"That took a little time. We had to develop a technique for measuring zinc in the saliva. What we did finally was adapt an atomic-absorption-spectrophotometric technique to measure the tiny amounts of zinc involved. We isolated the zinc-containing protein in saliva, and named it gustin. Gustin is responsible for the growth and maintenance of the taste buds, and in hypogeusia victims it is diminished in concentration. The result of our work was to establish that zinc is one essential of the taste process. And realizing that enabled us to revise our clinical thinking. We had made the mistake of using the serum-zinc concentration as a diagnostic measure. But now we know better. We now measure salivary zinc—and with notably accurate results. We find in an impressive number of cases that victims of hypogeusia have a low level of salivary zinc. And we find that an impressive number of such cases respond to zinc therapy. The salivary-zinc level goes up. And taste acuity returns. We're beginning to know who we can help—and who we can't. We've still got a long way to go. But I think we're over the hump.
"I mentioned that well over a million Americans are suffering from some form of taste or smell dysfunction. That's a lot of people, and problems of taste are very disagreeable problems. Eating is a basic pleasure. I would say that eating and sex are the two basic pleasures in life. We're being told now that the pleasures of sex may well be enjoyed into very ripe old age, and I hope it is true. But it is certain that eating is with us all the years of our life. A life without pleasure in eating—a life in which nothing tastes good and much tastes awful—would be hard to endure. We hope that we're on the way to bringing help to those unhappy people who are forced to endure it. Oh, there's so much ahead of us. I'm an activist and an enthusiast, and the potential in our work could hardly be more exciting. We're on the threshold of a new technology. I'm thinking beyond the treatment of hypogeusia— important as that is. I'm thinking, for example, of the day when we can order the chemistry of saliva in such a way as to prevent dental caries and gum disease. I'm also thinking of what a fuller knowledge of the physiology of taste could mean to the food industry. We know now that the taste receptors can be manipulated. Sour or bitter can be made to taste sweet. Think what the refinement and application of that phenomenon would mean to the diabetic, the obese, the hypertensive, the heart sufferer. Sweetness without sugar, sweetness without sweeteners. No more worries about saccharin or the cyclamates. Think—just think—how happy the U.S. Food and Drug Administration would be!"
[1977]
CHAPTER 17
As Empty as Eve
Natalie Parker, as I'll call her, is an attractive woman of medium height, with large gray eyes and light gray hair, but thin —still painfully thin. She is in her early fifties, and is an economist by profession. Her husband, Alan, is an artist and illustrator. The Parkers live in Washington, in an apartment on J Street that also includes Mr. Parker's studio. They have no children. Until September of 1973, when she retired for reasons of health, Mrs. Parker was employed—and had been for more than twenty years —at the Department of Commerce. Her work there involved certain aspects of the computation and analysis of the gross national product.
The misfortunes that led to Mrs. Parker's premature retirement began in the spring of 1972, when she learned from her dentist that she had a serious gum problem. He referred her to a periodontist of his acquaintance. In June, the periodontist, after a long and interested examination, referred her to an orthodontist for the realignment of several teeth affected by the condition of her gums. The orthodontic work was not a success. Indeed, as Mrs. Parker subsequently declared in an application for disability retirement, the results were both mechanically and cosmetically "disastrous." They were also emotionally daunting. As the summer passed and autumn came on, she began to despair, and fell into a deep depression. She was tired all day, she couldn't sleep at night, her teeth hurt, her appetite vanished. Her family physician prescribed a conventional tranquillizer. She continued to work, but with increasing difficulty. Her weight dropped from a normal hundred and eighteen pounds to a hundred and ten, and then to ninety- eight. By Christmas, it was down to eighty-nine. Her physician referred her to a consulting psychiatrist. The psychiatrist's prognosis was guardedly hopeful. He thought a period of rest in a relaxed environment would be a sufficient restorative. The environment he had in mind was that of a psychiatric hospital. Mrs. Parker was at first appalled. The idea was socially unacceptable. In time, however, her resistance weakened, and at last, too discouraged to care, she allowed herself to be admitted for observation to a well-appointed hospital with which the psychiatrist was associated. That, according to Mr. Parker, was on February 8, 1973, and his recollection is confirmed by the hospital records. Mrs. Parker herself has no recollection of that decisive event. She has, in fact, no recollection of any part of her hospital stay. Mrs. Parker's stay in the hospital lasted about nine weeks. She was discharged around the middle of April. Nothing of that time remains in her memory but an occasional shifting shadow, a half- heard sound, an indefinable feeling. She has had to recover the nature of the experience from sources outside herself. One of these, of course, is her husband. Mr. Parker came to the hospital every day for a leisurely visit, often joining her for lunch or dinner, and he sometimes took her out for a drive or for an afternoon of shopping. Another source—an almost eerily definitive source—is a series of letters that she wrote to her parents, in Boonville, Missouri, nearly all of which they fortunately preserved. The first of these letters was written on February 16, the ninth day of her hospitalization. It reads:
Well, here I find myself in a totally new experience for me, and one I never expected to have—residing in a mental hospital. This place is a nice new building. The atmosphere and decor are those of a hotel. The patients, nurses, and other staff members all dress in casual clothes—no uniforms. There are two patients to a room. Most of the patients here are perfectly lucid, though some are kind of mixed up. One woman laments that she knows that she is going to live forever, whereas she would rather die. There is a cute young colored girl who worries because she thinks the Communists are taking over the world etc. But all are perfectly harmless.
[Alan] has been coming over to have lunch and dinner with me. I am a unique patient here. Some are on drugs, some are on electric shock, some are on individual psychotherapy, and some are on group therapy. I seem to be on a sort of do-it-yourself therapy—in other words a sort of rest cure. I had been assigned to the head doctor (I mean the chief doctor; I guess they are all "head doctors"), but I felt dubious about him. Also, one of the patients told me that he is noted for wanting to give all of his patients electric shock. I told him that I had the same kind of intuition about him that I had had about the orthodontist—namely: This man doesn't understand my case. I said that after being turned into a monster by the orthodontist, I didn't want to take any chances on being turned into a hopeless lunatic by him. So I lounged around for several days in nobody's charge, and then was assigned to a young fellow (thirtyish) named Dr. [Smith]. I told him my problem was that I have to get adjusted to life as a damned ugly woman. He said, "You certainly have a gutsy way of putting it." Actually, the name of what ails me is depression. After fighting the battle of the hopeless dental work for so many months, I was so worn down that I lost all appetite for food, work, or anything else. Every little thing—even putting my clothes on—seemed as difficult as climbing Mt. Everest. I tried resting at home, and tried going back to work, but nothing got me into gear again. The medical doctor recommended that I talk to a "consulting psychiatrist," and the latter recommended that some time in the hospital—change of environment and no need to push myself—might get me going again. So here I am. I look at it philosophically, and when I get out I will tell people that it is "mod" to be "mad."
Don't worry about my being out of my head. It is not like that at all. I pulled myself together a few days before I came here and made out all the income-tax forms—federal and D.C. and estimated tax. I didn't want to leave poor [Alan] with that
job because I have always done the household paperwork and he wouldn't know how.
The next letter in the series was written about a week later, on February 25. It reads:
I continue taking it easy here—something like living in a college dorm. My main pals seem to be the girls in their twenties. Perhaps the teeth braces automatically identify me with the younger group. I had thought that I might get to tell my dreams and interesting life experiences. But instead I get a diet supplement and a laxative pill. There is quite a lot of humor around here of the type [Alan] calls gallows humor. One little girl is determined to commit suicide but can't figure out any way to do it here. I offered to save up a hundred laxative pills for her. She got the giggles. My case has been so mixed up that they only got around to giving me my entry exam a couple of days ago—two weeks after I had come here. Apparently I am O.K. except for being weak and run down. A nurse was doing something at her desk with rubber bands, and I told her in case I got violent, she could use one of those to restrain me.
A following letter in the series, written early in March, appears to have been lost. The next, and penultimate, letter is dated April 5. It reads:
I certainly am in a strange state. Early last week I suddenly came to—so to speak—and wondered where I was and how I got here. I learned that I had had something called "electric-shock treatments" that had caused me to lose my memory. Now I know how Eve must have felt, having been created full grown out of somebody's rib without any past history. I feel as empty as Eve.
I can remember a few things. I know my phone number and who my relatives are. However, the letters from you all that I found in my dresser were completely new to me. I reread them without any recollection of having read them before. There were a number of get-well cards, and some were from names I didn't recognize. There were a couple from a [Margaret Davis], who [Alan] says lives on our floor, but I don't remember her. Also some from people in the office whose names sound familiar but whom I couldn't visualize.
A cute-looking young fellow with a turned-up nose came in to see me and was asking how I felt. I told him I felt all right except that I couldn't remember much of anything. I asked him who he was and he said he was my doctor. Then I asked him what kind of doctor he was. He looked surprised, and said he was a psychiatrist. I said:
"A psychiatrist! Then I must be crazy." He said: "Oh, no, no!" However, I presume I must be off balance to some extent or I wouldn't be in what turns out to be a mental institution.
Actually, the so-called patients here all seem to be in command of their wits except for one—namely, the woman who has been my roommate for the past couple of days. She is a nice-looking woman and about my age, but she talks a blue streak, pure nonsense—on and on about the Pope and sex and euthanasia and syphilis and strangers' toothbrushes and God knows what all.
This morning I went to the orthodontist and this afternoon I have an appointment with the periodontist, Dr. [Brown]. [Alan] has kept track of my appointments—otherwise I wouldn't know about them. Oddly, I can remember Dr. [Brown's] attractive red-and-black waiting room, but I can't remember him—don't know whether he is young or old, short or tall. I haven't the slightest idea what kind of dental work he is doing to me.
Mrs. Parker wrote her final hospital letter to her parents on the following day, April 6. She had learned by then that she had been given a total of eight treatments. Her letter reads:
For the first several days after those electric-shock treatments were over—possibly as long as a week—I felt just fine, perfectly relaxed and comfortable and also very hungry, as if I were making up for lost time. However, beginning Monday night (today is Friday) I began feeling all churned up and nervous and jittery and tense for no reason, and I have felt that way ever since. [Alan] said that what I was describing was the way I have felt for a long time. Then, beginning last night, in addition to feeling tense and agitated, I also felt scared, also for no reason.
Somebody the other day asked me to make a fourth at bridge and I refused, saying I hadn't played bridge for at least fifteen years. Then he said I had been playing right along for the two months I had been at the hospital. Also I was surprised to find a very pretty black-and-white checked raincoat in my closet. [Alan] told me I had bought it one day soon after I came here when we went out to get my hair fixed. They tell me that gradually I will get my memory back. I hope so.
Electroconvulsive-Shock therapy is a relatively recent refinement of a primitive procedure that was first employed around the turn of the eighteenth century. Johann Christian Reil (1759—1813), a German neurologist and anatomist whose name distinguishes several structures of the human body, is generally regarded as its pioneer proponent. Reil's curious contribution to psychiatry was a product of his interest in the then just forming humanitarian opposition to the traditional chain-and-shackle treatment of the mentally ill. Reil went further than most of his associates in the movement. It was not enough, in his opinion, that the inmates of the madhouse be merely freed of their fetters. They should also, he proposed, be given some sort of restorative treatment, and after consideration he came up with a plausible psychotherapeutic program. Its aim was to frighten, or shock, the patient into rationality. Reil's regime could be administered in many different ways. The unsuspecting patient might be suddenly seized and flung into a pond. Or a cannon might be shot off behind him. Or he might be wrenched from sleep to face a hovering ghost. More heroic measures were prescribed for stubborn cases. Medical historians of the period have reported elaborate tableaux (with large casts drawn from the madhouse staff) that depicted such salubrious horrors as a resurrection of the dead, the Last Judgment, the yawning gates of Hell. Reil called his treatment "noninjurious torture."
If Reil was the first to attempt an instant psychotherapy, he was also (except for the perennial hypnotist) the last. Most subsequent attempts to achieve an immediate emotional rehabilitation by means of a cathartic shock have employed a chemotherapy. The renowned eighteenth-century American clinician Benjamin Rush was responsible for one of the earliest of these. Rush treated mental patients in his Philadelphia practice with a shock therapy that involved the induction of suppuration at the back of the neck to excite a tonic discharge "from the neighborhood of the brain." The triumphant confirmation in the late nineteenth century of the germ theory of disease provided a more convenient method of producing a chemotherapeutic shock. In 1890, the Austrian neuropsychiatrist Julius Wagner von Jauregg used an extract of the tubercle bacillus to ignite what he hoped would be an explosively curative fever in an insane patient. This early effort was not a success, but many years later, in 1914, he tried again, with the malaria organism, and this time achieved a distinct improvement in the condition of a group of men suffering from general paresis. The discovery of insulin, in 1921, made possible a variety of chemotherapeutic shock that remains the awesome ultimate in the pharmacopoeia of psychiatry. Another Austrian, a clinical investigator at Berlin's Lichterfelde Hospital named Manfred Sakel (1900-57), is recognized as the discoverer of insulin as a psychiatric tool. Insulin is distinguished for its power to reduce the sugar content of the blood, and it is this power, of course, that makes it a salvational drug in the treatment of diabetes. Its impact on a normal person is very different. A large injection will produce confusion, deep sleep, and, finally, coma. It was this capacity that interested Sakel. He first experimented with the induction of insulin shock, or hypoglycemic coma, as a means of calming morphine addicts during a withdrawal period. The results (when he learned to reverse the action with a timely dose of glucose) were gratifying enough to encourage him to try the same treatment in other excited states, and in 1933 he reported its usefulness in the treatment of schizophrenia. Sakel's estimation of the value of his work was soon confirmed by other investigators, and insulin-shock therapy—though not without drawbacks, and even dangers—is still in widespread use. It is, however, most highly esteemed as the inspirational prototype of electroconvulsive therapy.
The pr
inciples of electroconvulsive therapy were developed by the Italian clinicians Ugo Cerletti and Lucio Bini, and first described by them in a report (entitled "L'Elettroshock") to the journal Archivio Generale di Neurologia, Psichiatria, e Psicanalisi in 1938. Electric shock differs from other forms of shock therapy in that it involves the direct mechanical manipulation of the brain to produce a generalized convulsion, or epileptiform seizure. It is thus a physiotherapeutic treatment. Cerletti and Bini conceived electric-shock therapy as a treatment for schizophrenia—as an improvement on Sakel's insulin shock—but subsequent investigators have found it most effective in treating the depression of old age (involutional melancholia) and the depressive phase of manic- depressive psychosis. The procedure currently in vogue is as simple as it is direct. Electroconvulsive therapy is usually given in the morning, and the patient is prepared for it as if for surgery: he is allowed no breakfast, and false teeth, if any, are removed. He is positioned comfortably in bed on his back, and given an intravenous injection of a muscle-relaxant drug and a complementing injection of a hypnotic to maintain normal respiration. An electrode is then placed on each temple, and an alternating current of (usually) eighty or ninety volts is passed between the electrodes for a fraction of a fraction of a second. In that stupendous instant, the brain is so raced that the mind cannot function, and it is from this eerie quietus that the beneficial results of the treatment appear to spring. Just why a halt in cerebral function should be therapeutic is not, however, known. Most cases of depression require several such treatments, and the usual course is between eight and twelve convulsions. In the early days of electroconvulsive therapy, before the development of a satisfactory muscle relaxant, fractures or dislocations were frequent in the moment of violent seizure, but they are now relatively rare, and the patient passes from a brief (four or five minutes) unconsciousness into a peaceful sleep.
The Medical Detectives Volume I Page 30