Innocence revisited – 7

The physical examination
The sign of the furrowed forehead

It is a good thing to have a logical and well-rehearsed system of physical examination; it is better if one has an eye for the unexpected as well. Dr Burleigh Jack gives us an example:
 
A patient from thirty miles out of town telephoned to say that she was coming in to see me. Apparently she had straightened up under the house an hour before, hit her head sharply, and was still bleeding profusely from the wound.

She duly arrived – a redhead, with a mass of clotted hair and an odd surprised expression on her face. Her scalp was indeed bleeding and didn’t want to stop, and yet the wound wasn’t all that bad.

Looking at that surprised expression again, I noticed she had a furrow around her forehead, just under the hairline. Closer inspection revealed a string tourniquet. My first question disclosed that, yes, her brother was studying for his first aid certificate, and he was the one who had smartly twisted the tourniquet on for her.

On releasing it, she not only lost the thyrotoxicosis, but the bleeding stopped as well.

Moral – always look for a furrowed forehead in early hyperthyroidism with secondary scalp bleeding, or vice versa.

Throwing light on a mystery

It can get harder. Dr D. Secundus was defeated by the Services: 

An unfortunate incident had inoculated an adolescent male with Clostridium tetani. The wound had shown the presence of the Gram positive rods with their traditional drumstick appearance. Sir Stanley Davidson’s recommendation of ‘nursing in a quiet darkened room’ was instituted.

Appropriate management was begun, and as the spasms increased the rank of the attending physician also increased. We went from a Captain to a Brigadier, yet the spasms continued unabated. Tracheostomy by a Major had been done, and even the nurse attending was a Major.

As the rank went up, so did the dose of chlorpromazine and myanesin. A thiopentone drip was commenced, and with a minimum of fuss, teams of Corporals and Sergeants carried out the manual intermittent positive pressure respiration. Chlorpromazine 100 mg, four hourly, was administered, the spasms ceased – and at 3 a.m. on the tenth day, he died.

The body was sent to the morgue, and the next day the pathologist rang me. ‘Captain, if you want to learn medicine, come over now’, he said.

I got to the morgue in a flash. Before me was a deeply jaundiced body. The postmortem showed acute hepatic parenchymal necrosis, due to excessive chlorpromazine. In the dark room, so essential for management, nobody had seen the jaundice set in, not even the Major General.

The mother tongue

It is one thing to examine and another thing to be examined. Dr Primus has a case in point:

One evening, a mother brought in her seven-year-old son who was distressed with abdominal pain. The child was thoroughly examined by the resident medical officer on duty, with us students also taking part.

After a rectal examination, the resident decided that the child was constipated and he ordered the nurse to give him an enema. The child was taken to the treatment room by the nurse, with his mother and all of us following. Naturally, the preparation of the nurses, of the dishes, pans, solutions and other equipment necessary for the enema, created quite a lot of clanging and banging which added to the child’s apprehension, and upset him even more. As he was crying, his mother vainly tried to placate him in their native language which, unknown to everyone there, I could understand as I came from the same country originally.

Naturally my ears pricked up, and you can imaging how difficult it was to keep a straight face when I heard her say, ‘Don’t cry darling, it’s all right, the nice nurse is only going to wash out your bottom because the nasty doctor put his dirty finger in there!’

Second thoughts

But even when you make the observation, what does it mean? Consider the dilemma of Dr J. Smith:

When I was younger, but scarcely wiser, I found it necessary to be a general practitioner obstetrician. The hospital was staffed by what seemed elderly spinsters to me at the time. The patients seemed to have a poor time of it, always in tears about something or other. The worst part was that always in the middle of the night, when all the difficult births seemed to occur, when I was adjusting the forceps or trying to feel for the anterior fontanelle to diagnose the fetal position (never the fetal ear, of course), I would need something from the Night Sister in theatre. She, poor soul, would never be anywhere to be found. She would duck out in the middle of it all and hide in the pan room, and so there was never the chance of a fresh glove or sterile catheter being readily available. Finally, in exasperation, I complained to the Generals who ran the hospital about ‘the staff inadequacies’. I must have raised my voice too loudly and I was sent packing after ‘launching a tirade against the Staff’.

Some time later, one of my blue-eyed patients was delivered of a son. I noticed in the nursery that he had brown eyes. The husband of the woman had blue eyes, and I let slip the remark that ‘it was not the child of the husband’. This was obviously a truth, but I considered it a meddlesome thought which could interfere with the family relationship.

Some years later, I had a telephone call from the husband. Did I ever make such a remark? ‘Yes, I am afraid I did’. ‘Well, we are going into this matter. We think we have been given the wrong baby’.

And it was true, they had. The hospital staff had mixed them up, but the parents of the two children decided to keep the children they had.

I have not heard any sequel to it, but many is the time I regret I did not take the initiative early on and have a quiet word in the ear of the mother.

First thoughts are often best. But does one ever become strong enough in character to act upon them?