University of Minnesota

“If It Isn’t Fun.” – The American Hospital of Paris Yesteryear Pt. 3

Fever of Unknown Origin

Mary Beth, I’ll call her, really had us stumped during the first two weeks of her hospitalization at the American Hospital in Paris. The sweet-natured young woman had encountered each of us on the house staff during that period. We had carefully explored every avenue in her history that might shed light on the elevation of her temperature each evening, sometimes to as high as 40 or 41 degrees Celsius. She had not traveled out of continental Europe for more than a year. She ate mainly fresh foods that she prepared herself, and no exotic foods. She had no roommates or unusual exposures. She had no allergies. Significantly, she had no symptoms or signs or laboratory finding or X-ray image that would localize the problem. We had run every test of which our hospital and the Institut Pasteur was capable, to culture her blood and urine and stool. On repeated occasions, I had made special preparations looking for active parasites. We had all probed, thumped, and ausculted her frail frame, listened diligently to her benign story, yet remained in a quandary over her FUO, fever of unknown origin.

Of course, we also explored her psyche with the limited tools at our disposal. She was an unusually giving woman, devoting her life to the American Friends Service Committee in Paris. And she was occupied with a variety of human services for displaced persons and refugees, for the homeless and the politically persecuted, including conscientious objectors who were afforded no legal status in France. Her whole life revolved around helping others. She claimed to be happy, wore a disarming smile, and had the intensity of a “born again” disciple, yet she did not appear to us irrational. Her spirituality, on the contrary, seemed to us hard-bitten interns, to be very practical and down-to-earth — a philosophy of good works that we could understand.

Mary Beth ate poorly and was losing weight slowly, at the rate of a pound or two a week. Otherwise, her general health, strength, and ability to move about the hospital chatting blandly with other patients and staff, seemed inconsistent with a deep-seated infection or malignancy sufficient to produce fever of the magnitude and duration of hers. We began to sense a schizoid detachment on her part from her illness, which, with her almost exaggerated kindness and graciousness, was deeply puzzling.

Finally, a couple of us interns figured we had better face the fact that this could be a Baron von Münchausen Syndrome — that is, feigned illness for ulterior motive, perhaps “a cry for help.” We knew not what we were looking for precisely, but only that we had to document every part of this strange illness, and that we should begin by taking her body temperature ourselves rather than leaving it to the nurses. We attributed to primness her insistence that one of the Sisters, rather than a male intern, insert the rectal thermometer. Typically the nun would do this, then leave Mary Beth’s room to complete rounds and return a little later to record her temperature.

By chance early one evening, I arrived just as the Sister, on her temperature rounds, was leaving our mystery patient’s room. I entered just in time to see Mary Beth snatch the thermometer from the top of the radiator and dash it under the covers!

Caught at last! She knew it. I knew it. The Sister knew it.

I held her hand and asked simply, “Would you like to tell us about it?”

Her story then poured out to me and the Sister, about her terrors at abuses as a child, experiences that were never a part of my medical education or even those in Havelock Ellis’s documented sexual pathologies. Back, back, back, the story went — obscene, rending, tragic. Her devoted missionary career, and the cries for help, began at age 15 when she ran away from home. She soon found herself in a Quaker institution for the homeless in Philadelphia, escaping the father she wanted so to adore but who preyed on her continually.

How strange it is that 40 years have gone by and only now is medicine recognizing that some of the syndromes of young women and men with inexplicable self-destructive behaviors, and exaggerated, obsessive preoccupations, may relate to their sexual or physical abuse by a family member. At any rate, Mary Beth was the toughest and saddest case of fever of unknown origin that I ever encountered. In time we got more competent psychological help for her than we were. Between this, and the support of her many colleagues and friends, she made a fine recovery, returning to her life mission of helping others.