HOUSE DOES IT AGAIN.

House has been our favorite TV show for some time. The reason is that Dr. Gregory House deals in medical truth. He does this both in the way he behaves and in the way he works up patients. For example, House is addicted to opiates, due to nerve injury in his leg.

Basically he reminds us that pain hurts, and that those who have it are not more stupid, nor weaker than those not in pain. “If you have a buttload of pain, you need a buttload of pills.” This politically incorrect and medically incorrect statement is nevertheless humanly correct. If someone were to insist House give them an analog scale of 1-10 on his pain, House would do something to actually give them pain, so they stop asking him questions which cannot be answered.

The analog scale is supposed to be about pain. However, what it really is about is INTENSITY. Pain intensity is, unfortunately, only ONE aspect of pain. If you carry a sack of groceries two blocks, they are not so heavy. If you have to carry them across the plains, they are VERY heavy. Those manageable groceries of two blocks will make your arms fall off somewhere around Omaha.

Central Pain is the worst pain state known to man because it is severe AND because it lasts. There is nothing which covers that on the oxymoronic, paradoxical, but impressive sounding, “digital analog scale”.  Translation: Someone has been playing you for the fool with the scale.

As every medical student not roped onto the Procrustean analog scale bed knows, pain must be evaluated as to quality, similarity to prior pain, exacerbations and relieving aspects, duration, intermittency, radiation, and location. All of these very important aspects are conveniently ignored in the 1-10 system. Consequently, the examiner risks remaining completely ignorant of central pain.

Because of this, medical science is leaning toward abolishing the term, “central pain”, which has unique clinical manifestations, and lumping it under the much less specific term, “neuropathic pain”.

If only we could summon Dr. House to put these befuddled, hurried clinicians in their place, by insisting they actually take a history and do a physical which differentiates Central Pain from all other conditions. The definitive test takes approximately ten seconds and was discovered back in the 1800’s by S. Weir Mitchell. It was confirmed by Carl Saab, one of the contributing authors here–now at Yale. We owe that marvelous institution known as Johns Hopkins Medical School, the flagship center for a very long time, to Mitchell’s efforts to bring in foreign doctors, such as Osler, to upgrade American medicine.

During the Civil War, Mitchell discovered that he could identify pain of central origin by applying light touch. If the pain was instantaneous, there was injury to a PERIPHERAL NERVE.  If the application of light touch required a latency of twenty or more seconds before exacerbation of the burning occurred, the pain was of central origin.  

He also established for his own mind that Central Pain was severe (despite his handicapping lack of a 1-10 scale) by noting that some of his bravest soldiers developed the temperament of “the most nervous girl” after acquiring Central Pain. This was evidence enough for Mitchell that nerve injury was terrible. He subsequently dedicated a wing at Hopkins to study of nerve injury.

Since then, things have gone downhill, so that Central Pain has shrunk in importance, until now it is in danger of being abolished altogether in medical terminology. After all, there are lots of other pain patients who offer up similar numbers on the 1-10 scale.  No one is looking to see if they have the temperament of a nervous girl. Either Americans are getting braver, or the disease is badly misunderstood.

However, there is still Dr. Gregory House. In Season 5, episode “Last Resort”, in order to induce very severe pain, House injects his fellow as well as the patient, with Capsaicin, in a small area. Both moan and wince. Capsaicin induces a burn something on the order of the dysesthetic burning of Central Pain. The House portrayal of Capsaicin injection may not capture much attention, but those of us who have to live with this, not just as a diagnostic test, but as a way of life, took notice of this episode. We also could not help thinking that while the two on House just had the pain in one little area, that many of us must endure it over the entire body.

So we are down to Dr. House, but because the pain is real, we know that eventually some real doctor will notice. He will have to “not care what others think” as much as House, because nearly everyone else is missing this symptom. That is because it is not THEIR pain. If it were, then nothing much else would be of concern.  Sound self centered? There is the Capsaicin on the pharmacy shelf, ready to test your moral judgments. Don’t forget to inject it everywhere.