The Medical Detectives Volume I

by Berton Roueche

  Dr. Wooten found his voice. He gave Turner a friendly good morning, asked him to sit down, and remarked that it had been u couple of years since their last meeting. Turner agreed that it had. He had been away. He had been working up in Alaska—in Fairbanks. He and his wife were back in Memphis only on a matter of family business. But, being in town, he thought he ought to pay Dr. Wooten a visit. There was something that kind of bothered him. Dr. Wooten listened with half an ear. His mind was searching through the spectrum of pathological skin discolorations. There were many diseases with pigmentary manifestations. There was the paper pallor of pituitary disease. There was the cyanotic blue of congenital heart disease. There was the deep Florida tan of thyroid dysfunction. There was the jaundice yellow of liver damage. There was the bronze of hemochromatosis. As far as he knew, however, there was no disease that colored its victims orange. Turner's voice recalled him. In fact, he was saying, he was worried. Dr. Wooten nodded. Just what seemed to be the trouble? Turner touched his abdomen with a bright-orange hand. He had a pain down there. His abdomen had been sore off and on for over a year, but now it was more than sore. It hurt. Dr. Wooten gave an encouraging grunt, and waited. He waited for Turner to say something about his extraordinary color. But Turner had finished. He had said all he had to say. Apparently, it was only his abdomen that worried him.

  Dr. Wooten stood up. He asked Turner to come along down the hall to the examining room. His color, however bizarre, could wait. A chronic abdominal pain came first. And not only that. The cause of Turner's pain was probably also the cause of his color. That seemed, at least, a reasonable assumption. They entered the examining room. Dr. Wooten switched on the light above the examination table and turned and looked at Turner. The light in his office had been an ordinary electric light, and ordinary electric light has a faintly yellow tinge. The examining room had a true- color daylight light. But Turner's color owed nothing to tricks of light. His skin was still an unearthly golden orange. Turner stripped to the waist and got up on the table and stretched out on his back. His torso was as orange as his face. Dr. Wooten began his examination. He found the painful abdominal area, and carefully pressed. There was something there. He could feel an abnormality—a deep-seated mass about the size of an apple. It was below and behind the stomach, and he thought it might be sited at the liver. He pressed again. It wasn't the liver. It was positioned too near the center of the stomach for that. It was the pancreas Dr. Wooten moved away from the table. He had learned all he could from manual exploration. He waited for Turner to dress, and then led the way back to his office. He told Turner what he had found. He said he couldn't identify the mass he had felt, and he wouldn't attempt to guess. Its nature could be determined only by a series of X-ray examinations. That, he was sorry to say, would require a couple of days in the hospital. The pancreas was seated too deep to be accessible to direct X-ray examination, and an indirect examination took time and special preparation. Turner listened, and shrugged. He was willing to do whatever had to be done. Dr. Wooten swiveled around in his chair and picked up the telephone. He put in a call to the admitting office of Baptist Memorial Hospital, an affiliate of the medical school, and had a few words with the reservations clerk. He swiveled back to Turner. It was all arranged. Turner would be expected at Baptist Memorial at three o'clock that afternoon. Turner nodded, and got up to go. Dr. Wooten waved him back into his chair. There was one more thing. It was about the color of his skin. How long had it been like that? Turner looked blank. Color? What color? What was wrong with the color of his skin? Dr. Wooten hesitated. He was startled. There was no mistaking Turner's reaction. He was genuinely confused. He didn't know about his color—he really didn't know. And that was an interesting thought. It was, in fact, instructive. It clearly meant that Turner's change of color was not a sudden development. It had come on slowly, insidiously, imperceptibly. He realized that Turner was waiting, that his question had to be answered. Dr. Wooten answered it. Turner looked even blanker. He gazed at his hands, and then at Dr. Wooten. He didn't see anything unusual about his color. His skin was naturally ruddy. It always looked this way.

  Dr. Wooten let it go at that. There was no point in pressing the matter any further right then. It would only worry Turner, and he was worried enough already. The matter would keep until the afternoon, until the next day, until he had a little more information to work with. He leaned back and lighted a cigarette, and changed the subject. Or seemed to. Had Turner ever met the senior associate here? That was Dr. Hughes—Dr. John D. Hughes. No? Well, in that case . . . Dr. Wooten reached for the telephone. Dr. Hughes's office was just next door, and he arrived a moment later. He walked into the room and glanced at Turner, and stopped—and stared. Dr. Wooten introduced them. He described the reason for Turner's visit and the mass he had found in the region of the pancreas. Dr. Hughes subdued his stare to a look of polite attention. They talked for several minutes. When Turner got up again to go, Dr. Wooten saw him to the door. He came back to his desk and sat down. Well, what did Dr. Hughes make of that? Had he ever seen or read or even heard of a man that color before? Dr. Hughes said no. And he didn't know what to think. He was completely flabbergasted. He was rather uneasy, too. That, Dr. Wooten said, made two of them.

  Turner was admitted to Baptist Memorial Hospital for observation that afternoon at a few minutes after three. He was given the usual admission examination and assigned a bed in a ward. An hour or two later, Dr. Wooten, in the course of his regular hospital rounds, stopped by Turner's bed for the ritual visit of welcome and reassurance. Turner appeared to be no more than reasonably nervous, and Dr. Wooten found that satisfactory. He then turned his attention to Turner's chart and the results of the admission examination. They were, as expected, unrevealing. Turner's temperature was normal. So were his pulse rate (seventy-eight beats a minute), his respiration rate (sixteen respirations a minute), and his blood pressure (a hundred and ten systolic, eighty diastolic). The results of the urinalysis and of an electrocardiographic examination were also normal. Before resuming his rounds, Dr. Wooten satisfied himself that the really important examinations had been scheduled. These were comprehensive X-ray studies of the chest, upper gastrointestinal tract, and colon. The first two examinations weir down for the following morning.

  They were made at about eight o'clock. When Dr. Wooten reached the hospital on a midmorning tour, the radiologist's report was in and waiting. It more than confirmed Dr. Wooten's impression of the location of the mass. It defined its nature as well The report read, "Lung fields are clear. Heart is normal. Barium readily traversed the esophagus and entered the stomach. In certain positions, supine projections, an apparent defect was seen on the stomach. However, this was extrinsic to the stomach. It may well represent a pseudocyst of the pancreas. No lesions of the stomach itself were demonstrated. Duodenal bulb and loop appeared normal. Stomach was emptying in a satisfactory manner." Dr. Wooten put down the report with a shiver of relief. A pancreatic cyst—even a pseudocyst—is not a trifling affliction, but he welcomed that diagnosis. The mass on Turner's pancreas just might have been a tumor. It hadn't been a likely possibility—the mass was too large and the symptoms were too mild—but it had been a possibility.

  Dr. Wooten went up to Turner's ward. He told Turner what the X-ray examination had shown and what the findings meant. A cyst was a sac retaining a liquid normally excreted by the body. A pseudocyst was an empty sac—a mere dilation of space. The only known treatment of a pancreatic cyst was surgical, and surgery involving the pancreas was difficult and dangerous. Surgery was difficult because of the remote location of the pancreas, and dangerous because of the delicacy of the organs surrounding the pancreas (the stomach, the spleen, the duodenum) and the delicacy of the functions of the pancreas (the production of enzymes essential to digestion and the secretion of insulin). Fortunately, however, treatment was seldom necessary. Most cysts—particularly pseudocysts—had a way of disappearing as mysteriously as they had come. It was his belief that this wa
s such a cyst. In that case, there was nothing much to do but be patient. And careful. Turner was to guard his belly from sudden bumps or strains. A l>low or a wrench could cause a lot of trouble.

  Nevertheless, Dr. Wooten went on, he wanted Turner to remain in the hospital for at least another day. There was a final X-ray of the colon to be made, and several other tests. In view of this morning's findings, the examination was, he admitted, very largely, a matter of form. The cause of Turner's abdominal pain was definitely a pseudocyst of the pancreas. But prudence required an X-ray, and it would probably be done the next day. It was usual, for technical reasons, to let a day elapse between an upper-gastrointestinal study and a colon examination. Two of the other tests were indicated by the X-ray findings. One was a test for diabetes —the glucose-tolerance test. Diabetes was a possible complication of a cyst of the pancreas. Pressure from the cyst could produce diabetes by disrupting the production of insulin in the pancreatic islets of Langerhans. Such pressure could also cause another complication—a blockage of the common bile duct. The diagnostic test for that was a chemical analysis of the blood serum for the presence of the bile pigment known as bilirubin. Dr. Wooten paused. The time had come to reopen the subject that he had tactfully dropped the day before. He reopened it. It was possible, he said, that the bilirubin test might help explain the unusual color of Turner's skin. And Turner's skin was a most unusual color. He held up an adamant hand. No. Turner was mistaken. His color had changed in the past year or two. It wasn't a natural ruddiness. It was a highly unnatural orange. It was a sign that something was wrong, and he intended to find out what. That was the reason for a third test he had ordered. It was a diagnostic blood test for a condition called hemochromatosis. Hemochromatosis was a disturbance of iron metabolism that deposited iron in the skin and stained it the color of bronze. To be frank, he didn't hope for much from either of the pigmentation tests. Turner's color wasn't the bronze of hemochromatosis, and it wasn't the yellow of jaundice. The possibility of jaundice was particularly remote. The whites of Turner's eyes were still white, and that was usually where jaundice made its first appearance. But he had to carry out the tests. He had to be sure. The process of elimination was always an instructive process. And they didn't have long to wait. The results of the tests would be ready sometime that afternoon. He would be back to see Turner then.

  Dr. Wooten spent the next few hours at the hospital and his office. He had other patients to see, other problems to consider, other decisions to make. But Turner remained on his mind. His first impression, like so many first impressions, had been mistaken. It now seemed practically certain that Turner's color had no connection with Turner's pancreatic cyst. They were two quite different complaints. And that returned him to the question he had asked himself when Turner walked into his office. What did an orange skin signify? What disease had the power to turn its victims orange? The answer, as before, was none. But perhaps this wasn't in the usual sense a disease. Perhaps it was a drug-induced reaction. Many chemicals in common therapeutic and diagnostic use were capable of producing conspicuous skin discolorations. Or it might be related to diet.

  The question hung in Dr. Wooten's mind all day. It was still hanging there when he headed back to Turner's ward. On the way, he picked up the results of the tests he had ordered that morning, and they did nothing to resolve it. Turner's total bilirubin level was 0.9 milligrams per hundred milliliters, or normal. The total iron-binding capacity was also normal—286 micrograms per hundred milliliters. And he didn't have diabetes. When Dr. Wooten came into the ward, he found Turner's wife at his bedside and Turner in a somewhat altered state of mind. He said he had begun to think that maybe Dr. Wooten was right about the color of his skin. There must be something peculiar about it. There had been a parade of doctors and nurses past his bed ever since early morning. Mrs. Turner looked bewildered. She hadn't noticed anything unusual about her husband's color. She hadn't thought about it —the question had never come up. But now that it had, she had to admit that he did look kind of different. He did look kind of orange. But what was the reason? What in the world could cause a thing like that? Dr. Wooten said he didn't know. The most he could say at the moment was that certain possibilities had been eliminated. He summarized the results of the three diagnostic tests. Another possible cause, he then went on to say, was drugs. Medicinal drugs. Certain medicines incorporated dyes or chemicals with pigmentary properties. Turner shook his head. Maybe so, he said, but that was out. It had been months since he had taken any kind of drug except aspirin.

  Dr. Wooten was glad to believe him. Drugs had been a rather farfetched possibility. The color changes they produced were generally dramatically sudden and almost never lasting. He turned to another area—to diet. What did Turner like to eat? What, for example, did he usually have for breakfast? That was no problem, Turner said. His breakfast was almost always the same—orange juice, bacon and eggs, toast, coffee. And what about lunch? Well, that didn't change much, either. He ate a lot of vegetables— carrots, rutabagas, squash, beans, spinach, turnips, things like that. Mrs. Turner laughed. That, she said, was putting it mildly. He ate carrots the way some people eat candy. Dr. Wooten sat erect. Carrots, he was abruptly aware, were rich in carotene. So were eggs, oranges, rutabagas, squash, beans, spinach, and turnips. And carotene was a powerful yellow pigment. What, he asked Mrs. Turner, did she mean about the way her husband ate carrots? Mrs. Turner laughed again. She meant just what she said. Elmo was always eating carrots. Eating carrots and drinking tomato juice. Tomato juice was his favorite drink. And carrots were his favorite snack. He ate raw carrots all day long. He ate four or five of them a day. Why, driving down home from Alaska last week, he kept her busy just scraping and slicing and feeding him carrots. Turner gave an embarrassed grin. His wife was right. He reckoned he did eat a lot of carrots. But he had his reasons. You needed extra vitamins when you lived in Alaska. You had to make up for the long, dark winters—the lack of sunlight up there. Dr. Wooten stood up to go. What the Turners had told him was extremely interesting. He was sure, he said, that Turner's appetite for carrots was a clue to the cause of his color. It was also, as it happened, misguided. The so-called "sunshine vitamin" was Vitamin D. The vitamin with which carrots and other yellow vegetables were abundantly endowed was Vitamin A.

  There was a telephone just down the hall from Turner's ward. Dr. Wooten stopped and put in a call to the hospital laboratory. He arranged with the technician who took the call for a sample of Turner's blood to be tested for an abnormal concentration of carotene. Then he left the hospital and cut across the campus to the Mooney Memorial Library. He asked the librarian to let him see what she could find in the way of clinical literature on carote- nemia and any related nutritional skin discolorations. He was elated by what he had learned from the Turners, but he knew that it wasn't enough. He had seen several cases of carotenemia. An excessive intake of carotene was a not uncommon condition among health-bar habitues and other amateur nutritionists. But carotene didn't color people orange. It colored them yellow. Or such had been his experience.

  The librarian reported that papers on carotenemia were scarce. She had, however, found three clinical studies that looked as though they might be useful. Here was one of them. She handed Dr. Wooten a bound volume of the Journal of the American Medical Association for 1919, and indicated the relevant article. It was a report by two New York City investigators—Alfred F. Hess and Victor C. Myers—entitled "Carotinemia: A New Clinical Picture." Dr. Wooten knew their report, at least by reputation. It was the original study in the field. The opening descriptive paragraphs refreshed his memory and confirmed his judgment. They read:

  About a year ago one of us (A.F.H.) observed that two children in a ward containing about twenty-five infants, from a year to a year and a half in age, were developing a yellowish complexion. This coloration was not confined to the face, but involved, to a less extent, the entire body, being most evident on the palms of the hands. . . . For a time, we were a
t a loss to account for this peculiar phenomenon, when our attention was directed to the fact that these two children, and only these two, were receiving a daily ration of carrots in addition to their milk and cereal. For some time we had been testing the food value of dehydrated vegetables, and when the change in color was noted, had given these babies the equivalent of 2 tablespoonfuls of fresh carrots for a period of six weeks.

  It seemed as if this mild jaundiced hue might well be the result of the introduction into the body of a pigment rather than the manifestation of a pathologic condition. Attention was accordingly directed to the carrots, and the same amount of this vegetable was added to the dietary of two other children of about the same age. In the one instance, after an interval of about five weeks, a yellowish tinge of the skin was noted, and about two weeks later the other baby had become somewhat yellow. There was a decided difference in the intensity of color of the four infants, indicating probably that the alteration was in part governed by individual idiosyncrasy. On omission of the carrots from the dietary, the skin gradually lost its yellow color, and in the course of some weeks regained its normal tint.