A set of connected medical mysteries

January 15, 2022 12:48 PM

"A View from the Bridge" by Matthew O. Dumont, MD is an excerpt from his 1994 memoir Treating the Poor: A Personal Sojourn Through the Rise and Fall of Community Health. Blogger siderea recommends it as "a medical mystery – a psychiatric medical mystery – that goes in a very unexpected and illuminating direction" and recommends: "This is worth reading unspoiled."

EVERYONE IN MEDICINE LIKES A CLASSIC CASE, A PATIENT WHO CUTS through the dross of biological variability and presents a textbook picture of "a disease." This assures us of comforting categories with neat boundaries, as opposed to the nebulous states of dis-ease, generalities whose manifestations are diffuse if not arbitrary....

Psychiatry, despite the pretenses of a diagnostic system organized to the hundredth of a decimal place, deals after all with human behavior, with all its ideological, cultural, and linguistic ambiguity about what is crazy and what is not. So there was something reassuring about seeing a classic case of what we used to call "involutional melancholia," a mid-life sinkhole draining away one's energy.....

In siderea's followup she asks followup questions about implications for psychiatric practice.

Previously on MetaFilter: "The Most Important Scientist You’ve Never Heard Of".

Jeremy Chrysler's The Air Letter covers "The NASCAR Exception" and social costs.

posted by brainwane (10 comments total)

One guy working toward a remedy with thousands of allies:
https://smartmuseum.uchicago.edu/blog/chicago-fundred-initiative-a-bill-for-il/
posted by homerica at 2:25 PM on January 15, 2022

This was a well written and sobering piece. Thank you for posting it with the caveat that it’s better to go in without knowing anything beforehand.

About 25 years ago I was assigned feminist geographer Joni Seager’s book Earth Follies for a course about gender and the environment. Both the book and the course were surprisingly intersectional for the time, noting the relationship between the brutal oppression by the military industrial complex of marginalized groups in general: those disadvantaged by gender, race, class, geography. It has stuck with me all these years and this piece could have been included in it.
posted by hurdy gurdy girl at 2:32 PM on January 15, 2022 [3 favorites]

The autism clinic I previously worked at asked every family who came in if their child had been tested for lead poisoning, because we know how significantly that can contribute to the sort of developmental delays that we see. I've never been at another clinic or hospital--as clinician or patient--that asked that. At my current practice I routinely ask about a number of physical contributors to mental health. When discussing with other clinicians, I bring these things up, and they don't have answers because they haven't asked.

At another clinic, I had a child client presenting with what appeared to be severe ADHD that had not responded to medication or therapy. In passing during the interview, the mother mentioned that the child bruised easily, which prompted me to ask if they had a thyroid condition. No, but it did run in the family. On further exploration a whole number of other red flags came up. This family had extremely limited time and energy for medical appointments, and they decided to focus on thyroid testing/treatment over therapy, which I totally supported. I haven't seen them again and can only hope the child got what they needed. It's something I ask about now, along with lead, migraines, caffeine intake, vision problems, and a host of others.
posted by brook horse at 3:56 PM on January 15, 2022 [7 favorites]

Well damn. I should get a blood test.
posted by jellywerker at 3:58 PM on January 15, 2022 [1 favorite]

From Caligula To Nero: There Might Be A Scientific Explanation For Their Eccentricities – Plumbism (or saturnism in Latin) was the name given to lead poisoning and the reason why most Roman Emperors had erratic behaviors., María Isabel Carrasco Cara Chards, Cultura Colectiva, September 10, 2018:

…Historians have come up with various theories to explain this matter of the emperors' peculiar personalities. For instance, some historians attribute the tragic episodes in Caligula’s life to his “madness,” others have claimed that he suffered from acute epileptic attacks, while others claim he had various mental afflictions, never giving any convincing evidence to support their theories, just anecdotes of his behavior. The same thing happens with Nero and many other of these “cursed” emperors. In Caligula's case, we could say that traumatic events can definitely lead to erratic behaviors. However, there’s one theory that actually fits even better with their stories, and that could explain why so many emperors during this period had these tendencies.
…
Throughout his career, Dr. Jerome O. Nriagu [Wikipedia], devoted his life to studying the lives of Roman emperors from 30 BC to 220 AD. According to him, there was an everyday habit in at least two-thirds of the emperors of this period: they ate lead-tainted diets that most probably resulted in lead poisoning. The lead was basically in everything these emperors consumed, starting with the containers where their meals were cooked and the vases where their water and wine were served. But then, why wasn't the whole of Rome affected by this too?

According to the theory, it’s probable that the vast majority of the population consumed important amounts of lead compared to what we do nowadays. However, the key here is wealth. Emperors were the only ones with access to these luxurious vases and containers, and for that reason, their intake of lead was dramatically superior to any other Roman citizen….

More in the article.
posted by cenoxo at 6:19 AM on January 16, 2022 [1 favorite]

I can't thank you enough for this.

All of these issues that require tons of money, intelligence, and will to ameliorate. At best, they get this kind of intelligence, but we keep the money and political will locked up in a room with things like private schools and chemistry camp.

Massachusetts, goddamn.
posted by allthinky at 6:24 AM on January 16, 2022

Thank you for posting this! I'd never heard of Dr. Dumont before, but I've ordered a copy of the book. I'm teaching a module for health professional students on whistleblowers in medicine; this will be a nice adjunct to Mona Hanna Attisha's What the Eyes Don't See.

What strikes me most about this story is not so much the medical details, but the fact that this guy had enough spidey-sense to go digging (sorry) when the patient was not responding to conventional treatment. It would have been so easy to just write her off as "treatment-refractory." Which she was, but not for the reasons you'd think.

Following that spidey-sense sometimes leads to the most unexpected places. The most famous example, to me, is NMDA receptor encephalitis (aka "brain on fire" after the book by Susannah Calahan). I was in medical school when it was first described. All these people -- mostly young women -- who had been institutionalized for refractory schizophrenia, now found to have a treatable* illness. At one point in my residency, we had 3 NMDA encephalitis patients on our unit at the same time, all with different cancers, all manifesting with different symptoms, all responding in some way to Rx.

I'm heavily involved in both medical student and resident education at my university, and having/maintaining that spidey-sense, even when you are exhausted and overworked, is what separates the wheat from the chaff when it comes to med ed. Unfortunately there isn't a metric or milestone for spidey-sense the way there is for efficiency and throughput. This is sort of why House became such a popular show** -- people WANT this level of detail and attention and curiosity from their docs, and that's just not possible in the era of 15-minute appointments. (Dr. Dumont sort of alludes to this in the posted excerpt that this was "before managed care" -- from what I can see of his other writings online, I can guess he'd be appalled at our current model of "charge 'em as much as you can for doing as little as possible"). I guess you get it with concierge/executive medicine? Which has always struck me as fundamentally inappropriate.

* as with many brain diseases, treated doesn't always mean cured, but able to return to independent/semi-independent life in the community instead of an institution? Sure.

** OK, not popular among doctors, but that's because it's ludicrous to imagine a hospital employing several physicians to take care of one patient. Let's face it, we were all jealous that House didn't have an RVU target to meet. Maybe that explains why this hospital literally had no radiologists/techs or phlebotomists or any other staff; they were spending their entire budget on Hugh Laurie's American accent.
posted by basalganglia at 6:42 AM on January 16, 2022 [4 favorites]

Good stuff, brainwane, tnx! No discussion of environmental lead toxicity is complete without a hat-tip to Alice Hamilton, the shoe-leather epidemiologist who was the first female faculty at Harvard.
posted by BobTheScientist at 8:37 AM on January 16, 2022 [1 favorite]

I read Dr. Dumont’s book in grad school while getting my MSW in Boston, so needless to say, it literally hit close to home and was the single most influential and memorable thing I read. The whole book is excellent and deeply depressing. Brook horse, I’ve never thought to ask about lead and/or asbestos exposure in my intake/assessment questions with therapy clients and love that suggestion - would love to include this in my practice with your blessing. Thank you!
posted by sleepingwithcats at 8:36 AM on January 17, 2022

Please do, I hope more clinics start doing these basic screenings! I haven't had anything noteworthy come of it yet, but I think just having that as a question makes me more mindful of considering the diverse factors that may be at play.
posted by brook horse at 10:32 AM on January 17, 2022 [1 favorite]