Symptoms of Unknown Origin: A Medical Odyssey

by Clifton K. Meador MD

Overview

For years after graduating from medical school, Dr. Clifton K. Meador assumed that symptoms of the body, when obviously not imaginary, indicate a disease of the body—something to be treated with drugs, surgery, or other traditional means. But, over several decades, as he saw patients with clear symptoms but no discernable disease, he concluded that his own assumptions were too narrow and, indeed, that the underlying basis for much of clinical medicine was severely limited.

Recounting a series of fascinating case studies, Meador shows in this book how he came to reject a strict adherence to the prevailing biomolecular model of disease and its separation of mind and body. He studied other theories and approaches—George Engel's biopsychosocial model of disease, Michael Balint's study of physicians as pharmacological agents—and adjusted his practice accordingly to treat what he called "nondisease." He had to retool, learn new and more in-depth interviewing and listening techniques, and undergo what Balint termed a "slight but significant change in personality."

In chapters like "The Woman Who Believed She Was a Man" and "The Diarrhea of Agnes," Meador reveals both the considerable harm that can result from wrong diagnoses of nonexistent diseases and the methods he developed to help patients with chronic symptoms not defined by a medical disease. Throughout the book, he recommends subsequent studies to test his observations, and he urges full application of the scientific method to the doctor-patient relationship, pointing out that few objective studies of these all-important interactions have ever been done.

Product Details

ISBN-13:	9780826514738
Publisher:	Vanderbilt University Press
Publication date:	04/22/2005
Pages:	200
Product dimensions:	5.50(w) x 8.50(h) x (d)

About the Author

Clifton K. Meador, M.D., is Clinical Professor of Medicine at the Vanderbilt School of Medicine and Meharry Medical College as well as director of the Meharry Vanderbilt Alliance. He is the author of eight books, including A Little Book of Doctors' Rules and Med School: A Collection of Stories of Medical School, 1951 to 1955.

Read an Excerpt

CHAPTER 1

An Unlikely Lesson from a Medical Desert

When I drove over the small ridge that had hidden Fort Hood, Texas, from view, my heart sank. As far as I could see, the land stretched into the distance to a faint line of horizon that barely separated sky from ground. I had no idea that such a desolate place would be the setting for one of the most important learning experiences of my medical career.

There were few trees. The entire landscape was pale brown, as though the color green had vanished. Geologically, it was an ancient seabed. Sixty-five million years ago, water had covered the entire area from Fort Hood to the Gulf of Mexico. Giant dinosaur footprints were still visible on the stone riverbeds to the north. I thought at the time that there are some lands too new for human habitation.

The year was 1957. It was the peak of the cold war. The world was poised for a nuclear exchange between the USSR and the United States that thankfully never came. I had just been drafted into the U.S. Army Medical Corps for two years' duty as a general medical officer. The doctor draft had continued after the Korean War, which had ended only a few years before.

The long stretch of bare ground in all directions could not have looked more different from New York City, where I had spent the previous two years in residency training in medicine at Columbia Presbyterian Hospital. The contrast in geography was not the only difference. Instead of treating the sickest patients in New York City, I was to be one of the army physicians who would care for the ten thousand healthy draftees who formed the Fourth Armored Division.

Fort Hood lay about two miles west of Killeen, Texas. The small town's only economic reason for existence was the presence of the army post. Everything about Killeen was tied to the army. There were pawnshops, pool halls, tattoo parlors, hunting and fishing stores, several beer joints, and a few scattered gas stations. Used and repossessed car lots with hundreds of colored triangular flags sat at each end of the town. The highway that ran though the center of Killeen was its business district. It was the highway from Fort Hood to Temple, Texas, twenty-five miles to the east. The treeless residential sections, all new, sprawled across the land in curves of duplexes.

The post hospital sat on the extreme western edge of Fort Hood. Looking out my office window in the dispensary, all I saw was a stretch of land that seemed to reach forever. In the early mornings I often watched the rising columns of dust thrown up by tanks and trucks as they moved slowly out to the impact zone for daily gunnery practice. The armored vehicles eventually disappeared over the horizon, and then all I saw was land and sky. Not only was I geographically isolated, but even worse, I was in medical limbo, banished from medical complexity and challenge.

In my medical training at Columbia Presbyterian Hospital, I saw only the sickest patients or those with complex or rare diseases. The admitting system permitted us to send the less sick patients and those with more common diagnoses to Bellevue or other city hospitals. This process screened out the ordinary illnesses and created a distorted view of medical practice. Medical care is a pyramid with its base in the general population and its tip in referrals and complex diseases. I had been trained to work at the tip of the medical pyramid but had now been assigned to the very bottom. Mostly I would see well soldiers who were suffering from the varied stresses of army duty — too little water (constipation), too much sweating (rashes, jock itch, athlete's feet), too much sun (sunburns), too much marching (blistered and infected feet), and too much weekend liberty (syphilis and gonorrhea).

I was lucky to be assigned to the post hospital. Most of the other drafted doctors were assigned to the various battalions of the Fourth Armored Division spread out across several miles of the post. Each battalion had its own aid station, the site of morning sick call. Whenever the troops were in the field, the battalion doctors had to go with them and live in mock combat conditions. We hospital physicians slept in beds in our own homes and rotated night call at the hospital emergency room. The only thing that determined who was assigned to the hospital and who was assigned to a battalion aid station was length of training before entering the service. Those of us in the hospital had at least one more year of training than the battalion physicians had. That fine difference of one year gave us rank and position at the hospital rather than assignment to the aid stations.

At noon, the battalion surgeons not in the field came to the hospital mess for lunch. These gatherings over lunch became midday rituals. We shared current cases with interesting twists or recalled fascinating patients from our residencies or internships. Often someone described a puzzling finding or a set of symptoms that did not fit into any known diagnosis. Members of the group made suggestions for tests or for specific questions to be asked in the ongoing history. It was a wonderful way to make a dull medical existence more livable — especially for the battalion doctors, who saw only the common results of army duty. They were starved for contact with more serious illnesses, so the informal noon-meal conferences became popular sessions.

Although I worked at the hospital, I also held sick call each morning for the troops assigned to Fourth Armored Division Headquarters. Technically, I was assigned to Headquarters, Headquarters Company, a designation I never understood. There were three doctors and about eight corpsmen at sick call. Each morning a variable number of soldiers would be in line when I arrived. On most days we saw around fifty men, which took about an hour. If there were maneuvers that day, the number could rise to one hundred, making two hours of work. If there was a dress parade on the post, the number could easily exceed two hundred, which took all morning and part of the afternoon. It was our job to see all comers, the sick and the well. It would be my first experience with seeing a patient even close to well since my days in medical school a few years back when we learned to do physicals on our classmates. On sick call, it was our job to separate those who thought they were sick from those who wished they were sick from those who acted sick from those who really were sick.

We had only two placement choices for the soldiers in training — full field duty or admission to the hospital. There was no in-between — no light duty and no way to allow the recruits in training to hang out around the barracks. (The commissioned and noncommissioned officers could go home or lie around the Bachelor Officer's Quarters, the BOQ, until they recovered from minor illnesses or injuries.) The motivation for the recruits to be admitted to the hospital was enormous, however: a soft bed, three hot meals a day, and a nurse or two to look after them. Contrast that with the heat and sweat of long marches, hard bedrolls at night, and cold food. It was no wonder that the number at sick call varied depending on the duties of the day.

We rarely saw anything medically complex among the drafted recruits. Keep in mind that the young men had a physical exam when first drafted that screened out most serious conditions. They had another physical exam on entry into the army before basic training, which screened out what the first process missed or whatever had developed in the meantime. In addition, most of the soldiers were between eighteen and twenty-two years of age, a very healthy period in life. We soon came to realize that we were dealing with an extraordinarily healthy population of young men.

Within a few weeks, I was seriously bored. Other than sick call, I was assigned to the outpatient pediatric department of the hospital. I begged the commanding officer to transfer me to an inpatient unit. I was thankful when he finally assigned me to the female-dependent service. I would be responsible for the care of all hospitalized female dependents on the post. My mornings on sick call were in sharp contrast to my afternoon and evening duty at the hospital, where none of the women had been screened for any disease. There was no prior physical exam to guide me. Any disease was possible and became probable if certain clusters of symptoms were present. My entire thought process had to shift radically from morning sick call, where complex disease was rare, to the afternoon civilian medical care, where anything could appear. Since finding and treating disease was what I had been trained to do, I felt much more at home with the civilians.

It was in the civilian ward that I met the patient who would change forever my views about illness.

At one of our noon gatherings with the battalion physicians, I began to share my problems with this patient. I will call her Amy. She was twelve years old with juvenile-onset diabetes mellitus (now known as type 1 diabetes in contrast to type 2, or adult onset).

Diabetes mellitus was a young internist's dream disease, or so I thought until I met Amy. Diabetes to my mind was the perfect medical disease, somewhat like myasthenia gravis: Some essential chemical (insulin, in this case) is missing from the body; tests (blood glucose levels) can accurately identify the problem; the missing chemical (insulin) can be given; and the patient is cured or at least maintained in a healthy state. Diabetes fit the biomolecular model of disease perfectly. The only job of the physician was to find the offending agent (as in the case of an infection) or the missing chemical (as in the case of a metabolic disorder) and prescribe something to combat the invading organism or replace the missing chemical. The patient, in my limited conception at that time, was only a carrier of the disease.

Amy appeared at one of my afternoon clinics with her mother. She had developed diabetes acutely at age ten, two years before I saw her. At the onset, she abruptly developed diabetic ketoacidosis and had to be rushed to a hospital. Like many juvenile-onset patients, she later went into a partial remission that lasted only a few weeks. During that period she was able to stop all insulin, but the need came back as abruptly as with her onset. She had been taking daily insulin injections for nearly a year when I first saw her.

Her mother also had type 1 diabetes and was quite knowledgeable about management, diet, insulin injections, and the variables that make control of blood sugars possible. In the preceding few months, Amy's control had become extremely unstable. Her mother had already made many adjustments in insulin and diet to no avail.

I relished the challenge of straightening out Amy's clinical state. If there was any disease for which I was fully prepared, it was the treatment and management of diabetes mellitus. Diabetes mellitus had been a special interest of the faculty at Columbia Presbyterian, especially for my chief of medicine, Dr. Robert F. Loeb. Loeb was an authority on the treatment of patients with diabetes, as well as editor of Cecil and Loeb's Textbook of Medicine, a leading text of that time. I remember thinking to myself: At last I have a case that I can really get my teeth into. Amy's management would relieve some of the tedium of sick call and the more-or-less routine cases of the other women on my ward.

I spent considerable time reviewing Amy's diet. I moved some food to the afternoon and then a bit to bedtime. I was precise, calculating the grams and calories of carbohydrate, fat, and protein. Dr. Loeb would have been proud of my scientific approach. But none of my changes made any difference. The wild swings in glucose level continued. Amy suffered another episode of ketoacidosis while under what I thought was my most careful observation. I seemed to be having no influence on the disease process.

I changed insulins and altered doses. I tried all the insulin preparations of the day — protamine zinc insulin, Lente, semi Lente, and NPH insulins — adding injections of regular insulin just before meals and at bedtime. All these efforts were to no avail. I tried to get Amy's mother to see a specialist at Scott White Clinic nearby. She refused. I tried to send Amy to Walter Reed Hospital in Washington. She and her mother refused. Her mother kept telling me that they would stick with me, that eventually we would figure out what would work. She was extraordinarily helpful in keeping records and following my advice, but she refused to allow Amy to be referred.

I was spending increasing amounts of time with this patient. I admitted her to the hospital more times than I can recall, at least once every two or three weeks. When she was in ketoacidosis, I felt obligated to stay at her bedside, as I had been trained. The whole affair was becoming a nightmare. My frustration increased week by week. Here was the prototypical medical disease, one for which I had special training. Yet I was failing to make any difference. I had taken every variable into account, but the problem continued, and even got worse.

Our physician lunch group wanted day-by-day reports about Amy. I kept them posted with detailed accounts of her urine and blood tests. I followed several of the group's suggestions for diet or insulin changes. Once we gradually reduced the insulin dose to very low levels and thought we had the problem solved, but the wild fluctuations in her clinical state began again.

The group began to wonder if Amy's mother was up to some bizarre tricks like withholding insulin or upping the dose. I admitted Amy for a prolonged period to test this idea, and the swings in glucose continued even while she was under careful observation in the hospital.

I used everything I had been taught. One member of the group suggested the novel but dangerous idea of putting Amy on small doses of prednisone (a synthetic glucocorticoid compound) so the diabetes would become more severe and therefore somehow more stable and controllable. In my desperation, I actually considered following his advice. It was a dangerous idea, however, and I rejected it.

Then Amy and her mother disappeared. A week went by. Maybe she had switched to one of the other doctors in our group — I asked the group at lunch if anyone had seen her. No one had. I assumed she had finally taken my advice and gone to the Scott White Clinic or to the civilian doctor in town. I felt both relieved and worried. More weeks, then several months, went by, still with no word about Amy. I was puzzled by the lack of a call for her medical records. I wondered if her father had been transferred to another army post. Worst of all, I even began to wonder if she had died.

One day I walked into the waiting room of my afternoon clinic, and there stood Amy and her mother. At first, I held back. But then I saw both were smiling broadly and walking toward me. Both were talking at the same time, excited to tell me where they had been and what had happened. I invited them into my exam area.

The mother quieted Amy with one hand. In a slow and calm voice, she told me what had happened.

Amy had suffered only one hypoglycemic episode in the intervening four months and no episodes of ketoacidosis. Both of them laughed when the mother told me that. I was so puzzled, I said nothing. I was truly dumbfounded. What had I missed? What confounding underlying disease had been discovered? What could possibly produce such a miraculous turnaround?

Amy's mother told me that a new family had moved into the house next door. They had a three-year-old little girl who immediately attracted Amy's attention. From almost the first day, Amy was inseparable from the little girl. To the delight of the young child's mother, Amy did everything for the little girl: changed her clothes, gave her baths, read to her, even fed her. Amy became an adoptive parent. As her mother spoke, Amy smiled and contributed bits of things she liked to do with the girl — riding her on her bike, pulling her in a wagon, and endlessly dressing her in grown-up clothes. It was clear that she was absorbed in the care of the child.

The mother then told me that in addition to the appearance of the little girl, they had given Amy a kitten of her own. Between the little girl and the kitten, Amy's life was filled with joy. Within a week, her diabetes became completely manageable and the wild swings ceased.

(Continues…)

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Excerpted from "Symptoms of Unknown Origin"
by .
Copyright © 2005 Vanderbilt University Press.
Excerpted by permission of Vanderbilt University Press.
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Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

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Table of Contents

Acknowledgments vii
Introduction ix
Prologue 1
1 An Unlikely Lesson from a Medical Desert 5
2 Texas Heat 15
3 Dr. Drayton Doherty and Miss Cootsie 20
4 All Some Patients Need Is Listening and Talking 27
5 Diagnoses Without Diseases 33
6 The Woman Who Believed She Was a Man 40
7 Mind and Body 49
8 Sweet Thing 55
9 New Clinical Interventions 61
10 Florence's Symptoms 66
11 Symptoms without Disease 81
12 Looking Back on Fairhope 95
13 The Diarrhea of Agnes 102
14 Dr. Jim's Breasts 108
15 The Woman Who Would Not Talk 114
Meador pages.indd 5
16 The Woman Who Could Not Tell
Her Husband Anything 124
17 Staying out of God's Way 133
18 A Paradoxical Approach 142
19 You Can't Be Everybody's Doctor 150
20 In Tune with the Patient 155
Bibliography 165
Index 169

Editorial Reviews

. . . it is rare to find an articulate, analytic account of experience, and even rarer to see how it happened. Unlike a magician, Meador not only shows the empty hat but also where the rabbit was hidden. . . Meador taught himself to eschew mind-body dualism and to expand the range of communication between physicians and patients that can illuminate the meanings of symptoms. For these reasons, I recommend Meador's Medical Odyssey to family physicians who may be fellow travelers.
—Family Medicine

Clifton Meador is undoubtedly a gifted clinician but his greater gift is his uncanny ability to capture and define the problems in medicine for which there are no easy labels and no easy cures. Meador's thoughtful, anecdotal style allows every reader entry into that most complex of subjects: body and mind in health and disease.
—Abraham Verghese, author of My Own Country and The Tennis Partner

We owe Dr. Clifton Meador . . . a debt of gratitude for teaching us techniques to more effectively listen to the stories our patients want to tell.
—Journal of the American Medical Association

From the Publisher

4 Stars! from Doody

Reviewer: Sally Ling, M.D.;FACP(University of Missouri-Kansas City School of Medicine)
Description: In this beautiful book, the author, an experienced internist and endocrinologist, shares the stories of his patients who had challenging symptoms or problems that could not be resolved when they were treated according to the prevailing biomedical model of disease. The author shares his gifts as a physician in a way from which we can all abundantly learn.
Purpose: The book artfully illustrates that for many patients that we encounter, an expanded model of disease is necessary to understand, enlist, and direct them to uncover the causes of symptoms which henceforth could not be explained by the narrower biomedical model. To be able to help a patient decipher or demystify a complex situation, usually at the same time simplifying the patient's medical regimen, can only be a worthy goal.
Audience: Physicians already in practice are likely to most appreciate the complexity and depth of the scenarios described. Dr Meador's writing is powerfully provocative in spite of his humble voice. This book should be read by all physicians.
Features: The author describes several patients that were in his care over his 50-year career. Each patient's story illustrates fascinating circumstances and Dr. Meador brings us into his doctor-patient relationships to understand and appreciate how he navigated the course.
Assessment: This book is a gem. It should be read by all physicians.

Doody's Review Service