Shahar Madjar, MD

George lived in a trailer park at the edge of a Midwestern town. He was 71 and alone. One neighbor said that George was a veteran. Another knew that his wife left him decades ago. “He used to work at General Motors, on the assembly line,” a third neighbor added. His niece came to visit every several weeks. When his refrigerator’s rubber door seal broke, he taped the door shut and used only the top freezer. He stockpiled on frozen tater tots which he ate in every meal.

His niece brought him to the emergency department several months ago. He told the doc that for the past 6 months he had been bleeding and bruising easily and that his stool had turned black. “My gums are bleeding when I am brushing my teeth,” he said, “my head feels light, and I can’t breath.” George was skinny. “I lost a lot of weight,” he said.

Dr. Wise, the doc at the ED, started to add things up. The lightheadedness may be a sign of a heart disease. The easy bruising and bleeding gums may indicate a problem with George’s platelets, or a failing coagulation system. The dark stool may indicate that George had been bleeding into his digestive system, from a stomach ulcer, for example (the digestive system would then break down the red blood cells in the blood and turn the the stool black). His shortness of breath may be the result of a lung disease. The weight loss may be the result of malnutrition, severe infection, even cancer. There were many possible causes and many explanations. But which one was it?

A good doctor is always in search for a single explanation for multiple symptoms.

Dr. Wise examined George and ordered some blood tests. George was breathing normally and his lungs were clear. His heart pounded at a regular rate and a normal rhythm. His oxygen level was normal. But he appeared ill, his gums were bleeding, and he was missing several teeth while other teeth appeared loose. And there was a rash of purple spots on his chest, arms, and legs.

George’s blood tests were quite normal including his platelet count and his coagulation factors. There was nothing that would indicate a problem in the system that allows for normal coagulation and clot formation, and yet, George’s hemoglobin was low. He was obviously bleeding. A likely source of bleeding could be his digestive system.

The doctors examined George’s digestive system from above and from below using flexible fiberoptic instruments (esophago-gastro-duodeno-scopy and colonoscopy). There was no bleeding ulcer. All they could see were small patches of red spots along the lining of the intestine.

When everything else fails, a good doctor re-examine the patient, the way a good detective returns to the crime scene in search for additional clues.

On re-examination, Dr. Wise noticed that the hair on George’s chest wasn’t straight, nor curled. Instead, it took the shape of a corkscrew. He also noticed small areas of bleeding around each hair follicle.

And BOOM! The pieces in Dr. Wise’ mind came together into a complete puzzle.

The story he heard at a lecture in medical school and the images he had created during that lecture flooded Dr. Wise’s mind: he saw hundreds of sailors aboard British battleships in a voyage that took place in the 18th century. The sailors who had started the expedition in good shape and spirit gradually became pale, weak, and depressed. Their eyes were sunken. Their gums turned soft. Their teeth became loose and fell out. Their skin began to show small blood blisters. Old scars, earned in previous battles, opened up, exposing raw flesh. Most of them died of massive hemorrhage. In one such journey, out of the six battleships, only one remained. And 1400 of the 1900 men aboard these ships died–not in the hands of a vicious enemy, but as a result of a mysterious disease.

Dr. Wise asked himself, Is George’s condition the same as the ailment that afflicted thousands of British sailors in the 18 century? If so, the solution would be simple and George’s life would be saved. If not, the search for the right diagnosis must continue.

I will tell you about George’s fate in my next column (to keep the story continuity I recommend clipping and saving this column).

Editor’s note: Dr. Shahar Madjar is a urologist at Aspirus and the author of “Is Life Too Long? Essays about Life, Death and Other Trivial Matters.” Contact him at smadjar@yahoo.com.