This is a transcript of the article (see the Second Case below) referred to by Ken Norman in his email and subsequent letters to those in authority.
You might also want to ask in case one: Why if a doctor accepts the parent's story with a pinch of salt - did it take 6 YEARS before they questioned the symptoms given, especially as the mother had a similar history of urinary tract infections?
Why did it not occur to them that mum might have a psychiatric problem and needed help earlier?
Plenty of fancy words but little common sense.
THE LANCET, AUGUST 13, 1977
Hospital Practice
MUNCHAUSEN SYNDROME BY PROXY
The Hinterlands
of Child Abuse
Roy Meadow
Department of Paediatrics and Child Health, Seacroft Hospital,
Leeds
Summary
Some patients consistently produce false stories and fabricate evidence,
so causing themselves needless hospital investigations and operations. Here are described
parents who, by falsification, caused their children innumerable harmful hospital
procedures - a sort of Munchausen syndrome by proxy.
Introduction
Doctors dealing with
young children rely on the parents’ recollection of the history. The doctor accepts
that history, albeit sometimes with a pinch of salt, and it forms the cornerstone
of subsequent investigation and management of the child. A case is reported in which
over a period of six years, the parents systematically provided fictitious information
about their child's symptoms, tampered with the urine specimens to produce false
results and interfered with hospital observations. This caused the girl innumerable
investigations and anaesthetic, surgical, and radiological procedures in three different
centres. The case is compared with another child who was intermittently given toxic
doses of salt which again led to massive investigation in three different centres,
and ended in death. The behaviour of the parents of these two cases was similar in
many ways. Although in each case the end result for the child was non-accidental
injury, the long-running saga of hospital care was reminiscent of the Munchausen
syndrome, in these cases by proxy.
Case-reports
FIRST CASE
Kay was referred to the paediatric nephrology clinic in Leeds
at the age of 6 because of recurrent illnesses in which she passed foul-smelling,
bloody urine. She had been investigated in two other centres without the cause being
found. In the child's infancy, her mother had noticed yellow pus on the nappies,
and their doctor had first prescribed antibiotics for suspected urine infection when
Kay was 8 months old. Since then, she had had periodic courses of antibiotics for
presumed urine infection. Since the age of 3 she had been on continuous antibiotics
which included co-trimoxazole, amoxycillin, nalidixic acid, nitrofurantoin, ampicillin,
gentamicin, and uticillin. These treatments had themselves caused drug rashes, fever,
and candidiasis, and she had continued to have intermittent bouts of lower abdominal
pain associated with fever and foul-smelling, infected urine often containing frank
blood. There was intermittent vulval soreness and discharge.
The parents were in their
late 30s. Father who worked mainly in the evenings and at night, was healthy. The
mother had had urinary-tract infections. The 3-year-old brother was healthy. At the
time of referral, she had already been investigated at a district general hospital
and at a regional teaching hospital. Investigations had included two urograms, micturating
cystourethrograms, two gynaecological examinations under anaesthetic, and two cystoscopies.
The symptoms were unexplained and continued unabated. She was being given steadily
more toxic chemotherapy. Bouts were recurring more often and everyone was mystified
by the intermittent nature of her complaint and the way in which purulent, bloody
urine specimens were followed by completely clear ones a few hours later. Similarly,
foul discharges were apparent on her vulva at one moment, but later on the same day
her vulva was normal. On examination she was a healthy girl who was growing normally.
The urine was bloodstained and foul. It was strongly positive for blood and albumin
and contained a great many leucocytes and epithelial cells. It was heavily infected
with Escherichia coli.
The findings strongly suggested an ectopic ureter or an infected
cyst draining into the urethra or vagina. Yet previous investigations had not disclosed
this. Ectopic ureters are notoriously difficult to detect, and, after consultation
with colleagues at the combined paediatric/urology clinic, it was decided to investigate
her immediately she began to pass foul urine. No sooner was she admitted than the
foul, discharge stopped before cystoscopy could be done. More efficient arrangements
were made for the urological surgeon concerned to be contacted immediately she should
arrive in Leeds, passing foul urine. This was done three times (including a bank
holiday and a Sunday). No source of the discharge was found. On every occasion it
cleared up fast.
Efforts to localise the source included further radiology, vaginogram, urethrogram,
barium enema, suprapubic aspiration, bladder catheterisation, urine cultures, and
exfoliative cytology. During these investigations, the parents were most cooperative
and Kays mother always stayed in hospital with her (mainly because they lived a long
way away). She was concerned and loving in her relationship with Kay, and yet sometimes
not quite as worried about the possible cause of the illness as were the doctors.
Many of the crises involved immediate admission and urgent anaesthetics for examinations
or cystoscopy, and these tended to occur most at weekend holiday periods. On one
bank holiday, five consultants came into the hospital specifically to see her.
The
problem seemed insoluble and many of the facts did not make sense. The urinary pathogens
came and went at a few minutes notice; there would be one variety of E. coli early
in the morning and then after a few normal specimens, an entirely different organism
such as Proteus or Streptococcus faecalis in the evening. Moreover, there was something
about the mothers temperament and behaviour that was reminiscent of the mother described
in case 2, so we decided to work on the assumption that everything about the history
and investigations were false. Close questioning revealed that most of the abnormal
specimens were ones that at some stage or other had been left unsupervised in the
mothers presence. This theory was tested when Kay was admitted with her mother and
all urine specimens were collected under strict supervision by a trained nurse who
was told not to let the urine out of her sight from the moment it passed from Kays
urethra to it being tested on the ward by a doctor and then delivered to the laboratory.
On
the fourth day, supervision was deliberately relaxed slightly so that one or two
specimens were either left for the mother to collect or collected by the nurse and
then left in the mothers presence for a minute before being taken away. On the first
3 days, no urine specimen was abnormal. On the first occasion that the mother was
left to collect the specimen (having been instructed exactly how to do so), she brought
a heavily bloodstained specimen containing much debris and bacteria. A subsequent
specimen collected by the nurse, was completely normal. This happened on many occasions
during the next few days. During a 7-day period, Kay emptied her bladder 57 times.
45 specimens were normal, all of these being collected and supervised by a nurse;
12 were grossly abnormal, containing blood and different organisms, all these having
been collected by the mother or left in her presence. All the specimens were meant
to be collected in exactly the same way as complete specimens, and the mother was
using the same sort of utensils as were the nurses. On one evening the pattern was
as follows:
Time: Appearance: Collection
5.00 P.M. Normal By nurse
6.45 P.M. Bloody
By mother
7.15 P.M. Normal By nurse
8.15 P.M. Bloody By mother
8.30 P.M. Normal By nurse
On
that day the mother was persuaded to provide a specimen of urine from herself. She
produced a very bloody specimen full of debris and bacteria which resembled the specimens
she had been handing in as Kay’s urine. The mother was menstruating. ‘Kay was given
xylose tablets so that we could identify which urine came from her. All the specimens
handed in by the mother contained xylose which meant that each specimen contained
some of Kay’s urine. The help of the Yorkshire Police forensic laboratory was obtained.
Kay and her mother had similar blood-groups, but erythrocyte acid phosphatase in
the blood in the urine specimens was of group Ba which was similar to the mother’s
but not to Kay’s. At this stage, there was enough evidence to support the theory
that the mother’s story about her daughter was false, and that she had been adding
either her own urine or menstrual discharge to specimens of her daughters’s urine.
Other
abnormal findings could similarly be explained by the deliberate actions of the mother.
The consequences of these actions for the daughter had included 12 hospital admissions,
7 major X-ray procedures (including intravenous urograms, cystograms, barium enema,
vaginogram, and urethrogram), 6 examinations under anaesthetic, 5 cystoscopies, unpleasant
treatment with toxic drugs and eight antibiotics, catheterisations, vaginal pessaries,
and bactericidal, fungicidal, and oestrogen creams; the laboratories had cultured
her urine more than 150 times and had done many other tests; sixteen consultants
had been involved in her care. The various fabrications occupied a major part in
the mother’s life and arrangements were made for her to see a psychiatrist at a hospital
near her home.
At first, she denied interfering with the management of her daughter. However, during
the period of psychiatric outpatient consultation, Kay’s health remained good. The
urinary problems did not recur and her parents said that they felt that “since going
to Leeds, Kay had been much better and their prayers had been answered”. Later it
emerged that the mother had a more extensive personal medical history than she had
admitted and that during investigation of her own urinary tract she had been suspected
of altering urine specimens, altering temperature charts, and heating a thermometer
in a cup of tea. She was a caring and loving mother for her two children. Kay was
a long-awaited baby (in the hope of which the mother had taken a fertility drug),
but after the birth she sometimes felt that her husband was more interested in the
child than in her.
SECOND CASE
Charles had had recurrent illnesses associated with
hypernatraemia since the age of 6 weeks. He was the third child of healthy parents.
The attacks of vomiting and drowsiness came on suddenly, and on arrival in hospital
he had plasma-sodium concentrations in the range 160—175 mmol/l. At these times his
urine also contained a great excess of sodium. The attacks occurred as often as every
month; between attacks he was healthy and developing normally.
Extensive investigations took place in three different centres. He was subjected to radiological, biochemical, and other pathological procedures during several hospital admissions. These showed no abnormality between attacks, and his endocrine and renal systems were normal. When given a salt load, he excreted it efficiently. The attacks became more frequent and severe, and by the age of 14 months it became clear that they only happened at home. During a prolonged hospital stay in which the mother was deliberately excluded, they did not happen until the weekend when she was allowed to visit. Investigation proved that the illness must be caused by sodium administration, and the time relationship clearly incriminated the mother.
We did not know how she persuaded her toddler to ingest such large quantities of
salt (20 g of sodium chloride given with difficulty by us raised the serum-sodium
to 147 mmol/l only). The mother had been a nurse and was presumably experienced in
the use of gastric feeding tubes and suppositories. During the period in which the
local paediatrician, psychiatrist, and social-services department were planning arrangements
for the child, he arrived at hospital one night, collapsed with extreme hypernatraemia,
and died. Necropsy disclosed mild gastric erosions “as if a chemical had been ingested”.
The mother wrote thanking the doctors for their care and then attempted suicide.
She too was a caring home-minded mother. She had an undemonstrative husband, a shift
worker who did not seem as intelligent as she. As a student she had been labelled
hysterical, and during one hospital admission had been thought to be interfering
with the healing of a wound.
Discussion
These two cases share common features. The
mothers’ stories were false, deliberately and consistently false. The main pathological
findings were the result of the mothers’ actions, and in both cases caused unpleasant
and serious consequences for the children. Both had unpleasant investigations and
treatments, both developed illnesses as a result of the malpractice and the treatments,
and the second child died. Both mothers skilfully altered specimens and evaded close
and experienced supervision. In case 1, a specimen of the child’s urine collected
under “close supervision” was abnormal, but it emerged that the mother had momentarily
persuaded the nurse to leave the cubicle and leave the specimen unguarded for about
a minute. Expressed breast milk collected from the mother of case 2 early in the
course of the illness had a very high sodium content. It had been collected under
supervision for chemical analysis, but when the supervisory nurse was instructed
not to leave the specimen between its emergence from the mother’s breast and its
delivery to the laboratory, the next specimen was normal.
During the investigation
of both these children, we came to know the mothers well. They were very pleasant
people to deal with, cooperative, and appreciative of good medical care, which encouraged
us to try all the harder. Some mothers who choose to stay in hospital with their
child remain on the ward slightly uneasy, overtly bored, or aggressive. These two
flourished there as if they belonged, and thrived on the attention that staff gave
to them. It is ironic to conjecture that the cause of both these children’s problems
would have been discovered much sooner in the old days of restricted visiting hours
and the absence of facilities for mother to live in hospital with a sick child. It
is also possible that, without the excellent facilities and the attentive and friendly
staff, the repetitive admissions might not have happened.
Both mothers had a history of falsifying their own medical records and treatment.
Both had at times been labelled as hysterical personalities who also tended to be
depressed. We recognise that parents sometimes exaggerate their child’s symptoms,
perhaps to obtain faster or more thorough medical care of their child. In these cases,
it was as if the parents were using the children to get themselves into the sheltered
environment of a children’s ward surrounded by friendly staff. The mother of case
1 may have been projecting her worries about her own urinary-tract problems on to
the child in order to escape from worries about herself. She seemed to project her
own worries on to the child in many different ways, once informing another hospital
that a specialist from Switzerland was coming to see her daughter in Leeds because
she had an incurable kidney tumour which emptied into the vagina causing the discharge.
This
sort of fabricated story is reminiscent of the Munchausen syndrome. The parents described,
share some of the common features of that syndrome in which the persons have travelled
widely for treatment, and the stories attributed to them are both dramatic and untruthful.
But those with Munchausen syndrome have more fanciful stories, which are different
at different hospitals. They tend to discharge themselves when the game is up. They
cause physical suffering to themselves but not usually to their relatives. Munchausen
syndrome has been described in children, the confabulations being made by the child.
Case 1 seems to be the first example of “Munchausen syndrome by proxy”. The repetitive
poisoning of a child by a parent (case 2) has been described before. Rogers and colleagues(2)
described six cases in 1976 and they suggested that such poisoning was an extended
form of child abuse Larsky and Erikson(3) suggested marital conflict as a possible
cause for such poisoning, one spouse harming a child who was considered to be unfairly
favoured by the other. The resulting illness of the child tended to restore marital
relations at the child’s expense.
None can doubt that these two children were abused,
but the acts of abuse were so different in quality, periodicity, and planning from
the more usual non-accidental injury of childhood that I am uneasy about classifying
these sad cases as variants of non-accidental injury. Whatever label one chooses
to describe them, these cases are a reminder that at times doctors must accept the
parents’ history and indeed the laboratory findings with more than usual scepticism.
We may teach, and I believe should teach, that mothers are always right; but at the
same time we must recognise that when mothers are wrong they can be terribly wrong.
Asher began his paper on Munchausen’s syndrome4 with the words “Here is described
a common syndrome which most doctors have seen, but about which little has been written”.
The behaviour of Kay’s mother has not been described in the medical literature. Is
it because that degree of falsification is very rare or because it is unrecognised?
This paper is dedicated to the many caring and conscientious doctors who tried to
help these families, and who, although deceived, will rightly continue to believe
(for 6 years? - ed.) what most parents say about their children, most of the time.
REFERENCES
1.
Sneed, R. C., Bell, R. F. Pediatrics, 1976, 58, 127.
2. Rogers, D., Tripp, J., Bentovin, A., Robinson, A., Berry, D., Goulding, R. Br. med.J. 1976, i, 793.
3. Larsky, S. B., Erikson, H. M. J. Am. Acad. Child Psychiat. 1974, 13, 691. 4. Asher, R. Lancet, 1951, i, 339.
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