May 13, 2003

Song Boy

1234 N. Melody Lane

Beverly Hills, 90210

Dear Songboy:

First of all let me say that I am happy you have been relieved of the face and head sweating that you initially sought care for.

No, I originally sought care for my facial hyperhidrosis, not my facial sweating. Big difference. Anhidrosis on my whole upper body is not a relief in any sense of the word.

I am sorry that you have had so many other problems and I will try to address your concerns as you described in your letter.

As for you [sic] initial concern regarding my time spent with you I must inform you that the standard post-operative visit for hyperhidrosis surgery takes 5-10 minutes. During each of your post-op visits we spent at least 30 minutes addressing your concerns and trying to answer your questions.

 More like 15-20 minutes, but who’s counting.

Yes, I am busy but I always listen and pay attention to what you are saying and your impression that I am not interested in [sic] incorrect. Just because I am not able to offer an answer or a cure for each concern does not mean that I do not care. In addition, although that [sic] I have said that problems often fade with time, I certainly never promise that they will go away.

Dr. Smith made a video of himself saying, “But we’ve found is we get about, uh . . . 1 out of 5 patients who will develop a mild and transient problem with some moisture over their chest or their back that’s called ‘compensatory sweating’ and it has tended to go away over the first year in all of the patients that we’ve studied.”

Throughout your letter you discuss numerous problems you have encountered and wish you would have known about ahead of time. As I am sure you remember I discussed in detail with you the known and published risks of post-operative Horner’s syndrome and compensatory sweating in great detail.

His entire explanation of Horner’s syndrome was “it’s a little bit of a droopy eyelid”. He went on to suggest that some people find a droopy eyelid to be “sexy”.

These are the two main problems encountered by people undergoing surgical sympathectomy.

Here he admits that he only warned me of 2 things.

Most of the other problems you have described are neither common nor frequent and in many cases you are the only person in my personal experience of over 500 cases where these problems have occurred.

Liar.

Yes, I do learn about this operation and its side affects [sic] by following up and talking to my patients. However, I can not describe to you potential complications that I have never seen or read about despite having read over 100 papers on the subject.

Maybe he has a “study screener” that won’t allow him to see ETS studies that actually show side effects, so he only sees the ones based on patient questionnaires that don’t actually measure anything. Or maybe he’s just lying.

Now to address your concerns in order:

A: Sweating - I am afraid you misquote me in this very important subject. When asked if sympathectomy will affect your bodies [sic] ability to sweat in order to thermo regulate I often give the example of the guy walking in the desert. He is able to sweat to regulate body temperature and will not get fever or heat stroke. You do not need to sweat above the nipple to accomplish this act of thermoregulation.

There you have it. Dr. Smith, a Ph.D. in medicine, on the record saying “you do not need to sweat above the nipple to accomplish this act of thermoregulation”. ETS patients can still regulate body temperature somewhat, but Dr. Smith’s clear implication is that sweating of the head is unimportant. False. About 45% of the heat radiated out of the body comes from the head. Head sweating is very important to thermoregulation, and ETS patients typically cannot tolerate warm temperatures nearly as well as before surgery.

Although you “thought” this surgery only affected nervous sweating, you were incorrect in thinking so.

Man, was I ever incorrect. Most incorrect I have ever been in my life. And notice how he puts quotes around the word “thought” as if he doesn’t believe me. At least when I accuse Smith of lying, I come right out and say it.

It eliminates abnormal nerve related sweating as well as regular sweating from the head, face and hands and if T4 is included axillae as well.

Here he is repeating his infamous “two types of sweating” lie, but with a new twist. He still falsely implies that only the “abnormal” sweating is “nerve related”, but then correctly adds that regular sweating from the face is destroyed by ETS. This is an attempt to claim that he explained the lack of sweating to me, while still using the same linguistic construction that he originally used to deceive me. 

I am sure that I made it clear to you that your face and head would not sweat after the surgery even if you exercised vigorously and this appeared to be what you wanted.

No he did not make it clear. He flat out lied to me and said ETS has no effect on normal sweating. I specifically asked about it, and he intentionally lied. What person doesn’t want to sweat from the head when they exercise, or when it is hot? Just wait, later in this letter he slips up and admits that he might have “forgotten” to tell me about the inability to sweat.

Knowing this it is hard for me to understand how you would think the surgery only affects nervous sweating.

It’s easy to understand how I thought that. I thought it because Dr. Smith said it.

Because people come to me to eliminate sweating problems you are the first to say it was horrifying to realize that you would not sweat above the nipples.

No I am not the first to tell him that. I know of 3 other patients of his who all say that they too thought that ETS only affected hyperhidrosis, without affecting normal sweating. People do not come to him to “eliminate sweating problems”, they come to him to eliminate hyperhidosis problems. Big difference.

Finally the moisture level of your skin depends on your level of hydration and not how much sweat you have on your body.

Come on. ETS causes anhidrosis of the upper body. Of course ETS affects the moisture level of skin. What kind of doctor could spew this nonsense?

The supple texture of skin depends on the natural oils you secrete.

Well, as long as we are on the subject, ETS can denervate the sebaceous oil glands too.

I have difficulty understanding the statement that if you knew your skin would not have sweat (you say water) or if [sic] you would not have had the surgery, but this is exactly what was explained to you when we discussed that the effect of doing a sympathectomy is that it will eliminate the sweating of your face and scalp.

Liar. Dr. Smith told me that ETS would only stop the excessive sweating.

B: Dry hands-Yes, the affect [sic] of this surgery is to create warm, dry hand [sic] which for people with sweating palms is a very pleasurable result. Of course people who present with face and head sweating do not really want any change in their hands.

No kidding.

However, there is no way I am aware of to eliminate the facial sweating without taking the nerve that also affects the hands.

. . .and the nerve that affects the heart, and the nerve that affects the blood vessels, and the nerve that affects the lungs, and the nerve that affects the thyroid, and . . .

 While several people have noted increased dryness of their hands in these situations, the sunburned, caked in alkali feeling you describe is most unusual.

He never said anything like this in my consultation, but he’s still understating the hand dryness issue. Lots of ETS patients have very dry hands, to the point where they must use lotion all the time. That’s what patients need to be told, and Dr. Smith failed to do that too.

Again, I must note that you misquote me when you say I have patients unable to tolerate touching certain textures.

Dr. Smith has many patients who are averse to touching dry textures such as paper. It is a very common complaint from ETS patients all over the world.

I have patients whose sensation while touching textures has changed because before they touched them with wet hands and now touch them with dry ones.

Here he admits that ETS changes the sensation of touch. That too would be a good thing to mention to patients before surgery. If, before surgery, Dr. Smith had said to me, “I have patients whose sensation while touching textures has changed . . .” I would not have needed to hear the end of that sentence. This, and this alone would have scared me away from ETS.

You can imagine the difference this makes when feeling something like velvet or silk.

No, Dr. Smith, you can imagine the difference. I don’t have to imagine it. I experience it. And it is hateful.

The one patient I think of most in this regard is a young man in the printing business who has to feel subtle difference in paper texture and thickness and he was quite happy with his tactile ability following surgery. When you change what I say it becomes very easy to become upset or feel mislead, but I assure you that I did not hold back “secrets” from you in order to convince you to have surgery.

Then why did you hold back so much crucial information, if not to convince me to have surgery?

Your bad reaction appears extreme and unprecedented.

No it is not. My symptoms are in the literature. Look them up. Talk to your other patients, especially all the ones who are suing you.

C: Blood Pressure: In regards  to your concerns about your heart, I strongly recommend that you seek an evaluation by a cardiologist.

I did have a cardio workup, which showed a low heart rate and low blood pressure, though my heart itself is fine. My heart function, however, is not fine, it has been partially denervated. I believe Dr. Smith knows that my dysfunction is not necessarily something a cardiologist would detect, but rather is in the province of neurology and neurocardiology.

I am sorry if you feel I accused you of being out of shape. I simply meant to suggest that this was one possible explanation. I know of no other patients with this problem and again recommend that you seek expert help.

Lie after lie after lie. I complained of a heart that wouldn’t pound, and a basic understanding of the sympathetic nerves would suggest an obvious connection between decreased heart function and sympathectomy. See Drott and Claes from 1994, for starters.

Regarding blood pressure, again you misquote me. I certainly realize that the sympathetic nervous system has a great deal to do with the regulation of normal and reactive body blood pressure. If you remove of kill the entire sympathetic nerve, blood pressure drops significantly and becomes very difficult to control. However, the effect of removing the T2, T3 or T2,T3 and T4 ganglia on body blood pressure is negligible.

Taking static blood pressure measurements may indeed yield insignificant changes after ETS. It is the response of blood pressure to stimuli such as exercise, or fear that drops significantly after ETS, and it is in the literature.

Numerous scientific papers addressing this issue including the affect [sic] on exercise by athletes have been published revealing no serious side affects [sic]  of limited T2,T3 or T2,T3 and T4 sympathectomy.

I haven’t seen those. I’ve been looking.

I am happy you have taken the initiative to look things up but you must be precise in your understanding of what you read. As for the fact that your blood pressure does not rise with exercise, I again advise you to seek evaluation by a cardiologist. I am not an exercise physiologist and if I implied to you that blood pressure should not rise with exercise, I apologize in that I was referring to mild levels of exercise.

In a phone conversation, Smith tried to convince me that blood pressure is not supposed to rise during exercise. I caught his lie, and here he is backtracking.

In addition you ask if I am interested in your sources and I certainly am interested especially if voluminous data is available.

By the way, where is the voluminous data for your study?

You describe your experiment during which you get light headed and need to catch your breath – you may think it’s due to blood pressure regulation but again, I suggest a cardiology work-up.

Well, the nice folks at NIH think that these symptoms (and many more) are the direct result of a sympathectomy.

I have no good explanation for your heart complaints – we have never seen anybody have a problem like this before.

Liar.

If I had known that ETS surgery would change your body’s ability to regulate blood pressure (which I am not sure it has) or respond to fear, I would not have offered you the operation.

Why do you think that ETS is done to treat social phobia and other psychiatric disorders? It is because it reduces the physical reaction to fear and strong emotion.

D: Goosebumps: Your goosebumps problem is unique and singular to my practice.

Huh? In a follow up visit, Dr. Smith admitted full knowledge that the sympathetic nerves control goose bumps, and the “chills” that go up the back and down the arms. Now he denies it.

He didn't say WORD ONE about any change to the blood vessel function before surgery. After surgery, he admitted that ETS interferes with vasoconstriction, and tried to make it sound like a good thing in our phone conversation.

E: I do not characterize throbbing hands as a good thing.

He did so.

What I said was if your hands are cold due to vasoconstriction secondary to increased sympathetic tone then sympathectomy can improve blood flow to the hands and make them warmer and more comfortable.

What he didn’t say is that if my hands were not cold due to vasoconstriction, then they might end up throbbing. Sympathectomy paralyzes the smooth muscles that constrict blood vessels. Patients certainly have to be told this, and I certainly wasn’t.

You are in no danger due to good blood flow to your upper extremities.

ETS doesn’t cause “good blood flow to the upper extremities”. It paralyzes blood vessels in the denerved region, leaving surface vessels unable to constrict, and deep vessels unable to dilate, thus destroying the body's ability to redistribute blood flow in response to exercise, cold temperature, and emotion. Not good. Bad.

F: Heat Rash: I am sorry but you are the only patient I know of with this complaint and the inability to tolerate the Jacuzzi.

Liar. It’s called “heat intolerance” in the popular press, or thermoregulatory failure if you want to get fancy. Even many ETS surgeons themselves admit it now.

I plan to make a copy of your letter available to all potential sympathectomy candidates who wish to know of every possible side affect [sic] which may cause them to reconsider proceeding with surgery.

Raise your hands, how many out there think Dr. Smith printed up a stack of my letters and handed them out like lollipops? Not. And for crying out loud, you have a Ph.D. Learn how to spell “side effect.”

G: Recovery: I told you the same thing about recover [sic] that I tell everybody. We have had people play tennis the day after a sympathectomy but most people just take it easy and 90% are able to go back to work or school 3 days after surgery. Some people take longer to feel better. Your response to every other portion of the operation has been bad therefore I do not see why recovery from surgery would be an exception. I do know of only one other person who experienced pain 5 months after the surgery which is an abnormal but not unheard of problem.

Here he admits previous knowledge that ETS can cause chronic pain. This too would have been pertinent information to have known pre-op. It certainly would have scared me away.

I do not mean to lead you to believe anything – I can only relate to you the experience of the other 500 patients who went before you. The painful nipples are also a very rare finding after this operation but at least this went away. I must ask where you thought the numbness comes from.

Gee, let’s see. I’m lying in a hospital bed, waking up from nerve surgery, and for some reason my whole chest is numb. I don’t think it takes a creative genius to wonder if maybe the wrong nerve got cut.

I tell my patients that I do a nerve block to help decrease post-op pain.

No other Smith patient I’ve spoken to remembers anything about a nerve blocking agent. I’ve often wondered if maybe Smith knew he damaged something extra, like perhaps my intercostal nerves, and hoped it would heal up before the nerve block wore off. Just a theory.

I am sorry you had mortal fear related to this but you must have forgotten a portion of the story.

Nope. I took notes as he told “the story”. I’m looking at them as I write this. Nothing here about a nerve blocking agent that makes the whole chest numb for months.

H: The Theory:

I must respond to most of your complaints by nothing [sic]  that yes in reality you are the only patient to complain of most of these things.

Liar.

Your cardiac complaints are a mystery to me and require professional evaluation.

Repeat after me. ETS causes cardiac denervation and bradycardia. Look it up. Claes, Drott, 1994, among many other studies.

Again, I am very interested in your sources and would be happy to look at them. Maybe you would care to look at some of mine. Let me know.

Hey, let’s get together and have a science fair! My wife can bake cookies!

I: What you want:

I must insist that I discuss lack of sweating above the nipples with all patients having a T2,T3, and T4 resection because I do not want anyone to be surprised.

Liar.

The term “may not” sweat above the nipples is appropriate because some patients do still experience axillary sweating with exercise after this procedure.

He is referring to a phone conversation after surgery in which he said patients “may not” sweat above the nipples. In my consultation, Smith did not say “will not sweat” or “may not sweat” or anything of the sort. He said that ETS has no effect on normal sweating, and that it only affects excessive sweating.

That fact that you do not recall me telling you this either means that I forgot or you forgot.

Oops. Did you hear that? He let it slip out. Here he admits that he may have forgotten to warn me about not sweating. He writes this whole long letter, apparently laboring very hard with his spelling and grammar, claiming over and over that he warned me about everything and then . . .says that maybe he forgot to warn me after all. Well, allow me to clear up any uncertainty. Dr. Smith did not tell me that I would never again sweat above the nipples. He positively said that ETS has no effect on normal sweating. Those were his exact words. Several other Smith patients were told the same lie, and are willing to testify in court.

There are numerous other things outlined in this letter that I know we discussed that you appear to have either misinterpreted of heard differently then [sic] I know they were stated.

Such as?

All I know is that it is my standard to mention this phenomenon and I will continue to do so in the future.

1)    I am happy to send you your records.

2)    Due to patient privacy laws and the new federal regulation of HIPPA, I am unable to give you other patient’s [sic]  numbers or e-mail addresses. If someone tells me that they would like to discuss problems related to sympathectomy with another patient, I would be happy to put them in touch with you if you would be so kind as to provide us with a written authorization to do so.

I did send in written authorization to be contacted by patients, and thus far I have heard from approximately . . .roughly . . .I’d have to say . . . somewhere in the neighborhood of . . .zero.

3)    I assure you that learning about this disease, it [sic]  treatment and complications are foremost in my mind.

Hyperhidrosis is not a disease. It is a cosmetic condition that embarrasses people.

 I am not an exercise specialist but have read papers specifically focused on sympathectomy and exercise and I have not come to the same conclusions as you.

4)    For the sake of future patients, I will distribute a copy of your letter outlining the potential post-op honors [sic]  of sympathectomy. If this saves one person from repeating your ordeal it will be worth it no matter how many people refuse surgery.

Somehow I doubt he followed through on his promise to distribute my letter.

Finally, although you say you realize no surgery is without risk, I am not sure that you mean it. You have had all of the known and many of the unknown complications of sympathectomy that I would have not [sic]  method of predicting let alone warning you about.

Huh?

I NEVER told you the benefits of the surgery without telling you all of the risks. You were allowed to ask ALL the questions that you wanted and you asked a lot and I answered then [sic] thoroughly and as honestly as I could.

As honestly as you could? What does that mean?

You were well informed but have suffered bizarre side affects [sic] which no one could have predicted.

No one, that is, except those familiar with the literature.

Believe me, if I knew you would have had these problems I would not have operated on you. I am never quick to sign anyone up for this operation.

I was on Dr. Smith’s surgery calendar within 5 minutes of completing the consultation, despite having never tried anything else to treat my problem.

It is an elective surgery you chose to have for a non life threatening problem while understanding risks are involved.

I didn’t understand the risks at all.

I would never force or encourage anyone to have the surgery against their will or better judgment. It is a choice you made after I presented my data on the subject.

The “data” Dr. Smith presented was a bogus sales pitch. Real data consist of numbers generated by taking measurements. In Dr. Smith’s own ETS study, it appears that he took no measurements at all. I haven’t seen his data yet, but if we have to issue a subpoena to get it, we will.

I talk of the tennis player but make it clear that surgery hurt [sic] and everyone recovers in their own way at their own pace.

Do I feel I gave you adequate information prior to your surgery? Absolutely! Did you hear or understand most of it? Absolutely Not!

I earn a living with my ears, so critical listening is routine for me. I’m a smart fellow if I do say so myself, and I was taking notes during the consultation. The notion that I failed to hear something or failed to understand is ludicrous. I was intentionally deceived.

I believe that this letter outlines in detail what I agree and disagree with. I am happy to send you your records and I truly hope in my heart that you are able to recover from the litany of side affects you have outlined. If I can help, I certainly will.

Sincerely,

Rick Smith, M.D., Ph.D.

Medical Director

A Major Lung Center

A Major Medical Center

CC: The Medical Board of A Large State