The fumigation chamber.
A woman I'll call Betty Page was awakened in the middle of the night, around three o'clock on the morning of Wednesday, May 30, 1984, by a spasm of nausea. She sat up with a lurch and a groan. Her husband, Lewis, lifted his head and asked what was the matter. She told him. She said she didn't understand it-she just felt sick and awful. She crouched there, wondering. Then she had an impulse. She had a sudden craving for milk-for a cup of warm milk. She went down to the kitchen and put some milk in a pan on the stove to heat. She drank a steaming cupful, sipping slowly, cautiously. She began to feel better. She went back to bed and fell asleep, and slept until morning.
The Pages live in a comfortable fieldstone house in Jenkintown, Pennsylvania, a pleasant suburb of Philadelphia. They also have a weekend cottage on a lake in northern Pennsylvania-a three-hour drive from their home-and a condominium apartment in Aspen, Colorado. Betty Page is a small woman, grayly blond with blue eyes and a wide, smiling mouth, and in May 1984 she had just turned 57. Lewis Page-big, bald, serenely poised-was 60. The Pages are both physicians. Lewis Page (Harvard College, the University of Pennsylvania School of Medicine) is an obstetrician and gynecologist in private practice. Betty Page (Wellesley College and Temple University School of Medicine, where she was elected to Alpha Omega Alpha, the Phi Beta Kappa of medicine) is an internist, and at that time was an assistant professor of clinical medicine at the University of Pennsylvania School of Medicine. She is now, and has been for three years or more, on leave from her academic duties. And for good reason.
"Lewis and I have been married for 39 years," Betty Page told me in a conversation we had not long ago in her home. "They've been happy years. We have a lot more in common than just medicine. But we have our differences. I like to ski, and he prefers scuba diving. His hobby is mineralogy. Mine is archaeology. His glass is always half full. Mine is always half empty. That was the way it was on that Wednesday three years ago, after that night. Lewis was satisfied that it was just one of those things. I wasn't so sure. I was still feeling a little funny. But I had some big distractions that took my mind off myself. Not just my work. Our daughter was getting married in July, on the 28th, and, as the mother of the bride, a lot of the arrangements devolved on me-for one thing, the invitations, the calligraphy. Plus I was making my own dress. Still, I got through the day on that Wednesday. I didn't feel too bad. At night, I fell right to sleep-and then it was the night before all over again. Except worse. This time, the warm milk wasn't really very effective. I took some Tigan, an anti-nausea medicine, and that helped, but only a little. And along with the nausea I had a little crampy feeling, abdominal cramps--what used to be called green-apple cramps. I got through the night. The next day, I did what I had to do, but it wasn't easy. I had an attack of diarrhea. I tell you, I felt like h--. Thursday night was another bad night. About the only thing that kept me going was the thought of our cottage on the lake. We had opened the cottage on the Memorial day weekend--May 25, that year--as we always do. Actually, I had done most of the opening, starting on the Friday. Lewis sees patients all day Friday, and until late on Friday evening. He does that to keep his weekends free. So now, a week later--that would have been Friday, June 1--I took off for the lake. I love the lake. I always feel wonderful there. It beckoned to me like a haven.
"I felt some better when I got there. I began to think, to hope, that I was overreacting. I did the necessary marketing and got settled for the weekend. There was a lot of work to do. It was a little discouraging. I thought we had done all that weekend before. The cottage is set in a lovely hemlock wood, and when we went up on the Memorial Day weekend there was hemlock pollen everywhere in the cottage. And now, a week later, there was another dusting of pollen all over the place. So I went to work again. Lewis arrived sometime after midnight. I woke up and we talked a moment, and then another wave of nausea came over me. Milk helped, enough to let me get back to sleep. In the morning, it was good being at the lake, but I really wasn't feeling any better. The nausea came and went, and my mouth was always filling with saliva. I kept having to spit. My abdominal cramps continued. And the diarrhea. I didn't complain to Lewis. I tried to keep it even from myself. I took my temperature. It was normal. That was something, but I still felt just punk. Lewis drove back home on Sunday evening, as usual, and I stayed over for another day of rest and then to close up [the cottage]. I drove down home on Monday afternoon. I hated to leave the lake and go back to work. I was sick, and I knew it.
"Well, now we were into June. I kept thinking, hoping, that tomorrowor the day after or the day after that I'd wake up feeling better. But nothing changed. I never vomited, but I was nauseated almost all the time. I had clammy cold sweats and an awful metallic taste in my mouth. I lost my taste for food. A little milk, some Cream of Wheat--I lived on baby food like that. My normal weight is around 110. Now I was losing something like a pound a week. And I was getting worried--really worried. I had a breast cancer back in 1963, and a radical mastectomy. There had never been any suggestion of a recurrence. But there is something that everybody who has ever had any kind of cancer knows. There is always a sort of subliminal anxiety. An ache, a pain, a feeling not quite normal, and you think, Is it cancer? So I pulled myself together and called a gastroenterologist I knew and made an appointment. Doctors are like lawyers. Lawyers don't represent themselves in court. I kept my appointment, and the gastroenterologist heard my complaints and was very concerned. He gave me a full examination--the complete mouth-to-anus workup. The results were negative, entirely normal.
That should have been good news. But actually it was frustrating. And the gastroenterologist was frustrated too. So he did what so many doctors do in a situation like that: he went the functional route. What else? He reminded me that I was almost 60. He said, 'Betty, your trouble is that you're not growing old gracefully.' He said 'Wait until the wedding is over. You're simply a nervous mother. Your histrionics are getting out of hand.' He said, 'Take a little nap in the afternoon. Try to relax.' He prescribed a medication. It was a mixture of his own--a mood elevator and a tranquilizer. I took his nostrum, and I thought I was going to die. I could hardly breathe. It did something to my chest muscles. I didn't have the power to move air in and out of my lungs. I got rid of the nostrum and at once felt better. I mean, at least I could breathe again.
"I may have been a nervous mother. I may still be. But that was hardly the cause of my illness. The day of Elizabeth's wedding came, and everything went off very smoothly, very beautifully--and I still felt sick. I had to take a leave of absence from my job. I couldn't manage anymore. I wasn't exactly idle. I had undertaken an ecological study of our lake. There is an association of families who summer there, and I was expected to read my report at the annual meeting, on Labor Day. I thought if I paced myself I could make the deadline. My long weekends at the lake gave me plenty of time to do the necessary research. And rest. I needed rest. The symptoms that sent to the gastroenterologist were still with me, and I also had some new ones. I was feeling a very unpleasant tightness in my chest, a viselike feeling, and my heart, even at rest, seemed to be skipping beats. You know how we doctors have fragmented ourselves with our medical specialties. My reaction was typical. I was choosing a doctor on the basis of my symptoms. When my symptoms were gastrointestinal, I went to a gastroenterologist. Now my heart seemded to be acting up, so I went to a cardiologist. I don't think he prescribed a nostrum. But the results were much the same as last time. He gave me a thorough examination--everything known to cardiac technology. There was apparently nothing wrong with my heart. Then some new symptoms began to develop. I had difficulty reading. After perhaps half an hour, I would begin to get double vision. Another problem was muscle weakness. Another was involuntary twitching in my legs. They twitched like a twitching eyelid. Do you remember Fourth of July sparklers? How we used to light them and then pass our hands through the sparkle and get the funny 'pinprick feeling'? I began to have that feeling on the bottoms of my feet. That was more than a little frightening. I couldn't help but think of amyotrophic lateral sclerosis--Lou Gehrig's disease. Well, the doctor I went to this time was able to reassure me. It wasn't that. Believe it or not, I was still playing tennis. Or trying to. I wanted to keep up my muscle tone and my muscle strength. I thought tat was the way to fight the weakness in my legs. But I was a blob. And my spells of double vision didn't help my game. Pretty soon, it was all I could do to climb the stairs to bed. Even marketing was exhausting. I remember one day that the supermarket. I was pushing the cart along and I just ran out of steam. I left the cart with all my groceries right there in the aisle and crept back home.
"My weight went down to 95 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 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 noticed it. It was too ordinary. When we bought the cottage, back in 1971, the then owners told us that they had had regular exterminators, 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 setting 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 of tightness in the chest and wheezing respiration, due to the combination of broncho-constriction and increased bronchial secretion. Gastro-intestinal 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 exactly. 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 chemical 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 a 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 residues of an organophosphate spray.
"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 the 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. 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 aspect 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 pesticides specialist's advice, we were going to arrange for a professional team to give the cottage a thorough scrub-down before we moved in on Memorial Day. Meanwhile, I was feeling very much better. The atropine was wonderfully effective. The only problem still my legs, my weakness. But even that was manageable. Maybe I overbid it on our November trip to the Loire Valley. 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 pin in my knee. I consulted an orthopedist there, a man who knows about all there is to know about ski medicine. He did and X-ray, looked at my history saw the 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 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. I mean, like brainless. I consulted a neurologist, a woman. There wee more tests. They showed 50 percent 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 12 by injection, and some muscle-strengthening exercises. I had the feeling I was beginning to emerge.
"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 an 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 facinating displays, and I think we must have walked through them all. I just very foolishly overdid it. But that was the only set-back. 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 I. 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 jest 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 of the samples--the befores and the after--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, prophyria, 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 precaustions 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. 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. Late in September, my knee flared up. It was really disabling. I had a friend and colleague, a rheumatologist, and I consulted her. 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 precedure 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 raisin with weights. Hamstring lifts. Bicycling. 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. 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 the linoleum flooring. We washed in a detergent solution everything that could be washed--walls, floors, and ceilings. Then we sealed the entire inside of the house with two coats of polyurethan 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 the last cottage exposure. I heard about that 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 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 asked 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 mad four visits in the course of the past 20 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 called diazinon. Diazinon! Another organophosphate! For some harmless little water bugs.
"I tell you, I was shaken. I was frightened. And when I got home I got to thinking. I don't know how such things happen. But I got to thinking about that flower show, about how I'd felt the next day. And the more I thought about it, the more I wondered. I went to the phone and called the Pennsylvania Horticultural Society and talked to a woman who had something to do with the annual show. I asked her about the use of the pesticides and insecticides. She said the society had nothing to do with that. That was up to the individual exhibitors--and there were hundreds of them. She thought it was very probable that some of them, maybe all of them, went in for some sort of chemical control. I thought so too."
Dr. Page smiled her wide smile and shook her head. The smile fades away. "I'm just beginning to realize that the world is a very dangerous place. It's something nobody really wants to think about. I mean the thousands and thousands of toxic chemicals that have become so much a part of modern living. I mean the people who use them without really knowing what they can do. I mean the were and how and why they use them. It's frightening. I think I'm pretty much recovered now. I haven't had any trouble for over a year. But you never know. The only think I'm sure of is that I'm going to be very careful for the rest of my life."
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|Title Annotation:||toxic chemical impregnated a summer cottage|
|Publication:||Saturday Evening Post|
|Date:||Jul 1, 1988|
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