Sicker Than I Thought

It never occurred to me when I sat at Rose’s bedside that she would be any different than the scores of patients I had treated with radioactive iodine for an overactive thyroid.  And as with the others, it wasn’t long before her tremulousness, typical of the disease, also infected me; I felt my body trembling in rhythm with hers. 

It was 1950.  I had accepted a fellowship in radioactive iodine research at the Beth Israel Hospital in Boston without even knowing what radioactive iodine was.  Few academicians anticipated that this isotope would herald the field of nuclear medicine.  That it would play such a significant role in my life was hardly in my mind; I initially thought of the job merely as a stepping-stone to an appointment as a Resident in Internal Medicine.  In fact it was to lead me to my wife and to a successful move to Israel.  But that’s another story.

Rose K., age thirty-five, looking fifty-five, was a mother of three children; the youngest was five years old.  Her husband, age forty, hadn’t been employed for several years because of unexplained bleeding in his extremities – more on this in a moment.  They lived in a three-room apartment in a public housing project, subsisting on welfare checks and food stamps.  One child had a seizure disorder, another, asthma.  Rose had little reason to smile.  On the contrary, she was haggard, appearing malnourished with cracked lips and a vitamin-deficient, smooth, red tongue.  Her gaunt cheeks sagged, as did the skin of her arms, indications of a recent twenty-pound weight loss.  Her skin was warm and her pulse, fast.  All of these signs were typical of patients with hyperthyroidism, an overactive thyroid.  But why didn’t she have protuberant eyes and an enlarged thyroid gland, other findings typical of this disease?  I would soon learn the answer.

At this point it was obvious that I would have another candidate to add to my growing research study dealing with the use of radioactive iodine in the treatment of hyperthyroidism.  A few more and a pioneer publication could be expected, maybe even a presentation at a national medical meeting.  This sequence didn’t unfold quite as I imagined it would.

I explained to Rose the nature of the radioactive iodine test to be performed the next morning.  It would measure the function of her thyroid gland, information essential for arriving at a proper treatment dose of radioactive iodine.  I even anticipated this treatment by explaining that radiation from the dose I would give her would gradually shrink her gland over six to twelve weeks and, thereby, reduce its function.  Most patients would be cured by the end of that period.

The following morning Rose was brought to my lab in a wheel chair – her muscles too weakened to permit walking.  I gave her a drink of a small dose of radioactive iodine.  The following morning she returned for measurement of the amount of radioactive iodine collected by her thyroid gland.  In normal patients the answer would be 15-30%.  In a patient with an overactive gland it would be 35-80%.  Imagine my dismay when Rose’s measurement was 1%.  First I blamed my technique.  Had I given her water instead of radioactive iodine?  The presence of a significant amount of radioactive iodine in a urine sample discounted that possibility.  Next I blamed the equipment.  I checked the electrical connections on our homemade, primitive set-up.  Finally a successful check of a known quantity of radioactive material proved that I had to look elsewhere for the answer.

After Rose returned to her room, someone suggested that she might have been taking diet pills and just neglected to tell us.  In that era diet pills contained thyroid extract in quantities sufficient not only to block thyroid function (and reduce the entrance of iodine into the gland) but also to cause adverse effects on the body, which simulate the findings of an overactive thyroid. We called the unit and had the intern ask the patient if she was taking diet pills.  The intern spoke with me.  “Rose appeared irate and emphatically denied this.” 

I thereupon requested the nurse to send Rose back to the lab for “retesting.”  During the time that she was with me – I feigned a change in technique for measuring her thyroid activity – the nurses inspected Rose’s bedside table and locker.  Lo and behold, two bottles filled with thyroid pills were found!  The nurse phoned with this startling finding.  The mystery of hyperthyroidism associated with low iodine uptake was solved, as was the absence of protruding eyes and an enlarged thyroid gland.  A dose as little as four tablets a day would mimic hyperthyroidism.

I took Rose into a private office and confronted her.  “Rose, tell me about the bottles of thyroid pills in your belongings.”

At first she looked at me with scorn.  I suppose it was when she realized that I cared about her, that she broke down, sobbing, “I want to die.”  In the ensuing hour her tale unfolded.  More than depressed, she was angry – angry at life but more specifically, at her husband.  “He’s never held down a job.  He just sits around all day listening to the radio or studying a racing form.  Of course, that is, when he’s not in the hospital.”

“Why,” I asked, “does he need to be in the hospital?”

“‘Need to be in the hospital?’  That’s funny.  He’ll kill me if I tell you.  Oh, what the hell!  I told you that he has bleeding in his arms and legs.  Your blood department has been struggling to diagnose a rare bleeding disease.  Well, there is none.  He just bangs his legs against the toilet bowl and his arms against the sink until they are black and blue.  He loves being fussed over by the doctors and nurses.”

“But, Rose, what’s this got to do with your taking thyroid pills?”  She had admitted to taking fifteen to twenty a day, a dose that, if continued, would eventually kill her.  She knew it.  I suggested that, “there are faster ways of killing yourself.”

“That’s the point.  I wanted to make my husband suffer as he watched me dying, not that he could care much once I’m gone.”  I was now getting over my head into psychiatric waters that called for the involvement of a psychiatrist; this I arranged for both Rose and her husband.  (The latter’s hematologists on first hearing of the self-inflicted lesions wanted to kill him for wasting their precious time and resources.)

Putting a name thyrotoxicosis factitia on Rose’s condition didn’t help except as the title of her case report that was published in a medical journal a year after our first encounter.  Rose was checked in the thyroid clinic ten months after stopping thyroid pills; her gland function was normal. 

It is a sad commentary that neither my memory nor the article gives any indication of the family’s psychiatric follow-up.  It’s not conceivable that I cared only about getting my name in the medical literature.  Or is it?