Throughout my years in medical training, I had heard the maxim, “Medicine is an art.” And yet this notion seemed abstract to me; after all, I had been steeped in science.

Then I came under the spell of a teacher, Professor S. M. Rab, the chairman of the Department of Medicine at DMC. It was he who finally showed me what the art of medicine was all about.

“Simply piling up scientific facts will not help you,” he emphasized. “You need more than that to care for your patients. You must learn to ask the right questions. And you must have a sense of your patients’ lives. You cannot separate their ailments from their daily living.”

Bedside manner played a big role in his teaching of the art: A doctor’s attitude and empathy were a part of healing. “Treatment begins with you,” he said. “No matter how serious the condition may be, you have to be reassuring at your patients’ bedside.”

A rapid diagnosis without a lab

I was soon able to take Dr. Rab’s advice to heart when a young woman was brought to our clinic with an acute, bizarre illness.

She was short of breath and complained of tingling and numbness of her mouth and fingers. While talking to me, she almost fainted. Then right in front of my eyes, her fingers went into spasms and her palms closed.

Alarmed, I wanted to do something in a hurry. But what could that be? I had to have a diagnosis first. My hasty, muddled history and physical examination were not helpful. She was nineteen and otherwise healthy-looking. And she did not have any injuries. I could not connect her symptoms.

Professor Rab then stepped in. “You are going to be fine,” he told her calmly. He touched her shoulder and asked her a few questions. He then asked me to get a paper bag. “Breathe into this paper bag,” he instructed the woman, and she did as she was asked. To my relief, her symptoms resolved quickly. I was amazed that Dr. Rab could so easily diagnose and cure her illness without resorting to laboratory tests.

Connecting physiology to symptoms

I was hoping that the professor would not ask me to explain what had just happened. It seemed like some sort of magic to me. But somehow he read my mind.

“What could be the cause of her dyspnea, Fazlur?” he asked me in his usual style, looking straight into my eyes. Being unsure of the answer, I listed as many causes of shortness of breath as I could think of: congestive heart failure, asthma, emphysema, pulmonary embolism, pleural effusion, pericardial effusion, and so on. If she was not having an acute asthma attack, she must have had something more serious, I thought.

“Remember, not every problem has a complex pathology,” he reminded me. “This patient is young, appears healthy, and has recovered quickly.”

His hints stumped me more. He kept looking at me for an answer. He had a habit of insisting the students think on their own.

“A chest X-ray may show fluid in her lungs, explaining her shortness of breath,” I said to get out of my impasse.

“Did you hear any rales or rhonchi in her lungs on auscultation?”

Of course, I did not, because her lungs were clear. I felt trapped by my own wrong guess. He then gave the answer himself.

“It is called ‘hyperventilation’ syndrome,” he said. “It is important to understand this kind of malady to avoid confusing it with more serious illnesses. Otherwise, patients will be subjected to unnecessary and risky procedures.”

“I still do not understand her rapid breathing,” I stammered.

“Her rapid respirations were induced by acute anxiety,” the professor said, “in which you feel a sense of impending doom.”

“But what about her muscle spasms, sir?” I asked. We never addressed our professors by their names, always as “sir” or “madam.”

The story behind the illness

Professor Rab now showed me how to connect symptoms and signs with physiology at the patient’s bedside.

“What did the young woman lose due to her over-breathing?” he asked.

That was an easy answer. “More than the normal amount of carbon dioxide while exhaling,” I said. “Exhaled air is rich in carbon dioxide.”

“Correct. But what did that lead to?”

I was not sure what he was getting at now. Seeing me perplexed and silent, he explained in detail the reasons for her problems.

“The excessive loss of carbon dioxide from the rapid breathing lowered the acidity and the calcium of her blood. This, in turn, induced muscle spasms. And the spasms enhanced her fear and made her breathe still harder, further increasing the loss of carbon dioxide. All this created a vicious cycle. Fortunately, the cycle was broken promptly by rebreathing her own air from the paper bag and replenishing the carbon dioxide she had lost. Once her metabolism normalized, her spasms disappeared. It is that simple.”

Professor Rab had a way of weaving the patients’ stories into the colorful history of medicine. And he was a storehouse of fascinating medical tales. This was another reason I loved his clinic so much.

Professor Rab emphasized that understanding the physiology of this case was not enough. I must also understand the story behind our patient’s troubles. I learned that she was a student at Eden College, next to our DMCH campus. She had fallen in love with a young man. But her family’s thinking was no different from that of the others in the culture of the time: Falling in love with a total stranger was improper. If she were that interested in men, her parents said, she must get married, and marry a groom of their own choosing. Or she should be transferred to another college where she could pay more attention to her studies, away from her romantic tangle. But the young woman would have none of this. Caught in between her love and her parents, she fell into a state of acute anxiety.

With this case and others, Professor Rab opened my eyes to another domain: that of mind-body medicine.

Fazlur Rahman is a hematology-oncology physician.