The Medical Detectives Volume I

by Berton Roueche

  "My weight went down to ninety-five pounds, but I made it to Labor Day. I went up to the lake on Friday, as usual, and Lewis came up that night. I gave my ecological report at the association meeting, and it seemed to be well received. I was nominated to serve on the board, and, weak as I was, I accepted and was elected. I was trying not to be sick, I was trying to be part of the living world. Labor Day weekend is always a little sad. It means the end of the season, the closing of the house until Memorial Day. We put up the boat and took down the tennis-court net and emptied the fridge and drained the pipes. I drove back home on Tuesday, and settled down for the winter, and everything went on as before. Except that by the end of September I began to feel a little better. I seemed to be in remission. I was still as weak as ever, but I seemed to be getting over that awful middle-of-the-night nausea.

  "At about that time, I got a notice from the association. There was a board meeting scheduled for the second weekend in October. I was expected to attend. Good. It meant one last visit to the lake. Lewis wasn't interested. I drove up alone on Friday. The meeting was Saturday morning. I had my dinner and puttered around and went to bed. And woke up in the night as sick as a dog. I was twitching and salivating and shivering with cold sweat. I couldn't believe it. I was stunned. I crawled out of bed and went into the kitchen and fixed myself a cup of warm milk. I sat at the kitchen table, as depressed as I've ever been. There was a paper on the table at my elbow. It was the exterminators' regular monthly invoice. I'd seen it earlier, but I hadn't really noticed it. It was too ordinary. When we bought the cottage, back in 1971, the then owners told us they had had regular exterminator, insect- pest-control service, and advised us to continue it. Which we did. It seemed like a good idea. We even increased it during the summer of 1983, when we began to see a lot of carpenter ants. We had always had some, but now there were hordes, and they were huge—really enormous. So we asked the exterminators to add ants to their regular insect controls. Well, as I say, I was sitting there at the table with my warm milk and looking at that invoice. My brain sort of went into gear. I had been feeling better, but now I was sick again. And these people had been exterminating every month for ants. The light came on. It was three o'clock in the morning, but Lewis is a night person. He would probably still be awake. I called him up, and he answered right away. I said, 'I think I know what's wrong with me. There's the exterminators' invoice here, and I'm as sick as I've ever been. Go to "Goodman & Gilman" and look up insecticides.' 'Goodman & Gilman' is 'The Pharmacological Basis of Therapeutics'—the standard text on the subject. I stayed on the phone, and Lewis came back with the book open to insecticides, to the organophosphates. He read off the clinical picture. Here's what he read: 'Respiratory effects consist in tightness in the chest and wheezing respiration, due to the combination of broncho-constriction and increased bronchial secretion. Gastrointestinal symptoms occur earliest after ingestion, and include anorexia, nausea and vomiting, abdominal cramps, and diarrhea . .. localized sweating and muscular fasciculation . . . fatigability and generalized weakness, involuntary twitchings . . .' Well, that was it. That was me. I was a textbook case.

  "I went to the board meeting, and left the minute it ended. Sunday, at home, was a long day. I was waiting for Monday. The first thing Monday morning, I telephoned the exterminators at the lake. I talked to the manager. I told him what I suspected, and asked what chemicals they were using to control the carpenter ants. He seemed astonished. He couldn't see any connection between the cottage spraying program and my illness. However, he called me back with the information I wanted. I thanked him, and told him to discontinue the spraying program. My hunch seemed horribly right, but I was trembling. The insecticides that his technicians—he called them technicians—had used were Ficam and Dursban. Dursban is an organophosphate. Ficam is methyl carbamate. You may remember reading about the so-called nerve gases that were developed in Germany just before the Second World War. Their active ingredients included one or more of the organophosphates. And that's what I had been cleaning up at the cottage on those summer weekends—the residue of an organophosphate spray. That was my hemlock pollen.

  "There are dozens of organophosphate insecticides on the market. They are wonderfully effective insecticides. They are very quickly and completely absorbed by all routes—through the skin, through the lungs, and by mouth. The organophosphates—and the carbamates, too—are what are called cholinesterase inhibitors. Cholinesterase is an enzyme found in the nervous tissue and in the blood—in the plasma and the red cells. It acts as a neural moderator. It controls the accumulation of an ester that governs the transmission of nerve impulses. It transmits the signal to raise my arm, say, or move my fingers. When that action is done, normally the impulse is erased. Carbamates and organophosphates block that normal procedure. They defuse cholinesterase. The result is a continued stimulation of the nervous system. That produces, directly or indirectly, the wide range of symptoms and signs in organophosphate intoxication.

  "I knew, or thought I knew, the nature of my illness. But, of course, I wasn't going to treat myself. I wanted expert advice. I inquired around and got the name of an expert—a Ph.D.—in pesticide operations in the Pennsylvania Department of Agriculture, in Harrisburg. I telephoned him and identified myself. And then I got a little tricky. I let him think I was asking for advice in the treatment of a patient. I thought I might get a more objective response if he didn't know that he was talking to the patient herself. As it turned out, he penetrated my little subterfuge very quickly, but I think it was a useful ploy. He was most sympathetic and helpful. He listened to my story. He agreed with my diagnosis. He pointed out a standard treatment. That was oral atropine sulfate, six-tenths of a milligram, every four hours around the clock. Atropine, or belladonna, can control many aspects of organophosphate poisoning, although not the muscle involvement. There is a drug that reverses the muscular weakness, but it can be used only in acute cases. My trouble, unfortunately, was chronic. The unhappy fact is that there is not much information about chronic exposure to subacute doses of organophosphates. As for the weakness and soreness in my thighs, the only therapy for that was hope and time. That and the avoidance of any further exposure. I remember he spoke of the accumulation of the insecticides in the ambient air of the closed cottage. He said that every time I walked in there on those summer Friday afternoons it was like walking into a fumigation chamber.

  "Well, there was no chance of that happening again. The cottage was closed for the winter, and, on the pesticide specialist's advice, we were going to arrange for a professional team to give the cottage a thorough scrubdown before we moved in on Memorial Day. Meanwhile, I was feeling very much better. The atropine was wonderfully effective. The only problem was still my legs, my weakness. But even that was manageable. Lewis's birthday is in November, and we had a long-standing plan to celebrate it with a tour of the Loire Valley. Which we did. We ate the wonderful food and drank the wine and saw the beautiful sights, and I managed pretty well. Maybe I overdid it. Because I began to get some twinges, some pain in my left knee. Still, I felt good enough to go out to Aspen in January. Now we're in 1985. I went to Colorado alone, as usual. Lewis went to Grand Cayman, to scuba dive. I'm a good downhill skier. But I wasn't this time. My legs were weak, and there was that pain in my knee. I consulted an orthopedist there, a man who knows about all there is to know about ski medicine. He did an X-ray. Negative. He found some contracture in my left hamstrings. There was no ligamentous instability. He advised me to warm up before skiing, and suggested that an arthroscopy—a kind of diagnostic surgery—might be desirable. When I got back home, I looked up a recommended orthopedist. I won't go into the hell that man put me through. He took one look at my history, saw the note about my mastectomy, and satisfied himself that I was suffering a recurrence of cancer. He put me through two agonizing procedures—an electromyography and an arthrography. Chinese tortures aimed at my knee. To no purpose. And, what was almost worse, he was always forgetting that I,
too, was a physician. 'Oh, yes—that's right,' he'd say. 'So sorry.' In other words, he treated me like a woman. I mean, like brainless. I consulted a neurologist, a woman. There were more tests. They showed a fifty per cent decrease in the strength of my left quadriceps, spontaneous muscle twitchings, and some reduced sensory response in my lower left leg and foot. Her diagnosis was peripheral neuropathy, most probably caused by organophosphate intoxication. She prescribed oral Vitamin B complex and Vitamin B,2 by injection, and some muscle-strengthening exercises. I had the feeling I was beginning to emerge.

  "I might mention that with that diagnosis established, I called one of the doctors I had consulted earlier. I thought he would be interested. He was. He said, 'Hey, my wife has a greenhouse and she uses malathion. Is that a risk?' Well, I was certainly having what they call a learning experience. About the contemporary practice of medicine."

  Dr. Page made a face. "But," she said, "good medicine or bad, tests—and I had them all—or not, I seemed to be getting a bit better. Some days were better than others, but I had only one sort of reversal. I woke one morning in March with real pain in my knee and some real weakness in my legs. The reason, when I thought about it, seemed clear enough. We had gone with some friends the night before to the annual Philadelphia Flower Show, at the Civic Center. To the opening night—very social, very black- tie. And, unfortunately, a tremendous amount of walking. The show contained acres—literally, acres—of the most fascinating displays, and I think we must have walked through them all. I just very foolishly overdid it. But that was the only setback. So then it was spring, and then Memorial Day was coming up, and I had the cleaning of the cottage to arrange. The state pesticide expert had insisted on that. I got in touch with a firm of industrial cleaners, and we set a date in May. We met at the cottage, two men and myself. It was a thorough scrub-down. They did the floors and the walls and the ceiling—it's a cathedral ceiling, with exposed beams. Plenty of surfaces. It's not my nature to just stand there. I pitched in and did the furniture. We also stripped the beds and took down the curtains and took off the slipcovers, all those things, and put them through the washer. Not only that. Before the scrub-down and after, we took samples by vacuum cleaner from all the likely places—door tops, kitchen cabinets, the baseboard radiators. The samples were sent to a commercial industrial lab—a company the state man knew about—and they did a professional analysis. When the results came through, they were shocking. All the samples—the before and the afters—showed significant amounts of organophosphates and methyl carbamates.

  The exterminator's technicians had certainly done a thorough job. They hadn't missed a nook or a cranny. And they must have simply drenched the place.

  "I say the lab reports were shocking, and they were. But I wasn't taken totally by surprise. Because by the time they came through I was sick again. I suppose what I did at the cottage was foolish. But it never occurred to me that there was still a risk there. After all, the spraying had ended back in October, and the cottage had been opened and repeatedly aired. Anyway, I went back on atropine, and it worked its usual wonders. The knee pain, the weakness, the twitching, the burning, all the neurological symptoms—they were just something I had to live with. I saw another neurologist. All the likely causes of polyneuropathy were excluded by appropriate studies. I didn't have diabetes, pernicious anemia, lead intoxication, collagen vascular disease, porphyria, or a malignancy. The diagnosis of organophosphate intoxication was reconfirmed. I talked with the state pesticide man, and he felt it was safe to use the cottage again if stringent precautions were taken— windows open, plenty of circulating air, fans. Which reminds me. Very early on, there was the question about Lewis and the cottage. Why wasn't he affected? The answer we decided on was fairly simple. By the time he arrived on Friday night, I had opened and aired the cottage. It was I who walked into the fumigation chamber every Friday afternoon. He didn't. Well, the summer of 1985 passed without any serious problems. I walked, and I swam a little, and I tried to play tennis. My left leg continued to hurt, but it's wonderful how one can get more or less used to pain. We closed the cottage, as usual, over Labor Day. Later in September, my knee flared up. It was really disabling. I had a friend and colleague, a rheumatologist, and I consulted her, hoping for some relief. And found it. She gave me a steroid injection, and for about ten days I was feeling great again. She referred me to an orthopedic surgeon for the procedure called arthroscopy—an examination of the interior of my knee. The surgeon did some repair work, but found no evidence of degenerative joint disease. I was put on an exercise program. Leg raising with weights. Hamstring lifts. Bicycling. Various things. I began, at long last, to improve.

  "I think I'll move ahead for a minute. I'm thinking of the problem of the cottage. It was the beginning of everything, but it wasn't the end. It was the scene of my last naivete. That was the Memorial Day weekend in 1986. I went up to the lake on Friday afternoon as usual. I aired everything out—that was second nature now. The weather was cool for May, chilly, even. Lewis arrived late Friday night. We spent Saturday working around the place, preparing for another summer. Saturday night was almost cold. The heat came on—our baseboard electric heating system. I woke up in the middle of the night. Nausea. Abdominal cramps. Twitching. All the old familiar symptoms. I realized at once what had happened. In spite of everything, there must still be some organophosphate residue around. On the radiators, perhaps. And the heat had volatilized it and blown it around the cottage. Well, we decided to volatilize it right out of the cottage, so we turned all the radiators on high, opened all the doors and windows, and started up a couple of fans. I heated some milk. I had my atropine. Then we drove back home. The whole thing was unnerving. We were in a real quandary. What were we going to do about the cottage? Abandon it? We couldn't sell it. That would be practically criminal. What we finally did—what we have only just finished doing—was another, and really drastic, cleanup. More than a cleanup, actually. We brought in another toxic-waste-disposal team. We discarded all upholstered furniture and bedding. We removed and replaced the baseboard radiators. We removed and replaced all linoleum flooring. We washed in a detergent solution everything that could be washed—walls, floors, ceilings. Then we sealed the entire inside of the house with two coats of polyurethane sealant. I had to be there to supervise, but I wasn't taking any chances. I wore a toxic-cleanup suit with a double-filtered mask, gloves, boots, goggles. I looked like a monster from space. But I survived. We left the house open all summer. Doors and windows—everything. I don't know exactly what we're going to do. I don't want to sell the cottage. I've always loved it. We'll probably keep it. It is almost literally a brand-new building."

  "That last experience at the cottage taught me something. The contamination that night from the radiators couldn't have amounted to much. It certainly had no effect on Lewis. But I was different. I was susceptible. I was exquisitely sensitized. I said the cottage was the beginning but that it wasn't the end. I don't know if there ever will be an end. I recovered from that last cottage exposure. I heard about a doctor who specialized in sports medicine, an expert on knees. He turned out to be wonderful. I began to get going again. He kept me on my exercise program, and encouraged me to branch out. Toward the end of the summer— the summer of 1986—I started seriously getting back into tennis. I mean, what's life without tennis! I signed up at a tennis school not far from home, a year-round school, with indoor courts. Actually, it was a general health facility. I worked with a coach a couple of days a week all through September and October and into November. Then, little by little, I began to get sick again. I remember one day I dragged myself over for a lesson and had to stop in the middle of play, I was so nauseated. I remember standing there leaning against the backstop and looking down at the court. It was a concrete slab on grade. And along the slab at the backstop were dozens, hundreds, of dead water bugs. I looked at all those dead bugs, and I had a horrible thought, a horrible suspicion. I called the therapist—the coach—over, and a
sked him if they by any chance had had any exterminating work done. He said, well, yes, some of the members had been complaining about an infestation of water bugs. The exterminators had made four visits in the course of the past twenty days. That was about the length of time I had been relapsing. I asked him if he knew what insecticides had been used. He didn't know, but there must have been something about the way I looked, and he said he could probably find out. So he made a phone call, and talked for several minutes, and came back with the answer. They used something, he said, called diazinon. Diazinon! Another organophosphate! For some harmless lit tie water bugs.