It was an inauspicious beginning. The patient lying on my examining table confounded me. "George, when did you get that telangiectasia on your belly?" He recognized the medical term for an array of dilated capillaries in the skin that was present over a large area encompassing a surgical scar.
"Oh, that began to appear a few months after my radiation treatment."
I was ashamed of myself. Somehow I had failed to elicit a history of either the operation or the radiation therapy. Had I really forgotten to ask about previous operations or had the patient tuned out the memory of an obviously life-threatening illness?
George took me off the hook. "Since I came to you with a breathing problem, I didn't think the belly thing would be of any importance."
George had come to the USA from Yugoslavia in the early 1920s at age ten. His schooling never went beyond the eighth grade; he quit to work on the railroad. As the oldest of seven brothers and sisters, his paycheck was crucial to keep the family from losing their home, for his alcoholic father worked only sporadically. By the time he was twenty, George had been promoted to foreman of a thirty-man crew, laying and repairing tracks for the railroad. By the time he was twenty five he married, had one child and was financing his wife Mary's college education. Mary became a highly respected school teacher. As a political scientist she was frequently called upon to address fraternal and church groups in the evenings. At the time I was learning about George they had celebrated their twentieth wedding anniversary. Regarding their marriage he answered, "Successful. Mary and the three kids are healthy and we all like sports. I have no problem keeping myself occupied while Mary does her thing – and the money she earns makes a big difference."
Does her thing is usually a condescending comment but he appeared to take his wife's academic achievements in stride. Yet, it all seemed a bit too pat. My suspicions would prove to be warranted.
"When did you have the surgery?"
"Oh, about ten years ago; I was thirty-five."
"What was the reason for the operation?"
He hesitated as though trying to find the right words:"My doctor found lump in my belly and asked a surgeon to take a look inside." George wasn't offering any more information than what I requested.
"And?"
"Well, he said it was not possible to remove it all. So he just took out enough to send to the laboratory."
"And what did the biopsy show?"
"Hold it a minute. I never can remember." He reached for his wallet and took out a crumpled piece of paper. "Here, you read it."
I flattened out the note. I couldn't believe my eyes. Sarcoma. "What! You're still alive! That's impossible, George. That's a very malignant tumor. If it were true, you would have died years ago. And it's obvious you aren't dying now. I've got to speak to the pathologist." At that moment the mild pulmonary symptoms for which George sought m examination paled in importance. A mystery was unfolding before me. I was ebullient.
Within two days our hospital pathologist got back to me. His excitement mirrored my own. He began."Because the patient was operated on here, I was able to retrieve the original microscopic slides and I was even able to make new slides from the original paraffin blocks. The tissue diagnosis not recognised at the time of the surgery is a benign tumor. Non-malignant fibrotic tissue encircles the ureters sometimes even closing them off. More often the tumor recedes spontaneously with no need for treatment. There's no evidence that the that the radiation therapy did him and good or any harm. Let's write an article!" (This we did; it was published in the The American Journal of Medicine.)
I invited George to return with Mary; I was too narcissistic to convey the glad tidings over the phone. George broke into broad smiles as I unfolded my report. He took Mary's hand and asked her, "Should we buy the pathologist a bottle of liquor?" Mary just stared out the window. I said to myself, "there is something phoney going on here." As George went out the door Mary tarried a bit, and whispering, asked if she could make an appointment for herself without George's knowledge. "Of course" I said, though I was wary of playing games with my patients.
A week later she entered my consultation room wearing sunglasses. "Very chic," I thought. Wrong. Mary removed the glasses to reveal a black eye.
She began. "You can't imagine what your diagnosis of my husband's condition has done for me. (I was fleetingly complimented.) True he had shoved me around a few times before his surgery, but after he was told that he had a fatal illness he began hitting me more and more. I assumed he was taking out his anger and fright on me; I thought it was my duty as a wife to let him. So many times I wanted to leave him but I was too ashamed beside I knew it would end soon. Hadn't the doctor told me his days were numbered? Then it was no longer days or months but years. I just didn't have the energy to do anything about my predicament. Whenever I threatened to leave, he would pull out his "But I'm dying card". That won't work anymore. I am so grateful to you. I have been to a lawyer and I'm filing for a divorce."
Mary's two-minute declaration exhausted me. She had put me on an emotional roller coaster. George's story was another of so many examples of doctors making snap decisions from inadequate knowledge. Bernard Lown at Harvard Medical School taught his students to interview a patient with the spouse present. I always thought the patient deserved to be seen alone during the initial interview. Had I followed Dr. Lown's advice, I might well have sensed negative vibrations and, exploring them, I might have prevented Mary's last beating. If she, herself, hadn't taken the initiative to consult a lawyer, she might have ended up on a coroner's slab.
Needing nothing more from me, Mary left. I was content that I had resolved a major medical problem for George and by so doing, enabled Mary to free herself from a life-threatening marriage.A month later, George returned to my office, crying. "Mary moved out. I'm lost without her." With a little probing he admitted that he had hit Mary "maybe once or twice but she made me mad." I gave him the name and phone number of a psychiatrist but I don't know that he ever saw him. Since he had survived one potentially catastrophic problem, doubtlessly he would survive this one as well. But would his next spouse?
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