It is impossible for a man to learn what he thinks he already knows. –Epictetus.
The human perception of smell, though much less acute than in most animals, can awaken memory as faithfully as any other sense. Today a faint odor took me back to the 60’s; to an old style small group ‘General Practice’ in a quiet agricultural town of about 15,000 souls; to a time when there was a very practical distinction between private and public medical care; when most physicians offered both free or low cost care in a county hospital, and full pay care in a private facility; a time relatively free from over-regulation and over legislation, and over litigation, when old time physician specialists and generalists cooperated easily to share the load; maybe that was in part because fees were so very low compared to todays’s levels, even when inflation is taken into account. In 1968 we debated long and hard before raising our all inclusive charge for prenatal care from $75 to $90. Our patients came from a broad range of socioeconomic circumstances, so that we often had to discusse with them the various optional costs of diagnosis and treatment . Our book-keeper negotiated and renegotiated terms for payment and wrote off accounts when the situation seemed hopeless, or it became more costly to continue billing than to forget a debt;we never turned over an account for ‘collection’ except in cases of clear abuse. We worked hard, treated many daytime emergencies in the office, went to the hospital ED for serious problems day and night. We provided 24/7 /365 care, were open Saturday morning, made house-calls, operated a full lab and Xray, did minor surgicenter type procedures in a one room surgical suite, with two beds for recovery, and for acutely ill patients who had to be treated or observed during the day. to avoid ER charges. Yet we lived comfortably, and were an integral part of our community.
Our office was constructed in the form of an H, housing four physician suites, with all shared facilities centrally. The larger, open windowed entrance waiting area , adjacent to records, served for intake and the front two office suites; a second waiting area served the the other two office suites, one being mine; it was cheery and bright but windowless and rather small, with a big fish tank and a lighted outdoor scene.
The smell was first apparent in this secondary waiting area. It was unmistakable, and flooded out and down the hallway; nurses alertly asked reception to retain newly arrived patients in the main waiting room until called, or very hurriedly placed them in treatment rooms. The problem was an eye watering acrid odor. It was not merely a semi-sensual French sort of fermone laden body scent, but and overwhelming stench, sufficient to physically or psychologically overwhelm the average patient’s senses within 30 seconds.
Being charitably prepared by my nurse, and my own nose. I introduced myself took the history, examined the patient, and outlined a plan for treatment of her sore throat. There was a not only a risk the patient would, or should, return some day, but the evident need to address a problem that had nothing to do with the chief complaint- as it would be to address an obvious melanoma of the hand. I simply had to pursue it.
“Please forgive me for asking; has anyone mentioned something to you about your body odor?” To my great relief, the patient seemed not at all offended. Without hesitation or offense, she responded:
“Yes. We all have it. It’s hereditary.
“Perhaps; even so, there is something that can be done. Otherwise it may affect you socially or in employment.”
” It has. It does.My whole family.” I had never heard if such a disorder, but imagined it was remotely possible if it were genetically dominant with 100 % expression.
“Does bathing help for a while, or deodorant or anti perspirant?”
“Nope. Been there done that. No help. Take a bath, it don’t help.”
“Do you mind if I examine you? I’ll ask the nurse to get a gown if it’s OK.”
“Other docs have checked it; but i suppose.” A brief exam was entirely unremarkable except for one thing: The patient’s bra and panties were blackened, and terribly soiled.
“When did you wash or change your underclothes?”
“I don’t know. They are still good.”
“When will you change?”
“When they wear out.” Bingo!
So I carefully explained that body odor is almost all due to bacteria that immediately grow again even right after a bath if there is no change of underwear. She was obviously doubtful, but agreed to try to change her habits. Curious, I asked her to call me to let me know the result. Within the week, she did. She was greatly surprised, saying her problem was very very much better, and thanked me profusely. I saw her again three weeks later for a UTI. She was pungent but inoffensive; either she was much better or I was olfactory -shocked, desensitized! So I carefully reviewed the facts again, asking her to be certain to both bathe and wash her underclothes at least every other day, and to use anti-perspirant or deodorant.
However I never saw her again. So after few months I pulled up her chart to call. There I found a ‘release of information request’ from a colleague; apparently my ex-patient had changed care to another physician.
One of the beauties of a small town, at least before the Age of Legislative /Regulatory Terrorism, was that physicians could speak freely at least to one another. So i asked my colleague about my former patient. Indeed, the doctor and his entire office staff were well aware of a patient with what they called Malignant Hereditary Body Odor Syndrome. But our conversation was interrupted at that point; I didn’t confess my expertise with the syndrome. I wondered if they had read the forwarded record; but on considering further, decided not to even risk the return of my patient ; or risk becoming vaguely known for this condition, or becoming involved with a new reg or law on Underwear, even if there would surely be some big bucks in it from the Underwear Manufacturers Association. Some things are best left to fate.