Something predictable, something surprising is a short story from Bernard Preston's third book of chiropractic short stories.
Anyone who has traveled will understand the sense of delight that Helen and I were lapping up after we arrived in the Netherlands. Naturally we weren’t surprised at the oddities. After all, in remote Shafton where we hailed from, they do things quite differently from the jostling crowds of touristy Cape Town. But in the far southern province of Limburg where I found myself swimming far out of my depth, few things caught my deracinated eye more powerfully in my first week than seeing children smoking on their way to school and a girl no more than thirteen walking down the street with her mother, both with fags in their mouths. Plenty of South Africans smoke of course, but never have I anywhere come across such a nation of dedicated ‘rokers’. The arresting sign on every pack; ROKEN IS DODELIJK seemed to have absolutely no effect; a waste of good ink.
Another surprise, this one pleasant, was that Limburgers actually took many of my recommendations seriously. Back home, in my native South Africa, if I tried to persuade my patients to lose weight or start exercising, the vast majority would smile politely and blithely ignore me. But, my patients in Limburg, to my surprise would, without question, go to bed for three days with their ice packs and do my exercises, and come in for the necessary treatment.
However, not many took me seriously when I gravely pronounced in my broken Dutch that smoking would, most likely, end their lives in misery unless they were lucky enough to have a mammoth heart attack or stroke. Few things focus the mind more steadfastly than watching both your parents die slowly and horribly. Many of my new patients were however not so enthusiastic about my thoughts on cholesterol and salads; rabbit food! So it came as no surprise that Limburgers have a very high rate of coronary artery disease. Sudden death amongst relatively young people is not uncommon.
So it was much to my surprise that Mrs Vestjens did in fact give up the weed. One of my first patients, she consulted me for an acute attack of pain in the joints where the ribs join the breastbone after yet another bout of coughing. The poor woman, at only fifty-two could barely walk forty or fifty metres without having to stop, heaving and gasping for breath. She was showing all the signs of advanced emphysema. Her left lower leg looked quite dreadful with two blue, almost black, toes and there was no palpable pulse in her ankle or foot. Mrs Vestjens had started smoking when she was only twelve and, forty years on, cigarettes had choked her lungs and blood vessels. She knew it, of course, and what she really needed, I reasoned, was a good hard shove, one with a strong emotional tweak.
‘Don’t you want to see your grandchildren grow up, Mrs Vestjens?’ I pontificated, determined to try just once. Doesn’t every grandmother? She scowled at me, her shrunken body heaving for breath. Literally, she was dying, and we both knew it.
‘My grandchildren don’t like me and you’re just the same as all my doctors, only you’re more manipulative.’
‘Of course! I’m a Chiropractor,’ I grinned but she didn’t get it. ‘Look, I’m not going to torment you, Mrs Vestjens but there are, you know, programs to help you quit. How about January 1?’ It was a few days before my first Dutch Christmas and, all across the Netherlands, there was a massive advertising program: NEDERLAND BEGINT MET STOPPEN; I was quite sure she must have seen it. How those verbs troubled me in my early days in the Netherlands, but my teacher insisted that struggling with them was the only way to unravel the intricacies of their grammar: Ik begin, Nederland begint, Wij beginnen. Ik stop, je stopt, ze stoppen.
‘Yes, and start again on January, the second.’ There was no glimmer of humour.
‘Think about it, Mrs Vestjans. It can be done.’ I added a few practical suggestions that I had developed over the years to aid people give up the pernicious weed. She shook her head, and left quickly after her adjustment without another word, leaving me unsure whether I was being a moral bully simply to assuage my own conscience. Would I see her again?
‘What made you decide to stop smoking, Mrs Vestjens?’ I asked some weeks after New Year. I could smell the difference. Her clothes and hair no longer stank.
‘Not your busy bodying.’ She gave her first little smile. ‘Mind you, when you described the misery your mother suffered, it did remind me of my father’s last years. They were simply awful. I suppose I had suppressed those memories.’
‘He died of emphysema too?’ I asked.
She nodded. ‘When he was only fifty five. He was a coalminer.’ I found myself wondering just how many diseases are really just the result of cumulative factors? Coal dust plus the tar from cigarette smoke has a deadly effect. Add in raised cholesterol and you have a terminal disease. So I asked her, ‘And how did you do it?’
‘Well, I did use a couple of your suggestions. First I wrote down a list of all the situations where I heard a Pavlov bell ringing. There were three biggies: having a cup of coffee, watching television after supper, and stepping into the motorcar.’
‘Which bell did you chose to ignore first?’
‘Actually, none of them. They came later. It was your other suggestion that really helped; not to smoke when there are others in the room, such as my grandchildren.’ She smiled again. ‘So, when my son and his family came to visit, I decided not to light up.’
‘Well done, Mrs Vestjens, that was an excellent start. I’m very proud of you. So what clinched it?’
‘Not emphysema, not you doctors, not my grandchildren. It was what you said about smoking being the stumbling block that was preventing my rib from healing. I’m just really, really tired of the pain.’
‘Really, that was it?’
‘Yes, you convinced me. Remember how you said that tissues starved of oxygen wouldn’t heal? I’m just plain sick and tired of the pain in my ribs. It hurt with every breath.’
‘And are you having less pain?’
‘Mm, I think so, but it’s only a few weeks since I quit.’
Chronic and degenerate backs can never be truly cured; but an occasional adjustment, along with a set of exercises, I finally realised, does make all the difference to the success of chiropractic care.
We doctors don’t cure too many conditions; appendicitis perhaps. But when Mrs Vestjens came in for her next grease and spray, she brought yet more surprises for me. Tears erupted as she told me about her granddaughter. ‘Thank you so much, doctor, for bullying me to stop smoking. It’s changed my life.’
‘Saved your life, Mrs Vestjens,’ I proudly rumbled on, wallowing in a little self indulgence.
Scowling, she protested. ‘No, I’m not talking about my lungs and my leg. Or that dreadful rib pain.’ For a few moments she pondered how to go on, whilst I just sat wondering and waiting. ‘I always thought that my grandchildren just didn’t like me; but now that I’ve stopped smoking, my little granddaughter wants to jump on my lap the moment they arrive. It’s only now that I realize that it wasn’t me she disliked; it was my cigarettes.’
Over the months she shared with me the long story of self doubt and depression brought on by the feeling that so many people disliked her. Was it because of her smoking? I doubt it; not in Limburg, but obviously her granddaughter hated the reek of cigarette smoke almost as much as I do! In fact, there were few of my patients that I grew to love more.
It should have been just as predictable, but I was nevertheless nearly caught out by Mr Herveille’s leg pain. He was referred to me by his doctor with a year-long history of low back pain radiating down his right leg. Could chiropractic help his sciatica? Low back pain with attendant pain in the leg is a daily event in every chiropractor’s clinic, and our clinic was getting medical referrals every week. Only a few weeks older than me, Mr Herveille looked ten years my senior. I am quite sure that it is only in the Netherlands that one might fill in ‘normal’ on the new patient form for smoking twenty cigarettes a day. Whilst most Limburgers would place their cross in the ‘normal’ line for smoking, Mr Herveille had gone for ‘heavy’.The X-rays that he brought with him should have been a dead giveaway, first to his doctor who had ordered them in the first place, and to me. We both missed the significance of almost no degenerative joint disease in his low back. Initially. Chronic sciatica is usually associated with significant wear and tear in the spine, or perhaps a very small canal (what we call stenosis), but the X-rays of Mr Herveille’s back were in fact a good deal better than my own. A bell of a different sort should have immediately started clanging.
One thing did stand out, however, and I took it as my cue. I speak to every new patient about the devastating effects of smoking, and the heavily clogged artery, the aorta, lying just in front of the spine, gave me my opportunity. ‘Your spine actually looks very good on the X-rays, Mr Herveille. It could of course be a slipped disc. That can’t be seen on plain film but my examination will confirm whether that could be the cause of the pain in your leg. But just look at all that cigarette ash lining your aorta!’
He looked at me suspiciously, not sure whether to take me seriously. Could cigarette ash really get into the arteries from the lungs? ‘What’s the aorta?’ he asked.
‘It’s that large artery carrying blood to your abdominal organs and the legs. It’s quite badly furred,’ I said, pointing to the telltale signs.
‘Is it serious?’ he asked.
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I replied: ‘Fortunately I can’t see any sign of an aneurysm – that’s a bulging of the aorta, which can be very serious. This stuff is clogging your arteries, which is why your blood pressure is raised and sometimes, yes, it may clog a critical artery to the heart, for example. But, to be quite honest, we see it on most smokers’ X-rays, and it’s not usually the cause of their back pain. How’s your cholesterol?’
‘It’s raised,’ he told me. ‘I take pills.’
I went back to the form he had filled in. There was a drug that I didn’t recognize and hadn’t taken the trouble to ask. I cussed myself. You’re getting sloppy, Preston. Not for a moment did I guess just how important it could have turned out to be in Mr Herveille’s case. ‘Right, let’s get on with the examination,’ I said, gesturing towards my table, fully expecting to find signs of a radiating sciatica. There were none. He could bend and twist and I could raise his leg without pain in the back or leg. Finally Pavlov started to make his presence felt. Leg pain, low back pain, but all the sciatic tests were negative. Strange. I went back over the history again with him: ‘Mr Herveille, tell me again about the pain in your leg. Is it worse when you sit?
‘No, it never hurts when I sit. Sitting relieves the pain! Unless I’m on my bicycle, that is.’
‘And if you work in the garden or when dressing in the morning,’ I asked, ‘or when you bend to shave?’
‘No, it doesn’t hurt then in my leg. Sometimes in my back it might be stiff and sore after gardening for a day or two, but never in my leg.’
‘Then explain everything to me again, please. What makes it worse and what relieves the pain?’
‘Like I said, it’s when I walk that the pain comes on in the calf and, when I cycle, I get pain in my thigh.’
‘Does it make a difference if you walk slowly, like when window shopping, or stepping it out?’ Because his problem was fairly uncommon, I still couldn’t see what was staring at me in the face, thinking rather of a short leg which frequently causes pain when you amble and stand, but not when one walks fast. In my defense, it had stared umpteen medical doctors in the face too. Thinking perhaps he had a deep vein thrombosis, I examined his calf carefully but found little of interest. Then I checked his hip. Perhaps an arthritic hip or myofasciitis of one of the hip muscles; but that was all normal too. What I did find were signs of a groin operation. ‘What’s this?’ I asked.
‘Oh, I forgot to tell you. I had a lump in the groin and my doctor diagnosed an inguinal hernia.’ He was becoming rather anxious, fully aware that I was taking an inordinately long time examining, and rechecking, his leg. Hernias in the groin are not uncommon so I went back through the basics that every chiropractor does. I again checked the orthopaedics (they were still all negative for a sciatica) and the neurology (all his reflexes, skin sensation and muscle power were normal). Something was nagging in the back of my brain. Ah, the pulses! I hadn’t checked the pulses in his leg! I started with his normal leg and quickly found the throbbing sensation of healthy arteries. They were pumping normally. But when I felt for the pulse in Mr Herveille’s naughty leg I immediately struck not just pay-dirt, but pure gold nuggets! No matter how carefully I prodded around, I could find absolutely no pulse on his foot, or behind his ankle or knee. There was a very weak pulse in the inner thigh and I started having grave misgivings about that lump in his groin. A hernia? It could have been, I supposed, but if I hallucinated a bit I thought perhaps I could palpate a pulsating swelling in his lower abdomen just above the groin. It’s not a place for a chiropractor inexperienced in the field to go prodding about – an aneurysm can be deadly.
Intermittent vascular claudication is a nasty and rather uncommon condition where the blood flow to the leg is restricted due to a blockage of the artery. There was just enough blood getting through to Mr Herveille’s leg when he was sitting quietly but, the moment he started to walk or cycle, the artery to his leg couldn’t provide enough oxygenated blood for the muscles, and they would start to complain. A short rest and the pain would stop as the demand for extra oxygen diminished.
‘Do you get any chest pain when you cycle?’ I asked.
He shook his head. ‘What’s that got to do with the pain my leg?’
I explained, ‘A heart muscle starved of oxygen causes a pain called angina. It’s worse with exercise.’
‘But, I thought,’ Mr Herveille said, ‘that the heart was full of blood. How ..?’ He stopped, realizing he had interrupted me. ‘I’m afraid I don’t have good news, Mr Herveille. You have a minor problem in your back, but it’s completely overshadowed by a serious blockage of the artery to your leg. When you exercise your leg isn’t getting enough oxygen. Fortunately it doesn’t seem to be affecting your heart. Yet,’ I added ominously. ‘You must go back to your doctor and have what is called a Doppler study done of your leg.
‘Where is this block?’ he asked.
‘I’m not sure. We won’t know until the ‘echo’ has been done.’ He nodded. He had never heard of a Doppler but he recognized the term ‘echo’.
‘Where do you think it is?’ he insisted.
I told him it was probably in the groin or his lower abdomen. ‘There’s a spot in the so-called External Iliac artery where that cigarette ash loves to collect.’ I pointed to the area just above his groin. ‘Probably somewhere in the region we looked at on your X-ray.’
‘You mean this lump in my groin had nothing to do with a hernia?’ He was starting to get angry.
‘I’m really not sure, Mr Herveille. You may have also had a hernia in the groin. The echo scan will tell all.’
He shook his head as he stood. ‘I just thought I was getting out of shape, but I couldn’t figure out why only my right leg was so unfit.’
I showed him to the door. ‘I will write a report tonight and fax it to your doctor tomorrow. If you want to see your grandchildren grow up, Mr Herveille, then change your diet and give up smoking. This stuff that’s clogging the artery to your leg is affecting every part of your body, not only this artery that we can see here on the X-ray.’ I stuck the stiletto in deep, pointing to his plain films that were still visible on my computer. ‘And keep exercising. Your bicycle has saved your life. The demand for blood in your leg is what makes other pathways for the blood develop. We call it the collateral circulation. It’s probably the only reason you haven’t had a heart attack.’
Two months later Mr Herveille came back for treatment for his back, bringing the scan with him. ‘Thank you, Dr Preston. You saved my life!’
‘Oh, I doubt that Mr Herveille. This was unlikely to kill you. What worries me is I can still smell cigarettes on you. That will kill you.’ He laughed. ‘It’s my wife’s cigarettes you can smell. When the surgeon confirmed what you said, I did what I’ve known for years I should have done.
‘Congratulations! That’s what has saved your life. I just pointed the way but you made the choice to walk in it. Did the surgeon give you a diagnosis?’ Mr Herveille stretched for his wallet, and pulled out the report which described the condition as Diffuse Atherosclerosis Obliterans rather than the large aneurysm that I imagined might be lurking in his belly.
‘You must make some dietary changes too, Mr Herveille,’ I said, and added, ‘Please bring your wife with you next time.’ I got on smartly with the treatment of his back after a couple of jolting rings on the phone from Claudia, warning me that I was again running seriously behind.
Like her husband, Mrs Herveille had aged prematurely. Her wrinkled and blotched cheeks gave it away, but I decided there was no point in saying anything. She knew. I thanked her for coming and said. ‘Mrs Herveille, I have some important recommendations about your husband’s diet.’
Twenty minutes later she asked; ‘Why didn’t our doctor talk to us about this? He just suggested that Bram start taking medication.’
‘You’d better ask him that, Mrs Herveille,’ I replied. Her husband nodded. ‘I hate those cholesterol pills! I’m sure they make my legs ache too.’
‘I have to say that it is easier to swallow pills than changing your diet, Bram.’ It was the first time I used his first name. ‘Many people don’t want to hear what I have to say. They answer me, “You really want me eat all that rabbit food?” They don’t want to believe that a salad every day, far more vegetables and fruit, and fish two or three times a week can do the trick for the majority of people suffering from raised cholesterol?’
‘So should I just stop the cholesterol pills?’
‘No, I wouldn’t do that. Start eating a sensible diet, and then ask your doctor to retest your cholesterol. It’ll drop in a matter of weeks.’
‘So, all I have to do is cut out all the fat in my diet and …’‘No, no, you didn’t listen carefully. A very low fat diet, coupled with a high carb diet is now thought to be the cause of a very serious neurological condition called Lou Gehrig’s disease. Nerves are covered with a lining of fat – without it they cannot conduct the impulses to your muscles. So, go on eating the healthy fats, particularly olive oil and the avocado, and cold water fish like salmon, but cut out all animal fat. All of it.’
I also decided to have my own cholesterol checked again. It should after all be done every year after the age of fifty and I had become inordinately fond of a very delicious Camembert.