The Tail and the Dog: Cause and Effect in Medicine


Does the tail ever wag the dog? Is an issue ever so compelling that cause and effect are reversed? Or at least suspended..? Sorry, I wonder about such things.

I remember reading a book many years ago by the British philospher A.J. Ayer called The Problem of Knowledge. In it he discusses a religious sect that believed its members were either born to go to heaven or born to go to hell. They spend their lives assuming and acting as if they were in the Heaven group, no doubt hoping to influence how they were born -the future influencing the past when you think about it. Effect influencing Cause. The very idea intrigued my teenage brain but I was unable to replicate the switch no matter how I tried. No matter the subterfuge, no matter the wording of the premise, I still ended up with a faulty syllogism.

But my misgivings have decreased in the intervening years and although I’ve never met a member of that sect, I believe I have encountered situations with eerie similarities. Disturbing parallels.

*

“I don’t think you’re really listening to me, doctor,” said the thin, immaculately coifed woman sitting across the desk from me. She’d been talking without interruption for five minutes or so. Sixty-five, and well into her menopause, she had short, greying hair, and a severe, noticeably-wrinkled face. She stared at me as if I had just insulted her and I could see her pale bony hands forming fists and silently massaging her lap as she spoke.

I’d just met her and was trying to understand why she’d been referred to me. “I’m sorry,” I said with a smile. “I was just trying to get a more complete history…”

“I’ve told you the relevent history doctor,” she interrupted impatiently. “You have to learn to listen!” I could tell she was deliberately italicizing words. The sigh that I tried to disguise did not go unnoticed, however, and her eyes sharpened like knife blades and attacked my face. “My doctor assured me you would listen to me.” She sounded almost petulant.

“Well perhaps I was too focussed on background details,” I said to mollify her, then sat back in my chair to indicate that I was, indeed, listening now.

“I have cancer, doctor. Nobody can find it, but I know its there as surely as I know this desk is hard.”

I kept my expression neutral and nodded for her to go on and explain things yet again.

“My sister died from squamous cancer of the cervix and my mother died of adenocarcinoma of the stomach,” she said, the terms obviously well-rehearsed. “And my uncle had some other kind of cancer that nobody could find until he died…”

That was certainly a lot of cancers I had to admit, but I couldn’t think of any obvious connecting factors. Stomach and skin derive from different tissues embryologically but the cervix cancer was almost certainly related to HPV –a sexually transmitted virus. And she didn’t know what type of cancer had killed her uncle.

Apparently satisfied that she had made her point, she straightened up in her chair and folded her arms tightly across her chest.

I nodded my head to encourage her to continue, but she merely slashed at me with her eyes, the skin of her face now tied so tightly I wondered if it would tear. I could see she was challenging me to contradict her. I managed a little smile but I didn’t really feel like it. “What makes you so certain you have cancer, Emily?” I thought maybe using her name might soften her face. “Is it the family history of so many cancers, or some symptoms you are experiencing?”

That seemed to catch her off guard and she unlocked her arms so her hands could wander back onto her lap. “It’s more of a feeling, doctor; it’s hard to explain.”

I sighed audibly and studied her face. It had gradually lost its anger and the skin seemed looser, older. She looked fragile now. Frightened. “Let me see what tests your doctor has done so far…”

“They’re all normal,” she said softly before I could even look at the referral letter. “I’ve been pestering my doctor for several years about my concern…” Emily looked almost embarrassed. “She did both abdominal and pelvic ultrasounds because I told her I was having pain. Then she did a whole bunch of blood tests to check my liver and kidney function but nothing showed up.” She stared at her hands for a moment. “I even convinced her to do a CAT scan of my head…” She looked up at me with a shy little smile hovering about her lips. “Headaches,” she said to ward off a question she could tell I was about to ask. And then she buried her eyes in her lap again. I could almost see her trying to think of something to convince me to keep searching.

“I’m tired all the time and I’ve been losing weight…” But even she didn’t seem convinced. Sad, burrowing eyes peeked out at me from behind deep ridges of skin that had come out of hiding as her anger dissolved. She chuckled half-heartedly. “I’m becoming so neurotic about this that sometimes I wonder if I’m creating a lot of these things out of whole cloth…” Her face brightened at the idiom.

Then she shook her head slowly. “You know, my cancer is almost like a religion: you have to take some of the tenets on faith alone. They don’t make sense, and you’d rather just ignore them, but something makes you go on. You still believe, because there’s something to it, something you suspect is true, even if you don’t understand why.”

I’d never thought of undiagnosed illness like that. I looked through the test results I’d been sent, but found nothing suspicious. No clues. Nothing that even suggested a direction for further investigations. Her pap smears were up to date and all normal; she’d  had a colonoscopy and had somehow convinced a gastroenterologist to investigate her stomach and esophagus. And a dermatologist had done some biopsies a couple of years ago because she had a few moles on her arms and legs. “Would you mind if I examined you?” I thought I’d better ask.

She shrugged and shifted in her chair. “You won’t find anything, but yes. You’re my last hope.”

Given the history, I have to say she had no more hope than I did of finding something. Anything. But I did a thorough examination –I took her blood pressure, I listened to her chest and checked her breasts for lumps. I palpated her abdomen for masses and pain. Lymph nodes filter out infections, but sometimes also tumor cells in the process of spreading, so I even felt for the lymph nodes in her groin to see if they were enlarged. People who run frequently have the occasional small lumps in their groins from incidental cuts on their toes, but she had some that were really quite large and painless, and on one side only.

Curious, I asked if she did a lot of running, or if she’d injured her foot or leg recently. She shook her head. “Do I look like a runner, doctor?” She had a point.

I was puzzled by the lumps, so I redoubled my search for an explanation. What had caused them? The only thing I could find, after doing the usual gynaecological examination, was a multicoloured, dark mole hidden in a labial fold near her vagina. It was on the same side as the lumps.

I finished my examination and asked her to come into the other room when she’d dressed.

“Did anybody mention they’d seen a mole near your vagina?” I asked, when she returned.

She shook her head. “I have moles everywhere,” she said, rolling a sleeve of her sweater past her elbow and showing me her arm. “I think everybody has been more focussed on my cervix because of my sister.” She couldn’t help smiling. “Even my GP just whips a speculum in whenever she’s in the area.”

“What about the dermatologist you saw?”

She chuckled. “He wouldn’t go anywhere near there.” Suddenly she stopped talking and looked at me. “Why? Is there a problem? The other moles were just benign nevi…” She had obviously been reading about her diagnoses.

“It’s an unusual place for a mole,” I said, somewhat hesitantly. “I think it should be removed.”

She studied me for a moment, nodded her head slowly, purposely, while the skin on her face tightened and then relaxed. Her eyes softened and she reached across the desk to grasp my hand.

“Thank you, doctor.”

I must have looked puzzled, because the smile on her face broadened in response.

“All these years…” she said, slowly, softly, and almost to herself. “I knew there was something; I just didn’t know where.”

“But…” I hadn’t even mentioned my concern about malignancy in the mole. If anything, I hoped I’d underplayed it so she wouldn’t panic.

She squeezed my hand. “I’d rather be on a path –any path- than wander around, lost.” She sat back in her chair, almost satisfied at the turn of events. “Our remedies oft in ourselves do lie, which we ascribe to Heaven.”

Wow: All’s Well That Ends Well. I wonder if she’d memorized that for just such an occasion. Perhaps she felt that discovery was tantamount to remedy for her… Vindication. Validation. I also wonder if Ayer would have understood.

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