Clinical Review

Assessment and management of medically unexplained symptoms

BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39554.592014.BE (Published 15 May 2008) Cite this as: BMJ 2008;336:1124

Banfield’s Chest Pain - Finding the elusive cause

As a teenager in the ealry 1960’s I experienced a brief sharp stabbing pain in the lower left side of my chest and when I asked my doctor about it he examined my chest with his stethoscope and said that there was no sign of heart or lung disease.
I then asked him if he knew the cause but he didn’t.
However the pain recurred on several occasions so he sent me for blood tests and x-rays but nothing was found, and like almost every other patient with that pain, I began to doubt if he had missed something.
One day, when I was in my early 20’s I noticed that I hadn’t had that pain for a while, but when I asked my doctor to explain why it stopped he couldn’t.
About a year or two later I was getting aches in my kidneys whenever I leaned forward, and a kidney stone was detected and treated.
I later started gettng abdominal pains, and then faintness, breathlessness, and dizziness, but despite various diagnostic procedures the cause was elusive so I decided to study the problems myself.
At high school I favored subjects of maths and physics, where facts, evidence, and proof were characteritic requirements, and on one occasion topped the class in a first term chemistry exam, and regularly participated in classroom discussions on various topics, and later, gained multiple scholarships to study leadership at the Institute of Technology where scientific principles and methods were part of the curriculum.
Consequently when I started studying health problems I made detailed observations, read the general medical literature, and then the research journals to get the best and most reliable information.
Within a few years I was able to identify that leaning forward was sometimes associated with various symptoms, and concluded that they probably all were including the chest pains I had as a teenager.
However I found general opinions that there was no evidence of physical illness, and that it was therefore impossible to have a physical cause and must be due to psychological factors such as worry, fear, or stress.
Nevertheless I also occasionally noted comments that the typical patient had a thin and stooped physique, and later found a book by Paul Wood which had a chapter discussing the problems as psychriatric states, but he noted that it was relieved by intramuscular injection of a painkiller, but not by subcutanious injection, and he concluded that it was related to fibrositis and low back pain, and may be due to postural factors, awkward movements, or anxiety which alters the action of the respiratory muscles and puts strain on the chest wall.
However I recognised that it indicated a physical cause of a physical symptom in a precise location.
His chapter also included a full page photo of a full sized portrait of the physique of the typical patient, and if his face was replaced by mine it would be the same.
Wood then presented his description of the personality of such patients describing them as insecure adults who had been timid children protected from the dangers of sport, gymnastics, and swimming, but I was an active teenager and participated in all of those activites, often as instructor or leader.
I found other comments that the cause of the pain was not evident on surgical inspection, and I wanted to attend an autopsy session to look at the region but was told that the only individuals permitted to do that medically qualified personel or students.
I also learned that J.M. Da Costa, in 1871, had reported that the symptoms seemed to be related to a clicking sound that he and others thought might be due to valvular disease of the heart, and he also noted that it seemed to be coming from outside the heart, but he couldn’t idenfity the source, so I became curious about the possibliities.
I also noted that although the research literature was reporting a general increase in knowledge, the actual cause could not be found.
I later began studying the problems again between 1994 and 2000 and looked for potentially useful information from a wide range of sources.
More than a decade later, in 2013 an internet contributor prompted me to send my ideas to the British Medical Journal, and after writing several essays on the chest pain L.Sam Lewis suggested I look into the topic of slipping rib syndrome, and after reading an essay by Leon G. Robb et. al. and others, I found an article by Jean-Yves Meuwely who used Valsalva’s Maneuver and sonograpy to examine a woman who overstreched her chest during a game of cricket.
The woman felt pain, he heard a click, and saw one rib bounce over another and rebound, which answered some of the questions.
I was then curious about an anatomical report by J.F. Holmes (1941) that the cartilage ends curl up under the ribs and he said that “there does not appear to be any clear conception of the development of this deformity”.
I then wondered why countless physical examinations, X-rays and CAT scans of my chest had never mentioned it, so I ran my fingers down my chest and found the 8th rib protruding, and all the pieces of the puzzle immediately fittted in place, so I described the cause and sent it to BMJ where it was published in April 2014.
I expected significant reports to be published about the solution to that major mystery but haven’t noticed any.
I have, however heard remarks like this . . . “You don’t need scientific methods to figure that out because it’s just common sense and anyone could have solved that problem if they tried”.
Needless to say the reason that my doctor didn’t know the cause in the 1960’s was because nobody in the world knew, and now, it won’t be long before everyone knows. It’s just postural pressure which makes a rib loose, and occasionally slip to pinch a nerve.

References:

1980, June, M.A. Banfield, The Matter of Framework, Australasian Nurses Journal, p.27-28.

2014, April 27th, M.A. Banfield, Posture as a cause of previously unexplainable left sided chest pain, The British Medical Journal (Online Rapid Response), BMJ 2008; 336:1124.
http://www.bmj.com/content/336/7653/1124/rr/695879

2014 (July 13th), M.A. Banfield, The Banfield explanation for anterior displacement of the eighth rib and the cause of previously unexplainable chest pain, The British Medical Journal (Online Rapid Responses), BMJ 2008;336:1124, Actual page of response http://www.bmj.com/content/336/7653/1124/rr/760594

1956, Paul Wood O.B.E., Diseases of the Heart and Circulation, Eyre & Spottiswoode, London, p.937-947.

2013, August 3rd., Leon G. Robb et al, The Slipping Rib Syndrome: An Overlooked Cause of Abdominal Pain, Practical Pain management.com

2002, March 1st, Jean-Yves Meuwly et al, Slipping Rib Syndrome, A Place for Sonongraphy in the Diagnosis of a Frequently Overlooked Cause of Abdominal or Low Thoracic Pain, Journal of Ultrasound in Medicine, Vol 23, no.3, p.339-343.

Competing interests: No competing interests

20 March 2016
Max Allan Banfield
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