Innocence revisited – 37

A strange set of circumstances

I was a junior registrar, my chief was a very famous physician. He phoned me one day from his rooms.

 ‘I have a case I wish to admit. Things aren’t quite right here. I have some ideas but I would like you to start this largely on your own,’ he said. 

The patient was in her late 40s, a demure, slightly built farmer’s wife and mother of three children, who lived in a small country town. She had presented to her GP because of recurring attacks of cyanosis. My chief had concluded that these were very unusual. He had taken, in his meticulous way, a very full history and realised that there was something quite strange in the overall circumstances.

It took us about a week to put the history together. The patient had been seen by most of the key consultants in the city. A senior surgeon had removed her normal appendix. Another surgeon had removed a normal gallbladder. The doyen of local O&G specialists had removed first one ovary and then the other, and eventually her uterus. All were normal histologically. She had presented to a senior urologist with renal colic and produced stones, one of which she passed while under observation at a private hospital. She had been seen by other physicians with a number of symptoms.

The pattern of communication back to GPs in those days was often cursory, and the surgeons had not communicated with each other. Even had they done so, it is likely that the recording of past medical histories was perfunctory. Nevertheless, they should have noticed the scars inflicted by their colleagues and pondered upon them.

We rapidly worked out that on this occasion the patient had methaemaglobulinaemia. We established that she worked part-time in a local baker’s shop and had access to colouring agents known to induce this disorder in some people. She produced one of her renal stones in our ward and we rapidly identified it as a bovine gallstone – quite common in the paddocks. A farmer’s wife would know where to find them.

Just as we were about to proclaim our triumphant diagnosis of Munchausen’s syndrome, she passed urine that she organised to be left in a pan. It went black overnight. A very bright chemical pathologist and a consultant involved in the case proved that the urine did not contain homogentisic acid, thus this was not a case of alkaptonuria. He was unable to discover what substance was being used to induce the phenomenon. This was before the days of modern spectroscopy. The specimen was stored for future investigation but later lost by mistake, alas.

Piecing together the puzzle

After 10 days we were in no doubt that this was some form of Munchausen’s syndrome, but knowing that this was a diagnosis of exclusion we needed to consider other causes. What was going on in a relatively isolated community with a demure farmer’s wife as the central figure? The denouement came through divine or natural intervention. My houseman and I were on the balcony of the ward one morning. The windows were open and a gust of wind blew a letter off the patient’s locker on to the floor. She made a frantic dive for the letter but I got there first. Although relatively junior and ignorant, I recognised the name of the addressee and the address of a very famous institution in another country. The patient swore loudly and crudely, promised to get even with me, dressed rapidly and left the hospital forthwith.

Because we had time in those days of non-rapid bed turnover, we pieced together the whole story. The farmer’s wife had been the top nursing student in her final year when she fell pregnant to a top graduate of a major medical school. He induced an abortion. The facts were somehow leaked to the matron of the hospital. He jumped on to a ship and left the country before any action was taken. The nurse was disciplined, publicly disgraced, dis.missed and banned from re-entering the profession. In theory, two young professional lives were destroyed.

The doctor went on to become an extremely famous person in another country. Like the ex-nurse and almost everyone involved in this story, he is now dead. Identifying the parties would be very difficult these days. The tragic young nurse and the lucky young doctor decided to wreak vengeance on the hospital and the nursing and medical hierarchies. They never succeeded in destroying the nursing hierarchy, but they could well believe that they had made fools of most of the senior consultants at the relevant hospital. 

About 35 years after these events I met two classmates of the doctor and gently introduced the tale. They nodded slowly and confirmed that we had deciphered the essential facts. Those two doctors are also deceased. As far as I am aware, no one has ever revealed the identity of the two young people whose lives were seemingly and so tragically, at least initially, destroyed when the whole world was before them in their future professions. One was professionally destroyed but settled down to domesticity; the other thrived.

Accepting the extraordinary 

Almost all doctors who practise over many decades have stories like this to tell. Thankfully, as we lose our innocence, we come to accept the extraordinary range of human behaviour, and the complexity of motivation underlying many bizarre episodes. Hopefully we learn also that apparent diagnostic triumphs may be mere shadows masking the reality of human tragedy. MT