The University of Chicago, Illinois, United States
In the morning the Medicine Consultation Service clears patients so they can undergo surgery. Fees from the operating rooms are the cash cow that drives the hospital. We read the electrocardiograms and declare no ischemia, lower the blood sugar with quick acting insulin, treat the hypokalemia with 20 milli-equivalents of potassium chloride added to the intravenous infusions, and send the patients off.
In the afternoon there was time to linger over coffee. The back tables of the cafeteria at the blind spot belonged to us, our voices the only intrusion while we grumbled about life, the institution, our schedules, and similar irritants that continued ad infinitum, until one Wednesday, mid-day, the neurology service asked us to see Mrs. Collins. Surgery was not in her forecast but her doctors needed help with the diagnosis.
A handsome and successful mother and wife, Mrs. Collins was slipping into dementia while her family were wringing their hands, bemoaning her fate and medicine’s ineptitude. Memory loss, muscle weakness, confusion, and spastic gait were never good developments.
And all the laboratory tests were normal, the family was told. I sat close, the side rail lowered, our heads inches apart, my chair snug to her bed, so I could hear her soft-spoken responses. Beribboned clay flower pots trumpeting broad green leaves vied for breathing space with a holiday of freshly cut annuals. Their rainbow hues struck a false gayety and their scent masked the waft of decay. “Doctor, do you smoke?” Mrs. Collins asked, lying at attention, molded by crisp hospital sheets. She grabbed my hand, her fingers long and graceful, and her thick grey hair exuberant in spite of her travails.
“No, I don’t smoke and I make it a rule to not provide cigarettes to patients, no matter how regal their presence,” I answered.
“Good,” she replied, “because terrible things happen to me when I smoke or when someone smokes around me, and when I tell my family and doctors about it they laugh, shake their heads, and snort in disbelief.”
I was listening, but not very carefully. I had heard just about everything.
“I go blind!” And she repeated it more emphatically: “I go blind! Is there anything crazier than that?” Tears navigated down her cheeks. “Even with smoke blown at me or entering a smoky room, the same thing happens. I can’t see!”
In all my working years I had heard every complaint from the bizarre to the sad. At times, I became a Bozo the Clown punching bag, my head nodding back and forth saying uh huh, uh huh, uh huh, but I had never heard about smoke causing blindness and I pulled myself straighter in the plastic chair, my interest piqued.
“That does sound strange, Mrs. Collins, but not crazy. Cigarette smoke makes you blind!” I repeated her words. “Thanks for telling me. I’ll try to find an explanation for that, and if one exists, I’ll find it. That’s what I do.”
“You’re not like the other people here, are you, Doctor?” pointing around the empty room with a shaky index finger. “They’re imposters. Why my family brought me here, I don’t know. My eldest son, it’s not really him.
“Did you see the movie, The Invasion of the Body Snatchers?” she asked. Her frailty didn’t stop her dialogue. “That’s what’s happening here, people aren’t who they seem to be.”
Every scene of that black and white classic was imprinted in my memory. The good doctor, Miles J. Bennell, played by Kevin McCarthy, elevated himself to stardom, as he investigated the strange happenings in Santa Mira. The final kiss, colder even than deep space, with the brand-new alien Becky Driscoll, still resonated in my dreams.
Gentle prodding kept Mrs. Collins awake while I completed the examination. The abnormalities in the unlucky lady filled a neurology textbook: hyperactive reflexes, loss of vibration sense, up-going toes, spastic pointing—her index finger wandering away to her ear when I asked her to touch her nose.
“Give me a few minutes,” Ursula sighed, as she left the library, fiddling with her door keys, about to lock up her office. The Chief Medical Librarian, she resided at the opposite end of the pole of her snappish coworkers that harangued me about leaving the stacks in a mess or about a journal’s index pages fused together with Wrigley’s Doublemint. Resigned to my brashness, Ursula knew complaining was pointless. Her children awaiting her home-coming were old enough to heat their own supper. She returned to her office, spread her coat across the back of her swivel chair, wriggled in next to the index card files, and started searching for answers.
Truth was I’ve always been a wise guy, and the worst kind, one frequently with correct answers. I chose to believe I made this institution a better place. I made eye contact and spoke knowingly, emphasizing points with my fist striking my open palm, so most of the time I got away with my attitude.
“Dr. Stiller, it’s Dr. Ted, a medical resident.” Dr. Stiller was the Chief of Ophthalmology and I’m telephoning him at home. “I’m attending a patient who becomes blind when exposed to cigarette smoke,” I told him. “And I know you’re an expert about that.” Who knew, maybe he was.
Dr. Stiller must have read the same articles that Ursula placed in front of me. I nodded thanks to her and flashed an unseen thumbs-up to Dr. Stiller.
“Dr. Frank Zitfield speaking, how may I help you?” The same question whether it was the White House on the line, or me, the flunky assigned to the Consultation Service. Frank was the Chief of the Service and the most thorough and friendliest of the successful downtown doctors. I would work with him in his private office after graduation if he would ask me. He hadn’t.
Frank agreed to host a combined meeting between the neurologists and our team for the following morning. Always a competitive get-together, these inter service conferences mimicked the roller derby and the AWA wrestling blaring on the cafeteria’s television set.
The morning of our event began with great promise: the city was cold, clear and sunny. Lake Michigan lies vertical, like a lavaliere touched by gravity, with the hospital and the entire city for that matter clinging to the bottom left. The mountain of clouds building high over the lake would swoop in later and bring rain.
The Chief of Neurology, short in stature, natty and self-assured, told us about the abnormalities detected on Mrs. Collins’ examination. “It mimics the combined disease of the spinal cord so characteristic of pernicious anemia.” But then he added with a sardonic smile, “Challenge number one, the patient,” he said patient, referring to Mrs. Collins in the third person, making her inanimate, distancing himself from her, a maneuver we all used when we’re uncertain about the diagnosis and the patient’s health deteriorating.
“The patient,” he repeated, “doesn’t have anemia and her red blood cells are normal in shape, and these abnormalities always are found in pernicious anemia,” he said with the right amount of professional concern, standing in front of the blackboard, lecturing to the uninformed.
The room, one of the snug conference rooms attached to every nursing floor, was crowded with house staff, students and attending doctors. Ledges became bleacher seats, bare skin stuck to white plastic office chairs, the light thickly filtered by accumulated dirt, the windows last washed in a previous even-numbered year. Stale doughnuts, tepid coffee and spilled cream littered the long, centrally placed and deeply scarred wooden table piled with outdated laboratory results, and sullied with both strawberry and K-Y jelly. The Consult team was prepared.
“It’s called tobacco amblyopia or blindness caused by cigarette smoke,” Dr. Zitfield murmured, catching everyone’s attention, almost a whisper, coupled with a practiced pause. In his crisp, charcoal gray suit, fresh from the dry cleaners, snug in the waist and three buttoned, he could be the poster boy for the American Medical Association. Doctors like him were at the vortex of attention, their opinions solicited and respected, their jokes repeated and their stories uninterrupted.
“I’m sure you all picked up on that,” he continued. Of course only we knew about it, and thanks to Ursula and the Chief of Ophthalmology we were experts. I added credence to our surprise diagnosis, distributing articles about this strange happening when nicotine exposure causes ocular vasoconstriction and temporary blindness.
“Even high school graduates,” it was my turn to expound, “realize that the combination of tobacco amblyopia and the Capgras syndrome, with the well known character misidentification symptoms that Mrs. Collins vividly displays, adds up to vitamin B12 deficiency or pernicious anemia, as already pointed out by the Chief of Neurology. The only problem, of course, is why doesn’t Mrs. Collins have the anemia?”
The audience was stilled by the hitherto unknown Capgras syndrome and feverishly wrote it down along with the intriguingly named, tobacco amblyopia. The latter, conjuring up the literary images painted in Erskine Caldwell’s Tobacco Road, featuring scantily clad, long limbed women with erotic urges.
“First described by the French psychiatrist Jean Marie Joseph Capgras, who observed that the patient’s delusion was often of a close friend or relative being replaced by an imposter, an exact double,” I continued. “Hey, I’m sure you all remember the movie with the alien pods taking over the citizens of Santa Mira. What the heck was the movie’s name?” I asked. My head down as I eyed my notes in faux concentration.
“The Invasion of the Body Snatchers!” everyone shouted. Audience participation was such a wondrous educational tool.
“Sometimes the sufferer thinks that their pet or even an inanimate object such as a sofa or book has been replaced by an exact replica. The patient is consciously aware of the changes, so it’s not a hallucination.”
“Thank you, Dr. Ted. Our senior student also discovered information for your edification.” Dr. Zitfield moderated. The student, well coached, lectured with the authority of a more seasoned smart aleck. “As you all know, vitamin B12 deficiency or pernicious anemia is masked by the administration of folic acid. One of Mrs. Collins’ sons is a pharmacist, and we thought it possible that he provided her with a preparation containing that vitamin.
“Yesterday evening he confirmed that his mother imbibes a potion of his own creation containing large amounts of folic acid. Folic acid treats the anemia, but not the neurologic abnormalities of B12 deficiency.”
This student had potential, I’ll ask the Chief of Medicine to interview him for residency training.
My turn again. I disliked giving up the floor.
“So we think Mrs. Collins has pernicious anemia as the cause of her neurological disease and her confusion. The cognoscenti know this as megaloblastic mania. It’s manifested by tobacco amblyopia and the Capgras syndrome, both of those disorders now old hat to you. The intra-muscular administration of 1000 micrograms of vitamin B12 on a weekly basis for several months and then monthly should prompt complete improvement, perhaps even in as short a time as weeks. Please start it, stat.
“Thank you all for the interesting consultation and bearing with us for this long-winded explanation describing the infirmities affecting the lovely Mrs. Collins. We appreciate your confidence in us by asking our team to see and comment about her and should there be any further questions, please don’t hesitate to contact us at any time.”
We humbly lowered our heads, gathered up our papers and quietly shuffled our way out of the conference room, victorious in our joust with the plebian neurologists. The slaughter rule was in effect. Not only did we provide a diagnosis for the neurologists but it was a neurology diagnosis. And as a bonus, we helped Mrs. Collins, who, as predicted, morphed into her bright and normal self.
“Mrs. Collins, you look terrific,” I offered at the follow-up examination just a month later during an unusual warm spell, the sun sprinkling through the windows and lighting up her face.
“Thank you, Doctor and thanks for your help. It’s okay, go ahead, light up a cigarette and blow smoke at me. Nothing bad will happen to my eyesight, but of course, I’ll have to report you to the hospital authorities for smoking.” Showing off her wit, she laughed loud and hugged me close. All the good things we pray for.
Michael Ellman, MD, MACR, is a retired physician, formerly professor of medicine and rheumatology at the University of Chicago. His military service was spent as a preventive medicine officer in the Canal Zone between 1965-1967. Ellman has also written several works of fiction, which have appeared in Front Porch Review, Hektoen International, Third Wednesday, and Black Heart Magazine. His Great American Novel about a third-year medical resident during the early 1960s is in search of a publisher.