Malignant Body Odor Syndrome

"It is impossible for a man to learn what he thinks he already knows." Epictetus

The nose knows what the mind may not, and brought to my mind today a flood of memories of times past. In the '60s our 5 physician group practice was located in a quiet agricultural town of about 15,000. Those were the days when there was a distinction between private and public medicine, so that most physicians offered free or low-cost care in a county hospital, and full-pay care in another. Each major case was discussed with the patient or family beforehand to reach an agreement on how to proceed. Office practice consisted, as today, of a broad economic mix of patients. Our bookkeeper negotiated bills ahead of time, and often arranged reduced charges, or long-term, interest-free payment agreements. Physicians, clergy, and their families were not charged. As a result of writing off losses before they occurred, our overhead was reduced and collections were always nearly 100%.

When the patients were responsible to pay bills directly, they were careful to avoid excess; and perhaps doctors and hospitals were constrained for the same reason. Fees in such a situation were relatively low. Full pay OB care from diagnosis to six weeks post partum cost $90 including prenatal lab and PAP smear. Normal vaginal delivery was $75, appendectomy $125, cholecystectomy, C section, or hysterectomy $350. The problem was too much work, rather than too little; specialists and generalists worked together with few "turf" battles. As a "general practitioner" with training in surgery, I took my turn as first on-call surgeon; if I encountered an unexpected problem beyond my capabilities, even during an operation, a surgeon who by prior agreement worked as backup for me would be called in to assume care of the case. Those too were the days (and nights) of house calls. Physicians generally managed new or ongoing patient illness 24 hours a day, whether in the office or the hospital. About one weekday and every fifth weekend we were on call for 24 hours for our group. Our own office technology was limited to X Rays, and IVPs re-read by a local radiologist, CBCs, Chemistries, and cultures. We had a two bed observation unit as well as a small surgery for procedures like vasectomy, fracture work, myringotomies, or (gasp) tonsillectomies. It isn't that our practice was perfect but it was very different from today. Ironically, our old office practice model might now seem attractive to managed care people and "gate keepers."

Our office was constructed in the form of an H, with an office suite in each arm; each suite consisted of three exam rooms and a physicians' office. One of our five physician partners was always elsewhere or on vacation. Each pair of office suites was served by a nursing station and an adjacent waiting area. The central core of the "H" contained lab, X-ray, a two-bed observation unit, surgi-center, records, billing and secretarial space. While the main entrance and waiting room was at the front with reception, the smaller interior waiting area serving the back two medical suites and the lab. This waiting area was meant to hold only 6 or 7 people; we tried to avoid a train station feeling, and hated to keep people waiting. And this smaller waiting area was where my new patient's problem first became apparent, (at least to me).

The problem could be perceived from five feet away, even with one's eyes closed. It was an overwhelming body smell. Not your pungent gallic sort of semi-sensual acidic animal aroma, but an overwhelming almost palpable odor, sufficient to physiologically and psychologically overwhelm the average co-occupant of the waiting area within 30 seconds. Although it was not necessary, I was charitably warned by my nurse of the problem before entering the room. After greeting my new patient, assessing the medical problem, and outlining a plan of treatment, I felt it was mandatory to bring up my own secondary concern, which was of such proportions as to jeopardize the possibility of future office visits.

As directly but carefully as possible, I addressed the problem of Body Odor. To my relief, the patient responded without the slightest evidence of offense, but with a touch of sadness, in her voice; yes, many people had commented. It was socially limiting, and made employment difficult. Unfortunately the problem was hereditary, and affected her entire family. I quickly groped through my memory for some dominant genetic B O disorder with 100% genetic expression, and came up with nothing. Unwilling to let it go at that, I questioned her further about bathing; tried that, no help. About clothes washing; same response. Underwear too? Bingo! It was a life-long practice for my patient and family to only buy new underwear when the current set was completely worn out. As an invisible undergarment, it remained in use until new underwear was purchased. It was not washed, ever. With some relief, and elation, I explained as carefully as I could, why the smell persisted despite bathing, and why merely clean outer clothes didn't help. I was very happy to inform the patient that the problem was not hereditary and was curable.

A week or so later, I saw my patient in followup; to my great pleasure, there was very little trace of her previous difficulty. She seemed grateful to have been relieved of such a heavy lifelong burden. A month later, she returned for a recheck of her chief medical illness, a complex but unrelated condition. Although her odor had returned somewhat it was no where near the intensity I had noted at the outset. (Or was I becoming desensitized?) I carefully reviewed the steps which should be taken to prevent a full-blown recurrence. However, the following month my patient cancelled her appointment, and failed to keep a subsequent one. I never saw her again. Several months later, her name came up in my "tickler" file, and I pulled her chart, hoping to call and reassure myself that her ongoing and more important illness was not being neglected. There in her chart was a release of information, as she had changed her care to another office.

I was curious. After 7 years in a small town, I developed the need to know. ("What can I say?") Unable to restrain myself, I spoke with my ex-patient's new physician. I suppose we really were an old boys (and girls) club, but I was, after all, required by the request for release of information, to disclose to the new doctor my findings. She recalled having a new patient with Malignant Hereditary Body Odor, whose problem was already well known to her and her staff. In the old interplay between heredity and environment, between potential and reality, "heredity" , seems to have prevailed. At least in real terms, this was an incurable case, confirming Epictetus' aphorism.