The Iceman Cometh and the Patient Goeth

Well, folks, listening to this podcast, you're probably sitting in an easy chair. Maybe it's end of a hard day's work or maybe you're relaxing in your office or even driving home. I hope it's a quiet time for you but during that time I want you to come with me if you will for just a few minutes back to a slate gray bitterly cold day in the great city of Chicago sometime in the early 1970s let's say about 1972 because at that time I was a third year student preparing for my first clinical rotation. Now with students who were actually going to interview and examine patients, we were becoming doctors. After two years of the basic sciences, as was the custom of the curriculum in those days, all of us, all 144 of us, were so excited to be put in front of a patient.

Now we had a choice of specialties back then for our first rotation. It could be one of any of the medical specialties or even a surgical specialty. But to put this podcast in context, you have to understand the state of neurology about the year 1972.

These were heady days for clinical neurology. Julius Axelrod and Bernie Katz had recently won the Nobel Prize in medicine for their discovery and their work on neurotransmitters. The most popular book for the medical service in the medical bookstore was Plum and Posner's classic Diagnosis of Stupor and Coma. In addition, the seminal textbook for medical students interested in neurology was Gilroy's Medical Neurology. It was flying off the shelves with its riveting chapters, particularly the one on the jumping Frenchman of Maine.

But the crowning event in neurology was the recent description at our medical school of the Bucey-Cleaver syndrome. Doctors Bucey and Cleaver had described a new syndrome characterized by, pay attention, hyperphasia, hypersexuality and anxiety. They were certain it was a newly described temporal lobe abnormality. So I and all of my classmates thought, gee, I'm hungry, I wanna have sex and I'm anxious. We all must have the Bucey-Cleaver syndrome.

And how exciting it would be to delve into this syndrome further as a student on a neurology rotation. So it was no wonder looking back that I, as did many others in my class, choose neurology as our first clinical rotation. So right on time at 7 a.m. I appeared in the medical service and was assigned to inpatient neurology. my dream rotation was about to begin.

Now I don't remember the individual's name, but the chief medical resident at that time was a very tall man from Texas. The guy wore cowboy boots and he didn't see a lot of cowboy boots walking down Michigan Avenue in those days. So this is a very strong and vivid memory for me. Well, after he had made the assignments to the other residents and the other students, I was there standing alone. He introduced himself.

looked at me and he said, and he had a bit of a draw, he said Gordon today is going to be a very special day in your evolution as a doctor. I was really excited. I said why? He said there's a man in room 848, DiGiacomo or Diacomo, one of those as he put it, Italian names. We think that man has a brain tumor, and you, the medical student, are going to find out where in that man's brain the tumor is sitting." And I was thrilled. I couldn't believe it. I said very meekly, I said, well, how am I going to do this? He looked at me and he said, have you ever heard of a guy named Baranay? I had not. And he said, Bárány got the damn Nobel Prize in medicine in 1914 for looking at the effect of temperature on the brain.

He figured out how to map the brain by changing the temperature of the goddamn eardrum.

Now I found this of great interest, but I had a little trouble imagining how my existence as a third-year student could ever link up with a Nobel Prize winner. Well, I said, I said, well, thank you. I said, that's interesting. Now he continued, now you're gonna do a test of Mr. Di Giacomo and you're gonna report back on afternoon rounds the location of Mr. Di Giacomo's brain tumor.

How am I gonna do that, I said. He said, you're gonna do a very special test. What test, I asked. He replied, it's a bedside test. The test is called ice water calorics.

Now, I had never heard of this particular test, so I took out my pen and my file cards and my paper, as was the custom in those days, and I said, well, how do you do the test? He said, well, you're all going to get a bucket of ice water, you're going to get a red rubber catheter and a 50 C syringe and brand new syringe will help you get it all together. Now, I'm writing this down to me in Chicago in February at five degrees below zero on On a gray day, it seemed a bit illogical to get a bucket of ice water, but what did I know? I was the medical student. I asked, well, what do I do after I get the ice water, the red rubber tube, and the syringe?

He said, you're going to go into this man's room, you're going to sit down next to him, and you're going to inject 50 cc's of that ice water into his ear. Okay, I said. Well, what do I do after I inject the water into his ear? And very deliberately, he looked at me and said, You're going to look at his eyes. Now, here's where the instructions became fascinating to me. I said, Okay, I'm going to look at his eyes, but what do I look for in his eyes that will help us find a brain tumor?

He looked at me. Actually, he looked down at me. He was a very, very tall man. He took a deep breath and he said the following, words which will stick with me until I leave this earth. And I can hear these words and that draw today as I recite this episode. He said to me, if upon injecting the ice water into the left ear, the right eye goes up into the right, then the tumor's in the superior sagittal sinus.

If on the other hand, the right eye goes down, then the tumor's in the cavernous sinus. If you then inject the left ear and the left eye looks over to the right eye, then the tumor's in the occipital sinus. Also, if you inject the left ear and the left eye looks outward, then you're pretty sure the tumor's in the left temporal lobe." He paused and continued. After that, you must inject both ears simultaneously, and Brenda will help you with this. After that, look at the eyes.

If both eyes look up, then the tumor's in the left cerebellum. If both eyes look down, then the tumor's in the right cerebellum. And if the eyes diverge with a rapid motion, then we're pretty certain that the tumor's in the torcula horophily. Now, if the right eye deviates to the right and the left eye deviates to the left, then the lesion is in the ventral posterolateral nucleus. And finally, if both eyes look outward, then we're pretty damn sure the tumor's impinging on the foramen of magendie or is in the aqueduct of sylvius.

Then he paused. Well, I tried to write this all down, these instructions upon observing the eyes and since I couldn't get it all on paper I very meekly looked at him and with extreme deference said could you please repeat that and he turned around and he looked at me without missing a beat and said if upon injecting the ice water into the left ear the right eye goes up and to the right then the tumor is in the superior sagittal sinus if on the other hand the right eye goes down then the tumor is in the cavernous sinus. If you then inject the left ear and the left eye looks over to the right eye, then the tumor's in the occipital sinus. If you inject the left ear, the left eye looks out, well then you're pretty certain the tumor's in the left temporal lobe. And as I said," he continued, after that, you must inject both ears simultaneously and Brenda will help you with this. After that, look at the eyes. If both eyes look up, then the tumor's in the left cerebellum. If both eyes look down, then the tumor's in the right cerebellum.

If the eyes diverge with a rapid motion, then we're pretty certain that the tumor is in the torcula horophily. Now, if the right eye deviates to the right, and the left eye deviates to the left, then the lesion is in the ventral posterolateral nucleus. And finally, and I'm not going to repeat this, if both eyes look outward, then we're pretty sure the tumor is impinging on the foramen of magendii, or is in the aqueductiv silvius. Now, I wrote down pretty much every eye motion that he had outlined and then the chief resident walked away. I went to the nursing station. I got a metal bucket full of ice and filled it with water. I then retrieved a large red rubber tube from Brenda, the famous nurse. Got a 50cc syringe and I began my walk down room 848, the room of Mr. Di Giacomo. Now this, folks, is a visual you really have to appreciate if you've ever been in Chicago in February. It's freezing cold, snow flurries are blowing sideways, and here I am walking down the corridor of a hospital with a bucket of ice water. I wasn't bringing colds to Newcastle but it was pretty darn close. The visual is almost as illogical as the test I was about to perform. I walked into the room and there was the patient. Now it's funny the things you remember about patients. Mr. Dr. Giacomo worked on Navy Pier in Chicago back when Navy Pier was, well, a Navy Pier.

It was one of the great freight stops along the Great Lakes. They weren't selling kale salads on Navy Pier in 1972. The patient looked at me and said, who are you? And I said, I'm Gordon, the medical student, and I'm here to do a test on you. He said, what are you doing with with a bucket of ice water. It's freezing cold outside. I said, we're gonna perform a test to try to localize an area of your brain where your doctor thinks you may have a tumor. He said to me, well, what kind of a test are you gonna do? I said, I'm going to inject ice water in your ear, then we're gonna look at your eyes.

He said, inject ice water in my ear, no, you're not. I said, well, sure, I've been told by the chief of residents in neurology that this is extremely important because we're trying to find out where a brain tumor is in your brain if, in fact, you have one. Mr. DiGiacomo said, quote, "'Look, I'm no doctor, "'but it's five degrees below zero out there. "'I can get freezing cold walking outside. "'I don't need you injecting ice water in my ear.'" Well, I thought it must be time for me to get back to the chief resident because the patient was really not excited about the performance of this test.

The chief resident came into the room and explained to the patient the importance of performing the essential test of ice water calorics. He spared me and the patient his description of what might happen to the eyes upon injecting water, but the patient was adamant. And just as the patient was giving his final refusal, the attending physician, a Dr. Melman walked in. He looked at the chief resident, looked at me, looked at his patient and said, what's going on? The chief resident said, well, Dr. Melman, you admitted this patient to our service with a suspicion of a brain tumor and we're gonna perform ice water calorics to find out where that tumor is sitting.

Dr. Melman said, we don't do that test anymore. I was speaking to Mel down an x-ray. We're not using ice water in the ear anymore. We're injecting some radioactive stuff into the bloodstream. You're calling it a brain scan, and it's gonna help us localize brain tumors.

The patient is now standing up looking at three modestly intelligent individuals and angrily said, I checked into this hospital because I have a headache. You think I have a brain tumor. This kid wants to inject ice water in my ear. It's goddamn five degrees below zero. And now my doctor wants to inject me with radioactive stuff.

I gotta get out of here. Mr. Di Giacomo dressed, packed his bag, approached the door, looked at us, and said, I may be the one with a brain tumor, but you're the ones who need your head's examine. Jesus. Ice water in my ear and nuclear stuff in my veins. And off he went into the cold Chicago late afternoon.

The ice man cometh, then the patient goeth away. I really can't stand but baby it's cold outside But baby it's cold outside This evening has ended and you are very nice I really can't stand but baby it's cold outside But baby it's cold outside