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September 11, 2001 (REVISED)
Medical Misdiagnoses and Their Consequences
Harold E Buttram, MD
Introduction:
As a matter of personal opinion and observation, there is at
present a dichotomy of almost schizophrenic proportions between
ongoing American scientific research in the medical field, most
of which takes place in academic institutions and medical
centers, and the genuine needs of the American public.
The scope and direction of this research, most of which is
funded by the National Institute of Health (NIH), is of
tremendous importance in that it forms a source of guidelines
and a scientific foundation for the clinical practice of
medicine. In other words, the clinical practice of medicine as
it exists today has been largely shaped by decisions made in the
NIH and other government health agencies in the granting of
research money. This is a system which has existed since the
1930s, but there may be serious misdirections which are proving
to be very costly in terms of the health and welfare of the
American public, especially as applies to its children.
There are two medical conditions from which it is predictable
that American society and economy will be strained to the
breaking points in coming years by overwhelming numbers of
medical indigents unless these conditions are addressed
effectively and decisively in the very near future. The two
conditions to which I refer are childhood autism and
environmental illness with chemical sensitivity, neither of
which are being recognized for their true nature by mainstream
medicine because of a misdirection of research funding in
certain key areas, as will be reviewed in the following:
Childhood Autism, Predominantly an Environmental Illness
In regards to childhood autism, a condition characterized by
severe mental regression, fifty or so years ago autism was so
rare that many pediatricians had never heard about it. At least
this was the experience of Dr. Bernard Rimland, founding
director of Autism Research Institute. In 1956 Dr. Rimland,
whose Ph.D. is in research psychology, had a son who was later
found to be autistic. In his annual DAN (Defeat Autism Now)
conferences Dr. Rimland is fond of telling the story about the
early days with his son during which he had great difficulty in
finding a pediatrician who knew anything about or who had ever
seen a case of autism. How different it is now. Childhood autism
has become so prevalent that there are very few who do not know
of a family with an autistic child. Families with two autistic
children are not uncommon, and I personally have seen a family
in which all three of the family's children were autistic.
Latest statistics estimate that over one half million American
children are autistic, (1) and with numbers steadily growing,
there is no end in sight. It can be expected that treatments
will improve the outlook of these children, but as far as is
known at present, many or most of these will require custodial
care for life, at an average cost to society as much as three
million dollars per child. (2)
In the opinion of this observer, the misdiagnoses in
childhood autism come not in the diagnosis of the condition
itself, something that is unmistakable once one has seen a few
children with the condition, but from a failure to recognize
autism as predominantly an environmental illness. (In this
instance the term, "environmental illness," is used to
include illnesses brought about by exposures to commercial
chemicals and medical interventions as well infectious
microorganisms and other exposures from the natural
environment). This statement is based on a recent seminar on
childhood autism held in the Washington D.C. area as sponsored
by the National Institute of Health and other health agencies
September 6th and 7th, 2001, at which the largest portion of the
meeting was devoted to areas of genetics and neuropathology of
autism. (3)
As related to childhood autism, it should be stressed that
the field of genetics involves a susceptibility to autism but,
except in rare instances, has nothing to do with its causes. The
same could be said about virtually all epidemic-type diseases,
in which there will be variability in genetic susceptibility. By
their very nature, epidemics always arise from environmental
sources of one type or another and not from genetic causes.
Genetic changes take place very slowly in an evolutionary scale
over a period of millennia and never with the rapid increases as
seen today with autism.
Major areas now under suspicion as being causally related to
childhood autism include childhood immunizations, (4) toxic
environmental chemicals, (5) commercial food processing, (6) and
the overuse of antibiotics. (7) The only possible way of
salvaging the situation is to find and modify the causes while
at the same time doing the very best we can to develop effective
treatments for those already afflicted with this condition.
Childhood Immunizations - Deficiencies in Basic Science and
Safety Guidelines
As reflected in a series of U.S. Congressional Hearings
concerning issues of vaccine safety which have taken place
annually since 1999, (4) there is now growing awareness of major
deficiencies in safety testing for current childhood
immunizations. A few examples will be given here:
(a) Safety studies on vaccinations are limited to short time
periods only: several days to several weeks. There are no (none)
long-term (months or years) safety studies on any vaccination or
immunization. (b) In 1994 a special committee of the National
Academy of Sciences (Institute of Medicine) published a
comprehensive review of the safety of the hepatitis B vaccine.
When the committee, which carries the responsibility for
determining the safety of vaccines by Congressional mandate,
investigated five possible and plausible adverse effects, they
were unable to come to conclusion for four of them because they
found that relevant safety research had not been done.
Furthermore, they found that serious "gaps and
limitations" exist in both the knowledge and infrastructure
needed to study vaccine adverse events. Among the 76 types of
vaccine adverse events reviewed by the IOM, the basic scientific
evidence was inadequate to assess definitive vaccine causality
for 50 (66%). The IOM also noted that "if research.(is) not
improved, future reviews of vaccine safety will be similarly
handicapped. (8) (c) In an article published in Adverse Drug
Reaction & Toxicology Review, (9) researchers Andrew
Wakefield and Scott Montgomery, who have been investigating a
possible causal relationship between the MMR vaccine
(measles-mumps-rubella) and the autism enterocolitis syndrome,
carefully reviewed inadequacies of the early pre-licensing
trials of the MMR vaccine with a maximum follow up of 28 days
and even shorter periods in some of the studies. They stressed
that such short periods of observation following the vaccine
were totally inadequate to detect delayed reactions, including
pervasive developmental delay (autism), immune deficiencies, and
inflammatory bowel disease, which are known from earlier
published reports to occur following both the natural measles
infection and the measles vaccine.
The most interesting feature of the Wakefield/Montgomery
article was that it was reviewed by four leading British
authorities, all of whom had previously held positions in the
regulation and licensing of medicines in the United Kingdom.
(10) Taken as a whole, the reviewers were supportive of the
article, three highly so. Peter Fletcher, formerly a senior
professional medical officer for the Department of Health wrote,
"being extremely generous, evidence on safety (of the MMR
vaccine) was very thin." Noting that single vaccines for
measles, mumps, and rubella already existed, he argued,
"caution should have ruled the day.the granting of a
product license was definitely premature." Professor Duncan
Vere, former member of the Committee on the Safety of Medicines,
agreed that the periods for tests were too short. "In
almost every case," he wrote, "observation periods
were too short to include the onset of delayed neurological or
other adverse events."
(d) In 1984 an intriguing study was reported in a little
noted letter-to-the-editor in the New England Journal of
Medicine in which a significant though temporary drop in
T-helper lymphocytes was found in 11 healthy adults following
routine tetanus booster immunizations. (11) Special concern
rests in the fact that, in 4 of the subjects, the T-helper
lymphocytes fell to levels seen in active AIDS patients. If this
was the result of a single vaccine in healthy adults, it is
sobering to think of the possible consequences of multiple
vaccines (19 within the first 6 or so months of life at latest
count) given to infants with their immature and vulnerable
immune systems. Unfortunately, other than clinical observation,
we can only speculate at these consequences, as the test has
never been repeated.
Environmental Illness - Deficiencies in Basic Science and
Safety Measures
In my opinion, the second area of misdiagnosis is the common
approach of mainstream medicine in dealing with environmental
illness and its related condition of multiple chemical
sensitivity (MCS). In contrast to the American Medical
Association, which denies the existence of MCS as a valid
diagnosis, there is a group of physicians in the field of
environmental medicine who believe that millions of Americans
are being made ill and sensitized in various degrees to toxic
airborne chemicals from a class of chemicals known as volatile
organic compounds (VOCs). (12) Illnesses brought about by
breathing these chemicals inside buildings are referred to as
"The Sick Building Syndrome." A number of official
government and health agency publications have been issued on
this subject. (13-18) However, the major thrust of most of these
publications is to stress how little we actually know about the
effects of these chemicals and emphasize the over-riding need
for further safety research in this area. As pointed out in the
text, Multiple Chemical Sensitivity, (National Research Counsel,
1989), "about 70,000 chemicals are used in commerce, of
which several hundred are known to be neurotoxic. However,
except for pharmaceuticals, only 10% have had any testing at all
for neurotoxicity, and only a handful of these have been
evaluated thoroughly." (19)
Since the publication of Multiple Chemical Sensitivity, the
situation has changed in one respect: There is now a substantial
body of literature dealing with occupational exposures to
solvent-type chemicals or VOCs, prominent among which are
publications by Lisa Morrow and coworkers at the University of
Pittsburgh, several of which are sited here. (20-23)
For the issue of multiple chemical sensitivity, on the other
hand, it is far different. Once again we are faced with major
deficiencies in safety-oriented studies on the effects of
potentially toxic environmental chemicals on the human system
and of safety measures that would have followed, had these
studies been done. Basic science in this area, at very best, has
been fragmentary. For this reason and this reason alone,
evidence for support of the diagnosis of MCS has not yet reached
standards of scientific proof. However, the fact that adequate
research has not yet been done to prove its existence, it does
not follow that MCS has been disproved or that it does not
exist. Yet, this is the practical conclusion one generally finds
in mainstream medicine.
Based on my own experiences in many workman's compensation
cases involving airborne chemical exposures, the near universal
response of mainstream medicine has been to deny its existence.
As a result, many patients with more advanced forms of
chemical sensitivity are becoming like the lepers of ancient
times, disabled outcasts of society, and their numbers are
growing larger by the day. (24)
However, we are not entirely barren in this area. Though
small in number and preliminary in nature, there are a number of
publications tending to confirm a widespread presence of MCS in
our population, publications which can form a nucleus for
further study. A few of these are enumerated below:
(a) Two publications involving studies with SPECT brain scans
have shown impairments in brain functions resulting from
chemical exposures. (20,25)
(b) In a recent study of a group of veterans with the Persian
Gulf War Illness, an activated coagulation system was found with
platelet activation and fibrin deposits on the endothelial
surfaces of blood vessels, which resulted in a constriction of
blood flow. The authors concluded that heavy exposures to toxic
chemicals during the Gulf War in all probability were the
underlying cause of the pro-coagulant state, although other
possible causes were also mentioned in the article. (26)
(c) Studies of patients with chronic fatigue and fibromyalgia
at the Electron Microscopy Unit at the Adelaide Institute of
Medical and Veterinary Science, Australia demonstrated
deformities in the red blood cells (RBCs) of these patients
described as dimpled spherocytes (rather than the normal oval
shapes of RBCs) along with increased rigidity of the RBC
membranes, these changes resulting in reduced flow of the RBCs
as a result of their deformities. The article went on to point
out that a great majority of these patients had been exposed to
environmental chemicals, some working in chemical factories,
others in wheat fields or orchards subject to periodic
pesticide/herbicide sprayings, many patients noting
deterioration following these exposures. (27)
(d) In an article by P Beaune and coworkers, the term
"suicide inactivation" was used to describe the
mechanism whereby foreign toxic chemicals may damage and cripple
the enzyme systems necessary for detoxification and elimination
of toxic chemicals. (28) This now thought or suspected of being
a major factor in the pathogenesis of MCS.
(e) Among those working in the field of environmental
medicine, (12) The Environmental Health Center in Dallas, Texas
has always been considered a major center of research in this
field. Authored by William J. Rea, M.D., much of the work of
this center has been recorded in a four-volume set of books with
the simple title, Chemical Sensitivity. (29) Many of those
familiar with this center believe it will in time be accredited
with being one of the earliest centers to fully recognize the
increasing impact of foreign chemicals on human health and to do
meaningful, systematic study in this area.
With reports such as these now in the scientific literature,
further documentation and confirmation of environmental illness
and MCS as valid diagnoses cannot be long in following, along
with a more realistic appraisal of their prevalence.
Finally, no treatment of environmental illness would be
complete without mention of possible ongoing damage being done
to the reproductive systems of both men and women when exposed
to toxic airborne chemicals during their reproductive years,
(30) or of fetal damage when women work in such conditions
during their pregnancies. (5) Although as yet largely
theoretical, sooner or later these are issues which must be
addressed.
Conclusions:
In the late 1800s and early 1900s there was a time now
referred to as the golden age of medical diagnosis. Those were
the times of Sir William Osler of Johns Hopkins University,
remembered as the father of internal medicine, and of other
stellar names of the times. In those days doctors took time to
listen to their patients, and equally important, took very
seriously the information given by the patient. It was a time of
clinical observation, when doctors believed what their eyes told
them and deduced diagnoses based on these observations. It is no
small coincidence that the mythical master of observation and
deduction, Sherlock Holmes, the creation of Sir A Conan Doyle,
was based on a physician that Doyle had known in his student
days.
How does this compare with today? Based on personal
experience, very few doctors listen to parents of autistic
children, or if they listen to them, very few believe what they
are told by the parents. (31) This is even truer for patients
with environmental illness who, in a majority of cases in my
experience, are commonly referred to psychiatrists or
psychologists by their physicians, their physicians telling them
that their symptoms are psychosomatic or imagined.
However, in defense of doctors directly involved in care of
the public, it is doubtful that there has ever been a time with
greater demands on their time combined with greater
economic/political pressures intervening in the care of their
patients than at present. Most of them are doing the best they
can under the circumstances.
I take great pride in being a medical doctor. I would not
change places with anyone in the world. But I also fear for the
future of my profession. Whether in the realm of nature or human
affairs, all things must remain relevant to survive. In the
natural world all life forms must adjust to their environment or
perish. In the healing professions, these professions must both
recognize and address the genuine needs of the public or stand
in danger of passing into the limbo of forgotten things.
Actually I believe the medical profession will survive, but to
do so will require a higher level of vision with issues
surrounding childhood autism and environmental illness than has
been the norm until now.
For practicing physicians to recognize the nature of their
patients' problems and treat them properly, the physicians must
be provided with valid science by those engaged in research,
science realistically directed at the genuine health needs of
the public.
References:
(1) On April 25, 2001 James J
Bradstreet, M.D., F.A.A.F.P gave testimony before the U.S. House
of Representatives, Committee on Government Reform recalling his
own experiences with an autistic son as well as providing a
broad review of issues surrounding childhood autism. In a
written supplement to the oral presentation, which can be
accessed on the website: http://www.gnd.org/Testimony/Congressional.htm,
Dr. Bradstreet provided current statistics on autism, pages 3-7.
(2) Ibid
(3) NIH/ACC 2001 Conference:
Potential Cellular and Molecular mechanisms in autism and
Related disorders Sponsored by NICHD and NIEHS, Co-Sponsored by
NIMH, NINDS, and NIDCD, September 6-7, 2001, Bethesda, Maryland.
(Having personally had the privilege of attending the meeting,
there were very excellent presentations having to do with neuro-anatomical
findings as well as genetics of autism, areas constituting basic
science for the field. A portion of the meeting was also devoted
to the possible roles of pesticides and other neurotoxicants in
causing autism, but even these were of an academic nature.
Clinical studies of potential value in either the prevention or
treatment of autism were notable by their absence.)
(4) Annual hearings
specifically dealing with questions about vaccine safety have
been taking place in the U.S, House of Representatives since
1999. This is only one of many indications of growing public and
professional concern on this issue.
(5) Edelson SB & DS Cantor,
Autism: xenobiotic influences, Toxicology and Industrial Health,
1998; 14(4):553-563. (This study, which appears to be the first
of its kind, points out that the breathing of toxic,
chemical-laden air in sick buildings by women during their
pregnancies may be a contributing cause of brain damage to the
fetus and a common factor in the rising incidence of childhood
autism).
(6) Among the many works
dealing with the adverse health consequences of "fast
foods," which form an increasing pattern in the diets of
American children, two books are recommended here: Nourishing
Traditions, by Sally Fallon with Pat Connolly and Mary G Enig,
Ph.D., ProMotion Publishing, San Diego, 1995 and Special Diets
for Special Kids, by Lisa Lewis, Ph.D., Future Horizons,
Arlington, Texas, 1998.
(7) No reference is needed here
- the overuse of antibiotics in medicine and the food industry
is now universally recognized and is being taught at leading
medical centers.
(8) Stratton KR, CJ Howe and RB
Johnston, Jr., Editors, Adverse Events Associated with Childhood
Vaccines; Evidence Bearing on Causality, Institute of Medicine,
National Academy Press, Washington D.C., 1994, pp 211-236.
(9) Wakefield AJ & S
Montgomery, Measles, mumps, rubella vaccine: through a glass
darkly, Adv Drug React Toxicol Rev, January, 2001; 19(3):1-19.
(10) Hurley DR, DW Vere, A P
Fletcher, Referee 1, 2, 3, & 4, Adverse Drug React Toxicol
Rev, 2001; 19(4):1-2.
(11) Eibl M et al, Abnormal
T-lymphocyte subpopulations in healthy subjects after tetanus
booster immunization, (letter), NEJM, 1984; 310(3):198-199.
(12) American Academy of
Environmental Medicine, with headquarters at American Financial
Center, 7701 East Kellogg, Suite 625, Wichita, Kansas
67207-1705, phone (316) 684-5500, Fax (316) 684-5709.
(13) Pesticides in the Diets of
Infants and Children, National Research Counsel, National
Academy Press, Washington D.C., 1993. (Although this book deals
with foods rather than air, it provides further evidence of
concern in leading scientific circles about the potential impact
of toxic chemicals on human health).
(14) Neurotoxicity, Identifying
and Controlling Poisons of the Nervous System, Superintendent of
Documents, Government Printing Office, Washington D.C., GPO
Stock # 052-003-01184-1, April, 1990.
(15) Environmental Hazards in
Your School, A Resource Handbook, US Environmental Protection
Agency, Washington D.C., Publication # 201-2001, October, 1990.
(16) The Healthy School
Handbook, Norma L Miller, Ed.D., Editor, a National Education
Association professional Library Publication, National Education
Association, Washington D.C., 1995.
(17) Multiple Chemical
Sensitivities at Work, Produced by The Labor Institute, NYC, 853
Broadway, Room 2014, New York, NY 10003, 1993 (funded by a grant
from the New York State Department of labor, Occupational Safety
and Health Training and Education Program).
(18) Multiple Chemical
Sensitivities, National Research Counsel, National Academy
Press, Washington D.C., 1989.
(19) Ibid, page 2.
(20) Callender TJ, L Morrow,
& K Subramanian, Evaluation of chronic neurological sequelae
after acute pesticide exposure using SPECT brain scans, J
Toxicol Environm Health, 1994; 41:275-284.
(21) Morrow LA, CM Ryan, &
M Hodgson, Cacosmia and neurobehavioral dysfunction associated
with occupational exposure to mixtures of organic solvents, Am J
Psychiatry, 1988; 145:1442-1445.
(22) Morrow LA, MJ Hodgson,
& N Robin, Assessment of attention and memory efficiency in
persons with solvent neurotoxicity, Neuropsychologia, 1992;
30(10):911-922.
(23) Morrow LA, CM Ryan, MJ
Hodgson, & N Robin, Risk factors associated with persistence
of neuropsychological deficits in persons with organic solvent
exposure, J Nervous & Mental Dis, 1991; 179:540-545.
(24) Michelle Conlin, Is your
office killing you?, Business Week, June 5, 2000, pages 114-125.
(In this article the authoress stated, "Experts predict
that the 5% to 10% of the population that is allergic to
chemicals will grow to 60% by 2020." She did not state
where she obtained these figures, but a general observation of
the American scene tends to support their validity.)
(25) Simon TR, DC Hickey, CE
Fincher et al, Single photon emission computed tomography of the
brain in patients with chemical sensitivity, Toxicol Industr
Health, 1994, 10(4/5):573-577.
(26) Hannan KL, DE Berg, W
Baumzweiger, HH Harrison et al, Activation of the coagulation
system in Gulf War Illness: a potential pathophysiologic link
with chronic fatigue syndrome - a laboratory approach to
diagnosis, Blood Coagulation and Fibrinolysis, 2000; 11:673-678.
(27) Buist RA, Chronic fatigue
and chemical overload, Intern Clin Nutrition Rev, Oct., 1988,
8(4):173-175.
(28) Beaune P et al,
Autoantibodies against cytochrome P-450; role in human disease,
Adv Pharmacol, 1994; 30:199-245. (Note: detoxification in the
body is centered around two enzyme systems. The first is the
P-450 system which, by a process of oxidization, converts the
lipid-soluble state of volatile organic compounds into a more
water soluble form, in which form they are more readily excreted
by the kidneys. There is a price to pay, in that the
water-soluble forms of VOCs may be more toxic than their parent
compounds. In health the second phase of detoxification, that of
conjugation, takes place immediately to neutralize the toxicity
in which process the toxic product is combined with various
natural substances in the body, predominantly glutathione. In
many instances in chemical sensitivity there appears to be a
relative deficiency of the conjugation enzyme activity which
results in an accumulation of the more toxic products of phase I
oxidation.
(29) Chemical Sensitivity,
Volumes I - IV, William J. Rea, M.D., Lewis Publishers, Boca
Raton, FL , Vol I, 1992, Vol II, 1994, Vol III, 1995, Vol IV,
1997.
(30) The Case for Preconception
Care of Men and Women, Margaret and Arthur Wynn, AB Academic
Publishers, PO Box 42, Bicester, Oxon, 0X6 7NW England 1991.
(31) Among the parents with
autistic children, a significant portion of these parents
believe that their children have been damaged by vaccines. A
common story in such instances is that the child was developing
normally into his or her second year, was beginning to speak a
few words, was affectionate with parents and playful with
siblings until a vaccination took place, after which the child
lost all speech and regressed into a world of its own, no longer
responding to parents or playmates.
As further evidence of such a
pattern, during October, 1999 an autism conference was held in
Cherry Hill, New Jersey sponsored by the Autism Research
Institute, referred to as a DAN conference. Over 1,000 people
were in attendance, the great majority of whom were parents of
autistic children. At one point in the meeting, when the
chairman asked those in the audience who believed that their
child's autism was caused by vaccines to stand, a large majority
of the audience rose to their feet. Reportedly there was much
the same response when the same question was asked at the DAN
conference in San Diego during October, 2000.
And yet, this writer has read
many evaluations of autistic children from major medical centers
without finding a single instance where vaccines were mentioned
or considered as a possible cause. In those instances in which
parents mentioned their suspicions about the vaccines,
apparently they were ignored.
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