7 One symptom does not make a syndrome

The Spendthrift and the Swallow: A spendthrift had spent all his fortune. He had nothing left save the fine woollen clothes on his body. It was early spring and he wondered where his next meal would come from. Then he spotted a swallow and perked up. He thought, "Ah! There is a swallow. Summer has arrived. I do not need these winter clothes anymore," and sold all his woollen clothes. The weather unexpectedly reverted and there wasa sharp frost that killed the swallow. When the spendthrift saw the dead bird, he cried, "You foolish bird! Thanks to you, I believed that summer has arrived. Now I am also freezing to death in the cold."

Velan, a 60-year old man who had been a hypochondriac throughout his life, woke up with hiccups. He remembered a Tamil proverb that states, he who has hiccoughs, will reach the heaven. He thought, "I am sure I have some terminal illness. I already feel weak and infirm."

Velan consulted many doctors, underwent very many tests and took various medicines. He spent all his savings on treating the hiccup which persisted for weeks. One fine morning the hiccups just disappeared as unexpectedly as it had started. Velan lamented, "You miserable hiccup! I thought I was going to die and spent all my savings on treatment. Now you have vanished and I am broke!"

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Comments

Misusing modern science to pander to myths and superstitions amounts to quackery. Hiccup being a 'killer symptom' is just one example of such false beliefs. I have seen several gullible persons fall prey to doubts and fears raised by proverbs, house-lizards, black cats, astrologers, palmists and numerologists.

People are susceptible to such divinatory practices and 'mind readers' because of Barnum Effect. This refers to the tendency among people to embrace generalised personality descriptions and predictions as idiosyncratically their own. Then they turn to modern medical science to quell their fears and phobias. Many medical practitioners are only too happy to exploit the situation as 'it is good for the business'. Shaw had some comments on this: "Without fear and credulity (in the public), half the private doctor's occupation and seven-eighths of his influence would be gone."

Under the pretext of ruling out all the possibilities and allay the anxiety, several tests may be performed. Tests should be critically selected to 'rule in' a disease rather than 'rule out' all other possibilities. The muddled thinking has percolated quite deeply into the current medical education and practice. It shows up best during an MBBS examination where the scene is often like this:

Examiner: Candidate: Examiner: Candidate: "So what is your diagnosis?" "Disease XYZ, Madam." "What laboratory tests do you want to do?" "Tests 1 . . ., 2 . . ., 3 . . ., etc., to rule out the disease XYZ."

The student wants to rule out the very disease that has been diagnosed by him! Imagine how judicious he would be while ordering diagnostic tests in medical practice. T.S. Eliot's warning against "action taken not for the good it will do but that nothing be left undone" applies to the offensive practice of the so called 'defensive medicine' (see Chapter8).

Once, I admitted an 80-year old man with multiple symptoms of recent onset and a

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clutch of prescription slips. On thorough examination, he only had moderate anaemia due to hookworm infestation and perhaps had it for several years. He responded well to treatment and visibly cheered up.

At the time of discharge, I asked him why he felt so much concerned about such a minor disease. He smiled and then confided in me, "I also wondered why. Then I remembered it. When I was ten years old, my father had told me that I shall be strong and live till the age of eighty. Then a health crisis may occur and if I could survive that, I shall live for a decade more.” He had forgotten all about it but the fear had survived in his subconscious mind and taken its toll after seventy years. This form of 'hex death' like situations are common in rural India even today.

Informed and enlightened individuals should break the shackles of age old myths and superstitions and become truly autonomous. Social and health activists have to join hands to reduce the gullibility of the community and to reduce the current practice of defensive medicine.

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