Innocence revisited – 2

In the midst of life

She was an 18-year-old veterinary nurse. A few days before her admission she had assisted her employer examine a sick horse. Among other things, they had examined it per rectum. It turned out to have encephalitis, but whether or not they had achieved the diagnosis in this way I do not know.

Early in the morning of her admission, she had woken and told her boyfriend that she could not breathe. It seemed to be true enough so he had phoned her family doctor and then resuscitated her using the Schafer method, the technique of the day. The family doctor arrived, took it all in, called an ambulance and the trio was conveyed prestissimo to hospital, and into my night duty.

I placed her in a tank respirator to alleviate the situation. This was in essence a large coffin: the patient’s head protruded out one end through a grommet hole and there were portholes along the sides through which hands could be intruded to attend to her needs.

The whole thing was connected to an electric pump which, for some reason or the other, made an enormous noise as the valves changed over. If you have ever heard an 18th century beam engine at work, it was a bit like that.

When the perspiring rescuers had taken their leave, and the emotional level had settled down, I noticed my patient could talk during both phases of the pumping – that is, while her chest was being expanded as well as while it was being compressed. Therefore, she had muscle power on her own, sufficient for speech against the pressure gradient. Leaning on the respirator, talking to her against the din, I opened one of the portholes very quietly and very slowly. After a while, though the pump laboured noisily as ever, there was no change in pressure in the box at all. She talked and breathed without difficulty.

We discussed how one can become afraid: she said that she thought that she had caught something from the horse, and feared mightily, for it had died. Then we talked of how fear can pass from one person to another, and through a group, and of how it is augmented thereby. She could see it all, and then I pointed out that she had been breathing without assistance and without consciousness of difficulty for many minutes.

There was a gasp, and then a smile: within ten minutes she was sitting comfortably outside the machine, ready for her breakfast. My narcissism purred and rubbed itself against my legs.

I visited her a few times during the day to make sure that all was well and it was, until about eight o’clock that night.

She was having difficulty breathing again, there was weakness of swallowing and of one trapezius. Lumbar puncture produced CSF containing far too much protein and far too many small round cells. I placed her back in the respirator and she died in it early next morning, with me sitting crushed and helpless beside her.

Some time later the pathologist told me that she had had severe bulbar poliomyelitis.

Diagnosis by ordeal

I almost wrote that he was an elderly gentleman, but he wasn’t really; more something of a ruffian. Coming home in the dark he had been up-ended by a small boy on a scooter, breaking both his right olecranon and his bottle of muscat.

At the local hospital the pieces of his humerus had been persuaded back into proximity and the arm plastered. Some weeks later, he had a very satisfactory x-ray and a useless arm. Puzzled, his doctors sent him down to the big hospital with a note saying that they thought he had hysteria. So did I. When asked to move his arm, he would wobble it about wildly but never extend it at the elbow. It could do nothing useful.

Interrogated, he said cheerfully that now he could get the pension that he had always wanted, that his arm would never get better, and that he would be able to do no housework of any kind, which in turn would drive the old woman out of her mind. He spent his time in the sunny corner of the ward smoking and yarning with the gentlemen suffering from chronic bronchitis and emphysema.

Days passed, and nothing happened. He was perfectly content and no doubt would have stayed in hospital forever, were it possible. Desperate measures were necessary; looking back some thirty years, desperate they were. I told him that I had a means of making all his limbs move, no matter what problems there might be in his mind. The prospect did not attract him but he could not refuse to participate and retain his dignity. The means was ECT; it must be remembered that in those days the treatment was unmodified.

He was positioned with care, I hit the button and off he went into the usual grand mal. The purpose of the exercise was to produce a situation in which he would wake up, confused, with both arms working, and be confronted with the fact that all was well.

There was a snag. Every part of him was having a grand mal except his right elbow, and the reason was plain to see. His triceps was disconnected from his olecranon, as no doubt it had been all along. A sympathetic orthopaedic surgeon listened to the story, and then sewed him up. The patient wasn’t particularly grateful but I was.

The fully rigged man

For reasons too complicated and trivial to narrate my office was in a surgical ward. One could not help but notice the surgical dresser, who wore high heels and bangles, and changed the colour of his hair to match his moods. His manner was friendly but shrill.

One day I heard the ward sister berating him outside my door. She was a lady of magnitude and purpose and I was glad that it was him and not me. Unexpectedly, there was a thud and then silence. Wishing to see which one of my fantasies had been correct I peeked out and saw an amazing spectacle. He lay on the floor, totally and instantly paralyzed from the neck down. His persecutor stood open-mouthed and silent: he was smiling.

He was taken off to the staff sick bay where he remained quadriplegic and at peace with the world for the next two weeks. Neurologists saw him and wondered; three lumbar punctures produced clear CSF. Finally, it was decided that the problem was in his mind and I was asked to do something about it. He didn't care what was done or who did it, which I thought boded ill.

I was much younger then and felt that the charismatic approach would be the best. I strode in, as though direct from Olympus, and announced with total conviction that within half an hour he would be able to sit up and eat his lunch. To his great surprise and mine, he did just that.

The improvement was maintained; all his muscles remained weak but possessed enough power to perform the minimal chores of living.

Slowly the staff divided itself into two camps. There were those who considered him a vile malingerer, fit for the stake, and those who thought him sadly misunderstood, who kept vigil lest I torment him even more.

Fortunately, this problem was resolved from without, for I moved from the general hospital to a psychiatric clinic and the patient decided to come with me.

For the first couple of weeks after the move, I noted that he continued to exhibit the same muscular weakness below the neck and that he was still totally unconcerned about it. But during the next week or two, I made the disquieting discovery that a gradual, patchy improvement had set in here and there.

It took him many months to recover sufficiently to leave the clinic. During much of that time, he was equipped with so much orthopaedic apparatus that sometimes he reminded me of a fully rigged ship and at other times a skinned Zeppelin, depending on the equipment of the day. Either way he was a living monument to my error, and occasionally he still walks around inside my head.

A fourth lumbar puncture demonstrated a massive rise in protein and a few monocytes – he had an acute polyneuropathy. The news failed to move him one way or the other.

Lesson learned

Each of us responds to adversity in his or her own particular way; it is important not to confuse the response with its precipitant. Neurosis confers no immunity against disease, and many patients have more than one disorder. MT