A piece of my mind. A great case.


A Great Case A “GREAT CASE” IS A CLASSIC PRESENTATION OF A RARE or dramatic phenomenon, with a resolution highlighting the skill of the physicians involved. I was once a great case. It was 1970. I was a 13-year-old girl in eighth grade. I am now a middle-aged internist, but I still think about it from time to time, from the perspective of the teenager I was. My daughter has just turned 13, which prompts me to reminisce about it now. In the middle of the frigid Midwestern winter, I was sweating profusely. I had had this problem for an eternity it seemed—at least a year, maybe two. Multiple times every day, a deluge of sweat would engulf me. In my teenaged mind, experiences separated into those thatwereembarrassingand those that were not. This problem was definitely embarrassing. Another dichotomy was “normal” vs “weird.” At that age our bodies were changing, of course, but this amount of sweating couldn’t possibly be normal. In the classroom when it would begin, I would glance around furtively to see whether the temperature in the room had suddenly changed. No, it was just me. I modified my clothing to prepare for these episodes. I gazed in amazement at the other girls confidently wearing brightly colored sweaters to school. I couldn’t understand their ability to do so. For me it would be torture to feel the wet wool against my skin. I worried about how my future would unfold. How on earth would I ever go out on a date with a boy? Despite my best efforts to appear attractive, at any moment I might melt into a socially unacceptable diaphoretic mess. I didn’t dare think about it. I asked my mother for help and was taken to the cosmetics counter of the local department store (in those days there were local department stores). She told the sales clerk that her daughter’s skin was very oily. I quietly protested, saying that it was actually sweat that was the problem, but we went home with makeup for oily skin, which ran down my face in rivulets when I tried to use it. I tried my best to hide my abnormality and was usually successful, as our desks all faced in one direction, toward the teacher, so no one had any reason to observe me during class. I could mop my brow, constantly if necessary, without being detected. One day, however, we had a school assembly with a more relaxed seating arrangement. As the inevitable sweating started and continued to relentlessly accelerate, soaking my clothes and hair, I could sense the girl next to me glance over, then look at me again, and then closely, again. She finally blurted out—the teenager’s worst nightmare—“Is something wrong with you?” Sweating was the main embarrassing problem that I suffered, but a second phenomenon that began to bother me was that I seemed to be going blind. I noted that I had a central vision loss and could see something only if I looked away from it. I told my father, who was a physician. He noted that “Everyone has a blind spot” (he has long since repented for that quick assessment). I tried to believe that my vision was within the range of normal, but it still seemed odd. As the problem escalated over several weeks, I began to be unable to identify faces in the school corridor, needing to guess who had just passed by, who I might have unintentionally snubbed. I could not tell the time on the clocks in the classrooms. My best subject was math, and I failed a math test because I couldn’t read the questions. I was completely mortified. Pathetically, I fell down the front porch steps one morning as I attempted to catch the bus to school, as I could not negotiate them with sight. My mother insisted that my father take me to the ophthalmologist. The distinguished physician examined me and then sent me into another room for a test. I remember a reassuring young woman who asked me to “Look at the dot” in the middle of a projection screen. When I told her I could not see it, she guided me to just guess where it might be, and look there. After the test I emerged from the room and sensed the seriousness of the result. There was no more banter from the receptionist, no words of reassurance from the physician. There was somber silence. I was admitted to the hospital that afternoon. This seemed like a positive thing, and validation of the fact that there might be something physically wrong with me—someone would figure it out and fix it. I had overheard that the initial medical concern regarding the papilledema was that I might have increased intracranial pressure, a brain tumor. I postulated that this would be fatal, but I did not fear death. I might end up as a tragic figure, but at least I wasn’t weird. The hospital experience began, as it usually does, with vital signs. Temperature. Pulse. The nurse’s aide seemed confused after checking my blood pressure. She struggled with it again, and again. She seemed upset with me. She asked me whether I was nervous. I wasn’t. A senior nurse came in, and then a physician, all checking my blood pressure. Then more physicians, and more. The differential diagnosis changed, and at the top of the list was pheochromocytoma. When a patient has been identified as a great case in a teaching hospital, a parade begins through the hospital room and continues unabated for days. The morning after admis-

DOI: 10.1001/jama.2011.905

Cite this paper

@article{Barker2011APO, title={A piece of my mind. A great case.}, author={Mary Kavanagh Barker}, journal={JAMA}, year={2011}, volume={306 6}, pages={588-9} }