Amelia M. Goodfellow
Writer’s Comment: Pick’s dementia is characterized by distinctive clumps of tau protein in affected neurons. This structural “clogging” causes degeneration of the brain’s structure and thus of its function. The result is the degradation of both neural information pathways and the patient’s fundamental self. This essay was written in Dr. Marlene Clarke’s marvelous UWP 104F course in 2011. The assignment: to illuminate an uncommon pathology with “threads” from history, personal experience, literature, poetry and music. In writing the essay, I wanted the reader to feel the insidiousness, the invasion, the confusion of dementia through Stalin’s catatonia during the German invasion of the Soviet Union, the tangle of Los Angeles freeways, and the isolation of the Lady of Shalott. The disease was chosen after a haunting experience with a psychiatric patient at a nearby emergency room. I hope the reader enjoys finding new links, parallels and metaphors woven throughout this essay.
Instructor’s Comment: When I ask students in UWP 104F (Writing in the Health Professions) to write a collage essay on a topic related to a health science interest, some stare, some groan, some look terrified, and some simply roll their eyes in dismay. A few, though, break into a grin. You can almost see their minds whirring in excitement as they contemplate possible connections between their topics and popular culture, history, literature, and/or the arts. Amelia Goodfellow was one of those students who “got” the idea of a collage from the very beginning, and only a day or two after I made the initial assignment she was in my office trying out ideas. In particular I was struck by her imaginative and insightful use of Stalin’s last days. What could Stalin, Tennyson’s “Lady of Shalott,” the Los Angeles freeway system, and a hospital intern’s experience possibly have to do with one another? Those connections become clear, even logical, in Amelia’s masterful collage essay. By the end, we not only understand what Pick’s dementia is; we’ve begun to experience something of its terrors for ourselves.
—Marlene Clarke, University Writing Program
He sits in his favorite armchair, the creased red leather comfortable now after several hours. The chair’s brass tacks gleam dully in the sunlight filtering in through the curtains. After many days of roiling worry, his mind is a blank. It’s easy now to sit, just sit. Somewhere outside, far away, they are approaching—death, maybe, he muses. It is so silent in the room of the dacha that he can hear each tick of the ancient mantle clock. Tick, tick, tick. He counts the seconds as they pass. Somewhere, they are taking over, he thinks, his old hands clutching the blood red of the chair’s arms. Tick, tick, tick.
L.A. was congested before there were freeways. In the 1920s, as the railroad gave way to the cheap and popular automobile, cars overwhelmed the existing roads. The area lacked the central planning and infrastructure to support the thousands of cars crowding the highways. Streetcar lines were ripped up to make room for freeways in the 1930s, but the transportation dilemma wasn’t even close to being solved.
I looked up as the EMTs brought her in. She was wheeled into Room 7, tucked under the thin green jersey sheets and promptly forgotten. I was assigned to keep her company. “Psych hold,” said one of the techs. I pulled back her curtains and pushed an orange plastic chair close—but not too close—to her bed.
She lay on her back, turned a little to one side, panting. “Get me the phone,” she said. “I have to call Renee. She doesn’t know I’m here!” She was confused and agitated, her eyes never quite locking to mine as she talked to me.
“Your sons are coming,” I said.
The point passed unacknowledged. I tried to make her more comfortable. She kept shifting, messing up her sheets. “Do you know where I live? I’ll tell you all about it. I live in that complex over there on, on, I don’t know. There’s a Mexican lady that lives by me. She’s a nun, I think. She always says hi. Never eats the food I offer her. Her house smells good. Cooking, probably. I got a phone call last night, that’s what started it.”
A protein is a long thread of amino acids curved and folded onto itself many times over. The shape of a protein determines its function, what it can bind to and how it can interact with other molecules. Each protein’s unique role within the cell is carefully choreographed by the cell’s DNA. One protein, tau, is present in all cells of the nervous system, concentrated in the long, wire-like portion of each neuron that connects it to other neurons. A cell’s skeleton holds its powerhouses, factories and control centers together, suspended in a delicate jelly of cytoplasm—and tau cements each cell’s skeleton. When the stretch of DNA that plans the protein tau becomes distorted, either through chance or inheritance, tau begins to malfunction. Its delicate fibers become tangled, and piles of tau begin to clump within the neuron, interfering with the cell’s normal function. These clumps are called Pick bodies.
She was maybe 60 or 65, but her graying hair was still streaked with blonde and long like a girl’s. I could see traces of coral lipstick at the edges of her mouth. She would have been pretty as a young woman. “Did you need the phone? If you have the number, I can get you the phone.”
“No, no. She won’t answer anyway. She’s not alive anymore, Renee. I used to call her all the time when I needed help and now I can’t. But I talked to her last night.”
“Yes, always. I was watching TV, and I got the phone call. She was talking to me. She told me, look at the cable box. Look at the lights. And what was there? A message!” She was triumphant, cackling at me.
“What did it tell you?”
“It said turn the pictures around.” Her eyes got wide. She leaned towards me from the skinny bed, her hospital gown billowing around her as she cut wide swaths through the air with her old hands. “So I turned them. All of them in my room, in my sons’ old room. Upside down and backwards so they wouldn’t see.” She relaxed against her pillows, having revealed her secret. I studied her carefully, glad the rail of the bed was between us.
There she weaves by night and day
A magic web with colours gay
She has heard a whisper say,
A curse is on her if she stay…
She knows not what the curse may be,
And so she weaveth steadily,
And little other care hath she
And moving thro’ a mirror clear
That hangs before her all the year,
Shadows of the world appear.
There she sees the highway near—
He gazes through the window, seeing past the tree limbs stretching across his view. First there were guesses, rumors, and then reports confirming Nazi troop buildup on the Western Front. When the marches started, he was caught off guard. They were everywhere at once, all of a sudden—his eye twitches, a glimmer of his old self showing through as he remembers the day of the first attack. A flurried rush of planning, strategy, orders, defense! They came in three massive companies instead of a single army, one for each planned conquest. They seemed to multiply into more and more groups, like a kaleidoscope picture, every time he looked. Tick, tick, tick.
When they form, Pick bodies are concentrated in the hypothalamus and the dentate gyrus, portions of the brain that house memory. Each clump forms in isolation, growing like a secret seed within its neuron shell. Pick bodies cause the neurons they inhabit to swell, interfering with the traffic of information into and out of the cell. As more and more clumps form, the brain’s communication becomes progressively impeded and confused. The portions of the brain affected most severely by the Pick bodies, often the frontal and temporal lobes, begin to waste away.
Thirteen years after its construction, the Arroyo Seco Parkway connected to the stack interchange in downtown L.A., symbolizing a new age of fast and sleek travel. The Arroyo Seco Parkway, the first freeway in the United States, runs from Pasadena to Los Angeles. It was heralded as a model for developing modern freeways in dense urban areas across the country. But much has changed since 1953. The Pasadena Freeway, as it’s now called, can’t carry trucks anymore. The lanes are tight, the entrance ramps still have stop signs, and it isn’t safe to exit at much faster than 5 miles per hour.
In three moves, the small groups had made a mockery of him. The first group swept into Leningrad. Tick, tick tick. Each cluster of them grew, tumor-like, wanting more and more from him. They wanted the old Capitol, the symbolic cradle of his nation. In a flash of emotion, he shifts in his chair, feeling again the hot rush of embarrassed anger at being caught off guard. They went next to the Baku Oilfields, after the blood of his proud military. Then they came to Moscow—Moscow! Split up, they had done more work than a united army ever could have: they attacked in parallel, choking the three areas of land almost simultaneously. They destroyed roads and fields, buildings and walls, leaving each city in dumb, crippled isolation. The siege on Moscow was, even now, leaving thousands dead. Bristling with anger again, he remembers the night he left. He considers this for a while. Tick, tick. He sits, sits, his old hands clenching quietly as his face shows no sign of emotion.
The progressive strangulation of the frontal and temporal lobes due to neuronal degeneration causes both abnormal behavior and abnormal cognition. The behavioral symptoms begin almost imperceptibly, perhaps with apathy and withdrawal from social activities. The patient may stop taking care of him or herself, forgetting to perform basic grooming unless prompted. His or her behavior may become increasingly disinhibited, or inappropriate, in social situations. The patient might begin to steal or have outbursts; he or she may cease to consider the possible consequences of his or her actions. Though it is rare, some patients experience delusions and paranoia. If their disease has spread to the limbic center, the brain’s seat of emotion, these patients may appear psychotic. The combination of decreased inhibitions and emotional separation from their environment may make Pick’s patients seem and act like criminals, sociopaths and manic-depressives. The patient’s personality will begin to reflect his or her new and confused perception of reality, shifting towards the bizarre and disturbing. He or she may become almost unrecognizable to friends and family.
I came back with her food tray. She was mellow now, making conversation with me, telling me about her sons and their families. She recounted her whole genealogy in perfect detail, proud of her big family. Her eyes lit up when she talked about her grandchildren, and she became the picture of a doting grandmother, showing a flicker of how she must have been, before. She talked with me as if we were two friends sitting over coffee instead of strangers huddled over a food tray in a stuffy hospital room. I began to like her. But she had a disconcerting way of spinning from normal conversation into random and disturbing outbursts. Her mind was like a train continually coming off its track, and I was caught off guard each time the train derailed.
“They were outside playing when I had to turn the pictures around.”
I tried to pull her back. “You know your sons are coming, right? What are they like?”
She leaned close to me, clutching the bed rails. “They’re nice.” She stayed a long time like that, looking at me. Instinctively, I didn’t make any sudden movements, submitting my face to her search. Her face darkened. “You know, my son Steve was married to a girl once.”
“Oh yeah? What happened?”
“She cheated. She loved men, she did. Right in front of my son’s face, she’d flirt, making a fool of herself. Very pretty though, she was. Long black hair and blue-green eyes, pink cheeks. Diana.”
I could feel everything twisting, becoming absurd. “Sounds like trouble,” I said.
“Yeah,” she said, breathing into my face. “You know, you kind of look like her.”
But in her web she still delights
To weave the mirror’s magic sights,
For often thro’ the silent nights
A funeral, with plumes and lights—
“I am half sick of shadows”
The body of his country is now diseased, defective. Each vile clump of the invaders crawling, crawling greedily toward oil, wheat and the seat of his power. Each nerve center of his country under siege. His greatest cities atrophied, his best men killed—and himself? They have reduced him to this helpless cretin. He remembers tucking his damp, sweaty handkerchief into the breast pocket of his dark, well-cut suit with shaking hands, and then—suddenly: a flash of clarity. Just leave, he had thought at the time. Just leave. The Politburo members stood like comical worried puppets, their mouths too big for their faces. Sir? Sir? He wished them away, the whole stupid lot of them. Already his mind is at the dacha. He closes his eyes now, picturing his ranks of troops falling like paper dolls, red flowers blossoming from their chests. Don’t bother me, he’d told them. Leave me alone. Tick, tick, tick.
As Pick’s disease progresses, the patient may experience memory loss and difficulty speaking. He or she may regress emotionally, frequently displaying mannerisms characteristic of infants. Pick’s patients retreat from their surroundings, ceasing to display emotional connection to their environment.
There are gaps in Los Angeles’ freeway system, gridlocking the roads with the worst traffic congestion in the United States. Still underdeveloped in the 1970s, L.A.’s freeways decayed further when popular support for mass transit left little money for freeway improvement. As of now, only a little more than 2/3 of the originally planned L.A. freeways have been built. The traffic’s chokehold on the freeways causes cars to spill out onto huge overflow throughways in cities like Wilshire, Santa Monica and La Cienega, roads never meant to hold so many cars. There are 4 million people in this city within just 500 square miles, and sometimes the freeways make it feel as if no one can get out.
I was apprehensive the next time I went to Room 7, this time with more blankets. She was cooperative with the nurses sometimes, but I’d had to hold her arms down so Sandy could draw blood. She only cooperated for me now, calling me to come back when I left her room for more than a moment. I watched the vial fill with dark blood. Had I ever seen blood that dark? I thought of it swirling around inside her body, lapping at her wormwood brain and pumping through her secret heart. I pictured her mind sparking randomly, the messages getting confused as they travelled to her mouth.
She was lying still when I entered the room again, huddled like a child under her blankets. We were prepping her for transfer upstairs. I was nervous about the switch.
“In the year 2050 it will all be much clearer,” she said, her hands gripping the blankets tightly. “And what year is it now? 3067, 3068, 3069…” A pleading note in her voice.
“No, ma’am,” I said gently, touching her arm. I felt uneasy, like a storm was coming. “It’s 2010. January.”
“Thank you, Diana.”
He hears a disturbance just outside the heavy wooden door, a step, a mutter. His brow creases in annoyance. Sir? Sir? A knock, harsh and too loud. He imagines the knock blowing back the curtains in the room, shaking it so the framed portraits on the walls go askew. He says nothing. The door opens, a pair of young, handsome officers too large for the room standing on the worn and beautiful carpet. We need your orders, sir. The German seizure— To the officers, his old head looks pale in the faint sunlight, silly age spots showing on the balding scalp; he is slumped in the chair, back to them. Sir, we are awaiting your orders. Like an overdramatic play. He’s tired of such histrionics. He raises a finger a centimeter above the dark red leather arm of the chair, and the officers fall silent. He leans back in his chair, closing his tired eyes. Tick, tick, tick. Like shots ringing out. If he strains, he can hear the gunfire, the Panzers rolling over the fallen. Let them, he thinks. Let them kill each other.
There is no cure for Pick’s disease, and treatment is confined to managing symptoms with antidepressants and antipsychotics. Pick’s disease causes death between 2 and 10 years after onset.
The tech and I rolled her gurney down the sixth floor hallway. She’d covered her head with her blankets in the elevator, refusing to talk to either of us. She seemed to have forgotten who I was. The tech went to prep the room, leaving us together in the empty beige hallway.
She leaned close to me, again. “You know who you look like?” She whispered. My gut went cold. I pictured trains crashing as they toppled off their tracks. “You look just like Diana. Just like her!” She lunged for my arm, but I yanked it back, my heart thudding in my chest.
“Okay, remember me? I’ve been sitting with you all day. You’re okay, you’re okay.”
“That’s just what she’d say!” She screamed. “Don’t lie to me. I know what’s going on! I know who you are!” The tech emerged from the room, too calm for the wrath filling the hallway.
“Okay, in you go,” he said. “The nurses will get you settled.” He turned and walked down the hall. I walked behind slowly, still shaken by the outburst. Halfway down the hallway, I turned to glance back as a nurse pushed her gurney into the room. She looked sad, confused, frail now. I caught her ice blue eyes with mine one last time as the heavy door closed behind her, the beige hallway silent again.
Highway 1 Pacific Coast Highway
Highway 2 Glendale Freeway
Interstate 5 Santa Ana Freeway and Golden State Freeway
Interstate 10 Santa Monica Freeway and San Bernardino Freeway
Interstate 15 The Ontario Freeway and Mojave Freeway
Highway 22 Garden Grove Freeway
Highway 55 Costa Mesa Freeway
Highway 57 Orange Freeway
Highway 73 Toll Road
Highway 91 Riverside Freeway, Gardena Freeway and Artesia Freeway
U.S. Highway 101 Hollywood Freeway
Interstate 105 Century Freeway
Highway 110 Harbor Freeway and Pasadena Freeway
Highway 118 Ronald Reagan Freeway
Highway 134 Ventura Freeway
Interstate 210 Foothill Freeway
Interstate 405 San Diego Freeway
Interstate 605 San Gabriel Freeway
Interstate 710 Long Beach Freeway
Out flew the web and floated wide;
The mirror crack’d from side to side;
“The curse is come upon me”
And at the closing of the day
She loosed the chain, and down she lay;
The broad stream bore her far away—