I ONCE HAD A PATIENT, a salesman who drove from Philadelphia to Boston unwittingly and made it as far as Leverett Circle, the 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 OK?”
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 will usually resolve within hours, leaving no permanent damage.
This was the late 1970s, and I was the senior resident on the neurology service at Mass. General (I’m now at Brigham and Women’s Hospital). C. Miller Fisher, then one of my professors, was the consummate observer. He insisted on reasoning backward from the minutiae of a neurological exam to further his understanding of how the brain works and how disease destroys it. It was Fisher, along with one of my other mentors, Raymond D. Adams, who had given transient global amnesia its name.
After examining the man from Philadelphia (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 trip. He did recall getting into the car 12 hours earlier but had trouble remembering the meal he had eaten five minutes ago.
Godfrey was in his mid-50s. He was a short, somewhat plump man, with a double chin and two-tone eyeglasses. As I moved around the cramped emergency room cubicle to examine him, 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, or the hospital’s — 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.
“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, and it wasn’t drug-induced, so it had to be either transient global amnesia or 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.”
But 20 minutes later, when I mentioned the meal again, he was perplexed. He had lost all memory of the pancakes. If it really were a benign TGA, there was no way I could justify admitting him as an inpatient. But I didn’t want to send him on his way just yet. Something didn’t feel right. His memory trouble had holes in it and was lasting too long. But without an alternative diagnosis, my only recourse was to admit him to the overnight ward. The next day, 20 minutes before he was due to be discharged, Godfrey 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: On weekday mornings, we gather in the library at 7:30, and two of the senior residents present cases they are about to discharge from our emergency department. Hannah had chosen to present the case of a 62-year-old woman who had developed memory problems after having sex with a casual acquaintance, apparently a weekly ritual. A neighbor had brought the woman to the hospital, Hannah told us, after she showed signs of serious confusion, asking the same question over and over at 30-second intervals, a characteristic feature of transient global amnesia. “I feel fine,” she kept saying. “How did I get here?”
“I asked what the problem was,” Hannah said, “and that’s exactly what she said: ‘I feel fine, but how did I get here?’
“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, she looked at me and said, ‘You know, I feel fine. How did I get here?’ ”
This time the line got a laugh from the group.
The gravity of memory problems is often disguised by their risibility. Someone whose perception functions properly but whose processing does not can unintentionally crack up a roomful of trained specialists. Cases like these are more bizarre than scary. Transient global amnesias, in particular, may last only 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.
The case of the 62-year-old woman was titillating — a regularly scheduled, amorous encounter that was intense enough to trigger amnesia, but not otherwise noteworthy. 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 his car, but 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 and the smell of the refineries. But his memory loss and his ability to retain what was happening around him, his autobiographical memory, were both spotty. 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 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. She didn’t know that the one thing people never forget is who they are. She was also unaware that memory works two ways.
In Through the Looking-Glass, Lewis Carroll’s second adventure in Wonderland, Alice has a frustrating conversation with the White Queen, who 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: anterograde memory, the ability to form memories going forward, and retrograde memory, the ability to retain memories of the past. What most people don’t seem to understand is that the two are inextricably linked: When you lose one, you lose the other.
In Blanche’s Hollywood notion of amnesia, 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, “OK.”
When I was a resident at San Francisco General Hospital, I encountered a striking case of catastrophic memory loss. An ambulance brought in a man in his 60s who had had a massive heart attack and was unconscious. His companion was a younger woman 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.
It was a tough resuscitation. When we were done, we discovered that the young woman out in the hall was the man’s girlfriend. He had a wife in Los Angeles, the girlfriend lived in San Francisco, and he was having an illicit weekend with her.
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 saying.
The neurologist who came to check on him was one of my heroes, a compact, perpetually smiling guy named John Caronna, 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.
Caronna 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.
“Who is the president?”
Caught off guard, Caronna said: “It’s not Eisenhower. Ford is the president!”
“Gerald Ford,” the fox said, “that idiot? I went to law school with him. He couldn’t possibly be president.”
It was amnesia — Korsakoff syndrome — a retrograde and anterograde amnesia, a permanent amnesia caused by the low blood flow to his medial temporal lobe during the cardiac arrest. He was now all finished as a lawyer; his memory had stopped, and for him it was 1960. It was stunning. He couldn’t remember what had happened, could not retain our names for more than 30 seconds, didn’t remember the girlfriend at all, and had no interest in who she was. She was in her 30s, nice looking, and when she figured out what was going on, she packed up and left.
From that day forward, the silver fox would live in a cocoon of past memories woven out of vintage thread, unaware that he had a problem. By way of compensation, like many Korsakoff sufferers, he would fill in gaps by confabulating plausible but nonetheless crazy stories. “I think I saw you at the ballpark,” he might say to someone he had just met. “That hot dog was great, wasn’t it?” The urge to fill in probably grows out of a need to save face. Many alcoholics do it in the early stages of the syndrome.
Clearly, it is possible to perform at a high level during an amnestic event, although faulty executive skills will become apparent: You might, for instance, get stuck driving round and round a traffic rotary.
BY THE FOLLOWING MORNING some of Godfrey’s memory had returned, but in a Swiss cheese fashion: There were significant holes in both retrograde and anterograde memory. This is not consistent with transient global amnesia. If Godfrey did not, in fact, have TGA, he was then, like the silver fox, in serious danger of losing his ability to form new memories, along with a significant chunk of his past ones. The clock was winding down. If I couldn’t come up with something, I would have to discharge him at noon.
TGA varies little from person to person. It is one of the few neurological syndromes that has inviolate borders, and Godfrey’s form of memory loss was too spotty, going backward and forward, to fall within those borders. There was also the issue of his awkward gait. I began to worry that a low blood flow to his temporal lobes was the true underlying problem and that he might be at risk of losing a divot from his brain with a stroke.
In the 23d hour of observation, the nurse called me and said that Godfrey’s speech had become slurred, and then the pieces fell together. He was having a stroke. When I walked in, his speech was indeed slurred. When I asked him to walk, I saw that his coordination had completely gone. Godfrey had a garden-variety arterial blockage from a cholesterol plaque upon which a clot had formed. As the clot accreted, it had caused decreased blood flow to the temporal lobes, resulting in an evolving stroke instead of a sudden one. It had most likely started around the time he got into his car.
Godfrey’s case had a fairly happy ending. We gave him an anticoagulant and an agent to raise his blood pressure and shipped him up to the ICU. He would be fine, and he left with minimal memory trouble and only a bit of difficulty seeing. Had I not held him for observation, the stroke could have cost him much of his long-term memory.
“BE VERY CAREFUL about what you call a TGA,” I told the residents that morning. “You’re looking for anything that doesn’t sound right for a fixed period of complete retrograde amnesia and complete anterograde amnesia.”
If Godfrey came into the hospital today, the awkwardness of his gait might have been enough to earn him an MRI (which did not exist back in his day), and the stroke might have been evident. Even so, an inexperienced or untutored resident or intern might just say: “No MRI for him. It’s just TGA. Let’s move him along.” His was an uncommon condition that mimicked a common one. In the end, it’s not really the scan but the painstaking examination that tells all.
The residents held the 62-year-old woman in the emergency department for a few hours, but having no memory of why she came and no awareness that anything was wrong with her, she insisted on leaving. When senior resident Hannah was convinced that her anterograde memory had returned, that it was nothing more than TGA, she discharged her. The hole in her memory would remain, and with it, all memory of her sexual encounter. Fortunately, she had another tryst scheduled for the following Thursday.