Symptoms of Unknown Origin

Cover

Download PDF (151.5 KB)
 

Table of Contents

Download PDF (51.3 KB)
 

Acknowledgments

Download PDF (53.5 KB)
pp. vii-viii

The following physicians reviewed earlier drafts of the book and made helpful suggestions and criticisms: Dean Steven Gabbe, Dean James Pittman, Dr. Jim Pichert, Dr. Kevin Soden, Dr. Taylor Wray, Dr. Eric Chazen, Dr. George Hansberry, Dr. John D. Thompson, Dr. Betty Ruth Speir, Dr. Kelley Avery, Dr. Eric Neilson, Dr. ...

Introduction

Download PDF (104.3 KB)
pp. ix-xv

It took me many years to come to that conclusion. I was pushed to come to that view through my experiences with patients who did not fit the narrow model. Too many exceptions forced me to find an expanded model of disease. These are the stories of those patients and my interaction with them as a physician over a fifty-year ...

Prologue

Download PDF (79.4 KB)
pp. 1-4

The double doors of the amphitheater swung open. A nurse and physician rolled a patient in a wheelchair into the bottom of the amphitheater. A white-haired fiftyish-appearing woman in a bathrobe and nightgown sat slumped to one side of the wheelchair. She was the most pitiful person I had ever seen. Her mouth was half ...

Chapter 1. An Unlikely Lesson from a Medical Desert

Download PDF (123.0 KB)
pp. 5-14

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 ...

Chapter 2. Texas Heat

Download PDF (76.5 KB)
pp. 15-19

During the winter after I arrived at the hospital at Fort Hood, I kept seeing a young soldier ambling down one of the long corridors. He slid his hand along the wall as he shuffled along aimlessly, pausing from time to time to stare out a window. He had the look of one of those zombies from a 1930s black-and-white horror movie. ...

Chapter 3. Dr. Drayton Doherty and Miss Cootsie

Download PDF (91.4 KB)
pp. 20-26

In 1961, I joined a multispecialty-practice group in Selma, Alabama, a town of about thirty thousand people. I would be the junior member of the group and the only internist and endocrinologist— the others were surgeons, general practitioners, and one obstetrician/ gynecologist. The senior partner was Dr. Drayton Doherty, ...

Chapter 4. All Some Patients Need Is Listening and Talking

Download PDF (94.2 KB)
pp. 27-32

One day Dr. Doherty said, “You know, medicine is very different now from when I came along. I see you do things that I barely understand. In my early days, we really didn’t have a whole lot to offer medically. Let me tell you a story that might help you understand what I mean." ...

Chapter 5. Diagnoses Without Diseases

Download PDF (93.3 KB)
pp. 33-39

In 1962, Dr. Doherty developed pneumonia and had to be away from his practice for several months. He asked me to take over the medical patients he had been following. The experience was an eye-opener. ...

Chapter 6. The Woman Who Believed She Was a Man

Download PDF (106.7 KB)
pp. 40-48

Despite my periodic contact with patients with multiple unexplained symptoms, most of my time was spent with patients with well-defined endocrine disorders. One such patient riveted my attention. ...

Chapter 7. Mind and Body

Download PDF (93.5 KB)
pp. 49-54

From 1968 to 1973, I served as dean of the School of Medicine at the University of Alabama in Birmingham. My odyssey had washed me onto the shore of a strange land of parents, faculty, state legislators, fiscal officers, lawyers, and federal regulators; most of them were angry about something or wanted something. By the time I ...

Chapter 8. Sweet Thing

Download PDF (81.8 KB)
pp. 55-60

One of my first patients when I returned to Vanderbilt in 1973 was a teenager—“Sweet Thing,” her grandmother called her. The nickname was unintentionally ironic; the girl’s mother had died in her sleep with diabetes mellitus the year before. The exact proximate cause of death was unknown. All I ever heard was that the mother ...

Chapter 9. New Clinical Interventions

Download PDF (97.0 KB)
pp. 61-65

It became apparent to me that I needed to set some definitions around what I was doing clinically. Since returning to Vanderbilt and Saint Thomas, I had begun to see a large number of referred patients. Word got around that I was interested in seeing patients who had symptoms of disease but no objective evidence of disease. ...

Chapter 10. Florence’s Symptoms

Download PDF (158.9 KB)
pp. 66-80

Florence was a plain woman. Although she had never been in a psychiatric hospital, her hair was cut like most back-ward psychiatric patients—straight bob with bangs, as you might imagine some rushed attendant would cut it. Her hair was uncombed, tangled, and dirty. She wore a colorless smock, an oversized sweater, no ...

Chapter 11. Symptoms Without Disease

Download PDF (151.8 KB)
pp. 81-94

In 1976, I decided to analyze as a group the patients I had seen with symptoms of unknown origin. By then my belief that there is not there is no diagnosis. There is just a series of connected thoughts, actions, conflicts, and stress. The body responds with symptoms. Any misplaced diagnosis will prevent discovery of the underlying ...

Chapter 12. Looking Back on Fairhope

Download PDF (92.4 KB)
pp. 95-101

In 1981, my medical odyssey took me to Fairhope, Alabama. Each Friday, four or five clinical faculty members flew in the university airplane out into the small towns of south Alabama to give lectures, demonstrations, and consultations to practicing physicians. Late in the afternoon, after the faculty members had been picked up, each ...

Chapter 13. The Diarrhea of Agnes

Download PDF (91.5 KB)
pp. 102-107

Agnes was referred to me by a physician from the next county. I had returned to Vanderbilt and Saint Thomas from my sabbatical in Fairhope, even more determined to explore and define the problems of patients with SUO. Agnes had suffered from chronic diarrhea for nearly a year. An extensive GI workup by her referring ...

Chapter 14. Dr. Jim’s Breasts

Download PDF (93.4 KB)
pp. 108-113

There is an old dictum that the patient will tell you what is wrong with him if you listen carefully. That rule was reinforced by my experience with Dr. Jim. ...

Chapter 15. The Woman Who Would Not Talk

Download PDF (122.0 KB)
pp. 114-123

I was asked to see Adelaine because of her diabetes mellitus. When I first saw her, she was a patient on the psychiatric unit in a state of severe depression. She had talked very little since admission and was about to receive electroshock therapy. I was asked to evaluate her medically prior to the electroconvulsive treatment. Adelaine ...

Chapter 16. The Woman Who Could Not Tell Her Husband Anything

Download PDF (114.5 KB)
pp. 124-132

When I first saw Joyce in the hospital, she was in coma from diabetic ketoacidosis. The scene was familiar. The cardiac monitors were running. Paper flowcharts were all over the bed table and the end of the bed. There were scattered blood-tinged syringes and empty blood-specimen tubes mixed among them. Long strips of ...

Chapter 17. Staying Out of God’s Way

Download PDF (117.2 KB)
pp. 133-141

Marie was sixteen years old, an upcoming junior in high school. Until she got sick, she was head majorette for the marching band. She had two older brothers and a younger sister. All four had been highly successful in their school activities and academic performances. Both the mother and father were in high school ...

Chapter 18. A Paradoxical Approach

Download PDF (107.3 KB)
pp. 142-149

Ordinary and standard clinical approaches fail with some patients. In the patient I am now going to discuss—I will call her Regina— some will say that I went too far or that I should not have done what I did. ...

Chapter 19. You Can’t Be Everybody’s Doctor

Download PDF (74.6 KB)
pp. 150-154

When I first saw Veronica, I was still working closely with Dr. Harry Abram, head of liaison psychiatry at Vanderbilt. My encounter with her occurred early in my experiences with patients who had symptoms of unknown origin. I have put her story toward the end because she is an extreme example of symptoms of unknown origins. ...

Chapter 20. In Tune with the Patient

Download PDF (127.4 KB)
pp. 155-164

My journey didn’t end with my adoption of Engel’s biopsychosocial model as a clinical paradigm. I knew that I lacked the reflexes and clinical tools this broader clinical model would require. It was time for me to retool and learn to listen and to guide and coach patients. I had to undergo a “slight but significant change in my own personality,” ...

Bibliography

Download PDF (78.4 KB)
pp. 165-168

Index

Download PDF (102.4 KB)
pp. 169-175