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Off North Road: Perils of diagnosis, Part II
September 22, 2005
By Russell Hoxsie, M.D.
Despite a sound diagnosis and treatment for peptic ulcer, Walter Wyczinski continues to feel poorly and lose weight. Further thought and diagnostic work between the two clinic "colleagues" reveal an unexpected result. The episode in the life of the patient is true but details, names other than the Drs. Wolf and Wolff, and conversation are the product of my own invention.
Mrs. Wyczinski stayed at home looking after the children and doing the routine chores that kept a home together. She worried constantly about her husband, couldn't understand why he worked such long hours. She thought his ulcer pain came naturally as a result of the tension of his work. In fact, there was good evidence for her thoughts. In the late 1800s, William Beaumont had experimented on the stomach of the unfortunate Alexis St. Martin. As a boy he had required a permanent artificial opening into his stomach through the abdominal wall (gastrostomy) after the scarring of his esophagus from swallowing boiling hot chowder. Dr. Beaumont, a frontier doctor in Texas, had claimed that emotions like fear or rage could affect the lining of the stomach and its production of hydrochloric acid. In the 20th century at Cornell, Harold Wolff and George Wolf reported studies similar to Beaumont's on their subject whom I'll call Robbie. He was a subway laborer whose own gastrostomy had been so irritated by his dirty work, shoveling and lifting, that it bled, became infected and required hospitalization. The Drs. Wolf(f) obtained a job for him in their laboratories where he came in five days a week and cleaned the labs from the work of the day before. His conditions of employment required his availability for experimenting with his gastrostomy, taking certain measurements of acid production, looking inside with a primitive scope to see the changes reflected in the stomach lining under the influence of various external forces.
One day Robbie came into the lab and found one of the doctors looking grim and angry. "Look at this mess," the doctor said. "I thought we hired you to clean up; this pile of dirt is scattered all over." Robbie had been in an hour before and knew the dirt had not been there when he put his cleaning equipment away. At first he was terribly embarrassed. By this time the doctor had directed Robbie to the exam table. The scope revealed a marked reddening of the stomach lining similar to Robbie's reddening face. The longer he was chastised for the mess he had left, the angrier and paler Robbie became and his stomach lining reflected the same change. Of course, Robbie worried he might lose his job so he had to maintain control over his anger. That was obvious by the expression in his face and tightly held fists while the hydrochloric acid poured forth from his stomach in great quantity.
Finally, when the doctor left and then returned to apologize profusely for his "mistaken" accusation at this very conscientious and vulnerable man, Robbie's facial expression as well as his stomach lining returned to normal as did the production of hydrochloric acid.
It was hardly a jump to become convinced that suppressed anger and prolonged anxiety resulted in excessive acid production in the stomach and caused peptic ulcer. It was no large jump to see the logic of Walter's wife's conviction that the stress of his cab driving was directly the cause of his abdominal pain. Ironically today there is convincing evidence that peptic ulcer disease is largely an infectious disorder caused by a bacteria called Helicobacter pylori. Most patients can be cured for long periods if not for good with an intensive regimen of antibiotics, perhaps even to survive the vicious life of a New York cab driver.
Despite careful attention to diet, antacids, moderation of his work habits and relaxing with his two small daughters each weekend, Walter did not feel well. His nervousness continued, his weight continued to fall and his sleep was horrible. "I don't know if I can keep on, Doc," he said on the next clinic visit. By this time he and I had an easier relationship than I ever imagined was possible. I knew how often he stopped at a bar on Second Avenue before returning home for a late meal in the days of continuous cab driving. He was terrified to go back to school for his high school equivalency because he feared failing and humiliation. I thought I had uncovered enough psychic stress to account for his symptoms and I had prescribed small doses of phenobarbital. However, he continued to feel sick and discouraged.
Dr. Moore, as usual, remained interested. "Something is missing here," she offered at our twice weekly meeting. "He should be feeling well by now. His nervousness and weight loss and sleep loss could be due to a variety of things. Examine his thyroid again next visit and set him up for a basal metabolism examination and a protein bound iodine blood level." By the time I had reviewed Walter's physical examination I discovered several details I had overlooked or explained away. The record showed his pulse was always above normal, sometimes only 84 but often 102 or even 110 beats per minute. His blood pressure showed a wider than normal gap in the systolic and diastolic pressures, several readings being in the high zone like 150/66 and 162/70. My exam of his thyroid gland in the neck was unremarkable. I had little reference to go by and later Dr. Moore concurred that his gland was not enlarged. However, we both agreed there was a fine rhythmic tremor to his hands, worse when he became tense and that his weight loss had been slow but steady in the face of an excellent appetite and food intake. "Oh, yes," he'd said as he got into the swing of reviewing all his symptoms. "I've had a tendency to pass frequent loose stools in the past couple of months, didn't think it was important to mention." I hadn't asked him since the first time I'd seen him.
When his laboratory values returned to the chart and Dr. Moore and I sat down to go over everything, the picture became clear. Even with the rather inaccurate and non-specific lab tests we had in the early fifties, they confirmed a very over-active thyroid gland which clearly indicated that he had been suffering from more than just the peptic ulcer. I remained on the medical clinic rotation just long enough to see Walter start new medication, a combination of iodine and propylthiouracil to slow down the output of thyroid hormone. During my last visit with him, turning him over to Dr. Moore and her new student, I could see he was improved in all areas. His stomach was finally feeling well. His weight had leveled off and Mrs. Wyczinski congratulated her husband on now limiting his work hours to spend time with their children. He was sleeping all night and relaxing in the evening with a single beer.
I have always been grateful to Dr. Moore who encouraged me with patience and respect. She taught me that taking care of a patient meant constant vigilance, cultivating the ability to change course, question decisions and never to be satisfied with less than success. And she gave me a new thought for the time — always look for a second diagnosis. I learned to a degree at the expense of Walter Wyczinski who suffered symptoms for longer than he might have had I been more astute. I began to love the practice of Medicine in those early medical clinic days while learning the responsibility entailed in encouraging the trust of a patient.
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