The Yale Journal for Humanities in Medicine
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Diarrhea
Richard
Mansfield
richard.mansfield@med.va.gov
Almost
all triumphs and tragedies in the history of man have at one time or
another been immortalized and romanticized in writing. Love and war
are the foundations of the great epics - from Homer’s Iliad and the
Odyssey to Shakespeare’s Romeo and Juliet. Illness, disease and
epidemics have taken their place as well in the written expressions of
humanity: Lou Gerhig’s disease, Hodgkin’s Lymphoma, Alzheimer’s
Dementia, Duchene’s muscular dystrophy - the list goes on. It is
considered noble to be immortalized in disease. But say the word
diarrhea - no Pulitzer Prize comes to mind. I’m sure it played no
part in
Nobody wants to talk about it - including me. Traditional medical lecturers will pride themselves on how many questions can be asked of a patient about their chest pain: Where is it? How long did it last? Did it travel? Were there any other symptoms with it… The catalogue of questions is endless. Very few times, if at all, have I heard such a detailed list about diarrhea. Who really wants to hear the answers to those questions anyway? How much? How often? Watery? Bloody? Mucosy? Formed? Incontinent? Painful? Did it smell normal or really foul? Who really wants to know that much about diarrhea…
He’s 68. Over two years ago he underwent emergency surgery for an intestinal obstruction and perforation. His post-operative course was complicated by an abscess. He had a colostomy bag for months requiring a second surgery to reattach what was left of his intestines. But his ordeal didn’t end there. He was left with diarrhea. I reviewed his medical records before I met him. The surgeon had decided healing was adequate and complete - no reason to see the surgeon again. The last note by the gastroenterologist said, "patient still notes some loose bowel movements."
When I met him we talked about the usual things - blood pressure and cholesterol and the like. He didn’t mention the diarrhea so I asked, "Is the diarrhea better?"
He looked down, "No, its still there".
I really don’t like talking about diarrhea. But I asked - and now I would have to go down my list of questions and elicit the gory details of the diarrhea. "How many times a day do you have diarrhea?" At this point it was a conscious effort on my part to look empathetic and not divulge the fact that I really didn’t want to hear his answers.
"Eight or ten times a day - sometimes more." He said flatly, "It comes quick."
Something about his expression made me realize we were talking about more than his diarrhea - we were talking about this life. I tried to get over my issues with diarrhea and take one step closer to true empathy for him and what he was going through. "Are you able to make it to the bathroom when you need to?" I asked.
"Sometimes no." Each word was softer and quieter.
I was beginning to get a sense of what the diarrhea was doing to this man’s life. And I had a feeling that perhaps my specific questions about diarrhea weren’t going to get me the answers. I sat quietly for a moment; so did he. "That must be very frustrating…" I offered.
He nodded, staring blankly at the floor. There was a silence. "I missed my mother’s funeral." He said quietly.
"Because of the diarrhea?" I asked.
"Yes, I don’t like to leave the house. When I do, I try to keep my trips short. I’m afraid I’ll have an accident in public and people will see - or smell…It’s humiliating, a grown man soiling his pants. I don’t like coming here either. I’m afraid you’ll be late, and I’ll have an accident in the waiting room. My mother’s funeral was too far away - I would never have made it."
How sad, a humiliating problem and no one wants to talk about it. How curious that other shameful problems, in an odd way, benefit from a more acceptable social status: drug addictions and abuse – even breasts and prostates can be discussed at the dinner as legitimate topics of conversation, but not diarrhea. Yet it had nearly taken this man’s life - left him home bound, isolated, full of shame.
Several physicians had gotten their hands dirty trying to solve the puzzle of this man’s diarrhea. Now it was my turn. If you’ve asked yourself why one must put oneself and the patient through the rank discussion concerning the details of the diarrhea – its because of cases like this. Those details are potentially clues to the cause of these ruinous stools. However, in his instance, the particulars led to more possibilities than they did conclusions, which make the step from cause to treatment, from solution to resolution, quite nebulous. I retraced the steps through the work up of his predicament and explained further blood tests and procedures that could be done. I might just as well have placed a hundred pound weight on his shoulders the way they sank. I tried to hold him up by offering possible remedies – change in diet, medications, consultation with the specialist again.
He sighed, “I’ve tried those, but I’ll try them again if that’s what you say. You know, Doc, I could actually live with the diarrhea – if I could leave my house and not be afraid…”
We spent the next several minutes in what is probably the most serious discussion about adult diapers I’ve ever had. Yes, there is some amount of humiliation for an adult man to wear diapers - but it might give him just a little bit of confidence. Perhaps enough that a trip to the grocery store is not wholly permeated by fear of embarrassment. Perhaps he could visit his grandchildren. He will not have another chance to say good-bye to his mother - but he may have a chance to say hello to the world again.
Diarrhea: Not just a question of how much or how often - and certainly not the subject of Shakespearian sonnets, but it was perhaps the key to unlocking one man’s prison.
Published: April 20, 2005