Pitfalls

Front matter

Class ~RT fcS-.

Book.. £L2_

Copyright N°

Preface

In the writing of this book, the author has had always one object in mind and that was to bring before the minds of medical men, as well as the public at large, the many pitfalls into which they are ever in danger of being precipitated.

If the warnings contained in the following chapters should have the effect of opening our eyes to certain dangers, thereby preventing any future mistakes, I will feel that its object will be fulfilled, as we all know "It is human to err, and to forgive divine."

The chapters are taken from notes of twenty years' experience and — barring some frills — are true to life, showing the many peculiar incidents — tragic and otherwise — that crop up in the life of a doctor.

As to the author's connection with what is written here, all that may be said, my dear reader, is that they are only "Twice-Told Tales."

A. J. C.

Contents

CHAPTER PAGE

I. Koplik's Spots 13

II. "Belladonna"— "A Fool and His Doctor" . 18

Chapter I

One night Doctor X. said to me: "I have been waiting for four days for a call from the parents of a child, a little girl five years old, whom the father asked me to attend five days ago, but after my first visit, I was promptly discharged and another physician was employed."

Now, whenever Doctor X. makes some eccentric or puzzling remark I always know from past experience that he has something on his mind usually worth getting off.

I have for many years been what he calls a "boon companion" and, I dare say, that I have heard many things from him that to my mind were technically exquisite.

On the evening that he made this remark, I said: "Well, did you get the call?" He smiled and said: "Yes, to-day."

But that is all I could get out of him until a long 13

14 PitfaMs

time after when I asked him how he came out with that case where they called him back after dismissal.

He said, when he was called the first time he found the child up and running around, but her mother said she complained of a headache and just felt a little "dumpish" and "out of sorts."

He thought the mother was unnecessarily alarmed, because the girl being the only child she pampered her somewhat, but on closely examining her throat and mouth, he saw something that gave him a clue as to what was brewing and caused her dumpishness.

So he advised the mother to put the child to bed and keep her there and not allow other children to come to see her because she was coming down with measles, and while measles in themselves were not so bad, the child, if it is let run around, might get a chill and pneumonia set in which might prove serious.

The father came home at noon and when his wife told him that Viola — as they called her — had measles, he looked at the little girl and naturally said: "Where are they: I don't see any measles?"

So when his wife told him Doctor X. said they would come out in a few days, he doubted it very much and called in another doctor who always made it a practice to be optimistic and set the parents' minds at ease whenever they became alarmed.

Anyway this doctor told the parents that he could not understand why Doctor X. said Viola had

Koplik's Spots 15

measles, so he told them to let the little girl run out with the other children of the neighborhood, which they did, "because it was a shame to keep her in bed," and poor little Viola was happy to get the chance to run around again with her little playmates. The parents were happy to think they were not going to be quarantined. So they promptly discharged Doctor X.

He told me that the funny part of it was that both the mother and father as well as Doctor Y., had a good laugh at Doctor X.'s "ridiculous diagnosis," for a few days at least.

When I asked Doctor X. how he knew he was going to be called again as he said he was "waiting for four days for a call," he told me that on examining the child's mouth, he saw little white spots with red areola around them on the inside of the mouth scattered around on the buccal membrane; these little spots are known as "Koplik's spots" and they are a sure sign of approaching measles.

He told me that when he was discharged he suspected they called some one else who differed from him in his diagnosis — but he felt that when they found the other doctor was mistaken, they probably would discharge his colleague and call him back which was just what they did.

However, Doctor X. said, the worst part of the story, or the tragic part of it was, Viola started an epidemic of measles among all her playmates in the thickly populated neighborhood and the poor little girl developed a virulent pneumonia with the measles and for three weeks lingered between life and death and the poor parents were worn out with worry and loss of sleep watching anxiously at her bedside all this time, but fortunately she recovered.

However, unfortunately two of her little playmates lost their lives from pneumonia accompanying the measles contracted from Viola when she was allowed to run around and play with them until she broke out into a rash.

Had the doctor understood why Doctor X. said Viola was coming down with the measles, this tragedy to Viola's two little playmates might have been avoided.

Doctor X. said he often wondered why people make so light of measles ; he said it is an extremely dangerous disease, owing to the fact that there is always a bronchial irritation that goes with it, that very often develops into a septic bronchial pneumonia which is deadly in its effect on many children every year.

"Measles is a preventable disease and it is not necessary, as some mothers are foolish enough to think, for children to have this, or any other of the childhood diseases for that matter."

Children that grow up without going through diseases in their childhood are apt to be healthier men

Koplik y s Spots 17

and women than those who have the diseases, and one thing is certain, that they who escape the childhood diseases naturally escape the defects that very often follow them.

Chapter II

One evening I was sitting in Doctor X.*s office waiting for him to return from a call.

When he came in I knew he had gone through some exciting ordeal, for his collar was wilted and his hair tousled and his face all perspiration, so I said : "What in the world is the matter, doctor?" He looked at me with that smile and passed into his wash room to clean up. When he came out we went into his study, which he uses for a smoke room, too, and he lit his pipe and puffed away for awhile and said : "Wasn't it Shakespeare who said, that 'a fool will always be his own doctor'?" I thought to myself, gee I don't know, but I admitted it was. Then he said he could improve the aphorism by adding, "A damn fool will make his neighbor his doctor."

He said he was called in consultation that evening with Doctor V. who was in attendance on a patient who was suffering from lumbago. The patient was a very large stout lady who weighed probably £50 lbs. She was getting along finely under Doctor V.'s care and was around attending to some of her

"Belladonna"— 6 A Fool and His Doctor" 19

household duties. She was the mother of five children, the oldest of which was 22 years and the youngest 11 years of age. Her husband was living and well; his occupation as traveling salesman kept him away from home a great deal. The patient was about fifty years of age. Doctor X. said when he arrived at the house everything was in an uproar, the children crying and hysterical over the condition of their mother. Doctor V. was there doing all he could. The first thing Doctor X. noticed on seeing the patient was that the pupils of her eyes were widely dilated as if she had atropin drops inserted, but the family and Doctor V. said no. Doctor X. thought then that she might have been taking it internally, but Doctor V. said no, he had her under treatment with the salicylates. Doctor X. found the patient's heart rapid, her skin was dry, but she presented a wild appearance with the dilated pupils and he knew he had to think fast as the patient seemed about as far gone as was possible and still be alive; so while he was going over her he saw "something" which gave him a clue as to what was the cause of her collapse. He had no time to wait to get much of her history, but when he discovered the edge of a plaster sticking up above the patient's gown at the shoulder, he quickly stripped the gown down from her body and there found pasted on her large broad back six large-sized belladonna plasters from which she was absorbing the belladonna through her skin and being gradually poisoned from having them on for four or five days without Doctor V. or the family knowing anything about it.

Doctor X. said he stripped them off quickly and had to scrape the sticky paste off her back and have her daughter get soap and hot water to wash the back. In the meantime he injected pilocarpin and stimulants into her arm and after some hustling and hard work he finally with the assistance of Doctor V. revived her and then gave her a bawling out for using so many poisonous plasters on her back.

The history he subsequently obtained from her was that a neighbor had told her what was good for her lumbago. That she should go into a drug store and get as many belladonna plasters as her back would hold — and Doctor X. said, believe me, that back had room for many, and by this method she thought she could get rid of her pains.

The family were happy to find that Doctor X. discovered the trouble just in time to save the life of their mother and the Doctor said that he was sure she would have died within an hour as her condition was such that they both — Doctor V. and himself — had no hope until he accidently discovered what was wrong. Then Doctor X. told me of another ridiculous case where a lady came into his office one day with an abscess of the cervical gland and it looked to him as if it was just ready to break and evacuate the pus. The Doctor said when he

"Bellado7ma"—"A Fool and Hn Doctor" 81

saw it could be opened without her feeling it, he reached for his lance but she was watchful and suspicious, so when she saw him take the lance she "beat it." Doctor X. said : "Well, that would have been all right, it would open of its own accord anyway," but the lady went home and on reaching her place of residence she met an old colored woman who lived in the rear of her residence and whose husband was chef at one of the hotels. This husband, it seems, always kept frogs in his cellar, I believe, for the serving of frog legs to the patrons of the hotel. When the old colored lady saw what was wrong with her neighbor and heard her complain about how Doctor X. was going to cut her with a "big" knife she said: "Neah yo' mine, honey, I'se got sumpin' 'at'l fix dat all right; doan you' have any fummi-diddles wit' dem fool doctahs." So she goes into her own cellar and brings in an old bandanna handkerchief a large yellow bellied live frog. The afflicted woman didn't know just what the wench was going to do so she allowed her to tie the frog in the bandanna handkerchief to the abscess with its slimy yellow belly against the skin. Then the frog began to squirm and wriggle, and the lady began to scream — yelling "What is it? It's alive! Oh, mercy! Take it away!" But the wench persisted and held the knot tight over her head until the frog in its struggles scratched the abscess open and the pus run down into the bandanna and the lady's face, neck and clothing became smeared with pus. Doctor X. said the abscess being opened of course got all right after a few days, and would have gotten better without this grewsome treatment if it were let alone. Also the woman took a terrible chance; the frog might have set up a septic condition where she would have lost her life, but the worst part of the story, Doctor X. said, was these two ignoramuses; the lady and the negro wench think that the only cure for an abscess is to apply a big yellow bellied live frog to it, and the poor unfortunate children anywhere in the neighborhood who happen to get an abscess of any kind are frightened to death by the treatment recommended and administered by those two fools.

Chapter III

One evening Doctor X. was sitting in his study after office hours and his rounds of the day, and a young man about eighteen years of age called and was led into the doctor's study. Doctor X. had the habit of "taking in" everything unusual that showed externally on any one, before the patient was seated in his presence. He noticed this young man limped when he walked and that he had a peculiar expression on his face that made him think of "The man with the laughing mask." Doctor X. thought to himself, "Why does this man make me think of 'The man with the laughing mask'? Then, naturally, his thoughts ran back to his medical knowledge of

1 This case was reported in a more technical manner in the Journal of the American Medical Association, Nov. 5, 1910, and Doctor X. received a kindly personal letter from the late lamented Sir William Osier of Oxford, England, who saw the article in the Journal, congratulating him on the manner in which he stood by the young man and persisted in his treatment.

It was published also as a "prize story" under the caption "The Most Difficult Thing I Ever Did," in the American Magazine, November, 1915.

M Pitfalls

a grin-like expression that a patient acquires following an infection that results in a grave and frightful disease. This all ran through the doctor's mind before the young man said a word. Doctor X. asked the man why he limped and obtained a history as follows: He said, while out in the country, near one of the lakes, where he was taking a week-end, a number of men were having what they call a Marathon race across country, barefooted. He joined in the race, and when crossing the runway of an old barn, he stubbed his big toe, and it swelled up. He said he consulted Doctor Y. who was one of the party at the lake, and Doctor Y. said he had sprained the toe, and recommended hot compresses, of a solution of boric acid, which would be a rational treatment for a sprained toe, but he kept on getting worse and he decided to consult Doctor X. Doctor X. paid particular attention to the manner in which he stubbed his toe, "at the runway of an old barn." This brought to his mind that he had read somewhere in medical literature that certain virulent germs are found plentifully in manure and dirt around old barns, so he wondered if it was possible that the young man had a splinter buried in his toe, so he examined it carefully and sure enough noticed a spot near the top of the toe, where a splinter entered five days before, and which had closed quickly after the injury, so the doctor opened it under local anaesthesia and with a small mouse-

The Man With the Laughing Mask 25

tooth forceps removed the splinter of wood about three-quarters of an inch long. While he was removing the splinter, he noticed the young man was continually throwing his head backward and snapping and grinding his teeth, so this led the doctor to believe what he formerly suspected, when he noticed the grin-like expression, that lockjaw or tetanus, as it is termed by physicians, was setting in, so without saying anything that would scare the young man he immediately injected three thousand units of tetanus antitoxin and after dressing the wound, took the young man home and put him to bed. The next morning he called early, and the mother said the boy was complaining of an earache. Doctor X. knew it was not an earache, but a pain in muscles over the angle of the jaw, near the ears, that patients call an earache, so Doctor X., knowing how the parents loved their only boy, dreaded the ordeal of telling them that he had lockjaw. Still he knew it was his duty, so he called the father and mother aside and told them and made them promise that they would leave the boy in his care entirely and not disturb him in any way while he was trying to save his life and after the first shock of knowing the worst was over, they never saw the boy again for a whole week. Doctor X. had another physician take charge of his other patients and during the seven days and seven nights that Doctor X. remained by the bedside of this young man, he never slept one minute. He found that tobacco kept him awake, so he chewed tobacco continually and drank black coffee that was handed into the room, with food for himself and his patient. He had the druggist get all the antitoxin that was in the city at the time and when this was getting low he had more shipped from another city, so he kept on injecting three thousand units of tetanus antitoxin into his patient's body every three or four hours, night and day. Doctor X. knew that if he got a nurse and left the patient in her care, it would only add more excitement and that would bring on more convulsions. As it was, the young man was having violent convulsions, coming on every few minutes, when his jaw would snap suddenly, and if the tongue happened to protrude during the relaxation between the convulsions, he would bite pieces off the edge and tip of the tongue and blood would run from his mouth. Doctor X. made a sort of gauze gag that held the tongue back and this fixture saved a great deal of suffering. As I said before, Doctor X. gave his other patients over to the care of another physician and stuck by the bedside of this young boy continually, nursing as well as doctoring him. After he had injected about fifty thousand units of the antitoxin he noticed that following each injection the convulsions were not so violent as the first three days. During the first three days when the paroxysms occurred, the patient would arch like a bow. The convulsions would come with

The Man With the Laughing Mask 87

a sudden snap and the doctor feared the patient would tear his abdominal muscles. He would rest on the back of his head and heels, his body would arch into a bow-like "oposthotonos position," as the physicians called it, and would remain in a tense manner for about three or four minutes and then he would gradually relax his body and sink down on the bed and rest again until another convulsion would come, which reappeared usually about every five to eight minutes during the first three days, but, as I said before, after Doctor X. had injected fifty thousand units his rest between convulsions seemed to last longer, fifteen to twenty minutes. This encouraged the doctor to persist in injecting the drug, so he continued his labors to save the boy, and his anxiety and excitement in such a grave case with the tobacco and coffee kept him awake night after night and day after day at his task of life-saving, but after he had injected about eighty thousand units, following each injection, his patient would drop off into a sound sleep for two or three hours. Then he would wake with a sudden convulsion coming on but not so severe as at first. On the morning of the sixth day the patient was somewhat delirious ; at times, singing and whistling and thinking he was with his companions, and talking foolish in general, but Doctor X. found that his heart was strong and did not worry about the delirium, but persisted in the injections. Doctor X. noticed the boy's body was literally covered with a strawberry-like rash but knew such a thing occurs as a rule on injecting any serum in large quantities, so he knew it was from the antitoxin. The boy began to swallow more nourishment on the sixth day and had longer rest between the convulsions. Doctor X. continued the injections until the morning of the eighth day, when the boy was conscious, having no more convulsions or delirium, but only just weak after his horrible ordeal, and on that beautiful morning the doctor gave the boy back to two anxious parents, alive and on the road to health again. The gratitude expressed in their faces on seeing their boy alive, after that trying week, was something Doctor X. will never put from his memory. During the week he injected into his patient's body one hundred and twelve thousand five hundred units of tetanus antitoxin, which was the most ever used in the treatment of lockjaw in any human being up to that time. Doctor X. always felt that enough antitoxin had never been used before because of the expense of the drug, so he felt that a human life was worth more than money expended for the drug and did not consider the expense, thereby saving the life of his patient. The grin-like expression that made Doctor X. think of "The man with the laughing mask" is what physicians call the "risus sardonicus" which is a grinning expression produced by spasms of the facial muscles and later on in the disease come on spasms of the

The Mam With the Laughing Mask 29

chest muscles and all the muscles. The young man who went through this ordeal is now a very capable physician practicing in the same city as Doctor X. and many times helps the doctor out when his tasks become too hard and Doctor X. has a feeling toward him akin to that of his own son.

Chapter IV A Bronzed Man

One summer Doctor X. and his family were at a cottage out at one of the lakes and friends of a dentist who was ill for a long time heard of the doctor being at the lake which was near the village in which the dentist lived. They called and asked the doctor to come to the village and consult with Doctor Z. who was in attendance on the case. Doctor X., being reluctant to interfere without being called by Doctor Z., told them he would come if the doctor requested him, so the relatives told Doctor Z. to call him, which he did. Doctor X., on entering the sick room with Doctor Z., immediately saw "something" that gave him a clue to a diagnosis made later.

Doctor Z. told Doctor X. that his patient was ill for a year or more with a very grave stomach trouble and his condition was so bad that he had decided to take him to the city for an operation, which was necessary to save the patient's life. He also said his patient consented to go and have the operation, but relatives first thought it best to have a consultation. Doctor Z. privately told Doctor X. that his

A Bronzed Mem 31

patient was suffering from cancer of the stomach and an operation was his only chance. Now I said Doctor X. saw "something" on entering the sick room. The "something" he saw was that the patient looked like a "bronzed man" lying in bed. So, having his implements for examination along, he proceeded to get the facts and found first that all over the man's body the skin looked somewhat bronzed; then, his patient having an irritable stomach, that was his second clue to a later diagnosis. Doctor X. proceeded with a thorough examination and found that the man had an extremely low blood-pressure, being only 80 mm. systolic, where in a normal person it should be 130 mm. systolic. This gave him the third clue. And then, after finding by laboratory tests that his blood only showed slight reduction of hemoglobin and red cells and Wassermann negative. He made his patient get up on his feet and by tests found him to be extremely asthenic and dizzy and fatigued on the slightest exertion. This clinched the four cardinal symptoms that he was looking for; the bronzed skin, the irritable stomach, low blood-pressure and extreme fatigue on exertion are the four cardinal symptoms of "Addison's Disease." So Doctor X. called Doctor Z. into another room and told him not to take his patient to the city for operation or he would die on the operating table, so that's how Doctor X. added about ten years more to the dentist's life. Of course the disease is incurable, but there can be remissions with proper tonics, and in this case the patient got out of bed again and partly attends to his duties, but he is a very sick, incurable man, and will die in from eight to ten years. As far as medical men know about Addison's disease, it is said to be a tuberculosis of the adrenals, which means the suprarenal capsules or capsules of the kidneys, and no cure is known for it, but if recognized early, life can be prolonged. The disease is quite rare and is very often mistaken for cancer of the stomach, owing to the fact that people who have cancer have a discolored skin, but the discoloration is more ashy and not so bronzed or dark as in Addison's Disease. The disease is named after Thomas Addison, a physician who lived in London and first described the symptoms, away back in 1855.

Chapter V Look Before You Operate

One day a lady called on Doctor X. for some minor trouble, and in the course of her conversation said her sister, a beautiful young girl, about twenty years of age, was at a hospital for three months past with a stiff knee. She said Doctors D. and E., two well-known surgeons, had operated on her knee five times in the three months she was at the hospital, but her knee stiffened up just as bad as ever after each operation. She said the surgeons would put her under an anaesthetic and break up the adhesions in the ankylosed knee, but the next day it would be swollen and inflamed and painful, and in a day or two the pain would leave but the joint would be as stiff as ever. She said all this cost her father nearly a thousand dollars.

Doctor X. questioned her as to how her sister's knee became stiff and she said the doctors all said it was due to rheumatism. Doctor X. told her that rheumatism was only a symptom of some other infection and questioned her as to the condition of her sister's teeth and tonsils. She immediately became interested and said she knew her sister had an infected tooth that broke out on her upper gum every once in awhile and discharged pus. Doctor X. told her he thought her sister needed a dentist's care first before she consulted a surgeon. After the lady left Doctor X.'s office she went to her father and told him what Doctor X. said. The father took his girl out of the hospital and the care of the surgeons to his home, and called Doctor X. to see her. Doctor X. found she had a badly infected tooth and also suspicious looking tonsils. The girl was pitifully lame and her knee was ankylosed at an obtuse angle so when she walked she had to step on her toes and ball of the foot. Her father had a dentist extract the tooth and a throat specialist removed the infected tonsils. Doctor X. put her on a general tonic with all the other things that go with it, such as good food and plenty fresh air and rest, etc., and built her up generally, and after two months he took a young physician with him to her home one day and they fixed up an operating table out of the kitchen table, laid her on it, and the young physician put her sound asleep with ether, and Doctor X. broke up the adhesions in the ankylosed knee, working the leg up and down like a pump handle, after he had the thigh bent up on the abdomen. As I say, he worked the leg up and down until it seemed as limber as a normal knee. After this he let the lady come out of the anaesthetic and told the family to let her

Look Before Yom Operate 35

rest for that day, but he warned them that the leg would be sore for a week or so, but he would call every day and help her to get some motion in the knee joint. So Doctor X. called every day and in a skilful manner kept up the motion. He advised in his absence that some one should massage the leg with alcohol first, then after with olive oil, and in one week he had her where she could walk on the sole of her foot like any other woman, and inside of a month she went to dances with her young friends and danced as well as anyone, and to-day no one would ever know she was crippled and, not only crippled, but was despondent because she and her family thought she was going to be crippled for life.