"Mabe's disease"

Southern Quarterly, Summer 2003 by Klemmer, Philip Sr, Klemmer, Philip Jr

EACH YEAR I SURVEY MY NEW RESIDENTS to find out why they chose a career in medicine. Indeed, this same question is likely to haunt them during many a late and lonely night on-call, so I figure that they better come to terms with such existential musings. The answers are consistent and predictable. Most young doctors invoke a desire to help others. Of course, my residents tell me what they're supposed to tell me-it's a line that was around long before my days as a medical student, a belief that has almost survived this current age of cynicism.

Most doctors are good people. I have no scandal or intrigue to report from within the hallowed halls of healing. I do believe, however, that none of us may found his hopes for a happy and enlightening career solely on his ability to help others. As long as there are diseases beyond our power and biological mysteries beyond our understanding, a doctor must seek further fulfillment.

During the summer of 1977 I had just come on junior faculty at the University School of Medicine. The emergency room resident had asked me to evaluate a new patient's kidney dysfunction and hypertension. I found Miss Mabe behind the curtain in examining room #10. I didn't need to review her chart, however, to ascertain the true reason for Miss Mabe's emergency room visit. The young woman's face was locked in a mask of chronic pain and despair, its psychological twin. Bodily pain occurs for a reason; it's an alarm that notifies our brain of somatic malfunction, invasion, or external harm. Where did she hurt? Everywhere-arms, legs, hips, hands, back, feet-tone pain.

I leafed through the ream of records that I inherited from her family doctor. Miss Mabe had been ill for over a year when she quit searching for answers and relief at a Buncombe County hospital where she worked as an obstetrical nurse. Her file included a series of x-rays. Surely these would illuminate Miss Mabe's mysterious malady and the cause of her pain. Yet her bones looked perfect-well mineralized, as solid as Doric columns. Likewise, her pelvis and vertebrae were free of any abnormality. Whatever disease had afflicted these bones had left no fingerprints at the scene of the crime.

My boss and mentor Dr. McKnitt had practiced medicine before the age of CAT scans, MRIs, and anemia-inducing blood-work. His credo: when searching for a diagnosis, a doctor must first obtain a thorough personal history and perform a careful physical examination. The difference between McKnitt's method and the modern reliance on complicated (and expensive) testing is like the difference between fishing with a hook and fishing with a net. With one you catch a single fish while with the other you risk dredging up the entire ocean floor. I'm no technophobe; in fact, I have welcomed new instruments and laboratory tests into my diagnostic arsenal. My learning curve with gadgets, however, remains hopelessly flat. Last year one of my renal fellows, Jay, gave me his old Palm Pilot that is either broken or very difficult to turn on. I finally exchanged it for a "pad-pilot," a small notebook disguised as a PDA (this way, I can still blend in with the younger crowd during rounds).

When I first arrived at the University in '72 with an invading horde of Yankee medical school graduates, we were given a crash-course in local culture and dialect. I received a small, blue "North Carolina Medical Dictionary" that included such conditions as "Fireballs of the Eucharist" (fibroids of the uterus), "Smiling Mighty Jesus" (spinal meningitis), and "Roaches of the Liver" (cirrhosis). Since I never heard any of these terms actually used, I suspect someone was just trying to haze us northerners. I did, however, hear country folk refer to a small swelling as a "risin'" and a larger one as a "pone" (these are both are baking terms, I believe). I also discovered that North Carolinians are some of the best people around. Dr. McKnitt's understated brilliance, his quiet understanding befit the state whose motto is "esse quam videri" (to be rather than to seem).

Back to 1977: heeding my mentor's advice, I dug for more history from the patient. Miss Mabe did not take medications, she did not smoke, nor did she drink. I didn't actually inquire about the booze, but like a good, southern lady, she responded to my tobacco question with an unsolicited answer about alcohol, assuming that I was searching for sinful behavior rather than a medical diagnosis.

I admitted Miss Mabe to the hospital, figuring that observation might provide some clue as to the nature of her illness. She experienced no fever or weight loss, symptoms that might have portended malignancy or infection. Her thyroid gland was enlarged and blood testing confirmed thyroid hormone deficiency-hypothyroidism. Her fingers were painful and swollen, not at joints, but rather along the shafts of her bones, while her blood pressure remained high and her kidney function sputtered along at 50% of normal. Typically, defining the relationship between blood pressure and kidney function poses a "chicken-and-egg" conundrum. The loss of kidney function could easily result in hypertension, just as high blood pressure may damage the kidney. Causality is key, in medicine as in physics.