God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine

by Victoria Sweet

  Other than the change from Dr. Rachman to Dr. Romero, and the knowledge that somewhere out in the vast, unpatrolled spaces of the hospital were consultants inspecting, life on the admitting ward went on about the same. It was even busier, with ever-increasing numbers of patients without insurance who depended on the city’s fraying safety net. Now we were admitting four or five new patients each day. Usually they were from the County Hospital, though more and more often they were from hospitals around the city, or even, sometimes, directly from the streets—patients who’d been picked up, delirious, infected, and lice-ridden, by the police or the paramedics.

  Not only were there more patients, but they were sicker—with complex medical problems more appropriate for an intensive care unit than an almshouse. Now and again a patient came to us directly from the ICU, not even passing through the chimerical reassurance of a day or two on the step-down unit of the acute hospital.

  This increase in the number and acuity of the sick was unexpected, although it was the predictable outcome of the health-care policy decisions made in the 1980s. There’d been the shutting down of most of the almshouses in the country; then the phasing out of most of the free county hospitals; and, last but not least, the closing of the state mental hospitals. The closing of the state mental hospitals was particularly disastrous, the result of an unwitting but agreeable collusion of Left and Right; the Left being convinced that institutionalization of any kind was harmful, and the Right, that institutionalization of any kind was expensive.

  A trade-off had been arranged. Most of the state mental hospitals would be closed, and part of the money saved would be used for halfway houses, so that the previously institutionalized could be slowly reintroduced to society. Each halfway house would serve five or six patients; its live-in staff would be psychiatrically trained; and a psychiatrist would visit weekly to ensure that the newly released schizophrenic, manic-depressive, or brain-injured would get the medications he needed. A more humane, less costly solution for all concerned, and both Left and Right signed on.

  But shortly after the state mental hospitals closed, there was a budget crisis, and then another and another, and the money for this careful outpatient treatment was trimmed, pared, and finally excised. Many of the halfway houses were shut down, and their formerly institutionalized patients put out onto the streets without medication, supervision, or shelter.

  Some patients did well for a while, especially after they discovered that drugs—heroin, marijuana, cocaine, and alcohol—were pretty good medications for their schizophrenia, mania, depression, and anxiety. But in the decade that followed, many started to get ill—physically ill like everyone else—with high blood pressure, diabetes, cancer. Since they were homeless and unemployed; since Medicaid—the health insurance formerly provided to the “indigent adult”—had been taken away, and since most of the free county hospitals had been closed, these former psychiatric patients received medical care only at the last moment. Moreover, once their medical condition stabilized, they were discharged from the hospital, often without their psychiatric medication, which in the 1980s they’d won the right to refuse.

  So they got physically sick and stayed sick. They lost their legs or their sight to their untreated diabetes; they had strokes at an early age from their cocaine use or their untreated hypertension. They got infections that, undiagnosed, migrated into their hearts, bones, and brains. They broke their legs, their arms, their spines, and their skulls in fights, in car accidents, or in suicidal or drug-related jumps out of buildings. They wandered the city streets, physically ill and often psychotic.

  Eventually they would be picked up and brought, or would find their way—at least in our city—to the County Hospital, where they would be treated and stabilized. And then, because our city still had its almshouse, they would be sent to us. At the time of Dee and Tee’s visit, about one-third of our patients were these so-called “triple diagnosis” patients—with their three diagnoses of untreated complex medical illness, florid mental illness, and drug abuse.

  Of all these patients—and there were many—it was Jimmy Turner whom I most regret.

  He was the skinniest patient I ever admitted and one of the craziest. I use the term crazy as fitting in his case; no complicated DSM-IV diagnosis was needed: Jimmy was crazy, and he thought he was a vending machine. Like so many of the failures from the well-meaning policy changes of the 1980s, he’d taken up residence in our city’s beautiful park not far north of the hospital. He slept in a clearing, in a sleeping bag under his own tree, and there he’d been eating coins—quarters, dimes, nickels, and pennies. Someone—perhaps another ex-patient, a thief, or even the pleasant bicycle patrol—noted that Jimmy had been asleep under his tree for a very long time. The paramedics were called and found him alive but unarousable—that is, comatose—and they took him over to the County.

  At the County tests revealed that Mr. Turner had a life-threatening anemia (low red cell count)—an anemia so profound that he couldn’t stand up without passing out. But his anemia was not due to the usual causes, such as blood loss from an ulcer or a cancer, or iron deficiency from malnutrition. Rather, on X-ray Mr. Turner was found to have $1.26 in change scattered through his gastrointestinal tract. And, since coins are no longer made of silver, nickel, or copper but mostly of zinc, it turned out that Mr. Turner was severely zinc-toxic, his blood level being more than ten times normal. The zinc in the coins had seeped into his blood and interfered with his body’s ability to utilize copper. Since copper is needed to make blood, he was profoundly anemic.

  The doctors at the County Hospital went to work. They cleaned out his gastrointestinal tract with laxatives and enemas; and they made sure that they recovered all the coins—two quarters, five dimes, three nickels, and eleven pennies—from his stool. They transfused Mr. Turner, and they investigated him for other possible, though rare, errors of copper metabolism. They even treated him with an expensive drug, penicillamine, just in case he did. Nevertheless, even after all their work, Mr. Turner was still too weak to stand; he wasn’t eating enough to stay alive; and he was looking for coins. So they sent him over to us, for rest, relaxation, and rehabilitation.

  When I first saw Jimmy, sitting in the chair by his bed, I was shocked.

  He looked like a concentration camp victim. His temples were hollow; his cheekbones jutted out beyond his chin; his color, despite the transfusions he’d had, was sickly and sallow; and his scanty hair was the dry, reddish hair of protein deficiency. I could make out every vertebra in his spine, and his ribs were so prominent that I couldn’t get my stethoscope to sit right on his chest. Through his sunken belly I could see the edges of his beating aorta, and his arms and legs were just skin-covered bones.

  His main problem, it seemed, was that he wasn’t eating. He wasn’t talking either, so it was difficult to learn his side of the story—about the coins, I mean—and he had no family or friends to ask. Fortunately, the County Hospital had obtained a court order that let us give Mr. Turner the antipsychotic medications he needed, and I expected that soon he would begin to eat as well as to talk.

  It took longer than I thought it would. Even after the psychiatric medications began to work, and Mr. Turner became more sociable, he was never loquacious. Moreover, even though he seemed to try to eat, he couldn’t or wouldn’t. He was nauseated, he told me, and after a time, he began to vomit. I adjusted his medications, ran quite a few tests, and discovered that he had a second side effect from his elevated zinc level, decreased copper level, and severe anemia. He had an obstruction in his esophagus, the muscular tube that takes food from mouth to stomach. This obstruction was not another coin but a web—a weird shelf of tissue that sometimes grows when patients have a severe anemia, though no one knows why—and that web was preventing nutrition from reaching his stomach. Jimmy needed, therefore, to be fed for a while with a tube. So we got another court order and placed a feeding tube past the obstructing web into his stomach. And with that, Jimmy began to improve. />
  Significantly. What with the absence of coins in his gastrointestinal tract, and the nutrition and vitamins from the feeding tube; with a roof over his head, a bed to sleep in, and antipsychotic medications, Jimmy improved a lot. His body excreted the excess zinc; his copper level normalized; and his anemia resolved. The web in his esophagus dissolved, and we removed the tube. He began to eat quite a bit on his own. In fact, Jimmy was not only the skinniest patient I ever had, he was also the patient who gained the most weight, so that at the end of three months he was looking quite normal, quite presentable. At 140 pounds, with his reddish hair now shiny and combed, and his frame filled in, he looked even a little younger than his age, which was thirty-one. I was pretty proud and happy with his progress.

  So was he. Indeed, he told me one day about four months after his admission, he was ready to leave. No, he didn’t need a place to stay; he’d find some place to live himself. It wasn’t a big deal; he’d done it before. No, he didn’t need food stamps or General Assistance or a caseworker. He was strong; he’d find work. And no, he didn’t need any medications. Vitamins? No. What about his nerve medicines? The ones that kept him anchored to Planet Earth? No. Thanks. He didn’t think he’d need those either. No, really not. He didn’t like them. When he took them he couldn’t think properly.

  And, according to our psychiatrist—and I knew this already—Mr. Turner was quite within his rights. He had the right to refuse psychiatric medications, even if he was crazy, as long as he wasn’t so crazy as to be a danger to himself or to others at the time he refused them—even if the only reason that he wasn’t thinking he was a vending machine and eating coins was because he was being given his antipsychotic medications by court order. We could try to get a permanent conservator for him, our psychiatrist told me—that is, a legal guardian who would be awarded the right to consent to psychiatric treatment on Jimmy’s behalf. But, he said, good luck. It was almost impossible to get a conservator in our city. They were few, and they rarely took our patients, who, they knew, were well cared for. Besides, Jimmy looked and sounded great. No judge would take away his right to refuse medications.

  I was disappointed but not surprised by his assessment.

  Because I knew about the second, equally well-meaning and equally disastrous health-care policy decision made in the 1980s, around the same time as the closure of the state mental hospitals. This was the decision to give psychiatric patients the right to consent to, or refuse, psychiatric care. It had been a reaction to the excesses of the twentieth century: to the involuntary commitment of homosexuals; to electric shock therapy for anxiety, depression, or just plain orneriness; to lobotomy—that is, brain surgery—for what sometimes seemed, in retrospect, to be nothing more than a refusal to conform. That policy, of making involuntary psychiatric commitment difficult to obtain and of requiring consent for psychiatric medications, had not been wrong. It had been necessary. I knew that from Mrs. Lantos.

  I met her one day while I was taking care of the patients of a vacationing doctor. Although “met” would be an exaggeration. Rather, I passed her bed on my way to see another patient. But she stopped me cold.

  Mrs. Lantos was tiny; she was old; she was wizened; she looked like the witch in a Grimm’s fairy tale. Her legs and arms were contracted up so that she was even tinier. She took up less than a third of her narrow bed, and when I stopped, I saw that, although her eyes were open, she didn’t turn to look at me. She was staring into space and saying over and over and over again, in an anguished and desperate voice: “My cat, my cat, my cat, my cat.”

  That’s what stopped me.

  Who was she? Why was she here?

  What I learned from the fifty-year-old admission report still in her chart—one page, typed and yellowed—was that she’d been transferred to Laguna Honda from a state mental hospital in 1958. She’d initially been admitted to the state mental hospital in the 1940s at the request of her husband because, so the record quoted, “She wouldn’t keep house properly; she wouldn’t act like a good wife.” Back then, in the 1940s, there were essentially no effective treatments for psychiatric conditions. Patients were mostly hospitalized—committed—to back wards indefinitely, and, if necessary, they were restrained. And so, apparently, was Mrs. Lantos.

  When the first effective treatment for mental illness was discovered, it was considered a miracle, and its discoverer was awarded a Nobel Prize. The treatment was based on the observation that severing the connections between the frontal lobes and the rest of the brain calmed schizophrenics and even cured them. The operation was called lobotomy, and until 1952, when the first psychiatric medicine, Thorazine, was synthesized, thousands of lobotomies were done. Some were successful, and the patient was cured, or, at least, improved, and discharged.

  Many, though, did not improve, and some even worsened, and this is what happened to Mrs. Lantos. In the early 1950s she’d had a lobotomy, and it had not been successful. Whether she had or had not been schizophrenic, after her lobotomy she did not return home and start cleaning the house or being a proper wife. Rather, she shriveled up and contracted. And after that particular state mental hospital was closed, she was sent to Laguna Honda, where she was placed in a bed and turned every two hours to prevent bedsores and called out all day long in a high-pitched and distressed voice, “My cat, my cat, my cat, my cat.”

  It was because of patients like Mrs. Lantos that Jimmy Turner had won the right to refuse psychiatric medications unless he was psychotic—even though the reason he was no longer psychotic was that he was involuntarily taking them.

  In many ways it had been the right decision, but, like so many of our society’s decisions that end up as laws, it was intractable. It was a law. And, while medicating people because they don’t conform to our ideas of rationality had been incorrect, the more I saw of people like Jimmy—of the acutely psychotic, the real schizophrenic—the more inclined I was to believe that schizophrenia was not primarily a mental affliction, but a physical disease with mental concomitants.

  When I’d first read Jung and decided to become a Jungian psychiatrist, I’d accepted the idea that schizophrenia was a mental disease with philosophical significance. Then, during my year as a psychiatric intern, I’d been impressed by the success of the antipsychotic medications, though not entirely sure of the ethics of using them to change someone’s worldview.

  But at Laguna Honda I’d seen many more schizophrenic patients, for a much longer period of time, and I’d been struck by how stereotypic their symptoms were. The Chinese schizophrenic, the Filipino schizophrenic, the English schizophrenic, the Jewish, Greek Orthodox, Muslim schizophrenic, all had the same fear: that someone—the FBI, the KGB, the Grand Order of the Saints, the Kabala, the Devil—was following them, listening to them, talking to them, commanding them. Then, when given psychiatric medications, which block the brain chemicals of dopamine, serotonin, and other still-unknown compounds, they improved. The volume of their voices diminished; their fears lessened and even disappeared.

  Gradually I became convinced that schizophrenia is not primarily a mental disease, but a physical disease with a good, if not perfect, treatment. It is probably a chemical deficiency of some kind and, therefore, just as medical a problem as any other chemical deficiency—of insulin, of thyroid hormone, of cortisone—that also has mental effects. I also learned that it is a painful disease, a disease of solitude and terror, of waking nightmares, and of fear, a disease I would want treated if I had it. And it is a disease such that those who have it cannot know they have it and need treatment, any more than a patient hallucinating because of low blood sugar, too much thyroid hormone, or too little cortisone knows what is wrong and what is needed.

  So letting Jimmy sign himself out of the hospital without his medications was, to my mind, as mistaken, as wrong, as letting a delirious patient sign himself out without treatment. Our psychiatrist emphasized this when he observed that if we declared Jimmy’s delusions due to a medical condition—AIDS, syphilis, or Wil
son’s disease—we could treat him without his consent. But a schizophrenic like Jimmy? No.

  So one fine spring day at the beginning of April, Mr. Jimmy Turner, resuscitated crazy person, untreated schizophrenic, left the hospital. He took nothing with him but ambled out, wearing the Levi’s and the plaid shirt he’d picked up in our clothing department. Several weeks later the social worker told me that Jimmy had been spotted in a clearing in the park. He was dead.

  And this is a death I regret to this day. Because it was a preventable death, as preventable as a death from pneumonia. And also, in a manner of speaking, it was a preventable life.

  In the meantime, my studies of Hildegard and humoral medicine were coming along. I had taken all the courses that Professor Brown gave and all the classes that Dr. Weitz’s Department of Medical History offered, and I was well into my master’s thesis.

  As Dr. Weitz had warned me at my interview, his department was a very small department, beset by a modernity that did not believe in the value of history. Medical history, anyway, only really began at the end of the nineteenth century, when humoral medicine gave way to modern medicine. Before this, although there had been a kind of history of the Great Doctors, such as Hippocrates and Galen, and of new medicines, such as quinine and caffeine, medical history didn’t really exist. It had been the discontinuity between premodern and modern medicine that had created the need to understand the now-incomprehensible past.

  But by the time Dr. Weitz arrived, the department was at the end of its flush period, and during his tenure, as modern medicine became ever more successful, the past became ever less compelling. Every year his budget was cut, his endowments raided, and his tiny department threatened. He did what he could; every year he presented himself to the budget committee and pleaded the case for medical history. He opened his department up to the study of health care and changed its name from History of Medicine to History of Health Sciences. He gave free lectures and held fund-raisers and succeeded, amazingly enough, in building the department with new postdoctoral fellows, with PhD students, and even with a second professor, Jack Pressman.