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

by Victoria Sweet

  Page 149. Loiasis: I remembered what Dr. Em told me with the help of The Oxford Textbook of Medicine (5.426–5.427).

  Page 151. The Hospital of Saint Bruno: I have called the hospital the “Hospital of Saint Bruno,” but that is as much a pseudonym as “Dr. Hoefer,” though for a different reason. I don’t remember the name of the hospital where the rehabilitation unit took me. There is a hospital in the French pre-Alps called the Hospital of Saint Bruno, with the same history, look, and function, but I’ve been unable to verify that it was indeed the hospital with the doctors’ dining room and that wonderful cognac.

  CHAPTER SEVEN: DANCING TO THE TUNE OF GLENN MILLER

  Page 160. My new ward, E6, was one of the dementia wards: When I organized my index cards, I found that the thirty-four patients of E6 fell neatly into three categories. There were the very old, whose average age was eighty-nine (ages eighty-two to ninety-six); a middle group, whose average age was sixty-six (ages sixty-three to seventy-one); and a youngish group, whose average age was fifty (ages forty-four to sixty). Their age corresponded to why they were on E6: the elderly with an absent, frail, feeble kind of demented state; the middle group with hypertension, diabetes, and consequent strokes; and the young group with head trauma, psychiatric, and drug-abuse issues, and also, usually, some rare disease.

  Page 160. Although it was a dementia ward, it was not an Alzheimer’s ward: One problem with trying to understand the history of dementia is that what we call dementia wasn’t always called dementia; and what was called dementia wasn’t necessarily our dementia. For instance, Galen, writing in Greek, called the forgetfulness of old age morosis, and early Latin writers such as Isidore of Seville called it amentia. For a history, see Axel Karenberg and Hans Förstel, “Dementia in the Greco-Roman World,” Journal of Neurological Science 244 (1–2) (2006), 1-2: 5–9; Frances Boller, “History of Dementia and Dementia in History,” Journal of Neurological Science 158(2) (1998): 125–33; and N. C. Berchtold and C.W. Cothman, “Evolution of the Conceptualization of Dementia and Alzheimer’s: Greco-Roman Period to the 1960s,” Neurobiology of Aging 19(3) (1998): 173–89. Hildegard used both amentia and dementia, and her prescriptions suggest that she accepted Galen’s ideas that they resulted from a cooling and drying of the brain. For instance: “The herb, balsam, is more hot than cold. And if someone becomes demented, let him drink often a potion made from balsam and fennel. As for his regime, he should not use oil but butter [pace the Cholesterolationists!] and should not drink wine or even water, but simply beer [pace the Prohibitionists! And the Puritans!]. He should avoid foods that are drying. He should eat aged and delicate foods instead, which will bring good juices to his blood.” (From “De Balsamita [9] Lit, 45” CAP. CXCV, column 1202-D–1203-A; “Liber Simplicis Medicinae [Physica]” in S. Hildegardis Abbatissae Opera Omnia, ed. Jacques-Paul Higne, vol. 197). [my translation] These recommendations must have been in order to warm and humidify a cool, dry brain.

  Page 161. Dr. Pinel became fascinated by a group of patients: The quote is from Henry Maudsley in his Responsibility in Mental Disease (New York: D. Appleton and Co., 1876), 73. For Esquirol’s list of causes of dementia, see Jean-Étienne Dominique Esquirol, Mental Maladies: A Treatise on Insanity, E. K. Hunt, trans. (Philadelphia: Lea and Blanchard, 1845), 423–24.

  Page 161. In it, he defined dementia: “Dementia is a cerebral affection, usually chronic and unattended by fever, and characterized by a weakening of the sensibility, understanding and will…. Incoherence of ideas, and a want of intellectual and moral spontaneity are the signs of this affection” (Esquirol, Mental Maladies, 417).

  Page 162. Dr. Alois Alzheimer published his case: For an account of Dr. Alzheimer’s discovery, see David H. Small and Roberto Cappai, “Alois Alzheimer and Alzheimer’s Disease: A Centennial Perspective,” Journal of Neurochemistry 99 (2006): 708–10. In the photo of Auguste D., however, she looks more like a patient with a pituitary tumor than one with simple dementia. One wonders.

  Page 163. So in the 1980s a crucial redefinition was made: The story of how Alzheimer’s was redefined from a rare presenile dementia to the common dementia of old age is well told by Peter J. Whitehouse and Daniel George, The Myth of Alzheimer’s: What You Aren’t Being Told About Today’s Most Dreaded Diagnosis (New York: St. Martin’s Press, 2008). For a contrary view that accepts the notion that the plaques are, in fact, the disease, see Small and Cappai, “Alois Alzheimer.” At autopsy, up to 45 percent of the brains of demented patients show Alzheimer’s plaques and tangles, but, confusingly, so do up to 30 percent of brains without clinical dementia. Whitehouse and George suggest that the plaques and tangles may not be the cause of dementia but the brain’s reparative response to some other process, and that medications to dissolve or prevent the tangles and plaques may be harmful.

  Page 171. Dr. Pinel had also observed that work was therapeutic for the demented: Pinel wrote eloquently that “Nothing is more worthy of remark than the calm and tranquility which formerly reigned among the patients of the Bicêtre when the merchants of Paris furnished a great number with manual labor, which fixed their attention, and proved agreeable by a slight attendant recompense. I have been always prevented by circumstances from procuring land, and have been limited to subsidiary means, choosing the attendants from among the convalescent patients. In the hospitals of Holland much expense is saved by giving the duties of attendants to convalescents. The object of labor would be fulfilled in its whole extent by adjoining to a hospital a vast enclosure, or, rather, to convert it into a sort of farm, of which the laborers should be under the care of convalescents, and the products from the culture of which should go to their use” (Pinel, Treatment of the Insane, trans. Galt, 41). It was mainly the “peonage” suits of the 1970s, based on the Thirteenth Amendment outlawing slavery, that put a stop to the practice of letting patients work (Isaac and Armat, Madness in the Streets, 139).

  Page 173. Saint Isidore wrote that dementia: “Animus is the same thing as anima, but it is anima of life, and animus of judgment. Whence philosophers say life remains without animus and anima endures without mind.” Translated by Priscilla Throop in Isidore of Seville’s Etymologies (Charlotte, VT: Medieval MS, 2005), vol. 2, book 11, verse 11. The Latin is: Item animum idem esse quod animam; sed anima vitae est, animus consilii. Unde dicunt philosophi etiam sine animo vitam manere et sine mente animam durate; unde et amentes (Isidori Hispalensis Episcopi, Etymologiarum sive Originum, libri xx, edited by W. M. Lindsay, London, Oxford University Press, 1911). I interpret animus as signifying spirit, and anima as soul.

  Page 175. Matthew in the New Testament: “Then shall the King say unto them on his right hand, Come, ye blessed of my Father, inherit the kingdom prepared for you from the foundation of the world: For I was a hungered, and ye gave me meat: I was thirsty, and ye gave me drink: I was a stranger, and ye took me in…. Inasmuch as ye have done it unto one of the least of these my brethren, ye have done it unto me” (Matthew 25:34–40). These lines were the explicit foundation of monastic hospitality. “Christ’s association with the outsider was central to the monastic understanding of hospitality.” From Julie Kerr, Monastic Hospitality: The Benedictines in England, c. 1070–c. 1250 (Rochester, NY: Boydell & Brewer, 2007), 26.

  Page 177. He presented his recommendation to the board of supervisors: The only possibility that Dr. Stein didn’t examine closely was the one I’d seen at the Hospital of Saint Bruno—that is, renovating Laguna Honda. He did observe that a renovation would be costly and result in one-third fewer beds, and, in view of the coming wave of disabled Boomers, thought it would be a foolish choice. Ironically, one-third fewer beds would be the exact number of beds we would be left with in the new hospital. And renovation of the old place would be done anyway, though not for patients but for the city’s administrators. For the full text, see Mitchell H. Katz, “Options for Laguna Honda Hospital. White Paper.” San Francisco Department of Public Health (1998); twenty-eight pages at www.victoriasweet.com/documents.

&n
bsp; Page 177. The bond for a new Laguna Honda did go on the ballot: The arguments for and against Proposition A take up twenty-two pages, and though I have been fair to the gist of them, I have left out the passion and occasional vituperance in their arguments. For instance, the disability-rights advocate called the hospital a “warehouse” and the bond a “boondoggle for special interests,” while Sister Miriam wrote that no other place she’d ever been was as inspiring as Laguna Honda. The supervisors voted 9 to 2 in favor of putting the bond on the ballot—one of the two no votes being the new mayor, who, nonetheless, made sure to arrive for the groundbreaking and, eventually, for the ribbon-cutting ceremony.

  Page 180. It is best understood with a diagram: For more on this see the conclusion in Rooted in the Earth, Rooted in the Sky. See also Byrhtferth’s Enchiridion, Peter S. Baker and Michael Lapidge, eds. (Oxford, UK: Oxford University Press, 1995), 14–15. Hildegard, too, had a picture of how it all worked; it was the illumination I’d marveled at when I began my research. For an essay on the implications of the premodern geocentric cosmos, see Giorgio de Santillana and Hertha von Dechen, Hamlet’s Mill: An Essay Investigating the Origins of Human Knowledge and Its Transmission Through Myth (Boston: David R. Godine, 1992).

  Page 184. With bated breath: The evaluation of archaeological resources makes these concerns apparent; see David Chavez and Jan M. Human, “Archaeological Resources Evaluations for the Laguna Honda Hospital’s Institutional Master Plan.” San Francisco, California, 1994.

  CHAPTER EIGHT: WEDDING AT CANA

  Page 197. Community comes from the Latin communio: This etymology comes from The Oxford Latin Dictionary. Laguna Honda was, in actual fact, surrounded by a wall of neatly piled, round rocks. The story I heard was that it had been built by patients out of the cobblestones no longer used for city streets. That wall did define the community—inside it was Laguna Honda; outside it, wasn’t.

  Page 200. Its second letter arrived: This is the letter titled “Re Investigation of Laguna Honda Hospital and Rehabilitation Center,” and signed by Ralph F. Boyd, Jr., dated April 1, 2003, and from the Department of Justice. It is thirty pages long, and I summarize here only its most important demands. It did make some good points. We did have patients who could have been discharged if we’d had places to send them. But there were few apartments renting for what our patients could afford to pay; there was not a single locked facility in the city to discharge our demented patients who wandered; and no board-and-care facilities in the city accepted patients in wheelchairs. Besides, there was an unspoken agenda, or so it seemed by the choice of works the letter favored: Laguna Honda “violated” the ADA; it “failed,” “refused,” “delayed,” “isolated” its patients. It “discriminated” against them; it was not “proactive” in discharging patients; it merely “perceived” that there was no place to send its patients. For the letter, see Laguna-Honda-findings2.pdf at victoriasweet.com/documents.

  Page 200. Administration installed the minimum data set: The MDS coordinator did have to be smart and full-time, though; the form was twenty pages long, and the manual for filling it out was 538 pages.

  Page 201. The team did find eight patients to discharge: Statistics about discharges were never easy to come by, but Laguna Honda’s Quality Management did give me an accounting of two of the hospital’s patient assessments. The first (1999) assessment in response to the first DOJ letter asserting that 80 percent of Laguna Honda patients could be discharged, found eleven patients to have discharge potential within thirty days (most likely patients on the Rehabilitation Ward); and thirty-five additional patients within ninety days (most likely patients on the longer-term rehabilitation wards). The other 1,036 patients—that is, 90 percent—had no discharge potential. In the second assessment (2003) demanded by the second DOJ letter, 990 patients out of the then 1,040 patients—again 90 percent—had no discharge potential [personal communication].

  Page 201. Lawyers who, in the 1970s and 1980s, constituted the “Mental Health Bar”: For an excellent account of how the state mental institutions were closed by an idealistic group of lawyers coming out of the radical 1960s, see Isaac and Armat’s Madness in the Streets. They trace the antipsychiatry movement from R. D. Laing and Thomas Szasz in the 1960s to the creation of the federally funded Protection and Advocacy, Inc., in the 1970s to the alliance of the Left and Right in the 1980s and the consequent deinstitutionalization and abandonment of the mentally ill to the streets. By 1989, they write, much of the homeless problem could be accounted for by the displaced mentally ill: 42 percent of homeless men and 48 percent of homeless women had major mental illness (Madness in the Streets, 5). “Unsurprisingly, the civil libertarian lawyers who have spoken up on behalf of the ‘homeless’ are far from eager to advertise their own immense role in today’s tragedy. More than any other single group, they have been responsible for changing our laws governing civil commitment, making it impossible to hospitalize and to treat many of the most severely ill patients” (Madness in the Streets, 13).

  Page 201. Davis had many demands: For the Davis settlement, see www.pai-ca.org. For Olmstead, see Olmstead, Commissioner, Georgia Department of Human Resources Et Al. V. L.C., by Zimring, Guardian Ad Litem and Next Friend, Et Al.-527 U.S. 581 (1999) at www.supreme.justia.com. For a sense of how the lawyers of PAI viewed the settlement, see: http://www.dredf.org/press/laguna_settles.html.

  Page 202. But it did fund TCM: TCM’s initial budget was 1.5 million dollars. During its first year, TCM screened all of Laguna Honda’s patients and found seventeen patients it thought dischargeable. Of these, five died during the assessment period, implying that a discharge would have been out of the question. Nine were so sick that they had to be admitted to the County; only two were discharged (Minutes of the Joint Conference Committee for Laguna Honda Hospital and Rehabilitation Center, January 2005). After three years of operation, TCM had discharged 139 patients, so about four per month. It was not clear, however, how many of those patients would have been discharged anyway (from the TCM Monthly Report, May 2007), Aggregate Data Report. Similarly for TCM Monthly Report, December 2008. There is a section labeled TCM Program Outcomes, but by that is meant only how many total patients (“consumers”) were discharged from Laguna Honda. The report found at www.sfdph/tcm/rtz/december 2008 shows an average of 5.2 discharges per month over the preceding forty-eight months. Nevertheless, lawyers for Protection and Advocacy, Inc., continued to assert, “The TCM assessment shows that 80% of residents could be cared for in the community” (www.bazelon.org). Of interest, 49 percent of families and friends of those screened did not support a discharge. What happened to its patients after the TCM discharges was not public information as far as I could tell. When I asked, the TCM staff did not know or would not say. In any case, “nobody has ever actually proved that community-based care was either more humane, more therapeutic, or less expensive than state hospital care” (Madness in the Streets, 287).

  Page 203. The city’s Mental Health Rehabilitation Facility: The MHRF was funded in 1987 by Proposition C, a twenty-six-million-dollar bond to build a skilled nursing facility for the psychiatrically disabled of San Francisco. It took ten years to build, but by 1996 was up and running with 156 beds. According to a psychiatrist who worked there, its program was quite successful; most of its patients did not return to the streets. Discharging patients was always the MHRF’s biggest problem, and eventually it was just about filled with treated psychiatric patients who were homeless and had nowhere to go. Which was why Dr. Stein decided to turn it into a psychiatric board-and-care facility and why he was trying to discharge its patients—legally or not—to Laguna Honda. See SF4 LagunaHonda.org/media.html.

  Page 205. It was crowded and televised: For a transcript, see San Francisco Board of Supervisors, City Services Committee, Transcript of Laguna Honda Admissions Policy Hearing Audiotape, June 24, 2004. Dr. Stein seemed a little disingenuous when he portrayed Mr. Charles to the supervisors as “a psychiatric patient Laguna Honda didn’t feel comf
ortable with” (7). Dr. Stein’s quote was: “The money [to place Mr. Charles] would come from Laguna Honda’s budget” (24).

  Page 210. Happy from hap, as in what happens: Hap is “chance” or “fortune” and happy is “a feeling of great pleasure or contentment of mind, arising from satisfaction with one’s circumstances or condition” (The Oxford English Dictionary). As an example, it quotes Palladius: “It is simply the hap of a seed to turn into a tree.” (“Hit is bot happe of plante a tree to gete.”)

  Page 210. I would be pilgriming: A peregrinatio is a traveling away from home; a peregrinus is a foreigner, an alien (The Oxford Latin Dictionary). A pilgrim is a person who travels to a holy place, a traveler, wanderer, beggar (Middle English Dictionary).

  Page 212. A patient set the fire: Dr. Romero was “pressured to admit the arsonist who went AWOL from SFGH” (Transcript of Audiotape, 16). The next year a nurse explained to the state surveyors that there was no individuality to the patients’ spaces because the fire marshals wouldn’t allow it (Department of Health and Human Services, Centers for Medicare and Medicaid Services, Statement of Deficiencies and Plan of Correction for Laguna Honda Hospital and Rehabilitation Center, completed February 21, 2006, p. 119). The quote is attributed to a nurse in a discussion from 2005, but this is probably a misprint.

  CHAPTER NINE: HOW I FELL IN LOVE

  Page 228. Charity came into the West: On the history of charity and how it turned into welfare, see James William Brodman, Charity and Religion in Medieval Europe (Washington, DC: Catholic University of America Press, 2009); see also Gertrude Himmelfarb, The Idea of Poverty: England in the Early Industrial Age (New York: Knopf, 1984); and With Us Always: A History of Private Charity and Public Welfare, Donald T. Critchlow and Charles H. Parker, eds. (Lanham, MD: Rowman & Littlefield, 1998). The Oxford English Dictionary defines charity as Christ’s love; God’s love for man; man’s love of God and his neighbor.