Crocks Die Too

The aneurysm had ruptured. These findings explained her longstanding symptoms perfectly. (Abdominal CT and ultrasound, both of which would have shown the aneurysm, were not available until years later). As we watched the autopsy, Andy, my resident turned to the rest of us and said in his Southern drawl, “Well gahs, crocks dah too.” It was a lesson we would not soon forget.

All physicians have experienced having to deal with symptomatic patients for whom they are unable to establish a diagnosis of the cause of those symptoms, despite using all our available modern diagnostic tools. By default, these patients are given a diagnosis of psychosomatic disease. Unfortunately, these patients are likely to return and challenge us again and again. When this occurs, we often label them a “crock”. Indeed, many times during my medical school training and internship when presenting such a patient on morning rounds, we would tell the attending physician that among the lab results, the patient’s “serum porcelain level” was elevated.

The diagnosis of a psychosomatic disorder is one of exclusion, after we have exhausted all possibilities of finding any pathology. And the key words here are the last seven words of the previous sentence. My late father serves as an example. In July 1992, he began having vague abdominal pain radiating to his back, similar to Mary. He had been an otherwise healthy 86-year-old man, who seldom complained. GI barium studies, abdominal ultrasound, and abdominal CT studies were normal. (My partners who specialized in abdominal imaging confirmed this.) His gastroenterologist was considering labeling him a ”crock” but was disturbed by my father’s visible weight loss, and told me, “I think your dad has cancer. We’/re just not smart enough to find it.” In October he repeated the CT. The new exam showed a large carcinoma of the tail of the pancreas that was eroding into an adjacent lumbar vertebra. Unfortunately, in 1992 PET scanning combined with CT, that might have made an earlier diagnosis had not yet been developed. My dad died in February 1993.

I encountered similar patients when I was a General Medical Officer in the Air Force. One of the most common chief complaints I witnessed was, “I’m tired all the time,” in women in their early to mid 30’s. Multiple laboratory tests were all normal. Interestingly, I noticed a correlation between their complaints and their husbands’ ranks. On the enlisted man’s side, the rank was Technical Sergeant; on the officer’s side, the rank was Lt Colonel. The next higher rank for each was Master Sergeant and Colonel, respectively. In both instances the husbands were likely to finish their military careers at the lower rank, which would affect their pensions in retirement. Their wives were understandably frustrated as they saw their husbands’ peers promoted while their husbands remained at a virtual dead end. Psychosomatic symptoms were a cover for their disappointment.

When all possibilities of disease have been ruled out, physicians faced with declaring the patient a “crock” or having “Mishugosi Syndrome” (from the Yiddish, mishigas [craziness] or mishugener [crazy person]) should look for a reason why the patient is exhibiting their symptoms. John, a 74-year-old “frequent flier” who visited the ER at Allegheny General on a shortness of breath, chest pain, and abdominal pain to severe headaches. These complaints ordinarily result in the patient being admitted for observation and testing. John’s visits always coincided with whatever shift a particular attending physician, who incidentally had earned a degree in social work prior to going to medical school, was working. After several visits ended without any abnormalities being found, the attending put on her social worker’s hat and investigated John’s current living conditions. John lived alone with his dog on Pittsburgh’s North Side. His wife had died many years before and he was estranged from his children, all of whom lived far away. His frequent visits to the ER began when his dog died. John was lonely and the ER was one place where he could come for some interaction with caring people.

Sometimes technology, or the lack thereof contributes to a patient being labeled a “crock”. In Mary’s case CT and ultrasound had not yet been developed; in my father’s case PET CT had not been developed. In both of their cases, an early diagnosis was hampered by the fact that with bone destruction, approximately 50% of the bone structure must be destroyed before it is visible on a radiograph1 Today, MRI can show these elusive lesions early enough to affect the outcome. The paradox, however, may be that although we can make a diagnosis, we may not be able to cure the patient. In Mary’s case (in 1967) abdominal aortic surgery was in its infancy; in my father’s case (in 1992) an earlier diagnosis would not have changed the outcome. However, being able to establish a physical cause for the patient’s symptoms eliminates the diagnosis of “Crock”. As my resident Andy said over 50 years ago, “Crocks die too!”

Reference

For information contact John Fenner Email: fenner@fennercorp.com

1. Roberts CC, Daffner RH, Weissman BN, et al. ACR Appropriateness Criteria on metastatic bone disease. J Am Coll Radiol 2010; 7:400-9.

Dr. Daffner is a retired radiologist, who practiced at Allegheny General Hospital for over 30 years. He is Emeritus Clinical Professor of Radiology at Temple University School of Medicine.

The neighborhood of Troy Hill rests on a plateau overlooking the Allegheny River on Pittsburgh’s Northside; it is approximately 3 kilometers long and only 1 kilometer wide. In the center of this quaint village sits the Chapel of Saint Anthony of Padua which purportedly contains sacred relics, including the complete skeletal remains of a saint named Demetrius, a tooth of the chapel’s patron Saint Anthony, and a thorn from the true Crown of Thorns of the crucifixion of the Christ. All of the 4,000 to 5,000 relics in the chapel have original certificates of authenticity from the Vatican (the oldest of which dates from Aug. 12, 1716), except for one which mysteriously appeared on the evening of March 10 2023, — 102 and a half years following the birth of the village’s lifelong denizen, Lillian Abel Rausch.

“My mom Lillian and all of the Rauches love you!” I was told by a family member named Bobbie, who had married into my dear wife’s 12-sibling family from the North Hills suburbs several years after I had moved to the Steel City from the East Coast. “They all heard you say at the wedding at St. Anthony’s Chapel and afterward at the reception that you thought that Troy Hill was a wonderful, quaint old town and a