Medical Mysteries

There was something wrong with the charts or there was something wrong with their diagnosis. Something was not adding up.

Dilated pupils, photophobia, hallucinatory rambling. This particular constellation of symptoms would not typically be expected with the infection that the patient was being treated for. And the fever? The patient was hot to the touch, hot enough to fry an egg on by the account of one nurse, yet there wasn’t a drop of sweat anywhere on her body. Simply put, this patient’s clinical presentation didn’t make the slightest bit of sense, at least not until the old woman’s eyes gave out prompting a long-buried clinical pearl to spring to the forefront of the doctor’s mind.

“Hot as a hare, blind as a bat, dry as a bone, red as a beet, mad as a hatter.” The old mnemonic from medical school that they had often recited in a sing-song cadence. Every one of the patient’s new symptoms could be explained away by atropine poisoning, save for one. There was no hammering heart. If anything, the patient’s heart rate was dangerously low. The low heart rate was completely contrary to the typical presentation of atropine poisoning.  Besides, it took only a cursory glance at the patient’s charts to see that there was no atropine being administered to the patient at all. While the administration of atropine might be considered should her heart rate drop any further, at this point in time they wanted her to pass whatever infected material was in her body, not trap it inside with a medication that had well-documented anti-diarrhoeal effects.

So, the doctors returned to the drawing board, and the family was none the wiser about their dear grandmother’s rapid circling of the drain. Without sweat, her body temperature continued to rise with the fever, her brain began to cook. It was a race against time to solve the mystery of her condition. The task of prolonging that race fell to the nursing staff.

Carrying the old woman in a makeshift hammock of her bedsheets strung between the sturdiest of them, they took her down to the baths and settled her into the iced water in an effort to bring her temperature down. The shock of the sudden change in temperature could easily have given her a heart attack, but her heart continued to beat just as slow and steady as if she were sitting out on her porch enjoying a summers evening. The complete lack of cardiac reactivity to the ice baths only served to draw more confusion and beard-stroking from the cadre of doctors who, by now, were far more invested in the solving of their intriguing puzzle than in saving an old woman’s life.

The infection explained the rising fever, the reddening of the skin could be due to the infection having passed into the bloodstream. From the blood, the infection could rapidly spread to the eyes and brain explaining some of the patient’s symptoms, but if her blood were carrying a contagion throughout her body, surely there would have been more dramatic and possibly even potentially lethal signs of it by now. And what about the inexplicable halting of saliva, sweat and all other mucus production? If this were a simple bacterial infection, then how could it be producing so many different effects without any of their usual connotations?

Most puzzling of all remained the heart. It should have been hammering away as the body fought back against the infection. The fever alone should have set it into a frenzy, and the sudden ice dunk should have made it beat so fast as to be practically jumping from her sunken chest, yet there was nothing. It was completely contradictory to both the original diagnosis and the unspoken hypothesis shared among the doctors that some careless or incompetent nurse had accidentally injected atropine instead of the prescribed morphine that was intended to keep the old dear comfortable while she recovered.

They had no choice but to go back to basics. If they assumed that all of her symptoms were a coherent expression of a single illness, what would it be?

There were certain viral fevers that had the potential to provoke similar symptoms, at least going by second-hand accounts. The problem with that idea was that such fevers were typically too exotic to find their way to an elderly woman who hadn’t left her hometown of Boston for more than a decade and had a social life about as active as she was currently, laid up in a hospital bed. The ultimate detractor, however, was that none of these viral fevers were consistent with the patient’s lowered heart rate.

Bacterial pneumonia and appendicitis were both ruled out as swiftly as septicaemia. If it were any of these, there would have been specific signs that their testing could identify, even if the patient was generally asymptomatic. A kidney infection had been the original diagnosis and seemed likely given the blood that had been present in the patient’s urine, but that had subsided now.

The final suggestion, put forth by one of the younger doctors and reviled by all the others was that she had perhaps indulged in too many drugs of leisure, dosing herself with some cocktail of medications to ease her pain or her boredom prior to hospitalisation that were now interacting poorly with what the nurses were administering.

None of the upstanding doctors knew of any abuse of restricted substances, of course, nor could they countenance an upstanding woman of their generation having indulged in such nonsense. Testing of the blood that had been drawn from her had shown no irregularities that one might associate with the misuse of chemicals, so they were driven by their own preconceived notions back to the drawing board once more.

Meanwhile, the nurses continued to care for the old woman as though she were their own mother, lavishing time and attention on her that they could scarcely spare, given how busy the ward was. Dear kindly Jane even sat after her shift was done and held the woman’s hand as she drifted in and out of consciousness just so the poor woman wouldn’t be scared and alone.

The nurse ended up drifting to sleep with her head laid upon the patient, much to the doctor’s initial dismay, but then they realised the significance of it. Nobody could have tolerated laying their head upon the patient prior to now. A quick check showed that her temperature was dropping again. Whatever had caused the mysterious symptoms seemed to have passed away as surely as it had arrived. The old woman’s eyes opened and the doctors could plainly see that the vast black expanse of her formerly dilated pupils had shrunk back down to a normal size. She could see again, speak again, make some degree of sense, even if the fever had cooked her brain enough to ostensibly call her lucidity into question. The puzzling array of signs and symptoms, as mysterious as they’d been, now morphed back into what could reasonably be expected of a kidney infection that was being treated. Her heart, the mystery at the centre of everything, was back to beating a steady staccato rhythm.

For most of the doctors, that was the end. There were always too many patients and too many mysteries to let one that had solved itself weigh on them. In many ways, the human body was still a mystery, and the ways that it behaved when put under duress were equally mysterious. The woman, now scarcely more sapient than the bed she was laid out on, was old. Age brought with it a plethora of slow decay and a cornucopia of mishaps and malfunctions, some inexplicable, some absurdly paradoxical. Sometimes systems failed when they should have worked perfectly, sometimes systems worked perfectly when wear and tear should have dictated their failure long ago. In a machine as complex and enigmatic as the human body, things just went haywire once in a while, and the physician’s job became less about rooting out the cause and more about keeping the symptoms at bay until the machinery sorted itself out and started turning over the way that it was meant to again.

To the few that still entertained theories, their minds had all gone to the slow build-up of poisons in a system. The madness of a hatter has been attributed to felting chemicals, particularly mercury. Similarly, heavy metals like lead, mercury or arsenic, all common in this era, had the ability to prevent messages from travelling from the brain to the sweat glands, resulting in anhidrosis, the inability to sweat. If you considered the span of an entire lifetime of potential exposures, there were plenty of opportunities for this mystery to be solved.

Then it began all over again. Just as it seemed that the old woman had somehow beaten her infection, her heart began to slow and her respiration shallowed. Each breath that she took was a dry whisper, and the heat began to rise once more. It wasn’t so dramatic this time. There were no frantic rushes to dunk her in ice or the like, just the nurse by her bedside dabbing at her with cold water and cooing over her when she showed the faintest sign of awareness. And most terrible of all was that this sudden change of course would, in some sad way, have been a relief. If somehow she had survived the infection that was clearly meant to take her life and managed to claw herself back to some semblance of health, there would be no leaving the hospital for her. She would require care for the rest of her life, which would be immensely costly for everyone involved, and with nobody to advocate for her and no money to speak of, she most likely would have been quietly discharged to roam the streets, mindless and desolate until some other sickness or accident took her. If anything, it would be a kindness now for the sickness to finish her off. An act of long-delayed mercy by God.

When her breathing grew more shallow and her heart began to slow ever more, there was no questioning it this time around. It had lost all element of surprise. This was death, inevitable and kind. The same nurse who’d cared for her through the last crisis was back again, dabbing at her face with cold water, doing all that she could to make the journey to the next world more comfortable for her, but there was nothing more aggressive to be done. In the early hours of the morning, she passed away in such absolute silence that nobody even knew that she was dead until it was over.

It was another clue in the mystery if any of the doctors had still been interested enough to try and solve it. That silence. The absence of a death rattle. It would have supported their suspicions about atropine poisoning.

Examination of the body after death would have uncovered that the inflammation of the kidneys that characterised the infection had entirely receded, that the brain damage from the peak fever was considerably less widespread than would have been expected and that there was not, in fact, any good reason that the woman should have died at all. She was weak frail and elderly, but beyond that, there was no systemic breakdown or organ failure that might have explained her death. A clever medical examiner might have worked out that she had died from asphyxiation, but that there had been no signs of smothering. A very clever one, with access to blood tests that wouldn’t become available for decades, would have been able to identify the cocktail of morphine and atropine being pumped around the woman’s system as the primary cause of her death, with the morphine having weakened her breathing to the point where she could no longer survive. As for the inexplicable lowering of the heart rate, if they had access to studies that wouldn’t be published for a few more years, they would know that in low doses, atropine has the opposite effect to when a patient receives a full dose. If they’re receiving tiny but regular injections of atropine alongside their other medication, then it could quite easily have built up into both the observed symptoms from the crisis and the eventual cause of death.

This clever doctor, with foreknowledge of future advancements in medicine, could then have checked the supplies of both the drugs indicated, to determine whether they had been used in an inappropriate manner, despite the tiny doses being taken to cover up any theft. From there it would have been a simple enough matter to narrow down the potential culprits to the nurses working on the ward, and from there to pinpoint Jane, who had been so attentive to the victim in her dying hours.

Of course, no such doctor existed. Nor was any posthumous examination of the body ever made. If a doctor heard hoofbeats, they were beholden by logic to believe that they were dealing with horses, not zebras. The simplest answer was not some concoction of drugs being illicitly injected into the elderly, but simply that an old woman had succumbed to her illness. And so it went. One elderly patient after another dropped dead on the ward, and not a single eyebrow raised. One after another after another.