The Medical Detectives Volume I

by Berton Roueche

  "We drove back to L.A. on Saturday, July 31. On the way, Pat and I got into a fight. I can't remember what about. Maybe it was me. But we ended up not speaking for the entire seven hundred miles. We went to bed not speaking. I woke up at five o'clock on Sunday morning. I had this feeling that I had to do something. I can't explain it any better than that. I went into the bathroom and got down Pat's razor and took out the blade and began to slash my wrists—first one, then the other. Look! You can still see the little scars. I didn't want to die especially. I just wanted to take some action. I don't know why. And I don't know why it took that form. Anyway, I was standing there at the sink with the water running and washing off the blood when Pat woke up and saw me and began to scream. I remember how he screamed. I must have been an awful sight. But he had the sense to get me dressed and rush me to the emergency room of the nearest hospital. They stitched me up, ten stitches—and gave Pat a sedative. I let them do what they wanted. I wasn't saying very much, but I had the feeling that a great weight had been lifted off my shoulders. I don't know why."

  There was a pause. Mrs. Terry looked blankly down at her desk, then abruptly raised her head. "Two days later," she said, "I had my first psychiatric consultation." Her voice had an edge to it. "Pat had telephoned my parents, and they flew down and made the arrangements with our family doctor. I spent a month in a psychiatric hospital in the L A. area. It wasn't until I was settled there that I began to realize what I had tried to do. I was so ashamed, I felt so guilty. I told you I was raised a Roman Catholic. And the thought of all the trouble I was causing was almost too much to bear. And I was depressed. I hardly said a word for three days. Then I began to feel a little better. I suppose my guilt began to wear off. So I was discharged. The psychiatrist thought it best that I not be alone, and it was decided that I'd go back to Salt Lake City with my parents. That meant a separation for Pat and me, but I don't think either of us really cared. He felt humiliated by what I had done. Our marriage was shakier than we had thought. And, of course, I had other things to worry about. The hospital psychiatrist referred me to a psychiatrist in Salt Lake City. He and the psychiatrist in L.A. are one and the same in my memory. I don't mean they looked alike. I only mean they had the same moves. I'd been on Thorazine in L.A. The Salt Lake City man started me on Tofranil, and when that didn't seem to work he put me back on Thorazine—six hundred milligrams a day. At our consultations, he expected me to talk. All he did was listen. Whenever I asked a question, he simply threw it back at me: Why do you ask me that? He seemed to have made up his mind about me before I ever walked into his office. I realize now that I already had a permanent label, a category. And those people, the psychiatrists, deal entirely in labels. I was an attempted suicide. That translated into a case of hysteria. Everything I said was interpreted according to my category. Categories behave in such-and-such a way for such-and-such a reason. He went away for two weeks, and at our next meeting I said—just to be polite, just making small talk—How was your vacation? He gave me a smug look. Oh, he said, you're angry because I went away and left you. Actually, I was angry. But not for his smug reason. I was angry with him because something frightening was happening to me, and it didn’t bother him at all. I was having trouble with my hands, they fell shaky and clumsy. It was getting hard for me to do all kinds of manual things—like fixing my hair, or buttoning a blouse, or washing my face. I wanted to know why. He wouldn't, or couldn't, tell me anything. He would just nod and say I was angry with my husband. I remember asking, 'Why can't I make my hands stay still?' He said, 'Why do you think?' I got so sick of that kind of talk that I began to cancel my appointments.

  "That was in early October. He interpreted my behavior as antagonistic and suggested that I might do better in a hospital environment. I let him admit me to the psychiatric ward of a hospital he was affiliated with. I think he was tired of me. He saw me there, but only occasionally, and then he only looked in. The treatment was more Thorazine and group therapy. They put me to work making things—working with my hands. And I could hardly get a button through a buttonhole. I've always been a great reader, and I was spending most of my time reading. I read From Here to Eternity while I was there, and also some psychology so I could try to understand myself. But then I found I wasn't really absorbing what I read. I couldn't concentrate anymore. Oh—and also about that time I began to drool. That was almost the worst thing of all. And there was nothing I could do about it. I just sat there and drooled. The strange thing—although I didn't know it then—was that the usual effect of Thorazine is dryness of the mouth. But nobody seemed to notice or care. I began to get the feeling that I couldn't talk. I don't know how to explain that. I knew I could talk, and yet I felt I couldn't. I was so miserable. I began to feel I wanted to die. Really die. That whole period is a little blurred in my memory—partly, I suppose, because of all that Thorazine. But I remember certain moments vividly. I remember that just before Thanksgiving I had the feeling I was actually going to die that very night. My mother came to see me that afternoon, und I made her take my wedding ring and gold necklace. I was afraid one of the hospital people would steal them that night off my dead body. When I woke up the next morning and found I was Mill alive, I refused to believe it. I told everybody I was dead. I insisted. That's all I remember of that episode. But about that time they gave me a series of tests, physical tests. I don't know why they did, or why they waited so long. They did various blood tests, a brain scan, and a liver-function test. They told me my liver was enlarged. The reason, they said, was all that Thorazine. So they took me off Thorazine, and put me into electroshock therapy. I suppose they talked to my parents and got their permission. I had three treatments, and there seemed to be some improvement. My psychiatrist said I was sufficiently improved to go home. But they were mistaken. I began to feel I was really off my rocker. Pat came up to see me, and we were driving somewhere, and I tried to jump out of the car. The psychiatrist decided they hadn't gone far enough with my electroshock therapy. He put me back in the hospital for a full course. I had eight treatments. There really seemed to be some improvement this time. I felt less groggy, less dopey. I was discharged on January 1, and went home to my parents again.

  "My new routine was occasional psychiatric consultations, and group therapy. It was much the same as before. Everything was getting harder and harder for me—tying my shoes, opening jar lids, setting my hair, writing, even signing my name. But every time I tried to discuss it with the psychiatrist he simply shrugged and said what he had always said: This was my way of showing resentment toward my husband. Group therapy wasn't any more satisfactory. I wrote an account of what I thought was wrong with the way the group was run. I typed it out—hunt and peck; it took forever—because nobody could read my handwriting anymore. I asked the psychiatrist if I might read my report to our group. He refused. That finished it for me. I had stayed with it all spring and summer, but now I was through. I was totally fed up with him and his methods. He was really just laying his own hangups on us. So I resigned. That was in September. I was at a loss. All of my symptoms were worsening, and some new ones were coming on It was getting hard for me to chew and swallow. My right leg was acting funny, I was beginning to limp. My balance was off. I don't know how many times I tipped over and fell down. I was covered with bruises. But, worst of all, I began to have trouble speaking, I couldn't seem to articulate; everything came out slurred. Even my family had trouble understanding me. Pat couldn't cope with it. First suicide, then psychiatry, now this. He felt that I was shaming him, that I reflected on him as a man. We both realized that our marriage was over. We were too different. We started divorce proceedings. At the same time, I had a desperate idea. The only part of me that seemed still to be functioning normally was my mind. I could still think. So maybe my trouble wasn't emotional, psychological, functional. Maybe it was basically physical. I arranged to see a neurologist. We talked and he examined me. He checked my reflexes and my walk and so on. I went to see him four times. Finally h
e told me that my problem was entirely psychological. He said my physical problems were side effects of Thorazine. He put me on L-dopa, the drug they use to control the spasms in Parkinson's disease, and referred me to a psychiatrist. Not the one I had been going to. A different one.

  "Of course, there really wasn't that much difference. In my experience, there never is. Psychiatrist No. 3 took me off L-dopa and put me on another tranquillizer—an antidepressant called Sinequan. He told me that the cause of all my troubles was my unhappy marriage. He said my shaking hands were an expression of a suppressed desire to hit my husband. At home, I spent most of my time lying down—I could speak better and swallow better in that position. About all I could do was look at television. I had practically stopped trying to read. I couldn't keep my hands steady enough to hold a book. I began to lose weight. It was difficult for me to swallow even water. My parents were about out of their minds. My mother was a real nervous wreck. My father got desperate enough to take me to a hypnotist. That was supposed to conjure me out of my tremor. For maybe half a minute after I was hypnotized my hands stopped shaking. That was in December. My divorce was granted the following month. But that didn't faze my new psychiatrist. He simply shifted his ground. My problem was no longer related to my marriage. The cause of all my trouble now was simply that I didn't want to go back to work, I didn't want to accept responsibility. By the beginning of February, I had lost twenty-five pounds. You can imagine what I looked like. And I was becoming dehydrated. That was really frightening. I wanted help, real help, and all I got from my third psychiatrist was the usual questions and a few textbook answers. I finally told him that I thought I should go into the hospital again, but a different hospital this time, the biggest and best in town—the University of Utah Medical Center. He nodded his head. What I really wanted, he told me, was attention. I just wanted to be waited on. Oh, he was a real winner. But I insisted. I think it bothered him that I wanted to go into the Medical Center, because he wasn't affiliated there. He had to get a colleague to make the arrangements. I never saw him again. About a year later, I wrote to him and brought him up-to-date on my case. I thought he would be interested. He never answered.

  Mrs. Terry (Carol Francone) was admitted to a psychiatric ward at the University of Utah Medical Center on February 12, 1973. She remained a patient there for eleven days, until February 28, when "due to discontinuation of her insurance in December and unavailability of welfare insurance," she was discharged. Her "Discharge Summary," which included a comprehensive review of her case, largely confirmed her own recollection of those many months of conventional counsel and inexorably failing health. It opened, "This is the 1st UUMC admission for this twenty-six- year-old divorced white woman from Salt Lake City referred by Dr. . Chief complaint is given by the father, who reports her 'becoming catatonic.' " It continued, "The patient has a psychiatric history going back several years. She was previously hospitalized at by Dr. , the first hospitalization occurring in August of 1971, following a 'nervous breakdown' in California. She was treated with electroshock therapy X 3 and was discharged in approximately 1 week, showing marked improvement. She continued with Dr. in therapy, but relapsed in December of 1971, receiving 8 electroshock treatments while hospitalized Again she showed rapid improvement. Although the diagnosis of schizophrenia was never made, the patient did receive [Thorazine] treatment intermittently. The patient stopped seeing Dr. ----- and was referred to a neurologist, Dr. , for evaluation of muscle tightening on her right side and drooling, which was felt at the time to be a reaction to Thorazine. She did make improvement, but then, under Dr. -----'s supervision, the patient began regressing, at which time the diagnosis of secondary to Thorazine was not felt to be accurate, and, without evidence of neurological disease, hysterical-conversion symptom was considered. At this time, the patient was referred to Dr. , who treated her with Valium 20 mg a day and Sinequan. The patient has had a very stormy marriage, which was recently ended by divorce, final January, 1973. Since that time, she has progressively gotten worse, with increasing signs of muscle stiffness, drooling, and difficulty in swallowing. Prior to admission, the patient was not eating or drinking fluids properly, and was becoming dehydrated. She was not able to communicate, because of her unformed words."

  The review of Mrs. Terry's medical history was followed by an evaluation of her mental status. It read, "Alert, oriented. Patient speaks in a high, squeaky, almost unintelligible voice, which makes questioning impossible. Speech is slow, with short phrases. Follows commands readily. Psychomotor—rigid posturing of hands and fingers, hyperextended and stiff jaws. Patient moves in very mechanical fashion." The results of a routine physical examination (pulse, blood pressure, temperature, eyes, chest, heart, abdomen) were noted as being essentially normal, including "no pathologic reflexes." So, with one exception, were the results of certain laboratory tests: complete blood count, urinalysis. The exception was a test (SGOT) which determines the concentration in the blood of an enzyme whose excessive presence there is indicative of liver-tissue damage. Normal is forty to fifty units. Mrs. Terry's concentration was given as one hundred and ten.

  The "Summary" then reviewed Mrs. Terry's stay in the hospital. "It became apparent," its authors, a staff psychiatrist and a resident, noted, "that the patient did have some control over her movements, at times with a gross tremor in doing a task such as trying to tie her shoe, seeking attention and help; however, when the behavior was not attended to, the patient was able to manage adequately, at times with total cessation of her tremor. The patient improved with her food and fluid intake. Under hypnosis, the patient was able to totally relax, with entire control of all body tremors or movements. During sessions of behavior modification and shaping, her voice became very rapid; responding to socialization, it was easy to have the patient change her voice with the words becoming rapidly more distinct."

  It concluded, "Final Diagnosis: Hysterical neurosis, conversion type. Disposition: The patient is transferred to Granite Community Mental Health Center. The patient did not receive any medication during hospitalization nor on transfer. Prognosis: Fair."

  Mrs. Terry entered the Community Mental Health Center, as a welfare patient, the same day. There is no knowing how long she might have remained there—limping, drooling, trembling, mumbling—if chance had not intervened. Its instrument was a doctor on the Center staff named David Reiser. Something about Mrs. Terry's appearance prompted him to take a second look at her file. The history of her case only quickened a suspicion he had formed. Since the Mental Health Center's diagnostic facilities were not up to proving his theory, he sent her to John Shields, an internist at a neighboring clinic that was equipped to do more elaborate tests —a liver function test, a ceruloplasmin test, a serum-copper evaluation, as well as a slit-lamp examination of the corneas of her eyes.

  "I knew something important had happened," Mrs. Terry told me. "It was the way Dr. Shields and the ophthalmologist stood there looking at each other and nodding. I waited, and finally Dr. Shields turned to me. He wasn't exactly smiling, but he certainly looked pleased. He said they thought they knew what was wrong with me. He said they thought my trouble was basically not psychiatric. He said they thought I had a disease called Wilson's disease. He said he understood that it was treatable. And also, he said, it so happened that one of the leading authorities on Wilson's disease was here in Salt Lake City. His name was Dr. Cartwright, and he was the head of the Department of Medicine at the University of Utah College of Medicine. I heard what Dr. Shields was telling me. I drank in every wonderful word of it. But the thing that mattered most—the thing that put me up in seventh heaven —was that I had a real disease. I wasn't a psychiatric case. I wasn't crazy."

  Wilson's disease, though something of a rarity, is only too real a disease. It is also a peculiar one. It has its origin in a genetically structured derangement of copper metabolism, and is inherited through the coincidental presence of a certain morbidly aberrant chromosome in both the mother and the fat
her of the victim. The parents themselves, to the best of current medical knowledge, are unaffected by their possession of this baleful trait. Nor—even more baleful—is there any practical way to predetermine their carrier state.

  Wilson's disease takes its name from an early-twentieth-century British neurologist named S. A. Kinnier Wilson. His classic monograph, "Progressive Lenticular Degeneration: A Familial Nervous Disease Associated with Cirrhosis of the Liver," published in 1912, is generally accepted as the first more or less comprehensive description of the disease, and it contains an impressively accurate postulation: "There is evidence to show that the disease is toxic in origin." Copper, as mid-twentieth-century nutrition importantly established, is one of the several elements essential in minute quantities to the normal functioning of the human body (it makes possible the assimilation of iron), but like some other members of this company (most notably iron), its impact in large quantities, as has long been known, can be toxic. Wilson's disease is essentially a chronic copper poisoning. In it, the natural balance between copper ingestion and copper excretion is disturbed and the copper thus retained is stored in certain organs. The liver is its first and chief repository. In time, as the storage capacity of the liver is exhausted, the continuing accumulation passes from the liver into the bloodstream and is carried to the other organs for which copper has a grim affinity. These are most conspicuously the brain and the cornea of the eye. The relentless retention of copper begins at birth, but so efficient is the liver in its protective role that years, many years —ten, twenty, even thirty years—may elapse before the first intimations of morbidity are felt.