such as his wife, Jane, and never for men.

How does one explain that on Edgar’s list of allergies in his medical record?

Sally Straub is the only lawyer in town. Her father was the town lawyer before her. He went on to become a judge. Retired from the bench, sharp as ever at 78, he is still “of counsel” with his daughter’s law practice.

Sally is a sympathetic, no-nonsense woman with a big heart in a petite body. She is involved with every imaginable charity and public service organization in our community. Her husband, Jack, is a retired professor from the college up the road.

After knowing her for years, I learned that Sally was battling chronic anxiety and insomnia. To most people, she seemed to be the personification of self-confidence, but she constantly doubted her abilities, even though her social and professional accomplishments were remarkable by anyone’s standards.

“I’ve been in therapy on and off for most of my life, and I’m still not any closer to peace of mind,” she said the other day, adding, “and I don’t want drugs for this!”

I didn’t know quite what to say at first. I only had a few minutes scheduled with her, but she seemed to be at a point where she needed me to help move her forward, somehow.

Guided by a gut feeling, I asked:

“Do you have any regrets in your life?”

She seemed frozen for a few moments. Suddenly, tears welled up and she leaned forward, staring at her hands, which were now folded in her lap. She began:

“You know, Jack and I never had any children.”

I nodded. “I know.”

“Well, you don’t know this, but I was married once before, when I was in college. He was also a pre-law. My parents never liked him. I got pregnant and he didn’t want children. I didn’t feel I could tell my parents, and all the people who knew me told me to just have an abortion. I was scared.”

“So, that’s what you did…” I asked.

“Yes. They offered me counseling and everyone said it was just like having a tooth extraction. I knew right there on the operating table that I had made the wrong decision. I can still hear the sound of the suction device. I hear it every night, echoing in my head when I try to go to sleep. I imagine my daughter – I’m sure it was a girl…”

“And you never told your therapists?”

“They never asked. Or they didn’t seem ready to hear what I felt inside.” She wiped her eyes. “Paul’s and my marriage fell apart and we both moved on. I got busy with law school and my career.”

“Did your parents ever find out?”

“I never told them.”

“Does Jack know?”

“Yes, I told him when we first got together and he’s so sad, because he’s sterile.”

“Do you still blame yourself for making the choice you made back then?”

“Terribly.”

“You and I are about the same age. I know what many people said back then, but that probably wasn’t at all consistent with your values, and people didn’t know then what kind of grief reactions abortions created. Let me get a book I’d like for you to read,” I said. “I’ll be right back, okay?”

She blew her nose and nodded.

I quickly found the thin, blue volume in my office bookshelf and brought it back to Sally.

She took the book from my hand.

“The Four Steps to Healing,” she read out loud.

“It was written by a psychiatrist. It will help you get started. But you’ll need a therapist who understands and respects your values without trying to be politically correct. I know someone who might be able to help you.”

“I feel silly, fifty-eight years old and falling apart over something that happened almost forty years ago.”

I reached both my hands out toward her and she grabbed hold of them and squeezed them briefly.

I wrote the phone number on the back of one of my business cards. “Promise me to call Diane Fehrer soon.”

She nodded. “I will. Thanks.”