Chapter 8 Post 1
One day, I was called to the medical ward by Dr. Hickens, a consultant physician, to see a middle-aged lady who had had episodes of loss of vision with mild headache. After the usual introductions, I asked her about her attacks.
“The vision in my right eye goes suddenly. My husband says it’s a blackout.”
“Well, in one sense, I suppose it is, but ….”
“So you agree with him then?”
“Well, the term blackout can cover a multitude of problems. Certainly, it sounds as if your vision blacks out.”
“My obstetrician says my vision is fine.”
“The man who checked my eyes.”
“Oh, your optician, yes I see.”
“My doctor says its My Grain” she said, with equal stress on the “My” and “Grain” and a staccato-like separation between the two words.
“Migraine, yes possibly.”
After learning of several more diagnoses volunteered to Mrs. Johnson by members of various professions and the lay public, I was able to pin her down long enough to be able to extract some relevant information.
“Are there any conditions that run in your family?” I asked.
“Well, my father had trouble with his preposterous gland. He couldn’t pass water.”
“Prostate gland, yes.”
“Yes, prostrate gland.”
“And my cousin had celeriac disease. He couldn’t eat wheat and had to have a glutinous free diet.”
“Thank you. Coeliac disease treated with a gluten-free diet. Yes. Anything else?”
“My uncle had a problem with his gall bladder. He couldn’t pass water either.”
“Sorry, Mrs. Johnson,” I said, “there is the bladder, sometimes called the urinary bladder, which we use to pass water. The gall bladder is different; it lies near the stomach. It sounds as if the problem was with his ordinary or urinary bladder.”
“Well, he also had indigestion.”
“My mother had a gastric stomach.”
After thirty to forty minutes, I felt like a United Nations linguist carrying out translations of speeches in real time but had gleaned enough to conclude what was wrong with her. I explained:
“The problem is that, from time to time, the blood supply to your eye becomes blocked. Without its blood supply, the eye cannot function so you lose your vision. However, after a short time, the blockage opens up; the blood supply returns to your eye and your vision comes back.”
“I think that’s what Dr. Hickens thought. He said it might be a transit anaemic attack.”
“It’s actually called a transient ischaemic attack,” I said, “transient meaning temporary and ischaemic loss of blood supply. So it’s an attack consisting of a temporary loss of blood supply.”
“Why am I having transit anaemic attacks?” she asked.
“Well, we need to find out. We will have to do some tests to look at the circulation.”
“Ah, circular problems run in the family too. My aunt had vigorous veins.”
“Well, varicose veins are actually a bit different.”
“So it’s not My Grain?”
“Well, it could be migraine but I think it is important to make sure that there isn’t a problem with your arteries.”
“So the tests will look at my hearties?”
Varicose veins are the result of an improper selection of grandparents. William Osler
We transferred her to Sheffield for an angiogram, an X-ray of the arteries to the brain. My registrar wrote to her after her discharge from hospital to confirm the results. He was not a great communicator. His letter started off well: “Dear Mrs. Johnson, I am writing to let you know the result of the X-ray of the blood vessels in your neck.”
So far, so good. But then: “This shows extensive atheroma extending from the carotid bifurcation to the Circle of Willis bilaterally. As discussed when you were an inpatient, such lesions are not amenable to surgery.”
I hate to think what Mrs. Johnson made of that when recounting the findings to others.
For a doctor, modern medicine is a strange hybrid of science and clinical skills, which live uncomfortably together like a married couple who don’t get on but cannot do without each other. Science, of course, leads to medical advances and, by its very nature, is precise. Clinical skills represent more of an art form taking simultaneously into account the history of someone who is in no position to know the relative significance of one symptom over another, vague or non-existent signs on physical examination and a host of intuitary skills, assessing mode of presentation and body language of the patient. A doctor needs to assess the significance of what is unsaid as well as what is said.
In the sick room, ten cents’ worth of human understanding equals ten dollars’ worth of medical science. Martin H. Fischer
The arch proponents of scientific or “evidence-based medicine” as it is known in the trade would probably represent the right wing if medicine were transformed into politics, whilst the poor clinician, battling with soft policies, an uphill battle to get people better and a holistic approach to the patient as a person and not simply a vehicle for disease, would be firmly on the left. As we have seen, the right-winger can confine himself to situations for which there is a good scientific approach whilst not concerning himself with the witch-doctor methods of his softer colleagues. Some would argue that, with sufficient scientific advance, and consequent knowledge of the workings and failings of the human body, medicine could conquer all aliments and all disease, disorder and bodily malfunction would disappear forever. Others are religious.
What happens then is like what happens when we separate a jigsaw puzzle into its five hundred pieces: The over-all picture disappears. This is the state of modern medicine: It has lost the sense of the unity of man. Such is the price it has paid for its scientific progress. It has sacrificed art to science. Paul Tournier, M.D.
It is true that disease can be conquered. For probably a few thousand years, smallpox had ruled the roost through most of the world, wiping out anyone it didn’t fancy and disabling many more. Its authority had overruled King Louis XV of France, Tsar Peter II of Russia and Queen Mary II of England by removing them from their thrones and sending them underground. It has been said that smallpox killed one child in ten in Sweden and France and one in seven in Russia even by the eighteenth century. Survivors were facially disfigured from deep scars, known as pockmarks, often blind and decidedly unattractive.
Milkmaids, by contrast, often had unblemished faces and good vision and were pretty, at least relatively so. The farming community had reportedly long recognised that infection with cowpox from cows’ udders produced only a mild, non-disabling disease but provided protection from the much nastier smallpox. By the late eighteenth century, the widespread knowledge of the rural population had finally filtered down to the medical profession, at least that proportion that lived in towns. Dr. Fewster from Thornbury, Gloucestershire, presented a paper to the Medical Society of London in 1765 entitled “Cowpox and its ability to prevent smallpox”. These observations prompted Edward Jenner to test deliberately the effect of the administration of cowpox on the later risk of acquisition of smallpox.
A milkmaid, Sarah Nelmes, went to see Edward Jenner for treatment of cowpox. Doctor Jenner extracted fluid from the cowpox pustules and injected them into James Phipps, the eight-year-old son of his gardener. James contracted a mild case of cowpox but recovered. The physician then injected him with smallpox but James showed no reaction; he was immune to smallpox. As a result of this and later experiments, Edward Jenner has been credited with founding the principle of vaccination to provide resistance against infectious diseases.
This story should come with a “Do not try this at home” warning because, these days, Mr. Phipps would be required to provide informed consent on behalf of his underage son with death from smallpox being deemed to be an acceptable outcome and the General Medical Council may have something to say about the ethics of the experiment. Fee-hungry lawyers may not have much difficulty in establishing a case of medical negligence if something went wrong either. Anyway, the good news is that these little considerations clearly did not hamper the medical entrepreneurs of the day and vaccination for smallpox was born.
By the early 1950s, approximately fifty-million cases of smallpox occurred in the world each year, but increasing vaccination led to a fall to around ten to fifteen million by 1967. In that year, the World Health Organisation launched a programme of mass world-wide vaccination which led to formal recognition of the global eradication of the disease in 1980.
The last natural case was in Somalia in 1977. I always feel sorry for that person – if only the spread of the disease had stopped just one person earlier.
But that’s the only human disease that has ever been eradicated. Moreover, despite official declaration by the World Health Organisation in 1980 that smallpox no longer exists as an infection of people, the USA (Centers for Disease Control and Prevention, CDC) and Russia (The State Research Center of Virology and Biotechnology VECTOR, also known as the Vector Institute) continue to stockpile the virus. The official reasons for so doing are in case smallpox comes back and for possible research into resistance against biological warfare. Quite why this is necessary if the virus doesn’t exist anywhere else is unclear. Even the provision of jobs for unemployed and purposeless researchers hardly seems an overriding consideration. The need for techniques to resist smallpox warfare exists only as long as there is a possibility of using smallpox virus as an aggressive agent which exists only as long as the virus is stockpiled. So we have a wonderful self-reinforcing situation. Fortunately, potential use of the virus as an active agent of warfare is strongly denied by all authorities so it looks as if we can all rest easy in our beds.
The CDC website informs us: “The September 11, 2001 terrorist attacks in the United States raised concerns about the possible use of biological weapons such as smallpox. CDC helped prepare for such an attack by working with state and local health departments to vaccinate civilian health care response team members, so they could safely care for patients with smallpox.”
“More than 44,000 people were vaccinated against smallpox as part of the National Smallpox Pre-Event Vaccination Program, launched on December 13, 2002. CDC’s Immunization Safety Office (ISO) helped monitor the vaccine’s safety.” Oh dear! How depressing – poor old Jenner must be turning in his grave.
Before closing the subject of smallpox, I should point out that Edward Jenner was probably not the first to use cowpox vaccination against smallpox. Benjamin Jesty, a Dorset farmer, who had previously had cowpox, infected his wife Elizabeth and their two sons with cowpox in an attempt to provide resistance against smallpox when an epidemic came to Yetminster in 1774. They all recovered and did not catch smallpox.
As rewards for discovering and promoting vaccination, Edward Jenner received rewards from the House of Commons of ten thousand pounds in June 1802, and twenty-thousand pounds in 1807. George Pearson, founder of the Original Vaccine Pock Institution, gave evidence of Benjamin Jesty’s work of 1774, twenty-two years before Jenner’s, but various factors mitigated against Jesty’s well-documented case and he received nothing. I expect he’s turning in his grave as well.
In science, credit goes to the man who convinces the world, not the man to whom the idea first occurs. Francis Galton
Scientific progress in medicine is not lost on patients whose access to the internet has supplanted mother’s words of wisdom as the major information resource, director and comforter.
Tony Ward was referred to me by Dr. Bolton, Consultant in General Medicine, with a suspected diagnosis of peripheral neuropathy. Peripheral neuropathy is a condition in which the nerve fibres, mostly in the arms and legs, die off and cause weakness and numbness. The smallest nerve fibres are affected first and the condition then spreads to larger ones, in a pattern similar to the death of small twigs on a tree followed by involvement of larger and larger branches. As a result, symptoms of peripheral neuropathy start at the ends of the fingers and toes and spread back gradually up the limbs.
It was fairly soon apparent that the diagnosis of Mr. Ward was correct so I began to explain that peripheral neuropathy had many causes and we would need to do further tests to find out more. At this point, TW dived into his briefcase by the side of his chair and pulled out more paper than I thought the briefcase could possibly accommodate. His wife was already holding about another half ream, presumably the excess that the poor briefcase could not cope with.
“We googled peripheral neuropathy and came up with some information that you may be familiar with. However, we thought that we would bring it along for your comments” he said, possibly a touch patronisingly.
I made a quick assessment that, at fifteen minutes’ discussion per page, we could be involved in discussion for about two weeks provided we limited ourselves to eight hours per day. I hastily tried to steer him back to the more traditional roles whereby I was the giver, and he the recipient, of information. But I soon began to feel like a medical student being chastised for knowing next to nothing and not even bothering to open a text book in possibly a vain attempt to correct my inadequacy.
“Nobody has checked us for diabetes” he said.
This use of the first person plural “us” and “we” came to be a recurrent component of the discussion, if that is what it could be called, as if his wife had been sucked irrevocably into the whole disease process.
“Dr. Bolton checked your blood glucose and it was normal. That effectively excludes diabetes” I said, in as reassuring a tone as I could muster.
“Effectively perhaps but not definitely because it depends when the blood test is done. If we haven’t eaten anything, we can’t have any glucose in our blood.”
“Well, that’s not quite correct Mr. Ward. In fact, we often check the blood glucose level after a period of starvation as a better test for diabetes.”
“It’s not better in our opinion.”
He fumbled amongst his papers and I fully expected him to extract an article that he would see as the coup de grace to my authority – something like “Fasting Blood Glucose Misdiagnoses Diabetes” by I.M. Expert–Wannabee, MD (failed) in the Journal of Bad Research 1873. But he had moved on.
“What about acrylamide poisoning?” he offered. Acrylamide is a chemical used in various industrial processes and can sometimes cause a neuropathy.
“That is very rare. Have you ever worked in an industry that uses acrylamide?”
“No but it’s present in food” he said, a little too emphatically perhaps.
Indeed, acrylamide is present in food, especially chips and other starchy foods, but how he knew that I don’t know because that discovery was only made in 2002 and we were still in 1999. I expect he made a lucky guess but, since he was holding a sheaf of a few dozen pieces of paper when he said it, I found it difficult to be sure that the internet had not provided at least some backing for his claim.
“It will not be present in food in toxic quantities” I boldly suggested, hoping he wasn’t going to break into a grin and slap an internet printout on my desk in the manner of a parent beating his child at the game, Happy Families: sympathetic but inwardly delighted at the exercise of superior intellect and control. Luckily, he didn’t respond and I was safe.
The beauty of the internet for self-researchers is that indiscriminate searches will usually find some site that provides information to back any theory you care to put forward. Mr. Ward failed to find a backing for his idea that he had been rendered neurologically disabled by McDonald’s fries, not because such support did not exist somewhere, however unreliably, but more likely that he had not searched hard enough.