The Hypochondriac's Guide to Life. and Death.

by Gene Weingarten

  Here are the answers to some commonly asked questions about cancer.

  Let’s say you have cancer and are really depressed and want to drown your trouble in alcohol. What is the worst cancer to have?

  That would be Hodgkin’s disease, a cancer of the lymph system. People with Hodgkin’s disease sometimes get a searing pain in their lymph nodes every time they drink alcohol. No one knows precisely why.

  What is the silliest form of cancer?

  I would vote for a “chloroma” which shows up as a bright green lump. It can pop up anywhere. A 1970 article in the New England Journal of Medicine reported the case of a chloroma patient who had, literally, a green thumb.

  Wait a minute. Is that any sillier than a pheochromocytoma?

  Maybe not, now that you mention it. Pheochromocytomas usually hit you in the adrenal gland, above the kidney. This causes headaches and heart palpitations and hypertension and, sometimes, strange and overwhelming sensations of anxiety every time you pee.4

  What is the creepiest form of cancer?

  A teratoma. No question. This is a rare tumor that can arise in the male and female gonads. It sometimes has hair or teeth.

  What are the two most terrifying words in the whole entire world?

  That would be … heart cancer.

  What? You can get tumors in the heart??!!!!???

  Yes. And they can be pretty danged wild. The most common tumor that originates in the heart is something called a myxoma, which tends to grow like a blobby round mass from the inside wall of the heart chamber. Sometimes it will plop onto the valve like the float ball in a snorkel, instantly cutting off all blood flow and causing unconsciousness. You are on the precipice of death. Now here’s the nifty part: When you collapse, your body goes horizontal. The snorkel ball rolls out of the valve, and you wake up. This is occasionally how myxomas are discovered. They tend to be benign, and can be removed with surgery.

  So heart cancer isn’t so bad?

  Alas, it is. Myxomas are the most common tumors that originate in the heart, but they are not the most common tumor of the heart. Most heart tumors are metastases from other body systems, such as the lung, breast, skin, or kidney. By the time they get to your heart, they have spread elsewhere, too. This is very, very discouraging. Medical texts are usually short on adjectives, particularly scary ones: When the news is bad, they typically express this through dry statistics, mortality projections, and nearly incomprehensible prescriptions for last-ditch management (“hemodynamically significant effusions warrant pericardiocentesis to obviate life-threatening cardiac tamponade …”). With metastatic tumors of the heart, the textbooks make an exception. The most hopeful-sounding prognosis I found in any book was … “dismal.”

  1 Thus violating the ancient newspaper convention that all tumors must be compared in size to fruits and vegetables. I am hoping this is the start of a new era of creativity in tumor comparison. Just once I would like to see a doctor describe a tumor as “the size of a cheese blintz.”

  2 The epididymis feels like “a knotted strand of al dente spaghetti,” according to The Art and Science of Bedside Diagnosis, a colorful, highly eccentric text for doctors that relentlessly compares body parts to food. For the record, the testicle “feels like a hard-boiled pigeon’s egg.”

  3 James Lileks contends that God placed the testicles on the outside of the body specifically to torment hypochondriacs. He points out that if one is a man, one’s testicles are particularly unsettling terrain: They are the only actual internal bodily organs that are right out there in the open. You can inventory the lumps, even in the privacy of your own pants. Apparently having no sense of personal dignity whatsoever, James happily discussed this for publication. He observes that if it were possible to extrude your pancreas from your navel and examine it for lumps, hypochondriacs would be examining their pancreases forty times a day. With their testicles, they can do this, so they do.

  4 This is actually not the oddest phenomenon involving the act of urination. In “micturition syncope” a miscommunication between the vagus nerve and the blood vessels causes people to faint when they pee. Also, sometimes a tumor or ulcer will open up a hole connecting the colon and the bladder. This will cause people to urinate feces, and sometimes to exhibit pneumaturia: farting through the penis.

  Ulcers and Other Visceral Fears

  When I turn on my computer, after a series of clicks and groans, a message flashes and asks me if I am aware that my printer is not connected. (I disconnect my printer because it is also a fax machine, and if I keep it always operational, everyone who tries to call me would hear a high-pitched whine, as though this were the answering machine at the residence of Isidore the Bat.) Then another icon comes on to inform me that my sound has been disabled. (I disable my sound because I cannot stomach the “ta-daah!” drumroll that accompanies routine operations, such as reaching the end of a document, because it makes me feel like a four-year-old being extravagantly praised for remembering to flush.) Then my computer tells me it is performing a virus scan, though it has never, to my knowledge, actually found a virus, so this message is pretty much like the 120 on the speedometer dial of a Ford Escort. Then, finally, I try to actually type something and the computer says: ERROR IN WRITING TO FILE-ABORT? RETRY? FAIL?

  It is the annoying price we pay for technology. In the world of computers, this is called telemetry. It is the same technology that allowed NASA scientists to have feedback from a spacecraft, complex technical information verified by simultaneous data, so they instantly knew when Alan Shepard, unwilling to postpone a launch, peed in his space suit.

  Telemetry is the bane of the hypochondriac. The ordinary person is like an ordinary eighteenth-century piece of farm equipment—say, a wheelbarrow. He operates without much self-awareness. Fie will know he is in need of repair when his wheel falls off. But the hypochondriac is like a wheelbarrow designed by Microsoft. He has constant two-way communication between his body and himself. He is trying to perform ordinary tasks, such as lumbering up a hill with a load of fertilizer, when suddenly an icon flashes to tell him that rust has been detected on the starboard cotter pin.

  One intriguing medical hypothesis is that the hypochondriac is not so much a neurotic as a person who is unusually sensitive to, and in tune with, the mechanics and rhythms of his body. He can actually feel his food digesting and his kidneys manufacturing urine. He is bedeviled by sensations of which other people are unaware.

  Nowhere in the body are the incoming signals so prevalent, and so prone to misinterpretation, as in the abdomen. This is because unlike other body systems, the abdomen is a confusing mass of slop, thrown together willy-nilly into a space way too cramped to contain it all. It is like a house that has been flattened by a meteorite. You are likely to find the toilet in the living room. That is what your abdomen is like: Things that have nothing to do with one another are bosom buddies. Your liver is right there next to your lungs. Your spleen is tucked away near a kidney, just down the pike from your descending colon. Food is constantly hurtling around in lumps resembling tumors. Insignificant gurglings are sometimes indistinguishable from life-threatening burblings. It’s confusing. The skill and science of diagnosing abdominal problems often involves the very basic matter of fighting off extraneous information to figure out the precise source of your discomfort.

  When you went whining to your mother complaining of pain, she asked, “Where does it hurt?” This diagnostic technique operated on the reasonable assumption that if your foot hurt, you probably had something wrong with your foot. Not so with the torso. If the top of your left shoulder hurts, right where an epaulet would be, that could mean you have a ruptured spleen, which is down near the intestines. Really. This is a phenomenon known as “referred pain.” To the normal person this medical misdirection is fascinating, but to the hypochondriac it is unnerving. The hypochondriac desperately needs some basic sense of order, some way of limiting his fears to a manageable number of potentially disastrous explanations. If
the hypochondriac feels a searing pain in the pit of his stomach, he wants to be fairly sure it is an ulcer, or pancreatic cancer, something vaguely predictable about which he can haunt himself. He does not want an entire vista of other possibilities to open up. He does not want to think that the pain in his stomach might be the first sign of a coronary. But it might be. Heart attacks, particularly serious ones in the lower reaches of the heart, sometimes feel exactly like a perforated ulcer.

  Meanwhile, a perforated ulcer can feel exactly like a shoulder strain!

  A rupture of the esophagus can feel like a heart attack!

  A shooting pain in the back, directly beneath the right shoulder blade, can mean cholecystitis, which is a serious inflammation of the gallbladder. Pain in the lower back and side, radiating to the genitals, can mean kidney stones. Pain when you take a deep breath may have nothing to do with your lungs—you could have peritonitis, a serious inflammation of the membrane that covers the wall of the abdomen; you could also have an infection in the membrane around the liver.

  And so it is that when he asks where it hurts, the skilled gastroenterologist sometimes views your answer the way a classy French chef views a kosher dill pickle: mildly amusing, certainly interesting on its own terms, but too gauche to actually you know, use. Books on diagnosis are filled with helpful hints for how to listen to a patients complaint and then surreptitiously figure out what really ails him.

  For example, The Mosby Guide to Physical Examination, a bible for the diagnostician, urges the doctor to scrutinize the eyes of the patient as he examines him. If the patient keeps his eyes open, it suggests there may be something seriously wrong. If he keeps his eyes closed, it suggests there isn’t.1 The book also proposes that the doctor offer the patient something tasty to eat; if he is really sick, he probably won’t accept. And last, there is the so-called Apley rule: The doctor asks a patient who seems otherwise healthy to point to where it hurts. If he points directly at the navel, the doctor should suspect that the pain is psychosomatic. The farther from the navel the perceived pain is, says the Apley rule, the more likely it is to be organic in origin.

  Sometimes localizing your pain is not easy, and a doctor will try to elicit the Markle sign. This is an ancient, primitive test that reeks of quackery. It is one of those things that seem stupid but often work.2

  * * *

  Stand straight and rise up onto the balls of your feet, then suddenly relax so your heels hit the floor and jar the body. This can induce pain in the primary area of your problem; it can help diagnose appendicitis, gallbladder disease, diverticulitis, pelvic inflammatory disease in women, and peritonitis.

  * * *

  The gastroenterologist has spent his professional life refining techniques of physical diagnosis; he is skilled in squeezing you and thumping your body and listening for signs of inflammation, or rupture, or fluid buildup.3 On the one hand, it would be irresponsible and simplistic to attempt to summarize the art and science of abdominal diagnosis in a measly page or two. On the other hand, many popular, critically acclaimed books, such as the Old Testament, also oversimplify. We are told Adam and Eve begat Cain and Abel, and then we immediately learn Cain begat Enoch. Surely they left something out. Was there someone named Betty they didn’t tell us about?

  If God can oversimplify, who am I to draw a line?

  As he is examining you, your doctor is drawing lines. He is mentally partitioning your body into sections, the way butchers look at a cow and see those dotted lines separating the tenderloin from the rump. Your doctor is imagining a line running vertically from your sternum through your navel to the pubic bone, and a second line horizontally through the navel. This creates four quadrants. To these he adds at least one more region, tracing a circle just below the breastbone, about the dimensions of the top of a coffee can. He has highfalutin clinical names for these regions and their subregions, but the names are arbitrary. We can be arbitrary, too. We will name them after things that can hurt: Love, Hubris, Impulsiveness, Bad Clams, and Kissing a Wall Socket.

  Pain in “Love” (Upper-Left Quadrant, Near the Heart)

  Ruptured or inflamed spleen. Look for pallor and intense pain that worsens when the foot of the bed is elevated. Also, pain at the top of the left shoulder. The spleen usually ruptures because of physical injury, but it can become inflamed and painful for many scary reasons. Tumors can cause an interruption of blood flow to the spleen, causing the death of tissue. A swollen spleen can be a symptom of dozens of treacherous diseases, including leukemia, lupus erythematosus, Hodgkin’s disease, polycythemia rubra vera, which attacks the bone marrow, and amyloidosis, a mysterious illness that leads to tremors, fainting spells, heart failure, and death.

  Aortic aneurysm, a ballooning of the wall of the thoracic branch of the body’s largest blood vessel. Look for accompanying lower back pain; if this aneurysm ruptures, the pain will become explosive. You are rushed to surgery. It is usually too late. Most victims die from internal hemorrhage.

  Pain in “Hubris” (Upper-Right Quadrant)

  Liver disease. Could be cancer or hepatitis, or sometimes both. With hepatitis, look for fatigue, jaundice, lack of appetite, and what medical books cheerfully call “cola-colored urine.” By the time liver cancer is diagnosed, it has often spread to or from other body systems, and in that case you are a goner.

  Cholecystitis, an inflammation of the gallbladder. Can be caused by gallstones or infectious disease. Look for relentless pain, vomiting, fever, aching near the shoulder blade.

  Leaking duodenal ulcer. Look for episodic gnawing pain, heartburn, belching.

  Pain in “Impulsiveness” (Circle Below the Breastbone)

  Perforated stomach ulcer. Suspect it where there is a history of long-term stomach pain characterized by a dull, burning ache two to three hours after eating. Suddenly this will yield to excruciating pain, cold sweats, gray pallor, vomiting. Untreated, it can lead to peritonitis and death.

  Acute pancreatitis. Look for knifelike pain that seems to bore straight through to the back, and sometimes radiate to the top of the left shoulder. The central pain will later migrate south and toward the right. Sitting and leaning forward lessens the pain. Sometimes the navel dimples inward.

  Pancreatic cancer. Look for weight loss, depression, jaundice, pain in the lower back. Pancreatic cancer has a very, very bad prognosis by the time pain has developed; it often spreads to other systems before it is diagnosed.

  Stomach cancer. Look for a steady ache, radiating to the back.

  Volvulus, a twisting of the intestine on itself, like a Boy Scout’s half hitch. Look for pain at the lower reaches of this region, with abdominal distension, nausea, vomiting. This can also kill you if not caught in time.

  Pain in “Bad Clams” (Lower-Left Quadrant)

  Diverticulitis, an infection and inflammation of pouches in the large intestine. Look for flatulence and stomach rumbling.

  Colon cancer. Look for severe constipation preceding the pain.

  Pain in “Kissing a Wall Socket” (Lower-Right Quadrant)

  Appendicitis. Aching pain, nausea, vomiting, extreme tenderness when one finger is pressed down on the so-called McBurney’s point, which is about six inches directly to the right of the navel. Over the previous few days, the pain will have migrated down and to the right, from a few inches below the breastbone.

  Regional ileitis (Crohn’s disease). Look for severe pain following diarrhea. This is a debilitating condition of unknown origin that often requires surgical repair of the intestine, and sometimes a colostomy.

  Here are answers to some commonly asked questions about the abdomen.

  Can you die of stomach pain?

  Yes. Anton Cermak, the mayor of Chicago, was shot to death in Miami in 1933. His assassin, Giuseppe Zangara, told police he had been crazed from the pain of an upset stomach. So, in a sense, Mayor Cermak died of stomach pain. Just not his own stomach pain.

  I just had a large, greasy meat at Earl’s House of Undercooked Poultry. I have
a terrible stomachache and nausea. Might I have ptomaine poisoning?

  No. There is no such thing as “ptomaine poisoning.” Ptomaines are nitrogen compounds that are released by rotting meat, and they were once thought to be poisonous. They are not; in fact, ordinary digestion produces ptomaines in the body. There is probably rotting meat in your intestines right now. I don’t know how people can go about their lives knowing that inside their intestines are things that could make a vulture puke. Or what about food in the mouth? How’s this for a foolproof diet: Every ten seconds during a meal, you are compelled to open your mouth, look in a mirror, and observe the contents before you swallow. How come no one has ever proposed that diet?

  What is the scariest thing that abdominal pain can mean?

  I am not sure I should reveal that. Hypochondriacs might get alarmed.

  Oh, c’mon.

  OK. Sometimes a person—usually a man in his thirties, forties, or fifties—will feel a dull ache in the “Hubris.” He will ignore it. It isn’t very severe, and he is a tough guy. Soon he will find that he has a rather nice suntan, even if he isn’t out in the sun much. Still, no cause for alarm; this may actually please him. If he is a black person, his skin may lighten, turning a handsome brown-gray, like Ossie Davis. Months or even years may go by Then the man notices pain in the joints. He starts getting lethargic. Maybe his thinking gets a little confused. His heartbeat becomes irregular. He goes to a specialist. Maybe a cardiologist, for the heart symptoms. Or a rheumatologist, for the joints. Or a gastroenterologist, for the abdominal pain. Or a neurologist, for the mental confusion. Or a dermatologist, for the skin changes. Each specialist suspects and tests for some disease with which he is familiar. Nothing checks out. Months pass. Medical books liken this process to the blind men and the elephant: Everyone sees what he expects to see. No one sees the big picture.