Chapter VIII: more on the medical mind.

• Author: Fenigsen, Richard
• Position: Other People's Lives: Reflections on Medicine, Ethics, and Euthanasia

In Praise of Anecdotal Evidence. In this book I report a number of case histories, and I am often using these to make a point. Some scientific-minded readers may tend to dismiss these stories as merely anecdotal evidence. Please don't do that. Properly designed studies and controlled trials are not the only way to know reality. The bulk of knowledge humankind has accumulated in its history has not been derived from controlled trials. People found that Britain was an island, and how to bake bread, though no properly designed studies on these subjects had been conducted. Medical knowledge begins with case histories, that is, anecdotal evidence. Basic discoveries in medicine: that measles were contagious but left a life-long immunity; that black stools indicated a bleeding from the upper part of the digestive tract; that acute rheumatic fever led to valvular heart disease, and many hundreds of equally important observations, were all based on anecdotal evidence. It was on grounds of purely anecdotal evidence that Dr. Edward Jenner introduced in 1796 his cowpox vaccine, and Dr. William Withering his foxglove therapy (1785); yet Jenner's vaccine saved many millions of lives, and ultimately eradicated smallpox on this planet; and Withering's digitalis has relieved hundreds of thousands of people suffering from heart failure. It is not true that such discoveries could only be made in the 18th century, but are impossible now. We are still able to observe facts. Properly designed studies and controlled trials serve to deepen and verify our knowledge, not to make us blind to what is happening around us.

How Scientific Medicine Has Become. The notion that medicine is being transformed from old guesswork and empiricism into an exact science of "hard facts," laboratory measurement, and statistically significant findings, is partly true and partly based on a mistaken understanding. There has been an abundance of hard facts in traditional clinical medicine, and by no means are all assertions of the new "scientific" medicine hard facts or objective truths. If listening to a patient's heart we hear a very loud first heart sound preceded by a coarse murmur, and the second heart sound is followed by an additional "snap," so that the whole tune resembles a quail's call, we know that the patient has a valvular heart disease, namely, a narrowing of the orifice between the left atrium and the left ventricle (mitral stenosis), and this is a harder fact than the "scientific" measurement of the orifice's surface based on catheterization data since the latter method has many pitfalls: low flow, leaking valve, beat-to-beat variation, or failure to wedge the catheter into a small pulmonary blood vessel, all introduce errors to this determination. (87)

The new scientific medicine is not even free of some patent nonsense. The electrocardiographic diagnosis of "anterior" myocardial infarction is still based on the ingenious but mistaken "electrical window" theory. As a result, the localization and extension of the infarction, as determined from the ECG, prove wrong at the post-mortem in more than half the cases. (88)

What is a "Hard Fact"? The noted Polish-Jewish serologist Dr. Ludwig Fleck published in the 1930s a book in German on "The origins and development of a scientific fact." Many years later his theories gained some popularity among American historians of science, (89) Fleck, indeed, was a precursor of present day "post-modernism." In his view, a "scientific fact" was the result of a gradual process during which the circles having a say in science developed a conceptual apparatus and a vocabulary needed to formulate the new truth. I do not subscribe to Fleck's view and think that his use of language confused a natural phenomenon with its discovery and its acknowledgment by the scientific community. But I do find the uncritical faith in the self-contained existence of "hard scientific facts" a bit naive.

Hard as a Fact May Be, It Takes a Human Being to Perceive It. A curious and ominous disturbance in bio-electrical activity of the heart, described in 1965, is a good example. That year during my stay at Paris' Hospital Lariboisiere I spent some time at the graphic lab, which was the domain of Dr. Dessertenne, a tall, taciturn, collected man. He showed me a peculiar electrocardiographic finding he had recently published: the torsades des pointes, an extremely fast electrical activity of the heart's ventricles, conspicuous by gradual turning of the peaks of ECG waves which alternately pointed up for a couple of seconds and then for a similar period turned down, and this sequence of events repeated itself again and again. During this disturbance the heart does not contract and pumps no blood. Most often the torsades spontaneously cease after some seconds, but if the disturbance persists, the patient loses consciousness and ultimately dies. Before Dessertenne, bouts of this strange and ominous cardiac arrhythmia had been recorded by electrocardiographers all over the world but nobody paid attention; or sometimes this ECG pattern was misinterpreted as "ventricular fibrillation with large waves."

Dessertenne noticed that it was something else and specific, and most importantly, found out when, how, and why the torsades occurred: it happened if during normal heart rhythm the electric cycle of every heart beat (the Q-T interval of the ECG) was considerably prolonged. This discovery immediately opened the way to prevention and effective treatment: to suppress the torsades one had to shorten the Q-T interval. It could be achieved by removing the cause, quickening the heart rate, or injecting magnesium sulphate. The problem has considerable practical importance, because the cases are there: patients with long Q-T due to alcohol-induced potassium deficiency, inborn abnormality, side-effects of anti-arrhythmic drugs (amiodarone), or side-effects of chemotherapy For these reasons, quite a few people develop the life-threatening torsades des pointes.

But even after the publication of Dessertenne's work the torsades were still a long way from being universally recognized as a "fact of science." They are recognized now; but the delay was considerable. Articles published in English reach all corners of the world, but those published in French, in the Archives des Maladies du Coeur et des Vaisseaux, do not easily cross the Channel, let alone the Atlantic Ocean. Even in Leiden, Holland, I had the dubious satisfaction of introducing as "novelty" the torsades that had been discovered eleven years earlier by that quiet Frenchman.

"Medical Diagnosis is a Job Like Any Other." No it isn't. More often than not, appearances are misleading, and we are groping around a hidden reality

Should one order a chest X-ray when the patient complains of pain along one arm? Yes, if the pain is severe; the patient may in fact have cancer of the lung (the Tobias-Pancoast syndrome). What struck me was that the patient appeared to be so sick and so heavily oppressed by the pain. Immediate chest X-ray revealed a tumor's shadow at the very top of the left lung's upper lobe.

Our hospital's lab technician brought in her mother, age 45, who in the last few weeks was becoming breathless at the slightest exercise. The ladies sought the help of a cardiologist assuming that shortness of breath must be due to heart weakness. But the mother was strikingly pale. Examining her abdomen, I felt a tumor the size of a tennis ball. She was severely anemic due to a bleeding cancer of the colon, fortunately, operable. The patient's shortness of breath was due to anemia.

I remember a girl of twelve whom the family physician diagnosed as having acute appendicitis and referred for immediate surgery. What she really had was a pneumonia of the lower lobe of the right lung. The involvement of diaphragmatic pleura caused a painful tension of the abdominal muscles, which mislead the poor doctor.

A worker employed at the production of viscose was brought to my emergency room in Lodz by a doctor who found him acutely psychotic and suspected a poisoning with carbon bisulphide. The man screamed, fought the medics, and shouted obscenities. He died before anything could be done. Autopsy revealed a burst thoracic aorta. The patient's "mental illness" had been due to the sudden insufficient blood supply to the brain.

Eight hours after surgery to remove a clot obstructing her femoral artery, the 48 year old lady with valvular heart disease suddenly began to scream, complaining of an excruciating pain in her chest. The surgeon, certain that she was having...