While they were going out, a man who was demon-possessed and could not talk was brought to Jesus. And when the demon had been driven out, the man who had been mute spoke. The crowd was amazed and said, “Nothing like this has ever been seen in Israel.”
But the Pharisees said, “It is by the prince of demons that he drives out demons.” (Matt. 9: 32-34, NIV)
During my second year of medical school I was sent with two other students to a community hospital to learn the fine points of the physical examination and bedside manner from an internist who had been in practice for over twenty years. He greeted us in the lobby of the hospital and hurried us off to see his new admission.
Our instructor looked the part. He had graying hair that was immaculately combed, a tweed suit with stethoscope ears protruding from one pocket, a white shirt and a quiet tie. His manner was efficient without being quick, his face serious but friendly. We all wanted to be just like him.
But his eyes gave away something else.
Anxiety. As he made our acquaintances, his eyes kept flicking toward the hallway, to the patient rooms. After the short delay for introductions we set off behind him down the hall. He stopped just a few doors later. In the bed by the door lay a late-middle-aged woman, about the same age as our instructor. Her hair was perfect. She even had on make-up, and the sheet was pulled up to her chest then neatly folded down–a picture perfect patient. But even from the foot of the bed, through the eyes of a mere second-year student, it was clear she had suffered a major left hemisphere stroke.
Our instructor examined her quickly and pointed out the drooping lower face that spared the forehead, the right-sided motor deficits that paralyzed the right arm but only weakened the right leg, the “toe sign” on the right that was absent on the left, the left carotid bruit that signaled a narrow artery to the brain, and, in spite of her open eyes and brisk attention to her environment, the complete lack of speech. These were all the signs of a stroke in the distribution of the left middle cerebral artery.
Along with the other students I focused on the patient, busy making a catalog of the physical signs of her stroke and creating a mental image for future reference. I had little experience with real sick people and hungered for as much information as I could glean.
Then I looked from the patient back to the instructor and found him stroking the patient’s cheek with the back of his hand. She looked into his eyes, clearly trying to ask something, anxiety just beginning to give way to frustration. His hand slipped down and he took her paralyzed right hand, held it a moment, gave her warm smile, nodded, then left the room. We followed like a pack of puppies.
In the hallway, our distinguished instructor shook his head and seemed near tears. “I have known her for a very long time,” he said. Then he proceeded to the nursing station and gave a series of orders, most of which were foreign to us medical students. We marveled at his command of the jargon and his equanimity in what seemed like a very emotional experience.
One of those orders was for inhaled CO2. The theory back in the sixties and early seventies was that CO2 would dilate the cerebral arteries and mitigate the effects of the stroke. I understood the theory, but had also seen the latest research that showed the treatment was futile, possible harmful, because the CO2 only affected the normal arteries, not the ones in the stroke area. If anything, it shunted blood away from the damage. I didn’t say anything; it wasn’t my place.
The nurses rushed about to carry out his simple orders, to begin an IV and find a CO2 tank and nasal cannula. The doctor regained his composure and patiently reviewed the signs and symptoms we had observed. He reviewed the orders he had given the nurses and the reasons for each one. The only one that directly treated the stroke was the CO2.
Then he looked at us, clearly hoping we knew something more than he did, and asked, “Is there anything else they teach you at the university now on how to treat stroke?”
It was 1973. There was nothing. Aspirin wasn’t even on the radar then. The only thing we knew was that CO2 doesn’t work. I didn’t want to tell him. I didn’t want to take away the one thing he thought he could do. But I did.
We then returned to the bedside. He went to the CO2 tank and turned it off, asking the nurse to replace it with oxygen, a physician dedicated to the latest science, not his habit of practice, again modeling a good doctor. Then he went to stand at the foot of the bed. He looked at his friend, and she looked back, his sorrow and her fear now unmistakeable. He would never hear her speak again.
A stroke like this is caused by a thrombus that blocks the middle cerebral artery. But I think that calling it a demon is not inaccurate.
While they were going out, a man who was demon-possessed and could not talk was brought to Jesus.
During the next four years–the last two years of medical school, surgical internship, and the first year of neurosurgery training–I saw many tragedies. In medicine, things don’t always happen the way they are supposed to. Results are not predictable nor fair. Bad things happen to good people, and the converse also seems true; inexplicable good results come to addicts and criminals and just plain unpleasant people who don’t bother to take care of themselves. Medicine is fickle, and life is unfair. But even if this is true, it is no less sad, especially for me and the patients I fell in love with. I understood now the grief that came with a silenced voice.
Dr. Joan Venes, our chief of pediatric neurosurgery (and a courageous pioneer for women in neurosurgery), called me to her clinic when I was a first-year resident to introduce me to a new patient, Sam. He was nine-years-old, a little pudgy, round-faced, happy, sweet kid. He had complained of headaches, severe enough and frequent enough that they earned him a CT scan. On further questioning, he was an average student, not much of an athlete, and dearly loved by his mom and classmates.
The CT scan showed quite dramatic hydrocephalus, a buildup of cerebrospinal fluid (CSF) in the central cavities (ventricles) of the brain. This is not an unusual problem in children, but usually it is diagnosed when the child is still an infant. To treat his headaches and preserve his future intellectual development, Dr. Venes recommended a shunt procedure to drain the excess CSF into another body cavity where it would be rapidly absorbed back into the bloodstream. I helped her do the surgery. Sam went home five days later and we felt good about his future.
A few days later Sam came back with worse headaches. A CT scan showed his hydrocephalus had been over-treated. The CSF-containing ventricles had shrunken in size and the brain had expanded, but the pressure change in the middle of the brain had occurred too rapidly. The surface of the brain had collapsed away from the inner skull causing bleeding, a condition known as subdural hematoma.
Dr. Venes and I took Sam back to surgery, drained the subdural hematoma and removed the shunt, leaving an external CSF drain that we could open and close at the bedside if the pressure in his head became either too high or too low. Unfortunately, after the surgery, Sam woke into a bizarre kind of coma, twitching and groaning, unable to even open his eyes. He had unexplained fevers alternating with hypothermia. We attributed his state to “torsion on the brainstem” and his twitching to “thalamic fits,” but we really didn’t know what had happened.
For the next three weeks he stayed in the ICU while we regulated the pressure in his head and supported his breathing. Many complications plagued Sam, seemingly something new each day, including an infection in the drainage tube. When the pressure stabilized and CT scans showed complete resolution of the subdural hematoma, we took him back to surgery and placed a new shunt with a higher pressure valve.
After this operation, Sam improved from coma to a neuro-vegetative state. He opened his eyes and breathed normally, but never moved and never spoke. Each day for ten days I would come to his bedside, now out of the ICU, and do a sterile tap of the reservoir to sample the fluid and inject an antibiotic. His mother was always at his bedside. I would talk to Sam as if he understood, explain to him what I was doing and why, tell him about the weather and baseball scores. He simply stared straight ahead. After a few days, he would move and even chew and swallow if someone fed him. But he still didn’t fix his gaze on anyone or speak.
Finally, the CSF samples showed no sign of infection, and the CT scans showed treated hydrocephalus with no subdural hematoma. We had done all we knew how to do. He could go home, a silent child in a wheelchair.
I came by one more time to remove all the bandages and check all the wounds. As usual, I kept up my banter about bandages and baseball, then stood silently at the end of his bed. I felt guilty about taking a happy kid with a headache and turning him into a nursing home patient while traveling the “road of good intentions.” I was angry with my chosen profession. Mentally, I was begging forgiveness and saying good-bye.
Then, he fixed his eyes on mine and, with great effort, said, “Thank you, Dr. Lohse.”
I was astounded. After seeing so many tragedies, the sound of a lost voice seemed unbelievable.
And when the demon had been driven out, the man who had been mute spoke. The crowd was amazed and said, “Nothing like this has been seen in Israel.”
Jesus had just finished healing the blind boys and swearing them to secrecy (which, of course, they didn’t do). Now he leaves his home with his friends and is accosted by someone who brought a man who could not talk. This time the demon was driven out, but Jesus didn’t bother to ask them to keep it quiet. Maybe he gave up on secrecy. Or maybe he wanted the Pharisees to hear about it.
But the Pharisees said, “It is by the prince of demons that he drives out demons.”
When Sam started talking, I was amazed and delighted. I think Dr. Venes was too. But nobody else seemed to think much about it. Yes, yes, other residents would say, he finally recovered. Functioning shunt, no infection, the brain recovers nicely sometimes due to resilient neurochemistry that we don’t really understand.
Matthew didn’t record a response from Jesus to the Pharisees this time. But, a few chapters later, in Matthew 12: 22-23, Jesus heals a man both deaf and mute, and the Pharisees, apparently encouraged by Jesus’ previous silence on the point, repeat their accusation: “It is only by Beelzebul, the prince of demons, that this fellow drives out demons.”
This time Jesus answers his critics. “Every kingdom divided against itself will be ruined…If Satan drives out Satan, how can his kingdom stand?…But if it is by the Spirit of God that I drive out demons, then the Kingdom of God has come upon you.” (Matt. 12: 25-28, NIV)
I don’t talk much about demons and the prince of demons. I understand events in the physical realm in terms of cause and effect. But sometimes something good happens that is so prayed for, and so unlikely, that terms like miracle can be used. If I then start talking about pseudo-scientific causes, causes that I am only speculating about, to explain those miracles, then maybe that’s 21st century talk about demons and the prince of demons. Maybe I should choose to think that when Sam says “Thank you,” a lost voice speaks, and the Kingdom of God has come upon me.