The Medical Detectives Volume I

by Berton Roueche

  The states of mind of most patients emerging from the post- convulsion sleep are similar. There is a harrowing sense of confusion, and then a full awakening in the midnight dark of total amnesia. The patient has no idea who he is or where he is or what has happened to him. He is often also weak, unsteady, and dizzy. Nausea, sometimes with vomiting, and headache are not uncommon. Some sense of identity soon and spontaneously returns, and from the attending doctors and nurses the patient learns his whereabouts and the nature of his situation. At that point, reorientation slows, and the deepest amnesia remains. The distant past —the past of childhood and adolescence—is the first to gradually reappear. The middle past is more difficult to recover, and the immediate past—the weeks or months just preceding treatment— is almost always irretrievable.

  Psychiatrists are generally inclined to regard electroconvulsive therapy as a useful psychiatric tool. Some are more enthusiastic than others. The late Arthur P. Noyes, director of psychiatric education at the Pennsylvania Department of Public Welfare, and Lawrence C. Kolb, chairman of the Department of Psychiatry at the Columbia University College of Physicians and Surgeons, who together wrote the standard text "Modern Clinical Psychiatry," observe, "In the depressions of involutional melancholia and of manic-depressive psychosis, the improvement following electroconvulsive shock therapy is striking. In eighty per cent or more of these disorders, five to ten treatments are followed by full or social recovery." Justin Hope, clinical professor of psychiatry at the Tufts University Medical School, and Raymond D. Adams, Bullard Professor of Neuropathology at Harvard Medical School, take a somewhat guarded position. In a collaborative contribution to "Principles of Internal Medicine" they note, "Although carefully controlled experiments cast some doubt upon the efficacy of electric-shock therapy in terminating an individual depressive episode or preventing recurrences, nevertheless it is the authors' clinical impression that it does indeed favorably influence the course of the individual depressive episode." Aubrey Lewis, professor of psychiatry at the Institute of Psychiatry of the University of London, has expressed what seems to be the opinion of a majority of clinicians. "Electric-convulsive therapy," he suggests in a current monograph on the psychoses, "has been over-used in the last twenty years, being applied in unsuitable cases or when less severe methods would have sufficed; but this reproach has been taken from it since the new drugs have superseded it as the easiest acceptable form of somatic treatment."

  Most psychiatrists are satisfied that electroconvulsive therapy is as benign as it is beneficial. They are generally agreed (on the basis of numerous psychometric tests and other objective studies) that the patient undergoing such treatment runs no risk of basic intellectual impairment. There is less agreement on the question of memory impairment. Some investigators have recently suggested that the more or less permanent amnesia resulting from repeated electric-shock treatments may not be confined to the period immediately preceding treatment. Larry R. Squire, assistant professor of psychiatry at the University of California School of Medicine at La Jolla, reported to the third annual meeting of the Society for Neuroscience, in San Diego in 1973, that controlled tests involving memory of long-past events indicated that repeated electroconvulsive stimulation "apparently produces a defect in recall which can extend to memories that are some twenty years old, [but] it is not yet known how long this amnesia . . . persists." And J.-O. Ottoson, a participant in the 1967 International Congress of the Academy of Psychosomatic Medicine, observed in a paper entitled "Memory Disturbance After E.C.T.—A Major or a Minor Side Effect?" that while "in most cases memory impairment soon vanishes . . . some patients have prolonged, perhaps irreversible, disturbances." These, however, are minority cautions. The majority view would seem to be the one proclaimed by the editors of the 1973 edition of "The New Home Medical Encyclopedia." They conclude, "Memory may be somewhat impaired as a result of the treatment, but it returns when the full course of treatment is terminated." This is the reassurance that most patients are given as they prepare to leave the hospital after treatment. It is precisely the reassurance that Mrs. Parker received at the end of her hospital stay.

  Mrs. Parker's return, on April 13, to the apartment that had been her home for many years was something of a deja-vu experience. She had an uncertain feeling that she had been there before. It was strange, and yet familiar.

  "It was all very peculiar," Mrs. Parker told me shortly after her retirement. "I was puzzled—but only vaguely. I really felt too vague to care. Nothing really bothered me. Not at first. I felt physically very well. I felt vegetablized and calm. I didn't have enough memory to think, or even worry, with. And then, because the apartment was so familiar, my mind seemed to open up a little, and my memory began to come back. I mean my memory for where I was—for simple, household things. Although there were odd gaps even there. I remember my first morning at home. I thought of breakfast, and my mind was a blank. I turned to Alan: 'What do I usually have for breakfast?' He looked a little startled, but he told me—an egg and a cookie. Oh, yes. I remembered. I was full of questions. It was like beginning life all over again. I said something one day about the hospital, about the bills, and Alan said Blue Cross was taking care of it. Blue Cross? I didn't know what he was talking about. I'd never heard of it. And, of course, Watergate. I kept hearing 'Watergate' on the radio, and seeing it in the paper. It meant nothing to me. So Alan had to explain. That was the way I remembered, the way things came back, the way I relearned.

  "The hospital had told me to take it easy, to rest at home for a few weeks, not to even think about my job. I had a general memory of my job. I knew where I worked, and that I was an economist and analyst. But it was no problem not to think about my work. Work was just something that drifted across my mind from time to time. It didn't interest me. I was too comfortable doing nothing. I've always been a great reader, but even reading didn't interest me now. I read a couple of novels, and the minute I put them down I forgot everything about them. I read a book called Zelda, but I don't remember a single thing about it. Any more serious reading—a book that required any background of general knowledge—I simply couldn't read. I couldn't understand it. So I gave up trying and just let myself be comfortable. And I was comfortable. I got to know our friends again. We went out to dinner now and then. We went to the movies. I kept house. I functioned very well.

  "I went back to work in July. The rest at home and some sessions with a sympathetic psychotherapist had done me good, and I felt almost like my old self again. My memory seemed to be coming back the way the hospital had told me it would. I was eager to work, eager to put my mind to work again. And I was curious. I wanted to find out what I had been working on before I took my sick leave. So I went back to work one Monday morning and up to my office and sat down at my desk, and my old associates flocked around. Most of them looked familiar, and I was able to remember some of the names. I was still feeling pretty good. Then I started going through my desk—all the current papers and pamphlets and so on. I gathered that I'd been working on the income of securities dealers—relating their earnings to the gross national product. The papers were full of professional terms that seemed familiar. I knew what they were, but I didn't know what they meant. 'Over-the-counter,' for example. It was a familiar term, but I didn't know—I couldn't remember—exactly what it referred to. 'Mutual funds' was another. And 'odd-lot dealers.' All blanks. But I had a vague idea that there was something that might help, that might get me reoriented. I went to one of the girls. I hemmed and hawed, and said I'd forgotten but wasn't there some particular book that I had been using? 'Oh, sure,' she said. 'You mean that book you got at the National Association of Securities Dealers meeting in December.' I said I guessed that was it, but had I been at the meeting? She almost laughed. She said, 'Were you there? Why, Natalie, you practically ran it. It was you who asked most of the questions. It was you who got most of the information we needed.' It was a terrible moment. I thought I was losing my mind. I had no recollection of it at
all. And then, like a shadowy film, I got a dim sense of a man sitting on my left in a meeting room. But that was all. Just the shadow of a presence. My friend just stared at me.

  "I came home from the office that first day feeling panicky. I didn't know where to turn. I didn't know what to do, I was terrified. I've never been a crying person, but all my beloved knowledge, everything I had learned in my field during twenty years or more, was gone. I'd lost the body of knowledge that constituted my professional skill. I'd lost everything that professionals take for granted. I'd lost my experience, my knowing. But it was worse than that. I felt that I'd lost my self. I fell on the bed and cried and cried and cried.

  "But you know how it is. One always hopes, or tries to hope. I told myself that maybe it was only a matter of time. If I was patient, maybe in time everything would come back to me. So I went back to the office determined to try. I was going to start all over again. I was going to relearn. I started looking everything up and making elaborate notes. It was like learning to walk—I started out taking little baby steps. The days and weeks went by, and everybody at the office was good and patient and helpful. Every now and then, I'd get a little glimmer. But mostly it was discouraging. There weren't just gaps in my memory. There were oceans and oceans of blankness. And yet there seemed to be a kind of pattern. My childhood recollections were as strong as ever. That, I've gathered from my reading about electric shock, is quite typical. The fog of amnesia increased as I came forward in time. The events of the past several years were the blurriest and the blankest. Another area that didn't seem to be affected was ingrained habits—repetitive acts and procedures. I mean, I hadn't lost my command of the English language, I still knew the multiplication tables, I could still do double-entry bookkeeping. And then there was an area that I call emotional. I could still remember experiences from any period of my life that had had a big emotional impact. Good and bad. I could remember pains and hurts. And I could also remember a trip we took to Spain only a few years ago. A wonderful trip.

  "But the worst of all my problems was that I couldn't seem to retain. I couldn't hang on to my relearning. Or only a part of it. The rest kept sliding away again. I think there was.—and is— another factor involved in that. I mean my teeth. My ordeal at the orthodontist goes on and on. And it's a constant worry, a constant distraction. I think that stands partly in the way of my relearning. Anyway, sometime in August I was so discouraged that I had an idea. I was still seeing my psychiatrist—the psychotherapist. Well, one day I asked him about the possibility of recovering my memory through hypnosis. He said he didn't know but he would try to find out. The next time I saw him, he gave me the name of a professional hypnotist. I got in touch with the man and made an appointment. I told him my troubles, and I told him what I had in mind. My idea was to be put to sleep and then asked where I had bought the dress I had on. That was to sort of start my memory working. Then, if I remembered that, he was to ask me the meaning of a term we use at the office—a certain labeling of a concept on which I've written a dozen little treatises. But that wasn't what he wanted to do. He was a Freudian psychoanalyst at heart. He got me talking—to blubbering out a sort of intellectual life history. It began with how I could hardly wait to go to school when I was a little girl, and then on to how I never cared about amassing money but only about amassing mental capital— and now it's gone and I want it back. That was on my second visit. I saw him three times, but we never got together. All I wanted was a kind of parlor trick. I wanted him to pull my memory back. All he wanted was to analyze me. That was the end of it. He said he could help recover an emotional memory loss—but not a loss from brain damage. He didn't seem to know anything about electric- shock memory loss. He said he couldn't do much about that. So we both gave up.

  "I believe the electric-shock literature is right in one regard. My brain may be damaged insofar as part of my memory has been erased, but my mentality is certainly not impaired. I can still use my mind. And, except for that period of vegetating at home, I've never lost my intellectual curiosity. I was curious almost from the beginning to learn more about what had happened to me—about the whole idea of electric-shock therapy. So I began to look into the literature. I got a list of references from the National Institute of Mental Health. That was around midsummer. I went through the list at one of the medical libraries—the George Washington University library. The result was almost nothing. The authorities all seemed to be parroting each other. I couldn't find a single study that tested the permanence of memory loss. Then, almost by accident, I got started on a little investigation of my own. Soon after I went back to work, I devised a routine to handle my inability to recognize the names and faces of people around the office. I would say, 'I'm sorry. I haven't any memory. You will have to tell me who you are and what you do.' I was going through this one day with a man from one of our coordinating sections when he stopped .ne. He said, 'You don't have to apologize to me. My wife had shock treatments a couple of years ago, and she hasn't any memory either.' Well, you can imagine my interest in that. I got him to sit down and tell me all about it, and I made notes on it later. He told me, 'Within a few weeks after her discharge, my wife got reoriented to the main outlines of her life. After that, there was very little further spontaneous memory return. I'm a statistician, so I'll put it this way: maybe she improves three per cent a year. She gets by. For the life of a suburban housewife, she doesn't need much memory—the kaffeeklatsches and all that.'

  "That conversation was the beginning. I started bringing up the subject of electric shock whenever I met new people, and it's absolutely astonishing how many people have a relative or a friend or somebody who has had the treatment. I met a museum friend of Alan's at an art exhibition in Baltimore whose aunt had had the shock experience. He said her memory for the year that preceded treatment was a blank, but she could function. She has money, he said, and doesn't work—just lives quietly at home. I remembered an older woman from my home town who had had shock treatments maybe twenty years ago. She was a professional woman—a dietitian. I wrote and asked her about her experience. She told me, There was a lot of memory I never got back. But I did manage to relearn my work—all those recipes and things.' Another person I questioned was a man who had been at the hospital with me. He was a political analyst for the C.I.A., but he hadn't gone back to work. I talked to him at his home. He said he could remember the general type of work he had been doing but not the specifics. Then there was a lawyer I met. He had had shock therapy about four months before. He told me, 'I haven't any memory, but I have a book that I look things up in.' I questioned about a dozen people in all, and there really wasn't much difference in the answers. Their experience was pretty much mine. Oh, yes—I even wrote to Senator Thomas Eagleton. I thought his experience would be interesting. After all, it cost him the Democratic Vice-Presidential nomination. But he never acknowledged my letter.

  "All that while, of course, I was trying to work—desperately trying to relearn my job. But it was heartbreaking. It was so slow.

  I was relearning, but only a little, only after a fashion. It was like tunnel vision. I couldn't seem to see the whole panorama anymore. As far as my actual job went—the job I was being very well paid for—I was doing nothing. I was totally unproductive. I wasn't worth my salary, and I didn't see how I ever would be again. No one was pushing me. Everyone was wonderful. Still and all, the office isn't running a home for incurables. So I did what seemed to me the only sensible thing. I applied for disability retirement. I asked for one concession. I asked to be allowed to stay on—without pay—as what's called a 'guest employee.' They were kind enough to grant both of my requests. I have my retirement, and I also have a desk at the office. I go there almost every day. I can type. I can do low-level clerical work. And I'm trying, still trying, to rebuild my mental capital."

  Mrs. Parker and I had our first conversations in the fall of 1973. We met again, by prearrangement, some four months later—early in 1974. She told me at once that
there had been no appreciable progress in her efforts to recover her professional past.

  "But I don't want to sound like a pill," she said. "I mean, I mustn't give the impression that my experience with electric shock was a total disaster. There have been some beneficial results. For one thing, my physical health has improved. I'm beginning to eat again, my digestion is much improved, and I have no trouble with sleep. I also feel emotionally relaxed. And I've lost a lot of bothersome inhibitions. I don't shrink the way I used to. I got in a cab the other day that had a big 'No Smoking' sign, and the driver was one of those know-it-all non-stop talkers. But I interrupted him. I said, 'I see you have a rule against smoking. Well, I've got a rule against talking.' He gave me a look, but he shut up.

  "I'm thankful for those little blessings. I'm thankful that I got something for the price I paid. Because my memory is still as blank in those certain areas as it was when I went back to work in July. I walked out of the office one evening last week with a man I'd worked with very closely for a number of years. He was saying something about his children, and I asked how many children he had. He looked surprised. 'Why, six,' he said. I said, 'Well, that's a statistic I would certainly think I'd have remembered.' He said, 'Yes—I would have thought so, too. You were always telling me that six was too many.' That's just one example. I could give you dozens more. It happens all the time, and it makes me feel so stupid. It keeps reminding me of how much of myself I've lost. There are times when I almost wish I were back in those weeks of resting and vegetating at home. When I didn't know what I know now. But that's a little frightening. If I hadn't been a professional woman—if I hadn't been a woman with a highly specialized and demanding job—I might never have realized the extent of my amnesia. I would have thought that I was still perfectly whole and complete."