I THINK…

by Steve Goldfinger

Everyone gets them.  Those brief twists of intestine, small pockets of gas, maybe a swallowed seed in a tight spot before it passes along.  For most, they are mild enough—maybe a 1 or 2 on the proverbial scale of 10 and virtually ignored. But for a few, gut pain can ring in at a resounding 9 or 10, last a day, and obliterate any chance of carrying on with life’s activities.

They come to see me for an explanation, a visit of last resort. In their minds, an answer will assuredly yield the clue to relief. I take a careful history, perform my physical exam, and review each of the many CT scan, MRI, and ultrasound studies as well as the notes of docs who have come before me. Nothing, as I suspected at the start, will ring a cheerful note.

In the end, all I can suggest is that they are cursed with “hyperalgesia,” meaning they are exceedingly sensitive and thus overeactive to minor stimuli that others barely perceive. I describe studies on irritable bowel patients. When deflated balloons are placed in their rectums and air is gently introduced, they feel pressure and pain long before their normal counterparts are perturbed. Do these IBS sufferers have more nerve endings in that nether region? Do their nerve endings release more or different neurotransmitters than they should? Who knows? It’s probably infinitely more complex than this. But whatever the case, we give their pain a name: hyperalgesia.  The name covers our ignorance of what is really going on.

I wish I truly understood this disorder. Without such knowledge, I feel I am little more than a shaman with impressive certificates and degrees on my office walls. I try to compensate for my ignorance by resorting to the usual standbys: showing compassion, suggesting some medicine that hasn’t already been tried, recommending an alternate approach such as meditation or hypnotism. And then, providing the false hope that soon we will really understand the precise biological pathways that cause hyperalgesia and then be able to cure it. “Fat chance,” I say to myself.

Those pathways. I have seen diagrams displaying hundreds of tiny arrows suggesting the incredibly complex interplay of nerves, their neurotransmitters and hormones to explain the so-called mind-gut connection. And then I am reminded of the most fundamental question of all, the mystery that continues to plague neuroscientists and philosophers alike. How does the ephemeral domain of thought arise from the physical world of the brain? Can one even postulate a connection?

Rene Descartes thought he had the answer to the mind-body question with his famous iteration, cogito ergo sum.  “I think, therefore I am.”

Really? Years ago, quick witted philosophers added a playful tag line to dispel Descartes’ facile solution. I remember it from philosophy 101. Cogito ergo sum…cogito.  “I think, therefore I am….I think.”

“This new drug I am prescribing will surely reduce almost all your pain…I think.”

After a long career in medicine, Steve has been exploring his artistic side.  At BOLLI, he has taken writing courses, been active in the Writers Guild, and even tried CAST (Creativity in Acting, Storytelling, and Theatre) where his imagination made him a singular player!

THE FIRST CPR AT MGH

by Steve Goldfinger

The year was 1960, and an astounding report from Johns Hopkins had just appeared in a major medical journal. The authors described reviving patients who had died before their eyes by starting external chest compressions and mouth-to-mouth breathing, so-called cardiopulmonary resuscitation. Prior to this, the only maneuver that ever worked was to cut open the chest, reach in between ribs, grab the dying patient’s heart and start squeezing it. A ghastly way to usher out a life, as was usually the case. But now, there was something new.

An intern, working alone on a floor upstairs, I was called from the emergency room by a resident. And he sounded totally different from his usually unflappable self.

“You won’t believe this,” he began. “A woman was brought in by her children a few minutes ago. We took her to a back room and, just as we began to take a history, she died. Right in front of us. No pulse. No heartbeat. Eyes rolled up. So we began to push on her chest and breathe into her mouth. Like we read about.  And we got a pulse back! She actually looked at us! Seemed not to know what was going on.  Lots of moaning. I know we broke a few ribs when we were pounding on her chest, but we couldn’t help that. She’s very old, pretty frail, sick looking, but her vital signs are stable, and we’re sending her up to your floor. She’ll be there in a few minutes. Wow…we saved her! This is a first at MGH!”

She was indeed frail, very frail, I noted as she was wheeled into our open ward, her son and daughter-in-law trailing close behind. As the attendants began to transfer her into a bed, I took the two aside to tell them about the miracle that had just happened and to take a history. Tears came to their eyes as I explained the new maneuver and how it had brought her back to life.

But they were not tears of joy.

“You don’t understand, doctor,” the woman’s son said. “ She has end stage cancer. It’s all through her body, and it has moved into her bones. We brought her here to die.  We wanted her to be comfortable at the end.”

After a long career in medicine, Steve has been exploring his artistic side.  At BOLLI, he has taken writing courses, been active in the Writers Guild, and even tried CAST (Creativity in Acting, Storytelling, and Theatre) where his imagination made him a singular player!

IT WORKED!

by Steve Goldfinger

On a sweltering August morning in 1944, I sat outside the door of Camp Kee Wah Kee’s infirmary.  I remember the rough wooden bench, the buzzing of horse flies, and—above all—the excruciating headache and fever that had brought me there.

Hours later, my Uncle Dick arrived to put me in his car and take me home. On the way, I asked what was happening.

“Well, there’s a polio epidemic,” he said, “and the camp is closing.”

Just the word polio provided a major scare at that time, but I honestly do not remember how frightened I was during that ride home. I may not have realized that my headache was caused by the polio virus, which I associated only with life-long paralysis.  Later, I learned that three of the seven other kids in my bunk had been so afflicted.  As I later learned, fewer than 1% of infections cause paralytic polio.

*

On a cool evening in the summer of 1955, a long line of dad’s patients—children and adults—filed from the front door of our house, down the flagstone path, and onto a stretch of sidewalk beyond. They were all healthy and were there in order to remain that way. Once they entered the house, they would go through the waiting room and into the office. Dad then inoculated each of them with a dose of the just-released vaccine pioneered by the decade’s hero, Jonas Salk. Inoculation programs were underway all over the city.

*

One day in the 1980s, I was nabbed by a young doctor in training who was perplexed by one of the questions on the national board examination he had just taken. It described a young man who developed fever, then muscle pains, and, later, progressive weakness of both legs. There had been no loss of sensation in the legs. My trainee said he had never seen or been taught about such a case, and he couldn’t imagine what the correct answer was.

That’s how effective that vaccination program had been.

After a long career in medicine, Steve has been exploring his artistic side.  At BOLLI, he has taken writing courses, been active in the Writers Guild, and even tried CAST (Creativity in Acting, Storytelling, and Theatre) where his imagination made him a singular player!

Some may question the advisability of airing this confessional remembrance to a broad audience, but Steve says that, for him, it is a story of efficiency gone horribly wrong, an inadequate reaction, and a singular event that can haunt one for a lifetime.  

SURPRISE ENDING

by Steve Goldfinger

He was in his mid-forties, comatose, febrile, and near the end. His hemophilia had caused uncontrollable bleeding throughout his body, and bacteria had infected his blood-laden tissues. A young attending, I led my team of house staff and students on rounds in our critical care area, stopping at his bedside only briefly. We had come to recognize that a huge number of transfusions had not made a difference; we could not stop the bleeding; and no new antibiotic was going to reverse the course. His vital signs told us he had entered the final stage. There was no family to contact, no friends we knew of. I commented that death was near and that no new measures made any sense. As we moved on to the next patient, our senior resident left us and went back towards the nurse’s station. We didn’t know why; nor did we ask. There were too many patients to be seen.

About 15 minutes later, he returned. “Well, it’s over,” he announced. When I asked what he meant, he told us. He had loaded a syringe with a lethal dose of potassium chloride and injected it into the dying patient’s vein. Instantaneous death occurred when it reached the heart and stopped it from beating.

Silence.

I was staggered by what he had done, so staggered that I was unable to say a word. We looked at each other. The group looked at me. I could not talk, could not imagine how he could have done such a thing, could not find a way to convert busy patient rounds into an ethics seminar. Could not even reprimand him as much as I felt I needed to.

Why? I continue to ask myself 40 years later.  Was I so intent on getting to all the patients that I failed to take a mandatory time out?  Was I unwilling to chastise him in front of all the others?  Would doing so require an explication of the moral principles he had violated? And was I capable of summoning up those principles and expressing them in an articulate way without time to recall them, reflect on them? Or, perhaps, did a small part of me completely understand what he had done and found it within reasonable, if not ethical, boundaries?

We received his report, and, a moment later, moved on to the next bedside without comment. Nor did I bring up this abhorrent act for discussion the following morning.

To this day, I am ashamed. I wonder how those students and interns regarded my silence.  Did they think this was a routine rite of passing endorsed by me, my colleagues, our profession? I can only hope that, as they moved on in their training, they came to recognize the event as the horrendous anomaly it was.

But in thinking about it now, was that injection of potassium chloride very different from the morphine drip that would some day come to use…ostensibly to reduce suffering…but, so often, in amounts that terminate breathing prematurely?

Who knows?

After a long career in medicine, Steve has been exploring his artistic side.  At BOLLI, he has taken writing courses, been active in the Writers Guild, and even tried CAST (Creativity in Acting, Storytelling, and Theatre) where his imagination made him a singular player!

TWO CANCERS

by Steve Goldfinger

The patient had turned 50 and was in perfect health when she went for her first colonoscopy. There, at the very last segment of bowel to be examined, was a small cancer growing in the region of her appendix. Surgery to remove it was performed the next week. Seventeen months later, she was dead from metastases throughout her body.

At age 55, my father noted constipation. Within weeks, he was unable to have a bowel movement. As a physician who was well aware of his own body, he could recognize each wave of peristalsis curving in his abdomen and then stopping abruptly where his colon met his rectum. He told me these things the night he brought home the films from the barium enema he’d gone through that day. Without doubt, a cancer completely obstructed his bowel. The next day, he signed in to the local community hospital, spared the foreign intern by cavalierly writing his own history into the chart, and called upon his surgical buddy “Chippy” to do the operation. No need for a major medical center or a renowned surgeon to take care of things. And Chippy was pretty good at what he did.

My mother and I sat in the waiting room, she in her thoughts and I in mine.  A third year medical student having just completed a three month exposure to surgery, I expected the worst. When Chippy finally came in, I saw him smile. “No lymph nodes,” he exclaimed, “it all grew in.”  My father lived another 32 years with nary a bowel complaint.

“It all grew in.”

Just what signal from the interior of my father’s bowel had directed those cancer cells inward?  And with such force as to not allow any to escape in the other direction. Was it anything akin to the earth’s magnetic field that directs each salmon to its personal spawning rivulet? Impossible. Swallows travel 6,000 miles to return to Capistrano to resettle in their cliff nests each year. Instinct, memory, wind currents, and who knows what else. Nothing that seems to pertain to a cancer cell.

More likely, my father’s cancer cells didn’t all home inward. Perhaps some escaped from his colon but could not thrive in the outer world. Possibly, they found the soil of whatever tissue they reached inhospitable, not letting them set up shop and multiply. Or perhaps his cancer cells, unlike those of my patient,  were unable to secrete a fertilizing substance that would allow them to dig deep and flourish in foreign lands.

Questions begging for answers.

Who knows?

After a long career in medicine, Steve has been exploring his artistic side.  At BOLLI, he has taken writing courses, been active in the Writers Guild, and even tried CAST (Creativity in Acting, Storytelling, and Theatre) where his imagination made him a singular player!

WHO KNOWS?  NUX VOMICA

by Steve Goldfinger

When we made early morning rounds on the open ward, moving from bedside to bedside, I listened carefully to the resident in charge as he tended to each woman. Whenever he learned that one was suffering from abdominal discomfort—be it heartburn, cramps, gas or constipation—he would always prescribe a dose of something called nux vomica. A strange name, I thought. But even stranger, it often seemed to work, as we would find out at our next visit.

A year later, it was I who was the resident overseeing rounds, trailed by two interns. And it was I who was routinely prescribing nux vomica for belly distress. After a week or so, one of my interns threw a question at me that I had never thought about. “What is nux vomica?” he asked. When I looked it up, I couldn’t believe the answer: strychnine!

Only now, in recalling my long-ago reaction of horror and embarrassment, have I done a bit more research on nux vomica. Yes, it is indeed derived from the highly poisonous seeds of strychnos nux-vomica, a medium-sized deciduous tree native to India. Strychnine poisoning is a ghastly way for a life to end. Within 20 minutes of swallowing it, a person develops intense muscle spasms that cause gruesome facial contortions. Soon, every muscle of the body is activated into stiffening contractions that progress to writhing convulsions. The backbone arches taut. High fever adds to the agony.  After two hours, mercifully, breathing ceases.

The lethality of strychnine has hardly gone unnoticed by writers, including Agatha Christie (employing it to murder characters in three of her mysteries), Arthur Conan Doyle, Stephen King, and Alexandre Dumas. Strychnine killed Norman Bates’ mother and her lover in Psycho. And in Cape Fear, it ended the life of Sam Bowden’s dog.

So what about the women with belly cramps we were treating with nux vomica? Well, we were using an exceedingly diluted preparation that had made its way into our hospital’s pharmacy back in the 1960s. I doubt that it is there today, but one can still obtain nux vomica online from a host of vendors—herbalists, homeopaths, naturalists, and the like. They promote it as a remedy for digestive disorders but also for ailments affecting the circulation, eyes, and lungs as well as migraine, erectile dysfunction, and menopausal distress. Of course, there is not a single scientific study showing that nux vomica does any of these things.

So, what about the women on that ward?  Maybe strychnine, in miniscule dosage, actually did suppress their intestinal spasms.  Maybe it blocked the specific nerve fibers carrying pain to their brains. Or maybe it was simply a placebo effect that brought them relief.

In the absence of studies, it’s easy to dismiss all the claims made for nux vomica. But, of course, for the very same reason, it’s a real question–who knows?

After a long career in medicine, Steve has been exploring his artistic side.  At BOLLI, he has taken writing courses, been active in the Writers Guild, and even tried CAST (Creativity in Acting, Storytelling, and Theatre) where his imagination made him a singular player!