The Hunger Artist

We open with shots of the MGM Grand and the Excalibur (huzzah!), then flash to a woman's bare back as she wraps a towel around her torso. Ethereal music plays in the background; the camera pulls back, and we see that the woman, her back still turned to us, is standing in a lavishly appointed bathroom. There's a nearly full bathtub with suds, several candles burning, and the general impression that she's ten minutes from a Calgon experience. We see the woman slide her underpants down (she's covered by the towel) and kick them off; I'm getting the impression that we're supposed to notice how attractive she is. The water continues to fill the tub, the music continues to play, and we see her hand pouring some scented oil into the tub. The camera switches to an impressive manicure kit in a leather case -- there are implements here that those dentists-cum-torturers on Alias wouldn't be able to identify -- and then we see her sit down and pin up her hair. Again, this is all from the back. She then selects a pair of scary-looking tweezers. The camera switches to a now-full bubble bath, and we see a copy of Vegas magazine lying on the floor to the tub (and oh, how I want that tub; it's the proper claw-footed kind, not the crappy little rectangle thing in most apartments). We switch back to the view of the woman as shot from the back, and we see her plucking intently. Back to the tub and the magazine -- you think this will be important later or what? -- and the water begins to overflow.

Cut to my closed captioning saying, Phone begins ringing. We see Gil sitting in what looks like an office chair. My closed captioning says, Phone continues ringing. At this point, a receptionist looks up with concern. We finally hear the cell phone ring and Gil starts, then gets the phone. After assuring the party on the other line that he'll be right there, he crosses the office lobby to tell the receptionist, "Please tell the doctor I have to reschedule my appointment. Thanks." The receptionist protests that the doctor won't be a moment, but Gil's already heading toward the door. The viewers' interest sufficiently piqued -- what doctor? Why must Gil go to a doctor? -- Gil strides off. His work here is done.

We're then at a highway underpass outside Vegas; the sight of a man huddled over a burning trashcan provides the visual indication that this is where Las Vegas's homeless population lives. We see Brass and Gil meet by a shopping cart; they're hemmed in by a perimeter of yellow police tape marking off the area surrounding the cart. Brass dons the cape of his alter ego, Captain Exposition, and tells Gil that the body hasn't been ID'd. The body in question is a woman, blonde, wrapped in a blanket and stuffed into a shopping cart. Her face is covered in open sores of various sizes. There is literally no information about who this woman is and how she came to be resting in a shopping cart under a highway overpass. Brass says, "Whoever she is, she's not talking." Gil focuses the flashlight, then leans in to study the face. We get a close-up -- some of the wounds appear to be recent, some of them are scabbed over -- and then her mouth begins moving around, accompanied by wet, muffled sounds. Gil watches as the skin around the woman's mouth ripples and bulges, and then a dry, clean-coated rat emerges from the woman's mouth. Gil leans back, but keeps his eyes trained on the rat; Brass starts in disgust. As the music shrieks in a minor, discordant key, the camera returns to document the rest of the rat's exit, and lingers on the sight of the rodent's naked tail slithering across the woman's lips, just in case you're not sufficiently grossed out yet. Gil then turns to Brass and says, "I think she just ratted herself out." Brass looks back at Gil, his face mirroring disbelief. And maybe, just maybe, relief that this is the last time he'll be on the end of one of these pre-credit punchlines for the season.

Cue The Who. And now, I think, would be a perfect time to revisit the science from last week as the credits roll and we go into commercial. If the geeky digressions distract you from the recap, skip the four paragraphs.

Let's take a road trip to The Wide World Of Diabetic Ketoacidosis, as per the scenario in "Cross Jurisdiction". Our first stop on the tour: Diabetes 101. There are two broad types of diabetes -- Type 1 (which we had in the episode), and Type 2. The latter typically affects people as they get older, and is usually the result of a peripheral inability to tolerate insulin coupled with a reduced ability to create one's own insulin; as a result, if someone who has Type 2 diabetes doesn't get their insulin on time, they don't develop diabetic ketoacidosis (DKA). Someone who has Type 1 diabetes -- which is usually the result of the pancreas losing the cells which help it manufacture insulin -- has no ability to generate insulin, so they are a) dependent on external insulin for their health, and b) vulnerable to DKA. So, a greatly abridged definition of diabetes would be someone who cannot manufacture sufficient insulin.

Why is insulin so important? It's the anabolic hormone helps the body's tissues take up glucose. This is a good thing, as it means that assorted body tissues can then digest glucose (typically, most tissues have receptors for insulin; the insulin is connected to the glucose, and the tissues then uptake both the insulin and glucose). When there's an excess of glucose (because it's not being absorbed, thanks to an absence of insulin), counterregulatory hormones kick in, which leads to the increased formation of ketone bodies. In other words, someone undergoing DKA switches from a normal, carbohydrate-fed metabolism to a fat-fueled fasting-state metabolism. The reason the ketone bodies are so deleterious is because, being acids, they wreak havoc on the body's pH. As a result, the body's normal state -- where cellular osmosis (i.e. the movement of liquids in and out of a cell) is regulated by maintaining a specific pH -- is thrown out of whack as well, and owing to the ensuing diuresis, affected people lose water, as well as the minerals (sodium, potassium, phosphates) which regulate their body's pH. In a nutshell, DKA is a state of insulin deficiency leading to acidosis, dehydration, and hyperglycemia (abnormally high blood sugar).

And now, on to the fun stuff. DKA is a complication from diabetes; its underlying causes may be concomitant infection, missed insulin treatments, or newly diagnosed, previously unknown diabetes. How can you tell when someone is experiencing DKA? Here's a partial list of symptoms: dry skin, labored breathing, dry mucous membranes, decreased skin turgor (i.e. the skin begins to look saggy), and decreased reflexes. People with DKA typically experience the ketotic (fruity) breath, confusion, abdominal pain, and, in extreme cases, a coma. In order to treat DKA, one must address the body's aberrant functions; the patient needs to rehydrate, reverse the acidosis and ketosis, reduce plasma glucose concentration, and replenish electrolytes. Somehow, this seems a little more complex than shooting some Novalin and chugging a Gatorade. Indeed, treatment is usually a combination of an antihyperglycemic agent to lower plasma glucose and ketone levels (your insulin shot), a mineral solution like potassium chloride, which moves potassium out of cells (reversing ketosis), along with intense observation at your local hospital, as the rehydration typically throws a patient's potassium levels into flux, which could lead to further metabolic complications.

That our erstwhile serial killer was able to run around in a state of sustained ketoacidosis, apparently without it impairing his ability to woo Kari Wuhrer or execute complex schemes on a tight schedule, suggests one of the following: there are some things modern medicine can't explain; there are some things the episode could have handled better; or we have proof that in addition to their masterful command of time management, serial killers also have the ability to regulate their metabolisms. I'll leave that call to you.

Naturally, this is Gil's cue to spend some one-on-one quality time with a possible killer. We see him offering a hot dog to the crazy girl -- now shot so we can see her classically pretty bone structure -- and she accepts. Gil offers relish, and she goes into Sagacious Crazy Girl mode: "No, no...no, no...with all those preservatives, no, no, I don't want to be preserved. Thank you very much -- no. I mean, do you know what relish can do to your insides?" Gil deadpans that he'd have to investigate. Sagacious Crazy Girl tells him that he should, because "our insides can kill us." Gil asks if she has to be careful about what she eats. I'd snort about homeless people perhaps adapting to a more opportunistic dining philosophy, but I remember when I worked in DC, I used to give the homeless people by my Metro stop vouchers for the Health Zone over on K street -- you'd pay $1 per voucher, give out the voucher, and the recipient could head over to the Health Zone and get a hot vegetarian meal. So anyway, there I was, being careful and conscientious to be part of the solution, and not part of the problem, and one day, as I'm handing a guy a voucher, he lunges after me, screaming, "BITCH! I want meat or money!" And that's how I learned to begin asking panhandlers if they'd like a vegetarian meal instead of just giving them the coupon. I am surprised, however, when Sagacious Crazy Girl adopts the supermodel eating strategy -- "Everything's gotta come up -- out -- up -- out." Gil comments that she's just pretzeled Newton's Law. Sagacious Crazy Girl puts on a lucid expression and opines that everybody's twisted. Gil asks, "How about your sister?" Sagacious Crazy Girl replies, "My-my sister didn't have a sister." She then lays the Zone Diet on Gil. Gil takes all this in with his usual equanimity, then says casually, "Hey, Cassie, you know that scarf you gave Tookie?" Cassie acknowledges that she does; more importantly, she doesn't freak about Gil knowing her name. Thus emboldened, Gil continues, "Did your sister give that to you? Or did you steal it from her?" Cassie looks up from gnawing on her hot dog to say contemplatively, "I should have stole it." She gets angrier as she elaborates, "Because she-she stole from me." Gil watches Cassie nod emphatically and asks gently, "What did she steal from you?" "My life," Cassie asserts.

Cut to the modeling agency, where Rod is explaining that he "washed my hands [of Cassie]. Ashleigh was the only one who gave a damn. Get together with her every couple of weeks, make sure she had a decent meal, shower, clothes on her back." Catherine wonders what Rod did for Cassie; Rod replies, "Let me tell you something: for every piece of meat, there has to be a butcher." And for this guy, there has to be a subsequent episode in which he's filleted like a side of beef, if only to provide Catherine and Gil an opportunity to crack jokes about the butcher becoming the butchered. Catherine snorts that Rod led Cassie to the slaughter; Rod counters that Cassie went of her own free will. Rod then leads the CSIs to a blow-up of a Spa World magazine, with a January 2000 cover; the cover girl is Cassie. Ironically, one of the cutlines is "Bread: Can We Ever Eat It? (Diet Foods)." I wonder if that's intentional, based on the last scene. We find out that the cover was snapped three years ago. Rod explains, "See, Cassie got deep into freebase. No shortage of scumbags around to keep her supplied. I knew she had the sister in Witchita Falls..." Of course she did. This wouldn't be a clichd storyline about the modeling industry chewing up America's guileless lovelies otherwise. We flash back to one of Cassie's last shoots, where she alternates between a whacked-out apathy and a coke-fueled hissyfit. You can see the abacus in Rod's head sliding the beads and concluding that Cassie's return rate just dropped below acceptable yield; then he turns to look at the stricken Ashleigh (who's sporting that fresh-off-the-bus look) and the light bulb goes on over his head. Back in the present, Catherine's saying, "So, in Cassie's mind, she was the victim here. Makes sense she'd be angry." Rod snaps out of his reverie and corrects Catherine: "Angry was five flights up. Cassie was an obsessed basehead. Cocaine already had her paranoid. Once Ashleigh started modeling, everything became this big conspiracy. Naturally, yours truly was Satan." It's kind of amusing how Rod says that like it should surprise anyone. Gil muses, "Cassie threw her life away and her sister Ashleigh recycled it."

Back at the lab, Sara's still puzzling over the code; the page she's working on has the entries "QP 2, 1256 BC, 35 BF, 2095 S, 116 TC" in the plus column; the one below it has "NAGD, BFJ3 EVEN." It's like Bridget Jones' Diary was written by someone over at Bletchley Park. Gil comes over and comments, "It's like a crossword puzzle, isn't it? Once you pick it up, you can't put it down." Sara explains what she has so far, based on the details she has about Ashleigh -- "BFJ3 -- BF, Bellagio Fountain." Gil supposes the J3 is a date; Sara corrects him with, "What's one thing a model always knows? Who's shooting her. Three Js -- J. J. Jarrett." The name fails to ring a bell with Gil; Sara explains that he's a famous photographer, and she picked that up based on Ashleigh's employment contracts for the last year. Sara also notes, "As an aside -- she stopped working two months ago." Gil wants to know why; Sara concurs that that's a good question.

Off in another room, Brass is going 0-for-2 this episode as he tries to get Cassie to admit that she killed Ashleigh in a fit of rage. "Your sister took your career, and you wanted to get back at her. If you couldn't have success, she couldn't either. Isn't that right?" Cassie only replies, "The victims, the victims have victims too." Brass asks Cassie to clarify who the victim is here; Cassie replies, "I tried to warn her, the in-ing and the out-ing and the pick-pick, and the counting, and the counting, and the counting. I mean, I did, I tried. That's why I tried to really really save her." Enter Grandmaster Gil into the session: "You tried to save her...?" Cassie hisses, "She could never be pretty enough, and she could never be skinny enough, and she could never be perfect enough, and she could never be anything enough." During this sad litany, Cassie's eyes have been darting to the side, and now we see her going into a sort of flashback montage. It's fairly rapid-fire, but it starts with Ashleigh at a shoot, in tears, and Rod coming up to her crooning, "Hey, fat girl. I got what you need," before giving her a line of blow. Cassie whimpers in the box, and then we go back into the flashback, where Rod is bullying Ashleigh; then it flashes to Cassie, to whom he did the exact same thing; then back to Ashleigh, then back to Cassie, over and over, indicating that these seemingly interchangeable girls went through identically painful experiences. Cassie is near tears as she keeps telling Gil, "I tried to stop her, I tried to stop her, I tried to stop." We flash to Ashleigh bending over and vomiting, then more flashes between both girls looking wasted and miserable. Brass then interjects, "She's a needle freak, she doesn't know what she's talking about." Gil begs to differ. He then asks Cassie, "You tried to stop yourself, didn't you? But you couldn't?" This is one time when Gil's curiosity gets him in trouble; Cassie snaps and flies across the table at him, wailing incoherently. A few uniforms rush in and pull her off Gil -- now is probably not an appropriate time to note that she's got a set of abs to die for, nor to wonder if she's doing Pilates between fits, is it? Anyway, Cassie is carried off to a cell where she can calm down.

Then we're down in the morgue again, with one more shot of Ashleigh's face before noticing Ashleigh's innards resting in a steel bowl above her head. I don't notice anything that looks like bite marks, which saddens me, as I was hoping for answer to the "But how did the rat get in her body?" question. As Gil comes in, David says, "I found blisters in the back of her throat." "What? Forced oral?" Gil asks. David answers, "That's what I thought, until I noticed worn enamel on the tooth in conjunction with this red mark on the knuckle of her middle finger." Unfortunately, there are probably a lot of people watching who are hardly shocked by this revelation. "Eating disorder," Gil says, and then we see the TMICam shot of the vomiting in action. Boy, the TMICam crew really went all out for the finale, didn't they? But wait, there's more. David says, "She was bulimic -- and anorexic, which explains the down on her skin. Lanugo." I suddenly recall every YA novel I ever read that featured anorexia, like The Best Little Girl in the World and the countless others at the library; I still wonder if they were meant to be fiction or how-to manuals. Gil comments, "She doesn't seem that skinny." David says, "Not this week. Last week or the week before -- who knows? Binge and purge." Gil replies, "Until her entire system is in a state of shock." David says, "You know what's ." Gil says that the body begins feeding on its own muscles, and wonders if that's what killed Ashleigh. David replies, "Starving and purging weaken the immune system, but the cause of death -- failed kidney fueled by septicemia." Gil then wonders if the blood infection was a result of the injuries to Ashleigh's face. David wouldn't bet against it, then adds that Ashleigh had been septic for at least a month. Add to that anemia, a low red blood cell count, low iron, and high ESR (erthyrocyte sedimentation rate, typically used to assess acute and chronic inflammation, and often indicative of anemia), and, in Gil's words, "She didn't just die. She's been dying for a long time."

Gil has since retired to his office, and he's watching his office toy -- those balls that do the perpetual motion thing -- as the balls swing back and forth, concentrating hard on the sound they make. Catherine comes in and asks, "What do you know that's good?" Gil stills the balls, then extends a folder in Catherine's general direction, saying, "Cassie James's psych profile." Catherine reads; Cassie's apparently a classic paranoid schizophrenic. Gil explains that Cassie's mental illness explains why the interrogation room was too hard on her -- "the tighter the space, the more unbearable the feelings tend to become." Catherine counters that it wouldn't have hurt to take a look at the state of Ashleigh James' psyche either. Gil agrees. They puzzle over how Ashleigh got those facial wounds, and come up empty.

Meanwhile, Sara is going through all the stuff found in the car. She's sorting food wrappers by type and the back of a Tweenks snack cake (mmmm...golden brown cake with creamy filling and no unlicensed trademark use, just like the Donuts Donuts boxes!) wrapper catches her eye. We practically see the light bulb go off, then Sara mutters, "TBC, 48 BF, 870 S 90 TC." Sara reads the nutritional labels, then writes, "TBC, 48 BF, 870 S 90 TC" on a clean sheet of paper. She then turns to the minus side -- "2 EVO'd, 8 g, 1 TU, 7 G." There's a moment where we realize Sara's cracked the code using basic nutrition labels as the key, and then Sara looks shaken as she says, "You must have been so desperate."

Meanwhile, Catherine and Gil are establishing that Cassie's prints place her in her sister's apartment.

Nicky catches up with Liam in the hall; Liam's slurping some Ramen. Nicky, who apparently has made it his goal in life to extract revenge for all those awkward office moments by giving everyone a complex about their dietary choices, comments, "That stuff will kill you, you know." Fortunately, Warrick comes in before Nicky launches into a soliloquy on the perils of sodium and asks if Liam's run tests on the scrapings under Ashleigh's fingernails. Surprise, surprise -- the skin there is her own. Warrick looks a little uneasy at this; he's beginning to put the pieces together.

Cut to Sara telling the staff how she cracked the code: "So what I realized was, bulimia's a zero-sum disease; that's why she has a plus sign over here [on the left] and a minus sign over there [on the right]. Whatever went in had to be exactly cancelled by what went out." Catherine says, "You're talking about BDD -- body dysmorphic disorder." Actually, no, she's not. They're typically considered two very different maladies. In the words of clinical psychologist Steven Pittman, "Body dysmorphic disorder is a type of anxiety disorder. The disorder is different from eating disorders because it involves other factors besides one's weight or body size. Physical features or attributes are what provokes the person's anxiety and negative beliefs. Those with BDD have several 'cognitive distortions' about how they look. Cognitive distortions are distorted beliefs about a perceived flaw." According to the DSM-IV, symptoms of BDD include preoccupation with an imagined defect in appearance; if a slight physical anomaly is present, the person's concern is markedly excessive; the preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; the preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in anorexia nervosa). It's hard to come up with hard numbers for any appearance-related disorder -- I'm sure I can't be the only one who remembers the dust-up when Christina Hoff Sommers alleged in Who Stole Feminism? that Naomi Wolf had fudged her numbers in The Beauty Myth (Wolf later checked and, sure enough, had gotten the numbers wrong) -- but Katharine Phillips, M.D., director of the Body Dysmorphic Disorder and Body Image Program at Butler Hospital in Providence, R.I., and assistant professor of psychiatry at the Brown University School of Medicine, puts the number at one in fifty people.

Anyway, Sara claries BDD for the rest of her colleagues: "One theory suggests it's neurological, another that it's neurobiological, another that it's psychological -- people with extreme sexual or emotional anxiety unconsciously displace their feelings into the arena of appearance because it's more manageable." Nicky boils it down: "You feel like crap, blame your face." Warrick jumps in with, "Or your skin, or your hair, or that zit on your forehead." Or the sentiment that pops up in commercial media frequently implying that there's nothing wrong with your appearance -- and, by extension, you -- that a little old-fashioned Protestant work ethic can't fix. Sara explains the gouges in Ashleigh's face with, "Meticulous grooming when a person suffers from BDD becomes a destructive compulsion. One line that keeps repeating again in her daybook, over and over and over again -- 'I'm not even.'" Funny, but I've spent a lot of time staring at those Day Runner pages for accuracy's sake tonight and I haven't seen it once. I'll just have to take Sara's word for it. Warrick asks, "So you're saying she knew she was slipping." Sara clarifies: "No -- she literally means even. A large number of BDD sufferers are convinced that they're not symmetric, that one side of their face doesn't match the other." "All animals prefer symmetry in their mates," Gil says, helpfully fanning the flames of self-consciousness among his staff, all of whom are secretly wondering if they're really not all that symmetrical. ["In Gil's defense, studies have been done on this phenomenon, and apparently symmetry does play a huge role in how adults rank the attractiveness of potential mates." -- Sars] Gil then cites a bug example, prompting Warrick to say, "We're really not talking about being beautiful at all." Gil defends himself: "In terms of entomology, being beautiful is about being even. It signals the fitness to procreate." Nicky tries again on Warrick's behalf: "So we're not really talking about looks, we're talking about survival of the species." Sara settles the debate with, "The bottom line is the same: control and perfectionism. That's what her code was all about. Let's take HBWC/BC 90 BF 3930 S 114 TC. Three hamburgers with cheese, calories 530, five-thirty times three is where she gets 1590 BC. That's BC for bad calories, and at 30 grams a pop, that's 90 grams of BF." "Bad fat," Nicky says, picking up on the general theme. Sara continues, "The rest of her formula involves sodium, total carbohydrates, and the actual weight of everything she ate." Catherine looks pained. Gil says, "So she was operating like a scientist, seeking the perfect formula to take her pain away." Sara replies, in a subdued voice, "Or disappear all together. Which brings me to the minus side of the equation. She would write down the number of times she TU'd -- threw up, in this case, twice -- or EVO'd." Nicky asks about EVO'd. Sara replies, "Moving her bowels. The directions on her disposable enema box use the term 'evacuate,' so after her burger binge, she 3 EVO'd 14 G, 2 TU'd 9 G and 3 #1. She evo'd three times, but her calculations didn't stop there. G stands for grams." We flash back to a shot of Ashleigh weighing her feces (they're in a sandwich baggie). Warrick says, "Wait a minute -- you're telling me she weighed her bowel?" "Yeah. We bagged it," says Catherine, disgusted by God knows what.