Fantasy vs reality…….

BMJ Published 05 October 1996     Cite this as: BMJ 1996;313:887

A good friend of mine is a talented, if brittle, actress, and we once went to see her play the title role in Agnes of God. The eponymous heroine is required to go into labour on stage, and her writhing and moaning was more realistic than any “real” delivery I’ve ever witnessed. She was unencumbered by any drips or tubes, she hadn’t got 20 pounds of fluid holding her down, and she was a total and absolute show-off. So it was no surprise that her imitation was vastly more real than the real thing itself.

In fact, she was so stunningly life-like that I was almost going to stand up and shout to the rest of the audience, “Omigod! She really is having a baby!” The curse of the perfect artist had come upon her; she had been too true.

Great minds think alike, and G K Chesterton made the same observation in The Man Who Was Thursday, where a spy infiltrates the anarchists by assuming the identity of a crippled professor. When the real professor turns up, no one believes him, as the fake cripple is much more authentic and vividly paralytic. The fake, the simulator, has the freedom of movement and imagination. An old man in poor health could not be expected to be so impressively feeble as a young actor in the prime of his life. Artifice is a distinctive mark of the human genius.

Our medical textbooks are similarly unfettered by reality. In textbook fantasy-land the chest pain in a myocardial infarct will be central, crushing, and conveniently radiate down the left arm. The pulmonary embolus will have pleuritic chest pain and haemoptysis; the appendicitis will start with peri-umbilical pain gradually moving to the right iliac fossa, and elegantly accompanied by vomiting six hours later. The lung cancer will have a cough, perhaps haemoptysis, and can be diagnosed on first visit to the surgery.

But in general practice, regrettably, real life rears its dead hand; cardiac pain is usually quite indistinguishable from the one billion other chest pains we see every week. Or else it can present in terrifyingly uncommon and capricious ways.

A few years ago I was called out urgently to a patient who had diabetes and who thought she was going hypoglycaemic. When I arrived her glucometer reading was 1.6 mmol/l, so the diagnosis was apparently clear cut. But she did not respond to glucagon and dextrose, and she continued to look pale and unwell. She then developed explosive diarrhoea, which again seemed a reasonable explanation for her persistent weakness, so I was just about to leave her with advice on fluids and a prescription for codeine when my guardian angel tapped me on the shoulder and urged me to admit her “just in case.”

Until then I had never heard of a myocardial infarct masquerading as a typical hypoglycaemic episode decorated with explosive diarrhoea. And before anyone writes in to correct me, the astonishingly fortissimo borborygmi precluded use of the term “silent” infarct.



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