History is important. “The farther back you look, the farther forward you will see,” Winston Churchill once said. Particular to our profession as doctors, William Osler’s famous adage, “Listen to your patient, he is telling you the diagnosis,” rings true even to this day. But there is another, often forgotten edict, created long before these two figures came into being, handed down from generation to generation. And that is:
“Listen to your mother.”
I am living proof of the power of this statement.
Years ago in my early days as a otolaryngologist I saw a patient who was referred by one of the emergency rooms for dysphagia (difficulty swallowing). The E.R. had not called me but rather instructed the patient to call my office to schedule an appointment within a week. He was an elderly gentleman accompanied by his son who provided much of the all-important history, for I could barely understand what the patient was saying.
Since he was not having pain or fevers, I figured the ER concluded this was not a severe infection such as a peritonsillar or deep neck abscess—two potentially life-threatening emergencies. His dysphagia was not from a mechanical obstruction since he could actually swallow, but rather he appeared to have an oro-motor problem, meaning he had problems with the muscles in and around his mouth, causing difficulty chewing and operating his mouth properly, which was also causing dysarthria (difficulty speaking and forming words) and the reason for his unintelligible speech. He was otherwise in no acute distress and was actually laughing at times. Naturally, I wondered if he had a stroke.
“Nope, the doc at the ER said he didn’t,” his son replied. “They said they didn’t know what’s causing his problem, that it was an ear, nose and throat problem and that you’d figure it out.”
As a young doc barely out of residency, those were words I didn’t want to hear. Sure, I like challenges from time to time, but I was rather swamped, seeing other patients with urgent needs as I was still on-call for the ERs.
We talked a bit more. I examined him and found he had severe trismus (inability to open his mouth). There were no areas of tenderness but mainly a sense of tightness of the master muscles. “Lock-jaw?” spontaneously popped into my head without a deliberate thought process to put it there. “Lock-jaw” was a term my mom used when I was a kid, a term some of you may have heard growing up as well. “Don’t play with that rusty nail!” Mom cried out one day as I was about to do something really stupid, like play with a rusty nail protruding from a fence. “You’ll get lock-jaw!” came immediately after.
I didn’t know what she meant by “lock-jaw.” Mom said it was from tetanus, a nebulous thing found in rusting metal and I’d be sorry if I ever got it. Fast forward to medical school and I better understood the nature of tetanus. Through med school and residency however, I had never seen a case of tetanus, ever.
So there I was sitting in front of this patient with the words “lock-jaw” in my brain, much like a comic strip character with those very words alighting in a cartoon bubble floating over my head. Reflecting not on my accumulated medical knowledge but more on Mom’s lesson, I asked if he recently cut himself with anything rusty.
“You know, he did,” replied his son. “He cut his hand on an old chain-link fence about two weeks ago. He’s always outside working on things. He went to an urgent care for that. That’s why his hand is still bandaged.” I hadn’t noticed that detail before, perhaps it was the sleeve of his jacket partially covering it, but more likely I wasn’t being a complete doctor and instead focused too much on the head and neck as per my profession.
“When was his last tetanus shot?” I asked, which happened to be the day he was at the urgent care. Having immigrated into the U.S. some time ago, he never had a vaccination before, so that tetanus shot was his very first. I put two and two together and told them what I was thinking.
“You know, I’m not completely sure, but I think he has tetanus.”
His son looked at me blankly for a few seconds, then a sudden realization came. “Hey doc, that makes sense!” His father, hampered by the tight muscles, tried to smile but was able to laugh through clenched teeth. I immediately admitted him to the hospital (this was before hospitalists were available), consulted an Infectious Disease specialist who confirmed he had tetanus and started treatment. Unfortunately, he soon went into acute respiratory failure needing emergent intubation and mechanical ventilation, and sadly passed away not too long after. He kept his sense of humor to the very end, and I was surprised his family was very grateful for the care he received from us and everyone at the hospital. He was 97 years old and had a very happy life. The local newspaper had the story and his picture on the front page, as tetanus is indeed a rare disease.
I have not seen another case of tetanus since. From time to time the memory of this pleasant gentleman comes to me, as a reminder that the importance of obtaining history lies not so much in the medical catch-phrases or the algorithms we often mechanically use, but in the personal dialogue we have, and that much of our learning comes not only from formal study and our experiences as physicians, but from the most unlikely of circumstances, such as the memory of a silly kid playing in the yard and recalling many years later the wisdom of his mom.
©Randall S. Fong, M.D.