Chapter Six: Medical Learning

Chapter 6 Sub-sections

Shifting Dullness, Twice a Diagnostic Tool, Not Pleasant

As a senior medical student on OB in January 1958, while caring for a mother in labor, I noticed via abdominal palpation that her uterus had become hard and rigid, and the baby's heart sounds had disappeared. I was pretty certain that it was abruptio placenta, with intense hemorrhage under the placenta and loss of blood and oxygen to the baby. My OB resident and faculty member confirmed this. I monitored her, expecting delivery in time of the dead fetus, repeatedly evaluating her abdomen and uterus by palpation. After several hours, I detected fluid between her uterus and her abdominal wall when she was lying on her side. She had shifting dullness, indicating free fluid in the peritoneal cavity.

After some disharmonious discussion among faculty, the decision was that this was blood and that surgery was necessary. There were two or three units of free blood in her abdominal cavity. She recovered physically without incident, and we counseled her as well as we could regarding the loss of her baby. My observations in her case earned me a grade of ‘A' in OB. But within six months I had a grimmer case of shifting dullness, during my internship in St. Louis.

About 40 of my medical school classmates interned at St. Louis City Hospital. During my month in the emergency room, I saw a young woman; she and her husband were concerned because her skirts had been getting tighter and tighter, with no change in weight or eating habits. They had seen their family doctor who had said not to be concerned. She appeared healthy and there were no palpable masses. Examination in the supine and lateral positions disclosed shifting dullness, and I referred her as a patient with ovarian carcinoma and peritoneal metastases, later confirmed. A depressing evening!

City Hospital # 1 (Starkloff Memorial) was an older building, Catholic-oriented because St. Louis was. It had been built prior to use of antibiotics, so its wards were separated. While Cook County had separate buildings connected by tunnels, St. Louis City was on a smaller scale and had first floor connecting passageways between wings. The building was a darker red brick; seen from the south, there was a central building with 150 foot passageways going east and west to other portions. St. Louis was hot and humid, and the only air conditioning was in the hospital library. When we were scrubbed and gowned for surgical cases, we were incredibly uncomfortable in gowns and paper masks; nurses stuffed towels soaked in cold water down our backs.

Figure 5a
Fig. 5a. Pruitt-Igoe housing project in St. Louis in 1958

The hospital has now been converted to condominiums (Greenfield, 2007). It's called the Georgian, with 104 condos ranging from $175,000 to $320,000. It was 75% sold as of October 2007, and a two-bedroom 1350 square foot unit sold for $240,000. A far cry from what it was like when I was there in 1958-1959.

Pat and I lived in a 9 story large reddish-tan brick building in the Pruitt-Igoe city housing at 1300 S. 14th, now gone, one block north of the hospital, on the east side of 14th. She worked as a pediatric nurse. I earned $150/month, Pat about $300/month, and we paid $40/month rent. Our 9th floor apartment, #903, is just above Pat's right shoulder, Fig. 5a. We looked east toward the Mississippi River and August Busch's Budweiser brewery, which provided a constant strong beer processing ‘fragrance' all year long. There were 4 apartments on our square of concrete right under the roof of the building.

Our apartment was in the southeast corner, a white couple's was directly north of us on the northeast corner, a young black couple was just west of us, and a young black family was diagonally opposite us on the northwest corner. The latter family was particularly nice, and kept their ten children carefully distant from the rougher kids in the housing complex. The parents were our age; their tenth child was born about a month or so after we arrived. When Brian was born the next March, the mom was a ‘pro' in aiding Pat with breast feeding. The elevator serviced floors 1, 5 and 8, so moving our furniture in and then out a year later, was mixed with carrying everything up or down one flight of stairs. We had no air conditioning (inadequate wiring) and modest heating. We used tepid water in the bathtub to cool us in summer and warm water to warm us in winter. The humid climate intensified both heat and cold.

We couldn't see the river, but we could see the Mac Arthur Bridge to the northeast, now closed. The St. Louis Arch was built years after we left there. The Pruitt-Igoe project in time failed in combining differing populations, became a ghetto, and was demolished; Figure 5b illustrates the demolition of a portion, on April 21, 1972. Note the St. Louis Arch in the upper left background.

Figure 5b
Fig. 5b. used with permission, Associated Press/Photographer Fred Waters

Without a car, we walked all around our mixed racial neighborhood. While it wasn't a great area, all knew that local white people had medical functions and provided their medical care, so we were never bothered. Lafayette Park was nice with beautiful flowers in season. We took the Chouteau Avenue bus west to the wonderful Forest Park. St. Louis had a beautiful old fashioned railroad station, now remodeled. Since Pat's nursing school education finished 6 weeks later than the start of my internship on July 1, each week she took the train to Chicago on Sunday afternoon and returned on Friday evening. We walked the mile and a half to and from the station.

Measles-related Disaster: What Seemed Obvious Wasn't True

St. Louis had a serious measles epidemic in early spring 1959 and we saw several cases of measles encephalitis. We regularly performed spinal taps on measles patients so we wouldn't miss the easily treatable case of bacterial meningitis, but found none. When the next case came in, we decided against a spinal tap, since this boy was recovering from measles. He died of bacterial meningitis --- we had missed the diagnosis.

Emergency Room Drunks

Drunks were a logistical problem in the emergency room. There were quite a few and some were injured, although that wasn't always evident. They'd be brought in by the police for evaluation. If they weren't injured, they were taken to jail. If an injury was missed, and the drunk deteriorated in jail, the city could be sued. Yet, you couldn't do a complete physical on every drunk, or that was all you'd do for the night.

The emergency room protocol solved the problem: after 15-20 drunks had accumulated, we'd have them stand along the wall in a hallway, those that could stand. We instructed them to walk back and forth, raise their arms, bend over, reach to try to touch their toes, and other such routines to determine that they could stand without collapsing, meaning that they had no obvious injuries or malfunction. This ruled out serious problems and they were then turned over to the police. Some drunks were going into delirium tremens (DTs), and these had treatment in a specialized area.

Radical Application of a Potent Drug for Delirium Tremens

Psychiatry was the area for alcoholics with DTs. They were admitted directly from the emergency room because alcoholism was considered a mental disturbance. They were placed in padded cells so that they wouldn't injure themselves. They were wildly uncooperative, wouldn't eat or drink, and needed hydration with fluids. An intravenous was impossible to maintain, so the new tranquilizer Thorazine® (chlorpromazine) was used: 50 mg were injected intra-muscularly. This in part sedated them, but, more importantly, it produced vasodilation and diminished blood pressure in a fluid-deprived patient. If thrashing continued, it was repeated. With enough doses, the delirious patient recognized that he passed out every time he raised his head. He now tolerated an intravenous, his condition improved, and sedation/vasodilation was no longer needed. This radical approach would not be permitted today - an example of our changing medical ethics.