Medical Misdiagnoses and Their Consequences

Harold E Buttram, MD

september 11, 2001   (REVISED)

 
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.