Reaching Down the Rabbit Hole (8 page)

“I feel like I could go home today,” he said.

“Wally, who is Sanjay Sanjanista?”

“You are.”

“How does that work? How can I be Dr. Sanjay Sanjanista and Dr. Allan Ropper at the same time?”

“That’s your first name and your second, and you’re my wife’s cardiologist, and that’s when I first met you, and in your office there’s a sign, ‘Go Bruins,’ and that’s what attracted my eye, and that’s how it got started.”

“How are you sleeping?”

“I never did sleep well. I have to get up and pee a lot. Then there are these damn alarms here. But I feel like I’m much more rested.”

“Will you be able to manage at home?”

“Oh, yeah. The house is all set up.”

There was one other issue that bothered me. “Do you remember talking about Dwight Evans? You were under the impression that he had died. You might have been confusing him with Dick Williams, the Red Sox manager, who did die a few weeks ago.”

“You know what? I think I said . . . no . . . here’s what happened. The greatest right fielder the Sox ever had was traded, and what reminded me of it was when the coach died. Yeah, he was the coach when they won the World Series. And they had the greatest right fielder ever. He’s the one that ran the bases backward.”

“That sounds like Jimmy Piersall. Different right fielder, but a great one.”

“Oh, yeah, was it? No, you’re right, it was Jimmy Piersall.”

A light went on. It
was
Jimmy Piersall, and
not
Dwight Evans, who had been traded by the Red Sox, who had hit his hundredth home run while playing for Casey Stengel, who was traded soon after, but lasted four more years in the majors. I had waded into Wally’s stream of thought, and had met him somewhere in the middle. If Piersall could make it, I thought, so could Wally. And he did. With the help of Seroquel and lithium, he would soon be discharged and return to the problems that had driven him to us in the first place.

“I sold the locomotive,” he said. “I took a loss.”

“Better to be rid of it,” I told him. “You can’t pull freight with it anyway.”

4

My Man Godfrey

A poor sort of memory that only works backwards

In the late 1970s I had a patient, a salesman who drove from Philadelphia to Boston unwittingly, and made it as far as Leverett Circle, a traffic rotary near Massachusetts General Hospital, where he got stuck driving around and around for almost an hour. Eventually a policeman noticed him, pulled him over, and said, “Is everything okay?”

The man replied, “I don’t know how I got here.”

The policeman had the good sense to send him to the emergency room, where he was examined by a junior resident who found nothing amiss beyond the memory loss. Concluding that it was an episode of transient global amnesia, or TGA, a dramatic but entirely benign condition, the resident came to me to approve a discharge in anticipation of the expected return of the patient’s memory. Although it may sound serious, transient global amnesia can be set off in a variety of ways, has no obvious cause, and will usually resolve within hours, leaving no permanent damage.

At that time, I was the senior resident on the neurology service at
Mass General. After examining the man (I’ll call him Godfrey), I recall saying, “How can a brain function at such a high level and have no memory?” Godfrey had driven all the way from Philadelphia, yet he remembered little of the drive. He did remember getting into the car twelve hours earlier, but had trouble remembering the meal he had eaten five minutes ago.

Godfrey was in his midfifties. He was a short, somewhat plump man, with a double chin and two-tone eyeglasses that were out of date at that time although, ironically, back in style today. He was extremely pleasant, and despite, or perhaps because of, his confusion, he didn’t mind hanging around the hospital and getting a little attention.

As I moved around the cramped emergency room cubicle to examine him, I repeatedly bumped backsides with the resident working in the next bay (the semicircular curtains at Mass General had a restrictive diameter). I sensed that there was more to this case than met the junior resident’s eye. Godfrey couldn’t retain names—mine, the resident’s, the name of the hospital—and could not believe where he was. “Jesus Christ, Boston? You’re kidding!” As he remembered it, he had set out for Harrisburg, Pennsylvania, on a sales call. After a while, he came to accept that he was in Boston—he managed to retain that much—and even recalled that he had eaten pancakes for lunch, but when questioned later, he drew a complete blank.

“If this isn’t a transient amnesia,” I asked myself, “what else could it be?” There were only a few possibilities: a concussion, a viral infection in his brain, ongoing seizures, or a stroke. All four affect memory. Three out of four are life-threatening. His CAT scan was normal, seizures seemed unlikely, it wasn’t drug-induced, so it had to be either transient global amnesia or a stroke.

At our first encounter, Godfrey’s memory for the days, weeks, months, and years before this event seemed intact, as far as I could tell without being able to verify the name of his third grade teacher or his high school sweetheart. He reported a vague sense that something peculiar was going on with his mind, but he was not alarmed.

“The hospital meals aren’t bad,” he told me. “Those pancakes were spectacular.”

“What are you talking about?” I said. “This food is terrible. It’s what
we
have to eat every day.” But twenty minutes later, when I mentioned the meal again, he was perplexed. He had lost all memory of the pancakes. If it really were a transient condition, a benign TGA that would resolve in a few hours, there was no way I could justify admitting him as an inpatient. Yet I didn’t want to send him on his way just yet. Something didn’t feel right. His memory had holes in it and the problem was lasting too long. Without an alternative diagnosis, my only recourse was to admit him to the overnight ward.

The overnight ward was a way station where we could keep an eye on patients for a while without officially admitting them. It consisted of eight beds in the back of the Emergency Department, and it was run by the residents. We senior residents could admit people there, not to the hospital so much as to ourselves, for up to twenty-four hours. It was a great invention. All the drunks going through withdrawal, neurotics (to use an outdated but perfect term) we didn’t want to send home but didn’t want to admit, other characters we weren’t sure about—we could give them a bed and observe them. In the modern hospital environment, an attending physician would dress down a resident for admitting a patient like this one, but something seemed fishy enough about Godfrey that I decided to keep an eye on him overnight. The next day, twenty minutes before he was due to be discharged, he took a turn that made me awfully glad I had.

I found myself recounting this story recently during morning report, a fixture on every resident’s daily schedule. Each weekday we gather in the library at 7:30 a.m., where two senior residents present cases they are about to discharge from our Emergency Department. On that particular morning Hannah chose to present the case of a 62-year-old Colombian woman who had developed memory problems after a weekly ritual involving sex with a casual acquaintance. After the tryst,
a neighbor brought the woman to the hospital because she seemed very confused. In the emergency room she kept repeating the same questions over and over at thirty-second intervals: “I feel fine.” “How did I get here?”

“I asked what the problem was,” Hannah said, “and that’s exactly what she said: ‘I feel fine. How did I get here?’ So I explained that her friend brought her in because she seemed to be behaving oddly, and she thanked me. All of the social graces were there: voice modulation, natural body posture, alertness, eye contact. Everything seemed normal until thirty seconds later when she said it again: ‘I feel fine. How did I get here?’

“I told her that her friend thought something was wrong,” Hannah continued. “I asked her whether she had a sense that she was confused, and she said, ‘You know, I feel a little odd, but I think I’m okay.’ So I checked her orientation: What’s your name? Where do you live? Who is the president? How many fingers am I holding up? After answering all of these questions perfectly and my explaining why her neighbor brought her to us, she looked at me pleasantly and said, ‘You know, I feel fine but how did I get here?’”

This time the line got a laugh.

The gravity of memory problems is often disguised by their risibility. Someone in the throes of aphasia or agnosia, that is, someone whose perception functions properly, but whose processing does not, can unintentionally crack up a room full of trained specialists. Cases like these, replete with malapropisms and verbal absurdities, are more bizarre than scary. Transient amnesias in particular may last a few hours, almost always less than a day. Any number of things can trigger an episode, or nothing at all. Sometimes a heightened emotional experience, even sex, can set one off. In the Boston area, I tell the residents, there’s a big spike in these cases in early summer when people start swimming in the ocean. Cold water may be the opposite of sex, but it can create a shocking experience nonetheless, and can trigger TGA. If you have a sense of humor, you get to play the straight man.

“I feel fine. How did I get here?”

The case of the Colombian woman was titillating—a regularly scheduled, amorous encounter that was intense enough to trigger amnesia, but not otherwise noteworthy. It featured the usual stereotyped repetitive questioning with a loss of the ability to form memories going forward. Hannah chose to present it to initiate a discussion of amnesia and its causes, one of the hundreds of neurological syndromes that come up in the course of a year in these morning reports. But to be thorough, I felt our discussion had to go beyond this one case. We needed to consider something less benign, such as the disaster that nearly befell the man from Philadelphia.

At first, Godfrey could remember having set off in the car, yet he remembered nothing of the drive itself. After a few hours, some details came back to him. He vaguely recalled passing through Newark on the New Jersey Turnpike, the smell of the refineries. Under further questioning he could not recall events from a few weeks earlier. He knew the National League standings, but could not remember his last sales call. What bothered me even more was a slight imperfection in his gait. There is no reason in transient global amnesia for someone to have anything but a pure focal memory loss. Any departure from that pattern—the fact that his walk was just a little imbalanced, as though he were tipsy—could point to a potentially deeper problem. I recall him as a very pleasant man, but also as a lovable schlep, neither graceful nor coordinated. He was grateful for small attentions. He savored each one of his hospital meals as though they were the biggest treats he had enjoyed in years. Sitting up in his recliner bed, happy as a clam, he seemed to be a guy who needed caring for. But was awkwardness his baseline, or was it a symptom?

I once treated a woman who was involved in a minor plane crash—a two-seater landed hard and bounced around. Although she did not hit her head, immediately afterward she told the EMTs that she could not remember where she lived or even give her name. For the next few days
she turned it into a soap opera. “I roamed around the east coast and I didn’t know who I was,” she claimed, “and people were so kind to me.” In reality, she didn’t want to acknowledge an affair she’d been having with the pilot, who was also married. The Blanche DuBois routine was her way of feigning amnesia, but she didn’t know how to do it correctly. She didn’t know that the one thing people never forget is who they are. She had no idea that this curious thing we call memory works two ways. She would have benefited from reading Lewis Carroll.

In
Through the Looking-Glass
, the second adventure in Wonderland, Carroll tells of a frustrating conversation between Alice and the White Queen. The Queen, it seems, claims to live backwards.

“Living backwards!” Alice says, “I never heard of such a thing!”

The great advantage in it, the Queen replies, is that “one’s memory works both ways.” When Alice counters that her memory only works one way, the Queen says, “It’s a poor sort of memory that only works backwards.”

She was right. Memory works both forward and backward. Forward, or
anterograde
memory, is the ability to form memories going forward. Backward, or
retrograde
memory, is the ability to retain memories of the past. The two are inextricably linked: when you lose one, you lose the other.

In Blanche’s Hollywood notion of amnesia, post–plane crash, it was possible to lose track of who
she
was while keeping track of who
I
was. She thought she was going to put it over, but if forgetting her own name didn’t immediately give the game away (which it did), then “Please help me, Dr. Ropper” sealed the deal. She remembered my name.

I had to close the curtain and say, “Look, I get it. You don’t want the story to get out. Why don’t we work around that and why don’t you stop this?”

She said, “Okay.”

Years earlier, when I was a resident at San Francisco General Hospital, I encountered another striking case, this one of true catastrophic
memory loss. An ambulance brought in a man in his sixties who had had a massive heart attack, and was unconscious. He had been on the freeway when it happened, on his way to the airport. His companion was a younger woman—the devoted wife?—who followed the ambulance entourage and made it as far as the double doors of the trauma center, then paced around outside, anxiously awaiting the outcome. Inside, the code team descended upon the man, roughing him up pretty good. It was a tough resuscitation.

I was the code leader, and the case required a lot of very fancy dance steps to get him back. When we were done, we discovered that the young woman out in the hall was the man’s girlfriend. He had a wife in LA, the girlfriend lived in San Francisco, and he was having an illicit weekend. This would be their last one.

In any prolonged resuscitation, there is a good chance that the patient will emerge with some sort of brain trouble. That was on my mind when he woke up, but he looked great. He was an entertaining, joke-cracking, silver-haired fox of a guy. We told him he’d had a heart attack, and that it was a bad one, and he thanked us for what we’d done for him. “Just happy to be alive.” He kept thanking us each time we told him, over and over, what had happened. “Just happy to be alive,” he kept saying.

The neurologist who came to check on him was one of my heroes, a compact, perpetually smiling guy named John Coronna, who had been studying the neurological damage done by cardiac arrest and coma. He entered the room with his assistant to administer a standardized research questionnaire that was meant to uncover damage to the medial temporal lobes, the place that seems to serve as the clearinghouse for memories. It is also the area of the brain most susceptible to low blood flow.

John began with the standard questions: “Name? Where are you from? What kind of work do you do?” All went well. The silver fox lived in LA. He was a lawyer. Then John started in on the orientation questions.