Everyone knows the classic symptoms of a heart attack: pain below the sternum in the center of the chest, sometimes radiating to the neck or jaw or down the inside surface of the left arm, often accompanied by nausea and difficulty breathing. Many people think that those symptoms pretty much sum up the worrisome type of chest pain. Ha ha. Many people are nitwits. Significant chest pains come in many subtle variations, like fine cheeses. The thing to remember about chest pains is that on the surface they may seem as different as Velveeta and Brie, yet, by and large, in the end, they all indicate that something, somewhere, has rotted.
If the pain seems like a tightness in a band across the chest, and if it gets worse with exertion, emotion, or eating, it might be angina pectoris, known as ischemic heart disease. This is caused by blocked coronary vessels that don’t permit sufficient blood flow to the heart. If the pain is steady and oppressive and hurts more when you are lying down or breathing deeply, and less if you are leaning forward, it could be pericarditis. This is a potentially life-threatening inflammation of the membrane covering the heart, which can be caused by infection or tumor or even an oncoming heart attack. If the pain is deep and crushing, with nausea, weakness, and extreme shortness of breath, it could be an embolism in the pulmonary artery, or some other serious interruption of blood flow to the lungs. If the pain is sudden and nearly disabling, feeling as though your chest is being torn open from the inside, that could be a rupturing aortic aneurysm, which basically means your chest is being torn open from the inside. Usuallv, vou die.
But often, minor chest pains mean nothing. Doctors are forever trying to tell that to the hypochondriac, without much success. A case in point is the true story of Heart Attack Holmes, a man who became famous among the young residents at the George Washington University Medical Center emergency room in the late 1970s.
Mr. Holmes was a polite man who would come in practically every weekend complaining that he was having a heart attack. He described the pain with medical precision. Each time, doctors would check him out. Each time, he was perfectly healthy.
Heart Attack Holmes was a big joke among the smart young doctors at George Washington University Medical Center. Tending to him became something of a rite of passage. He was the classic hypochondriac.
One Saturday, Heart Attack Holmes came into the emergency room and said he was having a heart attack.
And he was. Dropped dead, right on the spot.
1 By the way, during a hernia exam, when a doctor says, “Turn your head and cough,” did you ever wonder why you had to turn your head? Is that somehow part of the incredibly sensitive musculovisceral response that he is feeling with his educated fingers in your groin? One day I asked the doctor why you have to turn your head. He explained: “So you do not cough on me.”
2 Speaking of which, there is a medical condition called “bitrochanteric lipodystrophy” in which most of the fat in your body is concentrated in your thighs and buttocks, which get grotesquely enlarged. The downside of this condition is that you waddle like a platypus and scare the neighborhood dogs. The upside is that on Halloween you can wrap yourself in aluminum foil, stick some toilet paper in your collar, and you make a fabulous Hershey’s® Kiss.
Are You an Alcoholic?
Nearly two-thirds of Americans drink alcoholic beverages, and in this health-conscious age, many of them are worried that their consumption is excessive. Studies keep suggesting that excessive drinking increases the risk of several diseases, including anemia, pancreatic cancer, oral cancer, esophageal cancer, and osteoporosis. At the same time, studies keep suggesting also that moderate intake of alcohol can actually be beneficial, lowering blood pressure, reducing cholesterol levels, preventing heart disease.
It’s all very confusing. How much drinking is moderate? How much is too much? What distinguishes the normal drinker from the problem drinker? Organizations like Alcoholics Anonymous have created simple diagnostic checklists to gauge whether your drinking makes you an alcoholic. Unfortunately, asking Alcoholics Anonymous if you need Alcoholics Anonymous is like asking your kid if you need a puppy. AA’s tests have a very low threshold. A typical quiz from Alcoholics Anonymous asks questions like these:
Do you sometimes feel “tipsy” after drinking?
Have you ever inadvertently consumed more alcohol than you intended to?
Do you ever drink alone?
Do people ever criticize you for your drinking?
Have you ever woken up with a headache from excessive drinking the night before?
And so forth.
You take the test and are fairly proud that you have answered “no” to most of the biggies. So you sit down to grade yourself and discover that a single “yes” answer means you are in danger of becoming an alcoholic. Two “yes” answers mean you are an alcoholic!
The average hypochondriac will at this point be in a blind panic; he will look up the signs of alcoholism in his extensive medical library and learn that the alcoholic has “increased mean corpuscular volume, increased gamma-glutamyltransferase, increased aspartate amino transferase, and increased low-density lipoprotein cholesterol.” He will have no idea what any of these things mean, but he will worry about them obsessively. He will suspect in himself the dreaded “beer potomania,” observed in people who drink more than eight quarts of beer a day, a condition in which you have too much water in your blood and do not pee enough, which causes “water intoxication,” which can lead to confusion and lethargy and death. He will realize he has exhibited signs of neurological weaknesses typical of alcoholics, which can include twitches that are very, very shockingly like the eyelid twitches he has been increasingly noticing since the first chapter of this book. He will strongly suspect Wernicke-Korsakoff syndrome, in which alcohol poisoning leads to a lack of thiamine in the blood, causing hemorrhagic lesions in the brain, impairing the loss of the ability to encode new information or remember recent events. Ffe will not rule out Marchiafava-Bignami disease, which is an alcohol-induced decay of the corpus callosum, at the center of the brain, first detected in chronic drinkers of red wine in Italy, causing a clumsy gait, followed by stupor and seizures.
He will not go to the doctor, because all of this is way too embarrassing, but he will relentlessly monitor himself for signs of neurological deterioration. To prove to himself that he is coordinated, he will, for the first time in his life, get out on a dance floor, where he will resemble a camel attempting to goose-step. He will constantly be checking his mental acuity, going up to total strangers in the street and saying, “It is Monday, the third of March, which is, by my calculation, the sixty-second day of the year 1997 and my mother’s maiden name was Frelinghuysen.” He will contrive to attend parties in which doctors will be in attendance so he can drop lines like, “So, I was just wondering whether a runny nose might indicate excessive gamma-glutamyltransferase in the blood.”
The hypochondriac will, in fact, tear himself apart, even though his drinking typically consists of a Pabst at dinner.
I contend this worry is in itself unhealthy. I contend we need to update the drinking test to weed out the healthy, normal drinker from the genuine alcoholic and to redirect the hypochondriac to more productive worries, such as whether that occasional stabbing pain up the rectum, the one that stops all conversation, might be cancer.1
Here’s a new test:
ARE YOU AN ALCOHOLIC?
Have you ever felt guilty about your drinking? Did another drink help?
Do you ever drink alone? Are you drinking alone right now? Directly from the bottle? Standing naked in the shower in case you vomit?
Do people sometimes criticize you for your drinking? When you attempt to punch them in the face, do you fall down?
When you drive drunk, are you generally sober enough to keep one eye closed so your vision is not double? Good for you.
Have you ever eaten the worm and then discovered that it was not, in fact, the worm, but something else wormlike that happened to be in the vicinity of the bottl
e, for example, an egg sac from a cockroach?
Have you ever awakened in an intensive care unit, with uniformed police officers standing over you, arguing with doctors who were saying you could not be questioned until you were “out of the woods”?
Are you ever slightly embarrassed to discover you have one alcoholic beverage in your hand, another on the table, and a third in a hypodermic syringe that you are about to inject directly into your stomach, for a better “rush”?
Do you sometimes find that you have been made the butt of a sucker bet among your friends, such as whether you will actually drink from the toilet with a Flavor Straw for a quarter?
At times when no alcohol was available, have you ever consumed other substances because you thought they might contain alcohol, such as naphtha or Massengill Sta-Fresh douche?
Have you ever urinated into an empty beer can to avoid having to negotiate your way to the bathroom, and then forgotten you had done this, and … you know? Has this ever happened more than once in the same night? Do you think it might have ever happened and you did not notice?
GRADING
You are not an alcoholic.
1 Sure it might!
Tumor. Rhymes with “Humor.”
This book is breathtakingly free of serious research, but I did interview a few dozen doctors. Each time, I would smile engagingly and explain that I was writing a humorous book about fatal diseases. The doctor’s expression would not change. If you are a doctor you must be adroit at hiding your reactions. A patient must feel the doctor is taking him seriously when he complains, for example, that he gets an erection every time he sneezes. So each doctor I was interviewing would hear me out stone faced and pray that someone would begin to hemorrhage in his waiting room so he had an excuse to bolt and run.
Interviews with oncologists were the hardest. Oncologists are grave. Their offices are grim places. While I was explaining to one of them the terrific ironic potential in disease, patients in the next room were undergoing infusions of poison. Eventually, as I got to the part about the delicate synergy between comedy and tragedy, the doctor said: “Fifty percent of my patients are dead within five years of their first appointment.”
Ah, I said.
I tried to lighten the mood. I observed that this 50 percent figure must be frustrating. It would be like being a lawyer who defends only skinhead homicidal maniacs whose crimes were witnessed by archbishops with video cameras.
“I have to tell people they are going to die,” the doctor said.
The interview was not going well.
“So, um, how do they react when you tell them they are going to die?”
“Badly. They get very upset.”
Ah.
I tried to think of something positive: “Is there any part of the human body that cancer cannot reach? Any organ, any body part, in which you cannot get a tumor?”
Evidently, no one had asked him this before. A quarter century of experience rolled through his brain. Cancer in bone, blood, muscle, skin, gristle. Cancers of the tongue, the pineal gland, the uvula, the tonsil, the penis. Cancers of the scrotum, the eyelid, the armpit, the scalp. Cancers of the ear, the elbow, the anus, the belly button. He shook his head doubtfully.
“The appendix?” I prompted.
“You can get cancer there.”
“The finger?”
“Yep. Big one, right under the nail.”
“The nipple?”
He looked at me like I was a protozoan. “That is breast cancer.”
Ah, right.
At last, he thought of one. “The lens of the eye!” he said.
That’s it?
“I think you can’t get a tumor there. Never seen one. Doesn’t mean it can’t happen.”
He excused himself. He had work to do. Death awaited.
I left his office depressed. I had begun to give up on finding humor in cancer when I walked into the Washington office of Dr. Henry Fox, oncologist. On that very day, Eric Davis, star outfielder for the Baltimore Orioles, had been diagnosed with a tumor in the colon. Inevitably, the media had described it as “the size of a baseball.”1
“Lucky he isn’t a basketball player,” said Dr. Fox.
A glimmer of hope.
So, Doctor, what’s funny about cancer?
He brightened. “I actually have a file here on humor somewhere,” he said. He rummaged in his bookcase and found it. It was as thin as a potato chip. A single newspaper clipping fluttered out. It was by me.
He put the file back on the shelf.
“Let’s see,” he said. “Humor. OK, what is the difference between Sloan-Kettering and Shea Stadium?”
Dunno, I said.
“At Sloan-Kettering, the mets always win.”
Ha ha, I said. What?
“See, ‘mets’ is an abbreviation for ‘metastasis,’ which is a cancer that has spread systemically from one organ or system to another.”
Ah.
A desperate silence filled the room.
“Actually,” Dr. Fox said, “I guess there is not much funny about cancer.”
Oncologists routinely get patients who have noticed a lump and are terrified. My hypochondriac friend James Lileks follows a basic diagnostic procedure when he discovers a hard mass that didn’t seem to be there the day before. Knowing that the human body is bilaterally symmetric, he feels to see if there is a corresponding lump on the other side of the body. Only if there isn’t does he get alarmed.
I told this to Dr. Fox, to illustrate the medical principle that James Lileks is a moron.
“Actually” he said, “that will work most of the time.”
Like all oncologists, Dr. Fox has hypochondriac patients. “I only have a few,” he says, “but I see them often.”
It turns out many hypochondriacs have figured out the Lileks Rule. But that doesn’t help: A test of symmetry does not screen out most of the harmless lumps that will bring people to oncologists’ offices. In increasing order of frequency, here are the four leading stupid causes of concern among the lumpin’ proletariat:
4. The xiphoid process: This is the bony prominence at the bottom of the breastbone. Everybody has one. Only one. Every oncologist has had to tell somebody, sometime, that the terrifying lump he has found is as normal as a nose.
3. The epididymis: This is a long, gnarled tube that carries sperm from the testicle to the penis.2 It arches near the top of the testicle, where it can feel hard and wormy; typically, one side feels lumpier than the other. It can feel like a third testicle. No one wants a third testicle.3
2. Zits: Particularly, those creepy painful gouty lumps in the earlobe.
1. The inframammary ridge: This is a firm line of compressed tissue along the lower edge of every woman’s breast, near the ribs. Even some doctors mistake it for a mass.
In an uncharacteristic exercise of good taste and judgment, I am not going to say much more about breast lumps in women. This is because I don’t want to write anything that might dissuade a woman from seeing a doctor if she finds a lump. Lives are saved by early diagnosis. See your doctor, ladies. Your only risk is that he is going to have to sit you down and patiently explain to you that different breasts have different textures and consistencies—that some (like Cindy Crawford’s) feel smooth and soft and creamy, like a baby’s bottom, while others (like yours) feel like a Hefty garbage bag filled with human molars and minestrone soup.
Wherever they occur, lumps are undeniably scary. There are no hard rules for diagnosing which are cancerous and which are not, but there are some general guidelines:
Pain is good. Cancerous tumors generally do not hurt.
Heat is good. A lump that is warm to the touch probably is an infection, not cancer.
Pus is good. You usually can’t express liquid from a cancerous tumor.
Change is good. A cancerous tumor will seldom wax and wane in size. It will steadily grow.
Soft is good. Cancerous tumors tend to be hard.
If a hypochondriac has no
lumps to worry about, he will look for moles. Moles could be malignant melanomas, some of the deadliest cancers around. They are a hypochondriac’s delight. This is because malignant melanomas are nearly 100 percent curable if caught early enough, and nearly 100 percent deadly if not caught early enough. This encourages obsessive vigilance. Dermatologists get a lot of hypochondriac traffic.
Concerned if your mole is malignant?
Solid color is good. Melanomas tend to be multicolored, often with patriotic tinges of red, white, or blue.
Small is good. Melanomas tend to be at least the diameter of a pencil eraser.
Symmetrical is good. Melanomas tend to have ragged edges and oddball shapes.
Hairy is good. Melanomas tend to be bald.
Boring is good. Melanomas sometimes change their appearance from week to week.
Dry is good. Melanomas sometimes bleed.
Smooth is good. Melanomas sometimes ulcerate and have a crusty texture. They can crumble to the touch.
Note to hypochondriacs: You might want to clip out the previous two lists. Good. Now flush them down the toilet. They are unreliable. Cancerous tumors are outlaws. Rebels. They don’t always follow the rules. To use a medical analogy, if the human body were Thomas W. Pyle Middle School in Bethesda, Maryland, and lumps and moles were the students of Mrs. Schlom’s eighth-grade science class, then a malignant tumor would be my son, Dan, who cut class, set a roll of toilet paper on fire in the boys’ bathroom, sneaked onto a bus taking another class to an art museum, and thereby earned himself a three-day suspension. In this medical analogy, Mrs. Schlom would be a surgeon with a great big sharp scalpel, and an attitude.
The Hypochondriac's Guide to Life. and Death. Page 10