In Praise of Anecdotal Evidence. In this book I report a number of case histories, and I am often using these to make a point. Some scientific-minded readers may tend to dismiss these stories as merely anecdotal evidence. Please don't do that. Properly designed studies and controlled trials are not the only way to know reality. The bulk of knowledge humankind has accumulated in its history has not been derived from controlled trials. People found that Britain was an island, and how to bake bread, though no properly designed studies on these subjects had been conducted. Medical knowledge begins with case histories, that is, anecdotal evidence. Basic discoveries in medicine: that measles were contagious but left a life-long immunity; that black stools indicated a bleeding from the upper part of the digestive tract; that acute rheumatic fever led to valvular heart disease, and many hundreds of equally important observations, were all based on anecdotal evidence. It was on grounds of purely anecdotal evidence that Dr. Edward Jenner introduced in 1796 his cowpox vaccine, and Dr. William Withering his foxglove therapy (1785); yet Jenner's vaccine saved many millions of lives, and ultimately eradicated smallpox on this planet; and Withering's digitalis has relieved hundreds of thousands of people suffering from heart failure. It is not true that such discoveries could only be made in the 18th century, but are impossible now. We are still able to observe facts. Properly designed studies and controlled trials serve to deepen and verify our knowledge, not to make us blind to what is happening around us.
How Scientific Medicine Has Become. The notion that medicine is being transformed from old guesswork and empiricism into an exact science of "hard facts," laboratory measurement, and statistically significant findings, is partly true and partly based on a mistaken understanding. There has been an abundance of hard facts in traditional clinical medicine, and by no means are all assertions of the new "scientific" medicine hard facts or objective truths. If listening to a patient's heart we hear a very loud first heart sound preceded by a coarse murmur, and the second heart sound is followed by an additional "snap," so that the whole tune resembles a quail's call, we know that the patient has a valvular heart disease, namely, a narrowing of the orifice between the left atrium and the left ventricle (mitral stenosis), and this is a harder fact than the "scientific" measurement of the orifice's surface based on catheterization data since the latter method has many pitfalls: low flow, leaking valve, beat-to-beat variation, or failure to wedge the catheter into a small pulmonary blood vessel, all introduce errors to this determination. (87)
The new scientific medicine is not even free of some patent nonsense. The electrocardiographic diagnosis of "anterior" myocardial infarction is still based on the ingenious but mistaken "electrical window" theory. As a result, the localization and extension of the infarction, as determined from the ECG, prove wrong at the post-mortem in more than half the cases. (88)
What is a "Hard Fact"? The noted Polish-Jewish serologist Dr. Ludwig Fleck published in the 1930s a book in German on "The origins and development of a scientific fact." Many years later his theories gained some popularity among American historians of science, (89) Fleck, indeed, was a precursor of present day "post-modernism." In his view, a "scientific fact" was the result of a gradual process during which the circles having a say in science developed a conceptual apparatus and a vocabulary needed to formulate the new truth. I do not subscribe to Fleck's view and think that his use of language confused a natural phenomenon with its discovery and its acknowledgment by the scientific community. But I do find the uncritical faith in the self-contained existence of "hard scientific facts" a bit naive.
Hard as a Fact May Be, It Takes a Human Being to Perceive It. A curious and ominous disturbance in bio-electrical activity of the heart, described in 1965, is a good example. That year during my stay at Paris' Hospital Lariboisiere I spent some time at the graphic lab, which was the domain of Dr. Dessertenne, a tall, taciturn, collected man. He showed me a peculiar electrocardiographic finding he had recently published: the torsades des pointes, an extremely fast electrical activity of the heart's ventricles, conspicuous by gradual turning of the peaks of ECG waves which alternately pointed up for a couple of seconds and then for a similar period turned down, and this sequence of events repeated itself again and again. During this disturbance the heart does not contract and pumps no blood. Most often the torsades spontaneously cease after some seconds, but if the disturbance persists, the patient loses consciousness and ultimately dies. Before Dessertenne, bouts of this strange and ominous cardiac arrhythmia had been recorded by electrocardiographers all over the world but nobody paid attention; or sometimes this ECG pattern was misinterpreted as "ventricular fibrillation with large waves."
Dessertenne noticed that it was something else and specific, and most importantly, found out when, how, and why the torsades occurred: it happened if during normal heart rhythm the electric cycle of every heart beat (the Q-T interval of the ECG) was considerably prolonged. This discovery immediately opened the way to prevention and effective treatment: to suppress the torsades one had to shorten the Q-T interval. It could be achieved by removing the cause, quickening the heart rate, or injecting magnesium sulphate. The problem has considerable practical importance, because the cases are there: patients with long Q-T due to alcohol-induced potassium deficiency, inborn abnormality, side-effects of anti-arrhythmic drugs (amiodarone), or side-effects of chemotherapy For these reasons, quite a few people develop the life-threatening torsades des pointes.
But even after the publication of Dessertenne's work the torsades were still a long way from being universally recognized as a "fact of science." They are recognized now; but the delay was considerable. Articles published in English reach all corners of the world, but those published in French, in the Archives des Maladies du Coeur et des Vaisseaux, do not easily cross the Channel, let alone the Atlantic Ocean. Even in Leiden, Holland, I had the dubious satisfaction of introducing as "novelty" the torsades that had been discovered eleven years earlier by that quiet Frenchman.
"Medical Diagnosis is a Job Like Any Other." No it isn't. More often than not, appearances are misleading, and we are groping around a hidden reality
Should one order a chest X-ray when the patient complains of pain along one arm? Yes, if the pain is severe; the patient may in fact have cancer of the lung (the Tobias-Pancoast syndrome). What struck me was that the patient appeared to be so sick and so heavily oppressed by the pain. Immediate chest X-ray revealed a tumor's shadow at the very top of the left lung's upper lobe.
Our hospital's lab technician brought in her mother, age 45, who in the last few weeks was becoming breathless at the slightest exercise. The ladies sought the help of a cardiologist assuming that shortness of breath must be due to heart weakness. But the mother was strikingly pale. Examining her abdomen, I felt a tumor the size of a tennis ball. She was severely anemic due to a bleeding cancer of the colon, fortunately, operable. The patient's shortness of breath was due to anemia.
I remember a girl of twelve whom the family physician diagnosed as having acute appendicitis and referred for immediate surgery. What she really had was a pneumonia of the lower lobe of the right lung. The involvement of diaphragmatic pleura caused a painful tension of the abdominal muscles, which mislead the poor doctor.
A worker employed at the production of viscose was brought to my emergency room in Lodz by a doctor who found him acutely psychotic and suspected a poisoning with carbon bisulphide. The man screamed, fought the medics, and shouted obscenities. He died before anything could be done. Autopsy revealed a burst thoracic aorta. The patient's "mental illness" had been due to the sudden insufficient blood supply to the brain.
Eight hours after surgery to remove a clot obstructing her femoral artery, the 48 year old lady with valvular heart disease suddenly began to scream, complaining of an excruciating pain in her chest. The surgeon, certain that she was having a myocardial infarction, called the cardiologist. But one had only to pull off her blanket to see what was wrong with her: there was a profuse post-surgery bleeding from the femoral artery into the thigh. This caused such a precipitous fall in blood pressure that the blood flow in the coronary arteries of the heart was critically reduced resulting in severe pain of angina pectoris. A quick blood transfusion and repair of the artery's suture solved the problem.
A man of 46 suddenly became sick in his living room and felt that he was dying. The family physician told me on the phone: "He seems indeed to be dying and I don't know why." The patient was in awful shape, ghastly pale, sweating and shaky. His pulse and blood pressure were normal. Which illness could make the patient feel so terrible, even feel "he would rather die," when there was no real danger of death? There is such a condition: acute vestibular dysfunction, as in severe motion sickness or the syndrome of Meniere. I recall the amazement of a medical student who was with me in the emergency room, when the first question I asked the presumably dying patient was, "have you ever had an ear infection?" He had, indeed, a long history of otitis media, left ear drura perforations, pus flowing out, and hearing loss. I could assure him right away that he would not die from the inner ear affliction that had caused his terrible vertigo, nausea, and the feeling that life was slipping away.
Hodgkin's disease, a malignancy of lymph nodes, may first manifest itself as pericarditis, an inflammation of the membranous sac around the heart, leading the diagnostic quest astray. The doctor becomes preoccupied, as he should be, with the manifestations of pericarditis, the pain, the audible friction rub, the electrocardographic changes. Large quantities of fluid accumulate in the pericardial sac and warrant needle puncture to relieve the heart from the constraint. Prednisone treatment is tried as a attempt to stop the accumulation of fluid. One tries to find the cause of the disease, of course considering first the usual causes of pericarditis: rheumatic fever, viral infection, and tuberculosis. Weeks elapse, and among all those preoccupations the doctor does not pay enough attention to the first warning from the radiologist that "a poly-cyclic shadow" in the middle of the chest appeared on some X-rays, suggestive of enlarged lymph nodes. Only the second such warning awakes you, and the idea dawns on you that the pericarditis had been a manifestation of an underlying malignant disease; that it must have been the malignantly transformed lymph nodes deep within the chest which grew into the heart sac; and since this is the only detectable cluster of diseased lymph nodes, these may be surgically removed, the site irradiated, and the patient cured. He was a 28 year old truck driver, and the delay of the diagnosis I just described was my mistake. An understandable mistake--yet unforgivable.
In Lodz, a 56 year old hitherto quite healthy man came to my office accompanied by a worried wife and two grown-up children. For two days he had been gasping for breath while climbing stairs. Now the public knows that shortness of breath may be due to heart weakness; that's why the man came to see the cardiologist. The patient's pulse and blood pressure were normal and further physical examination did not reveal anything remarkable. But he looked pale and straw-colored. It was late afternoon on a winter day, and neither in the electric light nor in the faint daylight when the lamp was switched off, could I make out for sure if his eye whites were yellow.
The man was healthy until two days ago; something suddenly happened that made him short of breath, pale, and perhaps yellow. One thing that could cause all that at once would be an acute massive destruction of red blood cells. "Have you noticed anything peculiar about the color of your urine? .... Yes, since yesterday it has been very dark. How did you know that?!"
My diagnosis of acute hemolytic anemia was immediately confirmed in the lab. Prednisone treatment to prevent the destruction of patient's remaining red blood cells was started the same evening.
The reasoning leading to such diagnosis is not unlike a motorist's who is driving a European car and sees, all of a sudden, that the red lamp is aglow showing that the battery is not being charged, and at the same time the engine is rapidly overheating. What single event would suddenly cause these disparate effects? A snapped fan belt, of course! Now, what would suddenly make a man pale, yellow, and breathless? A massive destruction of red blood cells (acute hemolytic anemia) is a single event that would explain all these effects at once. When the red blood cells are destroyed by antibodies, and release hemoglobin, the oxygen-carrying red dye, too little oxygen is transported to the tissues which makes the patient breathless, red blood no longer contributes to the coloration of the skin, lips, etc. making the patient pale, and hemoglobin released into the blood stream is converted into bilirubin causing jaundice. The excess of bilirubin in the blood is then filtered through the kidneys, making the urine dark.
How Complex is the Statement: For Patient's Swollen Legs, the Doctor Prescribed a Diuretic? Let's try to reproduce the doctor's considerations. "I wonder why she's got this edema of the legs. She is not breathless, the neck veins are not overfilled, the auscultation of the lungs and of the heart reveals nothing abnormal, and the liver is not enlarged, thus, she is not in heart failure. Her urine contains no albumin and the serum albumin is normal, so this is not a nephrotic syndrome. She recently had a full gynecological check-up, therefore, thank goodness, we don't need to worry about a malignancy in that area. This edema must be of 'local' origin."
There are other edema-producing conditions which the doctor does not even mention is his monologue. The patient has not traveled in the last week, so there is no reason to think of edema due to air travelers' leg immobility. The lady's smooth skin, vivid facial expression, and quick pulse allow the doctor to skip the possibility of thyroid insufficiency There is no history of sore throat, no subfebrile body temperature, no facial or eyelids' edema, thus, nothing that would cause the doctor to think of inflammation of kidney's glomeruli (acute glomerulonephritis). Jaundice, enlarged spleen, abdomen distended by fluid, purple "spiders" on the skin would make the doctor think of edema due to cirrhosis of the liver. The possibility does not even occur to him because none of these signs are present. Some drugs may produce edema, but the patient has not taken any medicines. Hunger edema is not exactly a condition that must be considered in a middle-class lady in Cambridge, Massachusetts, in 2001. Edema of only one leg would suggest thrombophlebitis, and in a person who just came back from Northern or Central Africa it would raise the suspicion of filariasis, infestation with a worm called Wuchereria Bancrofti, but both legs are swollen and the lady has not been to Africa.
As I said, all these possibilities are not even mentioned in the doctor's internal monologue; but this does not mean that no work has been done on them. The doctor did inquire about the patient's travels and circumstances, recent and previous illnesses, intake of medicines; he did watch her face, movements, skin color, he examined the abdomen, palpated the liver, tried to palpate the spleen, etc. Thus, it is not that the conditions just listed did not occur to him: the doctor has surveyed the terrain for signs that could have triggered the quest for these ailments, found none, and suppressed the thought.
Let's return to his monologue: "It must be local though she's hardly got any varicose veins, and while I don't like the arch of her foot, or the shape of her ankles, I don't really know how this can produce edema. Giving her a diuretic is not the most logical thing to do, but I won't start with support hose, not now in summer time. I do feel like giving her a diuretic because it would be nice to get some quick effect; moreover, there are these unpleasant reddish spots on her skin, perhaps an incipient capillary lymphangitis, so it's better to remove the edema rather soon. Mrs. T was her aunt, and she had adult-onset diabetes, therefore, I won't give her thiazide diuretics. I'll give her furosemide which is said to be somewhat less diabetogenic. Let's say, 40 mg daily for a week. We shall check her blood potassium, and if she needs the diuretic longer than two weeks, also her blood glucose." And he said: "This has nothing to do with your heart. It's only a trouble of circulation in your legs. Please avoid garters. Avoid standing for a long time, and while seated try to keep your legs up on another chair. Quick walking is better than slow. You may cook with the usual amount of salt, but don't use the salt-cellar at the table. And here is a prescription for tablets that will expel excessive water from your body. Take one such tablet every morning at least twenty minutes before breakfast."
How would the patient's friend, or bio-ethicist, relate the story? "For her swollen legs the doctor prescribed a diuretic."
Less is More, and Simple is Better. If the outsiders underestimate the complexity of medical thinking, they tend to make the opposite error in evaluating medical actions. TV images of seven green-clad, masked individuals doing some complex surgery represent the highest achievements of medicine in the public mind. Not in the doctor's.
It is a good rule not to prescribe a new treatment if the complaint can be cured by withdrawing one. Instead of doing prostatic surgery, first stop the patient's disopyramide capsules: they may be good for his irregular heart beat but impair urination. Before you prescribe a diuretic for a patient's swollen legs, first stop the indomethacin she is taking for arthritis. This drug causes retention of water in the body, and there is a good chance that after stopping indomethacin, the edema will clear without a diuretic. Indomethacin will then be replaced by aspirin, which does not cause edema. Do not hurry to start oral antidiabetic drugs or insulin if the patient has been taking hydrochlorothiazide for his high blood pressure. This drug may cause diabetes in predisposed persons. You should stop it and try to control the blood pressure with other medicines. Neither should gout in patients taking thiazide diuretics be immediately treated with anti-gout medicines; gout, too, may be a side-effect of the thiazide.
No physician with some common sense would choose a large intervention if a lesser one would do, and we always prefer the simple to the complex. Moments of pure joy and genuine hilarity occur in medical practice when a patient recovers without any treatment. We have even more fun when a self-cure occurs before we could make a diagnosis! We wouldn't use drugs if the complaint can be cured by changing the patient's body position. My grand-uncle, Dr. Oskar Pomper, used to advise (and probably discovered) a simple method to relieve heart-burn: turning to one's left side. Try it, and you'll see that it works. Upholding the supine patient's legs can do wonders in cases of fainting due to a fall in blood pressure. There is a curious, very uncommon, but interesting condition occurring in late pregnancy: fainting in supine position. It is caused by the large uterus compressing the lower body's main vein, the interior vena cava, thus cutting off the return of venous blood to the heart. The patient immediately regains consciousness when turned on her side.
While working in Lodz in the 1950s I was dismayed by the condition in which patients with breathing difficulties due to heart disease, and in particular those with pulmonary edema ("wet lung"), arrived at the emergency room. Small ambulances were in use, with space only for a medic's seat and a stretcher on which the patient laid supine. The latter posture is harmful for a person with congestion of the lungs: the patient arrived at the hospital dark blue, with utterly distended neck veins, and almost suffocating. In 1961, when I was appointed consulting cardiologist to the City of Lodz health department, my first act was to issue a new directive to the ambulance services: patients with breathing difficulties were to be transported seated in the medic's seat. The condition of these patients on admission visibly improved.
Premature heart beats (often called "missed beats" because of the longer pause that follows) can be quite vexing. Various drugs may help, but patients who get the premature beats while in bed, when their pulse is rather slow, can get rid of irregularity by getting up and walking around the room.
When someone's heart suddenly starts beating 180, 200, or even 240 times per minute, there is an array of methods that can be used to stop such an attack: drugs taken by mouth or injected, or cardioversion, which is applying an electric shock to the patient's chest with a device synchronized with the electrocardiogram. However, a common form of inordinately quick heart beat, the paroxysmal atrial tachycardia, often can be stopped by the patient herself: taking a deep breath, holding it, and attempting a forceful expiration against closed glottis and compressed nostrils. If this procedure, called the Valsalva maneuver, does not work, in many cases the doctor can stop the attack by pressing with his thumb on a particular spot on the patient's neck: the carotid artery just above the upper edge of the thyroid cartilage. This is the simplest, cheapest, quickest, and most elegant method. These are the treatments we like best.
Using the Means at Hand. In 1936, my native town's best surgeon, Dr. Kleinberger, was called from a bridge game to an apartment next door: a child was suffocating. Dr. Kleinberger saw croup membranes that almost entirely obstructed the child's throat, did a tracheotomy with a penknife sterilized by candle flame, and inserted an unused cigarette holder as the tubing. The boy recovered from the diphtheria, and the incision healed "per primam," that is, without inflammation or infection, and left a barely visible scar.
In Lodz, I was called out from a medical board's office to see a patient of mine who had syphlitic aortitis, lived nearby, and was in acute distress. He was coughing up quantities of dark-pink foam, and his lungs were full of wet rales: it was a life-threatening pulmonary edema. I kept him seated on a chair, put his feet to a wash-basin with hot water, found the house enema-apparatus in the bathroom, cut the rubber tubing into parts, applied tourniquets on his four limbs, and sent his daughter to fetch shots of a diuretic and morphine from the pharmacy. The patient recovered before she returned.
One day, at the University Hospital in Leiden, Holland, while standing with the head of the Coronary Care Unit, Dr. Oudhof and several residents and nurses at the bed of a patient with a runaway pacemaker, I suddenly saw on the ECG screen the onset of a deadly ventricular fibrillation. I jumped to the patient, said "sorry," forcefully hit his breastbone with the side of my fist, and looked up at the screen. The fibrillation stopped. I became the object of some jokes because of that courteous "sorry," but I had said this only to reassure the patient that he was not being assaulted by a madman.
Common Sense. Now and again an incompatibility is revealed between the perfect constructs of science and imperfect human beings. The doctor's common sense must then intervene to protect the patients from harm.
The participation of patients with coronary heart disease in exercise programs is a good example. Several studies suggested that only maximal exercise, at which the heart rate accelerated to 160-180 beats per minute, improved the condition o f cardiac patients and prolonged their lives. Later these studies were disavowed by other investigators, but for some years credulous doctors and patients were going to extremes in advising and performing maximal exercise.
Recently, in Florida, I found my circle of friends downcast after the sudden death of one of them, a brilliant and much liked man. A doctor friend told me about the final weeks of the deceased. After his myocardial infarction, he followed and sometimes exceeded the advice he had been given at the hospital. Dismissing repeated warnings of my informant, he ran at top speed along the beach where everyone else walked. He checked his own pulse rate, and when it fell short of 170 beats per minute, he increased his running distance and speed. There is no doubt in my mind that with moderate exercise, such as brisk walking, and a beta-blocker tablet (which, incidentally, would keep his pulse rate around 60 beats per minute at rest, and below 120 when exercising), the man would have had a better chance of staying alive. I don't know whether exercise killed him; he might have died anyway. But with a little common sense he would have known that the sensational results of scientific studies should be reviewed with some skepticism; that, as a general rule, moderation is better than going to the extremes; and that when a person's heart is damaged by disease, moderation may be particularly advisable. I very much regret his death.
Regular exercise, at a level fitting the individual's ability, is the best advice we can give to cardiac patients in stable condition, and to healthy persons as well. This is not a recent discovery, to some extent this truth has always been known. But in the last twenty years it has been corroborated by extensive statistics, explained in physiological studies, and broadly accepted in medical and social practice. It even became a fad; and that's where the disadvantages appear: excesses, and the reluctance to make exceptions.
While riding my bike along the Charles River from Cambridge to Watertown, at my own rate of speed, I regularly come across middle-aged joggers and runners. Some of them look quite happy. Others, pale and sweating, are running with an expression of suffering on their faces. They are in such visible distress that it is clear they are not doing what is good for them.
From Den Bosch, I recall a 78 year old lady, who was recovering from a myocardial infarction. A cardiologist was testing her condition by exercising her forcefully on a stationary bike. Before her sickness, she had never done any great amount of exercise. Never mind medical theory: with some common sense, the doctor would have seen that what the patient needed was to be able to resume her usual way of life. This included cleaning her small apartment, shopping, and climbing a flight of stairs. Was a heart attack at 78 a good reason, or the right time, to make her the athlete she had never been?
The Doctor's Most Important Quality. If I were to name a single crucial quality, one that makes a good doctor and the lack of which disqualifies him, it would be the habit, and the talent, of complete mental concentration. That the doctor should fully concentrate on the patient he is seeing may seem an obvious requirement, but is not easy to meet. The hospital and the whole world conspire to distract the doctor. Worse still, the tiredness, or the weakness of his will, may discourage him from the required effort, and encourage the easy way of routine and automatism. The problems of twenty patients linger at the edge of the doctor's conscience, and he is unpleasantly aware of the day's tightly packed schedule. He is not even half way into his ward round, there is a staff meeting to attend, the outpatient clinic, a heart catherization, and nurses' training in CPR, with possible emergencies in-between. The application for a research grant is not yet written, the deadline is approaching, $25,000 will be lost, and the project stopped. But all that must be discarded when I come to see this boy! He has had a rather severe diphtheria, was discharged from pediatric department of infectious diseases, and obstinately refuses to go to school. We have examined him thoroughly, haven't we, and couldn't find anything. Well, we have done what we could. Why wouldn't we send him to the child psychologist. And hurry to the next patient. This gives us a chance to finish the ward round in time.
No! Think about it! Such stubbornness in a child must mean something. Assume that he has a good reason not to go to school, he just cannot explain it. Let's examine him again. A little pale. Head, throat, lymph nodes under the jaw and on the neck: nothing abnormal. Heart: palpation unremarkable. Let's listen to it. The second heart sound is very clearly split, as is usual in children, but--hey! Wait a second! This second heart sound is broadly split when the boy is breathing out, it is the reverse of normal! There has to be a delay in the contraction of the left ventricle, the boy must have a left bundle branch block. It was not on his ECG recorded yesterday Let's record it again ... Yes, now there is a left bundle branch block. Everything is explained. The boy has diphtheritic myocarditis. (90)
All great physicians whom I've had the privilege to know had the striking, never failing ability of complete and undisturbed mental concentration on every patient they saw. The worst medical mistakes occur when doctors, while seeing the patient, think of something else. This pattern of mental dissociation is well known from daily life: we think of something else while brushing our teeth, and even while performing complex activities such as driving a car in the traffic. But with many kinds of serious work such dissociation is inadmissible, and in medicine it is an unpardonable sin. There are no excuses. The fact that the doctor is seeing his fifteenth or thirtieth patient of the day is no excuse.
A man of 27 was admitted one night to the Sterling Teaching Hospital in Lodz, complaining of pain in his right side, and breathlessness. The doctor on duty found the breathing sound considerably weakened on the right side, as when there is fluid in the pleural space, muffling the sounds of respiration. He diagnosed pleurisy. In the morning I saw the patient, a young man in good general condition. From the patient's first words I had to doubt the diagnosis. He did not have the typical pleuritic pain that occurs with every deep breath. He had had a single sharp sting, and fainted. Patients with pleuritis do not faint! But patients with spontaneous pneumothorax, a sudden collapse of one lung, sometimes do. There were no X-ray films available yet. On examination, the respiration sound was not just weakened over the right lung: it was totally absent. I told the student trainee who was with me: "Look, this is spontaneous pneumothorax. These things occur in slender young men when a bleb bursts on the surface of the lung, allowing the air to pass from the lung's airways to the pleural cavity, and the lung collapses. Let's take him to X-ray. There is no need of suction drainage just now. The patient is no longer breathless. If the hole is closed, there is a chance that the lung will gradually expand."
The student, a very smart young fellow, grasped everything in a flash. The X-ray revealed a pneumothorax. The right lung had collapsed to the size of a mandarin orange. I sent the patient with the trainee back to the ward and stayed for a while at the X-ray department. Back in the ward, I was told that Dr. M, the associate professor, had already been and seen the patient. "And what did he say?" "Dr. W who had admitted the patient presented him as a case of pleuritis," answered my trainee, "and the professor examined the patient, and said, 'give him the classical treatment.'" "For goodness sake, why didn't you tell him that the patient has pneumothorax?!" "Who, me? No, thanks!" I looked at the trainee, and said: "Young man, you'll go far in life."
M was a well-trained and experienced internist, with some special expertise in hematology; but he was busy promoting his career, attending important meetings, gaining support of the faculty, and developed the terrible habit of being in a distracted mood when seeing patients, always thinking about something else. He still had good days, now and then; but one could never be sure.
On Concentration and Beyond. Not only concentration is required, but perseverance: never stop thinking, never stop worrying. When you stop worrying, disaster looms. A few years ago I was struck by the unexpected death of E my friend and high-school classmate, a barrister at the Appellate Court of Paris. All I knew about his death was what his son and widow told me on the telephone; but it was enough to disturb my peace of mind. After they came back from a trip to Australia, my friend was sleepless and uneasy; he also lost his appetite. His granddaughter, a law school student, came for their usual tutoring session, found his appearance changed, and urged him to take his body temperature. It was 42 [degrees] centigrade (that is 107.6 [degrees] Fahrenheit)! A doctor, their neighbor at the Parisian suburb, was called, could not find the cause of the fever, and sent in a mobile X-ray unit. There was nothing unusual on the chest X-ray. The doctor prescribed an oral antibiotic and promised to return. The next day was uneventful. I don't know what my friend's body temperature was then because it was not taken. Early that night the patient got up to go to the bathroom, fell on the floor, stood up, fell again, and died.
For several days I could not stop thinking of his death. I recalled my friend's wit, erudition, incisive intelligence, eloquence in several languages, his perfect absorption of the French culture. I thought of his heroism in the Nazi death camps. These were stories he himself never told, I heard them from other people: how, putting on a show to mislead the guard, he pulled two small nephews of his future wife from the crowd selected for gassing, and chased them to the group destined for labor; how during the death march in the winter of 1945 he half-carried, and then actually carried his ailing father. Life would never be the same without him.
I engaged in mental dialogue avec ce con de praticien, with this fool of a family doctor. "Weren't you frightened seeing a man of 74, heavily overweight, with such a tremendous fever? Didn't it occur to you that he might die? This must have been a particularly virulent infection. Some of these infections are curable. A patient like this should have been immediately hospitalized, and thoroughly and hastily examined!"
Taking Risks. While practicing medicine, at every turn we take risks hoping for success. Thus, gambling is a quiet companion to medical practice. The doctor who is not willing to take any risk at all is a mortal danger to his patients.
In Nakskov Hospital, on Denmark's southernmost island, surgery was done only when the anesthetist approved it. She did not approve any surgery if the risk of the procedure, expressed as the operative mortality, exceeded a figure that she considered acceptable. Therefore, in Nakskov, a 70 or 80 year old patient with an abdominal vascular catastrophe, such as a bursting aneurysm of the abdominal aorta, or an occlusion of the mesenteric artery, would not be operated on, but instead, given morphine and left to die. The high surgical risk--a mortality of, respectively, 50 and 85 percent--was deemed unacceptable. A 100 percent mortality for patients not receiving surgery was deemed acceptable.
In Lodz, I was called by Dr. T, a surgeon, to see a patient at this department. The lady, 43, was acutely ill with an intestinal blockage, but surgery had been postponed because the consulting internist found signs of an inferior-wall myocardial infarction on the patient's electrocardiogram. She had no history of chest pain or fainting, and it was not clear when the infarction had occurred--perhaps it was recent?
I insisted on immediate surgery, and within a half an hour the abdomen was opened. The lower portion of the small intestine was occluded by a huge gallstone in the shape of a flattened pear, 2.5 by 1.5 by 0.5 inches in size. The gallbladder communicated with the upper small intestine through a large perforation; this was the hole through which the stone had escaped. The surgeon removed the stone, but necrosis of the intestine and diffuse peritonitis were already present. Delaying surgery for two days proved fatal. I was amazed and terrified by this course of events, and tried to understand how it happened. It was unlikely that a doctor, single-handedly, would make such a macabre blunder. Such a blunder required two doctors, neither of whom felt responsible for the decision. The young internist was hypnotized by the electrocardiogram. The surgeon, fixed on the internist's objection, must have been struck by a kind of mental paralysis. The patient died because the surgery, which was necessary to save her life, was too risky!
The personal risks doctors take involve their self-esteem, reputation, and career. But it is the patient who takes the enormous risk: her life is at stake. Therefore, the physician must be a cautious and discerning gambler.
There are exceptional situations in which a doctor's actions may impress an observer as almost pure gambling. It's the surgeons who probably most often experience this kind of situation, particularly while exploring organs within the abdominal cavity. A close friend of mine, Dr. J, had had his gallbladder removed and then underwent another surgery for a stone that had been missed in a bile duct. Months later he was still not well, with fever, chills, tenderness at the right upper part of his abdomen, and an elevated white blood cell count. There could be infection somewhere in the area, and Dr. Kieturakis, a talented surgeon, was called to explore the abdomen. The year was 1965, and CT scans, MRI imaging, and ultrasound were not yet available. Kieturakis opened the abdomen and immediately found a large abscess manifest as a bulge on the surface of the right lobe of the liver. He made an incision and emptied the abscess, and then went on inspecting and palpating the whole accessible surface of the liver. He found nothing definitely abnormal; and yet it seemed to him that a certain area of the right lobe offered less resistance to hand pressure than the rest of the organ. Kieturakis hesitated for a moment: the liver is a vital organ full of blood vessels apt to bleed profusely, and cutting it without necessity is a grave error. But he did find an area that slightly differed from the rest and to miss another liver abscess and leave it untreated would mean the death of the patient. Kieturakis made an incision at the suspect spot, and deep inside the liver there was a huge second abscess. It was emptied and the patient was cured.
From my own experience, I recall a case of almost pure gambling. One morning, in Den Bosch, a family physician announced on the phone that Mr. B was on his way to the hospital, a "young man of forty-two, complaining of some chest pain, which probably has nothing to do with his heart, but to be on the safe side I'm sending him in," said the doctor. I ran to the emergency room and saw a pale man in acute distress, carried in on a trolley. He tried to sit up, but fell back on the stretcher. I had to jostle away a woman--apparently his wife, who tried to talk to me--and jumped to the patient. He was unconscious and I could feel no pulse in his groin. The nurse pressed the electrodes of the scope/defibrillator to the patient's chest. The device is supposed to simplify our task: the electrodes pick up the patient's ECG, and if the tracing seen on the screen shows the deadly ventricular fibrillation, we deliver the electric shock that restores a normal heart rhythm through the same two electrodes. But for some reason--I never discovered why--no ECG appeared on the screen! Meanwhile the patient had no pulse and every second the danger of brain damage drew nearer. Maintaining the circulation with hand massage until an ECG was obtained would be the usual course of action, but would give the patient less chance of full recovery than an immediate defibrillation would, if successful. A defibrillation is not an innocuous procedure--it's hitting the patient's chest with up to 400 Wattseconds of power; it should only be done on good grounds. But the patient had no pulse, and when the heart stops pumping blood in the first hour of chest pain, ventricular fibrillation is the most probable cause. I shouted "Klappen!" (which means "Hit!", the Dutch hospital slang word for "defibrillate"). My excellent male nurse, De Jong, gave me a frightened look: he knew I had no ECG and no diagnosis. I repeated "Klappen! Klappen!" He pressed the buttons, the patient's body jumped, a pulse appeared on the femoral artery and the patient's eyes opened. I made a bet and I won. Now, thirteen years after the event, Mr. B is alive and well. He gave up his demanding job as managing director of a foundation governing one of the Dutch universities, and enrolled as a student in the department of philosophy.…