“If It Isn’t Fun.” – Junior Year Medicine, 1946-47
A SUMMER OF PHYSICAL DIAGNOSIS, 1946
So far, so good.
Sophomore year completed, we were faced with the first real summer holiday since high school, the wartime curriculum from 1942 to 1946 allowing no such luxury. Against this happy prospect was another and finally over-riding desire, to be a “real doctor,” not just a grubby med student. Medical school till now, despite its newness and fascination, had pretty much been an extension of college academics, with lectures and book learning and laboratory exercises. When would we ever become real doctors and examine and treat real patients?
In spring of 1946, we learned that a special elective course in physical diagnosis, the basic tool of clinical medicine, would be offered in summer term. More persuasive still was the announcement of the instructors for the offering, George Burch and C. Thorpe Ray, two of the more brilliant clinicians of those times. Eagerly, I signed up early.
There are few greater thrills in medicine than donning doctors’ gowns on that first day of physical diagnosis before entering the wards and making rounds with the masters. Student gowns were identical to house staff gowns in their cut and embroidered insignia, only they were tan rather than white. Each day a new technique was demonstrated elegantly on the real patients of Charity Hospital wards: history-taking, observation, palpation, percussion, and auscultation. We were happy initiates — nay — novitiates, in the ancient healing arts.
I still have our text and thumbing it evokes many images of that summer. One recollection is that I simply couldn’t stand working alongside Marascalco, my physical diagnosis partner for the summer, whom in my journal I labeled “a hapless clown!”
Residuals of Summer
But the experience having longest residuals from that summer of physical diagnosis was with one of my very first patients, a jaundiced Cajun lad. Despite my reviewing carefully the thin manual of history-taking before starting, the process went very slowly and painfully for both me and my patient. I had to refer frequently to the manual for each next step, while the young patient himself I would now class a “poor historian.” Recall, too, that I knew next to nothing about issues surrounding jaundice in a young male. I had little idea, for example, that it might be directly contagious.
So, the history-taking took the entire first day, during which time I had considerable contact with the patient and his surroundings. When I began the physical examination, of course, that contact was intensified. I did all the things we had learned: observation in good light; a careful eye, ear, nose, and throat exam.; palpation for liver edge, spleen, and lymph nodes. I sat on the bed to the side of and behind the patient to palpate and percuss and auscult properly. And then there were the closing rectal exam. and fecal smear for blood, ova, and parasites, followed by return visits to the bedside to fill in blanks omitted in the history and physical formulary.
The learning process was grim for the lad and grueling for me, but in the end we parted good buddies. I continued to stop by his ward with greetings till he was discharged. I now recall nothing about his hospital chart, which I suspect was off-limits during my preparation of the differential diagnosis and formal case presentation. Subsequently, I graduated to other patients, of whom I have no recollection, and gradually developed my clinical routine, the one that stays with you over the years and through thousands of histories and physical exams. Then one day, four or five weeks after the summer course was over, I became abruptly and severely anorectic.
Aversion to food became total over just a couple of days. My urine was dark and smoky, and by the third day of malaise my stool resembled clay. Never before nor since have I experienced such a profound lassitude, a zombie-like immobility for days on end. Fortunately, our extern schedule at the Marine Hospital, where I earned room and board, was flexible, and colleagues doubled up for the worst period in my illness. I tested my own urine, positive, for urobilinogen and felt for my liver and spleen tips; otherwise I sought no medical care and gradually returned to reasonable function.
The main short-term residual of my acute illness was a shocking discomfort in the right upper quadrant of my abdomen with any jarring motion such as stepping off a curb. By the time in fall that I asked the chief resident whether I might have had hepatitis, there was nothing more to check; a 2+ cephalin flocculation test and tender liver edge were hardly diagnostic. Clearly I had experienced anicteric hepatitis, presumably Type A, from an attenuated but prolonged exposure to the person and bedclothes and virus load of my first patient. In retrospect, it was quite a price to pay for getting a small jump that summer on being “a real doctor.”
A few weeks later, feeling quite fit, I went for a long trail ride on horseback in North Carolina and ended the day with a cool beer at the vacation home of friends. Boom! A paralyzing fatigue and tender right upper abdomen descended on me and the old anorexia returned for several days. I suspect that I had a smoldering hepatitis for some years afterward. This was particularly evident when as an intern in Paris I nicked a tiny pink spot on my cheek in shaving one morning. It erupted in pulsating arterial spurts, a classic spider telangiectasis.
At that time, I never thought that my liver would carry me through to my current considerable age, when I have a very good prospect of survival well into the millennium.