Off the scale

It is not often that an author in a major medical journal thinks it necessary to state that they are not mad. But in 1891 Dr W.J. Galbraith, Professor of Surgery at Omaha Medical College, writing in the Journal of the American Medical Association, reported a case so extraordinary that he thought it necessary to offer a disclaimer by way of introduction:

Incredible as it may seem, I trust the readers of The Journal, will not consider me a fit subject for an insane asylum in reporting what I sincerely believe to be a fact…I fully appreciate the amount of criticism I will receive in reporting this case, and I realize that you will take the same version of the case that I did before I examined her.

Dr Galbraith then claims that when he first heard of the case he assumed it was a hoax; but after looking after the patient personally for two months he had changed his mind. He also invites any colleagues who disbelieve him to examine the patient for themselves.

Mrs. M., aged 26, married five years, mother of one child two years old, medium height, light complexion and of rather a nervous temperament, has attended one course of lectures in the Woman’s Medical College at Chicago in the fall of 1889. On or about the first of December, 1889, she was taken sick with peritonitis and was removed to the Woman’s and Children’s Hospital, where she remained several weeks.

Both of these institutions were founded by Mary Harris Thompson, a remarkable physician who was one of the first women to practise medicine in Chicago. The Chicago Hospital for Women and Children opened its doors in 1865, with Thompson as its chief surgeon. She quickly realised that it was virtually impossible for women to become doctors without leaving the city, so set up her own medical college, attached to the hospital. The hospital still exists, but the medical college closed in 1902 – by which time many of the more established medical schools were admitting both men and women.

I will give only a brief history of her case before coming under my charge. After her recovery from the attack of peritonitis while in Chicago, she returned to her home in Kearney, Nebraska. On or about the 12th of April, 1890, she was again taken down with a severe attack of general peritonitis.

Peritonitis is an inflammation of the peritoneum, the inner lining of the abdominal cavity. I’m not sure, but I suspect that the doctor is using the word more loosely, to describe abdominal pain and inflammation of uncertain origin.

Her family physician, Dr. Duckworth, was called, and after making a careful examination satisfied himself that there was an abdominal or tubal pregnancy.

Or an ectopic pregnancy, as it would be known today.

The doctor treated the woman with hot poultices and injections of morphine. The following morning he was called out again, since the patient appeared to be suffering from labour pains.

After a vaginal examination had been made, the doctor was somewhat surprised to find a foreign body engaged in the cervical canal near the external os. He procured a pair of long and narrow-jawed forceps and removed the body, which proved to be a scapula of a four months old foetus. The pains increased in severity after its delivery. A half a grain of morphia had been given hypodermically when several more bones were delivered in the same manner.

A horrible turn of events – but is it plausible? There are numerous similar cases in the early medical literature, but – as we’ll see – there are features of this one which render it suspect.

The patient became somewhat exhausted and complained of being very feverish; after an examination of the radial pulse the doctor assured her she had no fever as her pulse was only 62, and in order to satisfy her attempted to take her temperature. The thermometer was placed under her tongue and left there about two minutes when, upon its removal, the mercury was found to be at the top of the thermometer, which registered 112 F.

112 Fahrenheit is 44.4 Celsius. Normal body temperature for an adult is around 37 C (98 F). So the doctor’s reaction to this finding is understandable:

Believing he had not properly shaken the mercury down, he took particular pains in doing so, and again placed the thermometer under her tongue, holding the end with one hand; in a short time he removed it, and to his surprise found it registered the same as before. Again shaking it down he placed it under the tongue and watched the mercury rise to the top almost instantly. This was too much for the doctor to stand, and as he expressed himself, “I believe I or the thermometer is crazy.”

Well, he had a point. Anything above 38 C (100.4 F) is usually considered a fever; if the temperature reaches 41.5 C (106.7 F) it is known clinically as hyperpyrexia. At such high temperatures, critical systems inside the body stop working. Enzymes, the biological catalysts that underpin many of the chemical reactions in our bodies, start to break down at 40 C. Unless something happens to reduce the core body temperature to below the critical level, brain damage, organ failure and death will inevitably ensue.

He immediately dispatched a messenger for his partner, Dr. M. A. Hoover, to come at once and bring two or three Hick’s thermometers along with him. After the peculiar circumstances were explained to Dr. Hoover, by his partner, they immediately proceeded to try the new thermometers,—placing one in the axilla and one under the tongue. This resulted in a repetition of Dr. Duckworth’s experience. Repeatedly the temperature was taken and with the same results.

Perplexed, the doctors sent a telegram to Chicago’s leading supplier of medical instruments, Charles Truax and Co., requesting a special ‘fever thermometer’, one capable of registering temperatures up to 125 F (51.7 C).

On the following day, after a chill, her temperature was taken, and to their horror they found the mercury had risen to the top of the thermometer, which registered 125 F., in less than one minute.

A temperature of over 50 C. Really?

Satisfying themselves that they must have a thermometer that would register higher, they again wired Chas. Truax & Co., of Chicago, to have a thermometer made that would register 150 F. On the arrival of the new thermometer, or within a few days, her temperature was found to register 145° F.

Yes, the patient’s temperature had hit an amazing 62 C. Not even Death Valley gets that hot.

At this point Dr Hoover decided that he needed an expert’s opinion. So he went to see Dr Galbraith, who was incredulous:

I assure you I felt sorry for him, as I supposed he had “slipped a cog” and his mental equilibrium was somewhat impaired. I advised him to return home and explained to him that he certainly had been deceived by a shrewd and hysterical woman; also advising him to say nothing to anyone else.

But Dr Hoover was persistent. A little while later he sent a telegram requesting Dr Galbraith’s immediate assistance. So the professor borrowed a highly accurate thermometer from a scientist friend, persuaded his colleague Dr Peabody to accompany him, and went to examine the patient for himself.

On our arrival the temperature was found to be two and two-fifth degrees below normal; this, of course, somewhat surprised us, but in less two hours we were more surprised to find the thermometer had reached 117 F., and at midnight, following a chill, the mercury registered in the axilla [armpit] 145 F., and at the same time registering 125° F. under the tongue.

But there was an interesting follow-up to this observation:

In less than thirty minutes the temperature in the same localities had fallen to three-fifths of a degree below normal, followed by sweating and a slight delirium.

Significant: the temperature in the armpit had apparently plunged almost 50 F (25 C) in the space of half an hour. Does that really sound plausible?

You can imagine that I was somewhat puzzled, and immediately apologized to the doctors. I could not believe my own eyes, and I assure you that Dr. Peabody was in the same condition. I thought that some form of heat must have been used or that she, in some manner, had tipped the thermometers upside down, unbeknown to me, or that, possibly it might be accomplished by some muscular action with which I was not familiar.

The following day, Dr Galbraith spent some time trying to see whether the patient was in some way faking her condition. The doctors removed all her clothes and examined her minutely, then watched her carefully as they measured her temperature to ensure that she wasn’t tipping the thermometer upside-down or employing similar forms of subterfuge.

We again proceeded to take her temperature; but, gentlemen, the result was the same, the thermometer under the axilla registering 137 F. while that under the tongue registered 131 F.

Pretty extraordinary. But after three months he had some even more dramatic figures to report:

The highest I have ever seen her temperature was 151° F., while the nurse’s record in the hospital shows it to have reached 171 F.

151 F is 66 C.

171 F is 77 C.

Both are equally unlikely – or rather impossible – in a living human being.

She has been delivered of over 1,000 pieces of bone; very few, however, are perfect, the most of them being deformed.

While there are many accounts of bones being delivered after fetal death, a thousand seems excessive.

Her general health seems to be quite good, considering her long and tedious sickness, and when she is free from peritoneal inflammation, is able to be up and about the house. At this writing, February 2, she is confined to her bed with one of her attacks of peritonitis. There is no special time for her temperature to rise; it is usually preceded by a chill. I have no theory further than I believe it to be some chemical change or combustion that takes place in the lymphatics, as its elimination is very speedy.

Dr Galbraith had suspected that his colleagues wouldn’t believe him, and so it proved. His article prompted several extremely sceptical letters. One, given the caption ‘Has Omaha Found Munchausen’s Mantle?’, was an exercise in sustained sarcasm.

A more reasonable response came from Dr W.L. Worcester, assistant physician to the Arkansas State Lunatic Hospital:

I cannot help thinking that there must be an element of deception in the very remarkable case reported by Dr. Galbraith in your last issue. Apart from the inherent improbability of the extremely high temperatures noted, it seems to me a physical impossibility, so long as the circulation of the blood is maintained, that the temperature in the axilla [armpit] should be 20 degrees higher than in the mouth. A temperature of 171 F, or even 151 F, can only be borne by the finger for a very brief time without severe pain.

All good points.

I would suggest, in case of opportunity for further observations of the sort, that the temperature be taken in the rectum, under close observation. If the case were my own, I should be satisfied that if the thermometer registered higher either in the mouth or axilla than in the rectum, there was fraud somewhere, whether I could detect the manner of it or not.

Rectal temperatures are a) a more reliable indicator of core temperature; and b) much more difficult to manipulate – so this suggestion is entirely sensible.

Dr Worcester also recalls a case previously reported in The Lancet, that of a woman treated in a hospital in London for

an inflamed condition of the stump of an amputated thigh, who gave abnormally high temperatures on repeated occasions, the highest being 133.6 F. This never occurred while she was closely watched, and she afterwards admitted that she had produced the high temperatures by means of poultices, hot bottles, etc.

As far as modern medicine is concerned, the highest recorded temperature in a human is 46.1 C (115 F) – and that was a man who was admitted to hospital with heatstroke rather than fever; despite multi-organ failure the patient survived. The highest reliably documented temperature in a patient who was suffering from fever was 43.1 C (109.6 F) – and that was shortly before the patient died.

So what was going in the case recorded by Dr Galbraith? Well, some kind of hoax does seem the most likely explanation, given that the doctors went to great lengths to ensure that their thermometers were accurate and their measurements reliable.

I have no doubt that Dr Galbraith was being sincere: he really believed that he had seen a patient with a temperature of over 60 C. But the bottom line is that the temperatures he thought he had witnessed are simply incompatible with life. They are biochemically impossible. So the question is not whether his patient was, as he claimed, a ‘pathological freak’; it is how she succeeded in fooling so many doctors for so long.