Chapter Three

MRS BOUCHER’S MANTRAP

Is not marriage an open question,

when it is alleged, from the beginning of the world

that such as are in the institution wish to get out,

and such as are out wish to get in?

Ralph Emerson 1882

In health practice you have to learn many things the hard way. In fact, your patients usually become your teachers and even on occasion your mentor. If you, like me, are a slow learner, then you especially hope they don’t sue you while you are ‘practising’ – on them.

My daughter’s music teacher was the one who taught me that if an older woman falls on her back or buttocks and has lower mid-back pain, then I must take an x-ray. Always. For the simple reason that they will often have a compression fracture of the spine, in which case manipulation is definitely inadvisable. Rose had slipped in the garden on wet grass one Sunday morning, landing on her buttocks. By the afternoon she was in considerable pain. Not agony but she was sore. Deep breathing was painful, as was moving her arms and when I percussed on the spine later that afternoon she found it a little painful. Again, not agony but enough to say: well, it could be… The other distinct possibility was a cracked or subluxated rib.[1] The problem was that the first two diagnoses definitely meant manipulation was the worst form of treatment. However, for a subluxated rib, manipulation was the treatment of choice. Ah, I hear you say: so what is your diagnosis, Doctor? That’s where I have great difficulty with those chiropractors who say: We don’t diagnose. We only adjust the spine. I made my diagnosis – and got it wrong.

In those early days, I was not unhappy to treat patients with whom I was not reasonably sure of the diagnosis (after all, is one ever totally sure?). Now I am a little older and, I hope, wiser.

Mistake number one: ‘We’ll give you a gentle treatment, Rose but, if you’re not much better in three days, then we must have an x-ray taken. Are you happy with that?’

‘Yes, Bernie, of course, if you think so. I’m in your hands. Literally!’ she said with a half-hearted wink. She was hurting.

Bernie thought so, but Bernie was wrong. He should have sent her there and then or at least, being Sunday, first thing next morning to the radiologist, without first treating her.

Mistake number two: Even my relatively gentle mobilisation of the joint aggravated the fracture – of course, I hear you say. Yes, of course. I made what could have been a serious mistake, but those were the days before my Golden Rules had been firmly established and formalised in my mind:

Take a good history: I knew she had fallen and could have fractured something.

Do a thorough examination: Possible fracture of a rib or vertebra, possible subluxation of rib-head or spinal joint, possible strain of back muscles (unlikely, as isometric testing was relatively painless), or even a sprain of the supporting ligaments. Or several of the above. Trauma often injures more than one tissue.

Use other tests to confirm diagnosis: that’s where Rose had to pay the price for Bernie being equivocal. He was trying to save her the substantial cost of an x-ray; they weren’t well off. Most of the music world seems to be disgustingly rich, or really quite poor.

Make the diagnosis and the differential diagnoses (other possibilities).

Only then begin treatment.

Well, Rose got better, once I applied the appropriate treatment, and she was largely pain-free within four weeks as long as she was sensible. Fortunately she wasn’t unduly hurt by an inexperienced chiropractor messing about and I didn’t have to refer her out. Fortunately it wasn’t a serious compression, but it was enough to make her miserable for a couple of weeks. Fortunately I wasn’t sued, probably because she was my daughter’s music teacher.

Mrs Boucher, on the other hand, made me laugh but ultimately also quite angry. At least I didn’t miss the diagnosis.

‘Doctor, I have pain in my back.’

‘When did it start, Mrs Boucher, did you have a fall or something? Did you lift something heavy?’

‘Yes, I fell in the night on the way to the loo.’ She wouldn’t look me in the eye, and I had the distinct sense that there was more to this fall. I had learnt to follow my intuition by that time – it was usually worth the journey.

‘Like to tell me about it?’

‘I tripped. Plain and simple!’ she snapped and her manner said it all: don’t pry, but I was in the mood for prying and it might, in any case, be important.

‘Was it over your slippers?’

‘Mind your own business. I tripped and fell on my buttocks. That’s all you need to know.’ She might have been eighty plus but that didn’t mean Mrs Boucher had lost any of her spirit. She was tiny, prim and proper, her long hair tied back in a bun but still she was a feisty woman; so I got on with it.

Flexion of her spine was very painful and, when I percussed with my reflex hammer, she gave a small cry of pain. The most common place for a fracture is where the highly mobile lumbar spine meets the much more stable thoracic spine (stable because of the ribs). Sure enough, it was the last thoracic vertebra that was so painful.

X-rays confirmed a serious compression fracture of the vertebral body. Fractures of that nature mean bleeding and because of the proximity of the kidneys and ureter, I decided to refer her to the orthopaedic surgeon who had bought Jeremy Thomas’s practice, a Mr Sinclair. He was in a far better position to manage the fracture, and any possible sequelae,[2] being in immediate contact with other specialists. Some specialists still like to be called Mister, a cut above the ordinary Doctor. I also used to stand on my high horse but, after being humbled numerous times, was very happy with plain Bernie Preston.

I got a brief letter from him, confirming that he had booked her into St Augustine’s hospital for a few days. Following that, she was to use a corset for at least six weeks, and he expected her to be largely pain-free within two to three months. Well and good, I agreed with his plan of action, and forgot about Mrs Boucher and how she tripped on the way to the loo in the night.

It was some eighteen months later that Mrs Boucher again appeared in my appointment book. I remembered her well, it was an unusual name and she was an unusual person. She hadn’t aged much but I could see from the way she walked and sat down that she was in a lot of pain.

‘Your back is still hurting, I see, Mrs Boucher. Did the pain never go away, or has it come back? Have you taken another fall on the way to the loo?’

She scowled at me. ‘The pain was about fifty per cent better after three months but, ever since then, if I do anything, even simple things, it gets very sore.’ She moved awkwardly in her chair. ‘I can’t play bridge anymore and…’ she winced, ‘and I can’t even go shopping or for a short walk.’

‘Have you been back to Mr Sinclair? Did he examine you?’

‘Yes, three times. Each time he just takes more x-rays and says that nothing can be done and that I have to learn to live with the pain. Now the nurse won’t give me any more painkillers – not that they helped much, and I am miserable; miserable enough to come back to you!’ Despite her pain she had a twinkle in her eye. Many of my patients like to tease, and mostly it’s fun. Fortunately she had brought her latest x-rays. I put them up on the viewing box. Sure enough the compression fracture had been bad, but it had healed, leaving a distorted and unstable back. I had misgivings about being able to help her. The picture wasn’t good, but five years in practice had taught me well: examination first, then the diagnosis and prognosis, and only then a plan of action.

The long and the short of it, confirmed by a two-minute examination, was that the pain in her back wasn’t coming from the fracture, but a good fifteen centimetres away in the sacro-iliac joint.[3] All the orthopaedic tests were positive: the Posterior Shear, Fabere, Yeomans, and the SI compression test, the lot. There was some residual tenderness at the fracture site but that wasn’t what was troubling her.

By the sixth treatment, Mrs Boucher was improving and smiling again. I had used a very conservative form of treatment on the elderly lady. She had quite pronounced osteoporosis as had virtually all women of her age, but nothing that couldn’t support a vigorous exercise programme, some cross friction on the muscles with active trigger points, and a very gentle Chiropractic adjustment. It was time to revisit our first consultation eighteen months ago.

‘You were very cagey about how you fell, Mrs Boucher, when you first consulted me. Are you ready to tell me?’

There was a short silence. She was lying face down on my table, out of eye contact, a position where patients feel free to talk if you’re willing to take the time. It was definitely worth it. ‘The old bugger is dead now, so I suppose I can tell you,’ she said. She squirmed as the cross friction on the Gluteus Medius muscle was quite painful. ‘We remarried and he became a pest.’

‘Remarried?’ I exclaimed. ‘Go on.’

‘I divorced my husband when I was about fifty. He was being impossible so I just left him, but it meant Poverty Street for me. I had to find a place to rent, I lost his medical insurance and his pension. I had to buy furniture, but it was worth every cent.’

‘Ah,’ I said.

‘Well, eventually I ended up in Olive Schreiner Home for women, and lo and behold he was across the road in Jan Smuts House for men. He was pretty miserable, and so was I, so I started visiting him occasionally. He was just as impossible as ever and our visits always ended up in an argument.’

‘So?’

‘Well, I decided to remarry him.’

‘That’s interesting. Was it for love or for money?’

‘Oh, for his money to be sure! My medical bills had started adding up. My blood pressure was high, I had developed a nasty tremor in my hand so the doctor put me on some very expensive medicine for Parkinson’s disease, and so I started thinking: if we got married again I could go back on his medical aid and, when he died, get his pension. We would go on living across the street from each other. I would visit him now and again, which I was doing anyway, we’d have another argument, and nothing much would change, except that I could then afford to pay your fees.’ She gave a muffled laugh.

I couldn’t help smiling, even though she couldn’t see me, rather like people smile or scowl at each other when talking on the phone. ‘Quite a schemer, eh! Did it work out?’

‘Oh yes. He died about six months later, and I am still on his medical aid – just as well,’ she added a little hotly, ‘and now I get his pension too.’

It gets to be a problem. People retire but, with double digit inflation, if they live another twenty years, medical costs become prohibitive. ‘But what’s all this got to do with a fall in the night?’ I asked.

She gave a little-girl giggle. ‘We remarried last summer. It was particularly hot those nights so I liked to leave my windows open. Next I knew, he was coming across the road at about midnight, climbing through my window, and trying to sneak into my bed. “You’re my wife, you know,” he would say. ‘Fancy that, with both of us in our eighties, him nearly ninety, in fact.’

‘So?’

‘So, I tied a long piece of string to the window, with pans and bells tied to it so that, when he came intruding, I would wake up and could shoo him away before he climbed in. Then one night I tripped over my own mantrap. I suppose you are going to say, “Serves you right for marrying him!”’

Oh, and why was Bernard Preston angry? Because Mr Sinclair obviously didn’t examine his patient again after that first consultation. He must have been in a hurry, assuming that her pain originated from the old fracture. I could easily fall back into that rat race, I thought to myself, still unable to forget the rebuke from a patient: conscientiousness is, mostly, what makes the difference between good and bad doctors. If Mr Sinclair had taken a little extra time, he would have known that Mrs Boucher’s pain wasn’t coming from the site of the old fracture. I was sad that Jeremy Thomas had left for greener pastures. We could talk, without either of us taking umbrage but I wasn’t so sure about this Mr Sinclair.

I could never cure Mrs Boucher. She went on consulting me once a month, mostly reasonably satisfied with her progress, and able to play her beloved bridge again, still complaining about the cost, of course, until she died quite suddenly, the way I would like to. I still think of her now and then, sad that I never made it to the funeral. The first I knew of her death was when she never arrived for her monthly consultation. Some patients you never forget.

Bat in my Belfry - Excerpt