Her panic growing, she led him to the sitting room. He appeared to be moving normally and his facial expression, though flat, was not asymmetrical and did not appear drooped (she had learned from the radio that this was something to look for if you thought someone was having a stroke). She sat down beside him on the couch.
‘Nath, it is me, Janet. Don’t you recognize me?’
He looked directly into the eyes of the love of his life. Briefly, she felt she saw him recognize her familiar features.
‘What time is it?’
By the time I saw Nathan in Casualty it was three hours since he had had his scrambled eggs and toast with his wife that morning. He looked very calm – almost serene – but his poor wife was in a terrible state. She was trying to hide her sense of fear and panic but could not stop the tears rolling down her face. She held his hand gently and led him through the crowded department as if she was guiding a child around a shopping mall. Her distress did not seem to register with Nathan. He seemed completely oblivious to what was happening.
By now, he had added a second question to the repertoire: ‘Where am I?’ Having said hello, he asked me, ‘Where am I?’ I told him he was in St Vincent’s Hospital Casualty. This was less than twenty minutes from his home and in an area he knew very well. He looked at me with the same lack of interest in his surroundings.
‘Where am I?’
He asked the same question over and over again, only occasionally looping back to ‘What time is it?’
It was close to two o’clock that same afternoon when the fog began to lift. The questions continued but the range expanded.
‘Where’s my car?’
‘Where am I?’
‘Where’s my wife?’
‘What time is it?’
Nathan’s neurological examination was normal – apart, obviously, from his ability to take in any new information. He could see. He could hear. He could drink the cup of coffee given to him. He could speak. The tone, power and coordination of his limbs were as they should be. His reflexes were all present and his big toes turned downwards when I scratched the soles of his feet. Yet he could not process his circumstances. He was not unlike a small child briefly separated from a parent in a supermarket – perhaps a little less upset but still vulnerable and fearful about possibilities not hitherto imagined.
About an hour later, Nathan suddenly piped up: ‘What the hell is going on?’ He sounded totally different. Gone was the robotic repetition. The blank-faced automaton was replaced by a playful, smiling, Santa Claus-like figure who reached out his hand to comfort his anxious-looking wife.
‘I’m fine, Janet,’ he laughed. ‘Why all the fuss and what on earth am I doing in St Vincent’s?’
Nathan’s last memory was asking his wife whether she had wanted some scrambled eggs at the breakfast table that morning. He had no recollection of his shower, the drive to Dun Laoghaire, the walk on the pier in the cold rain, or the drive home. The period of memory loss was about four hours, although he had occasional glimpses of images from the morning. As the day wore on, he recalled getting into the shower and some of the events in Casualty a few hours later.
Nathan’s scans and blood tests were all fine. His recovery appeared complete but he would never regain the lost time despite his best attempts.
I have seen hundreds of similar cases over the years, and the existential angst on the faces of people who have had an episode of transient global amnesia (TGA) is always striking. The same is true for the terror on the faces of their loved ones. Their horror is more than justified: a person is cruising through life with nothing but their ordinary hopes and fears when, out of the blue, the bright and funny person they love appears like a child on a long car journey, asking, ‘Are we there yet?’ again and again.
I can’t imagine what went through Janet’s mind during that terrifying time. Did she reflect on their courtship, their marriage and their lovely life together? Did she worry about their family business and what was going to happen? Did she look at a future without her best friend? Did she fear that he would be incapacitated and she would have to look after him for the rest of their time together? Possibly all of these things.
The exact cause of such bouts of temporary amnesia remains unknown. After meeting Nathan, my senior colleague mentioned a research paper from the 1970s by his own predecessor at St Vincent’s. Dr Martin called the paper ‘Amnesia by the seaside’, although the phenomenon had been described elsewhere some years previously. It has variously been thought to be due to either a stroke, a seizure or a migraine, but definitive proof of what causes it remains elusive. The unfortunate individual loses their short-term memory and the ability to lay down new memories for up to twenty-four hours. It can be provoked by immersion in water (hot or cold) or extremes of exertion and excitement. This suggests a Valsalva-type manoeuvre (that’s exhaling while keeping the mouth closed and pinching your nose or extreme straining to keep the air in the lungs – something you might see weight-lifters do prior to a lift; they do it to keep the lungs inflated and provide greater stability in their torsos), with subsequent congestion of the veins draining the memory centres in the brain, might be the cause. Sometimes MRI brain scans can show a lack of blood flow in the memory centres of the brain but this is variable in my experience. The precise cause remains mysterious.
Transient global amnesia usually occurs in people in their fifties or sixties but can occur in younger folk. Repetitive questions, in an apparent bid to orientate themselves, are often a significant feature. In most other respects the affected person appears to behave normally. It starts abruptly but recovery tends to be gradual. Understandably, those who observe the phenomenon in loved ones suspect they are having a stroke or a seizure.
Cathy went to the All-Ireland Football Final in Croke Park. Having driven up with her parents from Kerry, the excitement for the 26-year-old was enormous. It was only ten minutes into the game when the Kerry fans rose as one to acclaim a spectacular point, and Cathy suddenly forgot everything. She did not know who she was. She did not have a clue where she was or why she was among thousands of strangers looking down on a distant field.
Unsurprisingly, her parents were caught up in the excitement, and it was only at half-time that her father had reason to suspect that all was not well. ‘What do you think of the match, Cathy?’ he asked.
‘Where am I?’ she replied distantly. The answer soon afterwards was ‘on a hospital trolley’. Cathy’s last memory of what was, to that point, one of the most exciting days of her life, was hopping into the shower at home in Listowel before her trip to the All-Ireland.
One Saturday morning Gerald was awoken by his three-year-old grandson. Gerald brought him downstairs to his father in the kitchen and returned to bed to find his wife in an amorous mood. After they had what he later described, blushing, as ‘a bit of sex’, he could recall nothing of the subsequent three hours of his life.
His wife emerged from a post-coital shower to find her husband grappling with the concept of socks and what on earth he was to do with them. ‘What are these?’ he asked her, holding them up. He repeated the question dozens of times as she tried to help him dress.
Whether or not he had just had the best sex of his life, Gerald will unfortunately never know. When the couple eventually began to piece together the remnants of his ‘trip away from life’ later that evening, he kept asking her what it had been like. His wife assured him – albeit in a rather non-committal fashion – that it was up to their usual standards.
I have rarely seen TGA recur, but it can do so. A single isolated episode is the norm and investigations rarely yield any significant abnormalities. What is fascinating is meeting people after such an episode. They marvel at the fine line between health and illness, and how blithe we tend to be about being on the right side of it (as do I, even still, when I witness an episode). Many become anxious that a TGA experience might be a portent of future dementia but this is not the case. Previously confident people can become
anxious and less gregarious. While most people manage to bury their worst fears, at least ostensibly, some are never quite the same person again.
3
* * *
THE STUD
‘Every time we have sex I get a headache,’ Masud murmured sheepishly. ‘Not just any headache either, but it feels like I have been hit over the back of the head with a hammer whenever I climax.’
‘Every time?’ I asked.
I wondered to myself, was this guy making fun of me, or was this potentially leading up to a brain haemorrhage the next time he had sex? With his girlfriend, Sarah, beside him he was self-conscious, of course, but she cajoled him to divulge more. They were both in their mid-twenties and had met only a few months before in a nightclub in London. The attraction was instantaneous, mutual, and extremely lustful. Days at work were missed. They ate only to refuel before the next bout of love-making.
All could not have been rosier until, en route to his third orgasm that day, our young hero developed a searing pain in his neck that rapidly spread throughout his skull. Apologizing for ruining the moment, he held his head in his hands as she tried to comfort him. He walked to the bathroom of her flat, took two paracetamol and lay down. Gradually, and to his immense relief, the pain began to subside.
Within an hour, his urges overcame any fear of the pain he had endured and the coupling began again. This time all seemed well until he actually climaxed (or, as he put it later, ‘the money shot was in play, Doctor’). This time the head pain was instantaneous and even more intense than earlier. He said he felt like he had been hit by a brick on the back of his head the moment he reached orgasm. He collapsed on top of his unsuspecting and somewhat distracted partner.
She screamed in fear, but he was able to talk and move his arms, and he could see normally, so he felt he had done the sexual equivalent of pulling a hamstring and told her to relax. The rest of the day’s activities were, nonetheless, postponed. He lay down and the intense, sharp pain ebbed to a less severe throbbing one over the next hour or so. Three hours later he was back to himself, if a little more anxious, though he was too proud (or too scared) to share his worries with his girlfriend.
It was with ill-concealed temerity the following morning that Masud decided he would try again. Although apprehensive, given the events of the previous day, Sarah agreed to take things slowly, as the previous few weeks had been the best fun she had had since moving to London the previous spring.
Masud managed to forget his worries altogether for a while. As orgasm approached, he felt a tingle at the back of his head. He ploughed on, only to be felled once again.
Finally, fear won out over embarrassment and he ended up in front of me, a then junior neurologist, a week or two later. ‘Every time we have sex I get a headache,’ he explained. We were of a similar age but I was in an ill-fitting white coat with a rarely used stethoscope around my neck.
‘My dear Dr Tubridy,’ the eminent London neurologist who was supervising my training laughed when I presented Masud’s story. ‘You should try not to get so excited about neurology cases, however interesting they may appear to you to be.’ I cannot deny that I had this tendency.
He smiled and explained that what Masud was describing was a classic case of coital cephalgia – otherwise known, predictably enough, as ‘sex headache’. He instructed me to request brain scans, and to scan the blood vessels of the brain with an angiogram, to exclude the very rare instances of such headaches having a serious underlying cause such as a cerebral aneurysm.
A week later I went to the clinic waiting room in a very excited state, ignoring my boss’s admonitions, to tell Masud and Sarah the good news. The scans I had rushed through as emergencies were all clear, and their lusty endeavours could safely recommence.
To my horror, Masud had not turned up. Had I been wrong? Had the scans missed something disastrous? He still hadn’t arrived by the time I’d finished the morning’s clinic. My elation at the thought of delivering such good news had swung from fear to anger – anger that I had pulled in favours to expedite these scans (even if I had done it as much to satisfy my own curiosity as for Masud’s peace of mind).
I grew more agitated at the thought that he had simply not bothered coming back. How could they not turn up after all I had done for them? How could they deny me my moment of neurological glory? (Now I cringe at the vanity of it!) I decided to phone him.
A groggy Masud answered, doubtless having got over any reservations about further fun, and ignoring my ominous warnings to defer all orgasms until the test results were in.
‘Masud!’ I could barely contain my anger, ‘Where the hell are you?’
‘In bed, where do you think?’
In full pushy junior doctor mode, I demanded he come in to see me at once to discuss the precious scans. He apologized and he and Sarah made their way into central London that afternoon.
He was still soft-spoken and self-conscious when we met on this second occasion, but there was something else. He was no longer afraid, but appeared rather bashful. As I started to remind them, self-importantly, of all the trouble I had gone to, Sarah nudged Masud with her elbow.
‘Just tell him,’ she whispered.
He looked away but obviously something had shifted.
‘What is it? What are you not telling me?’ I asked, rather too frantically. ‘I cannot be expected to do the right thing for you if you are not telling me the whole story. Am I missing something?’
‘Go on, you have to tell him,’ Sarah pushed. I think she felt sorry now for his slightly psychotic young Irish doctor.
Slowly Masud reached into the pocket of his fleece jacket and produced a small tube shaped not unlike those used for sinus decongestion. He placed it on the desk and I examined it. ‘The Stud’ was emblazoned on the vial’s side. It was a nitrate spray he had picked up in Soho and had surreptitiously administered to the relevant area whenever he was about to perform his next round of sexual gymnastics. As anyone who has taken sprays for angina (cardiac chest pain) knows, these nitrate sprays dilate blood vessels not necessarily confined to the heart and headaches are a common side effect. Poor Masud’s performance anxiety had led to him purchasing a safety net of nitrate spray, only to induce severe headaches and maximum pain at what should have been moments of maximum pleasure.
Coital cephalgia is far more common than you might think. Through a combination of embarrassment and fear it is frequently ignored by those afflicted by it, until it becomes truly frightening. I have heard both young and old complain of pain so severe that they fear imminent death.
There are two main types of coital cephalgia. The first occurs before orgasm and tends to mimic a severe tension headache or may even feel like a migraine (indeed, many people with either type of sexual headache have a history of migraine). It comes on gradually over a matter of minutes and may relate to muscle spasms in the head and neck. The second occurs almost exactly at the point of orgasm and is described by patients as the worst headache they have ever had. We use a similar phrase when people present with ‘thunderclap’ headaches that can be an ominous sign of a blood vessel rupturing and bleeding in the brain (called a subarachnoid haemorrhage). This is a life-threatening type of stroke due to bleeding into the spaces surrounding the brain. When presenting initially, sex headaches are investigated as a possible brain haemorrhage until proven otherwise.
Only a third of patients will survive a subarachnoid haemorrhage with good recovery, another third will survive with neurological disability and one third will die. In some studies, as many as 10 per cent of people presenting with a subarachnoid haemorrhage report sexual intercourse as a precipitating event. So while it’s easy to snigger at Masud’s story, neurologists take sexual headaches very seriously indeed. As for those who routinely respond to a sexual overture with ‘Not now, I have a headache’ – that might be a job for a different type of doctor.
4
* * *
SANTA VISITS BARONS COURT
Haro
ld thought it odd the first time he stared out of his kitchen window in Barons Court in London and observed two young boys playing together in his small back garden. He did not recall having seen them before and didn’t think that his elderly neighbours on either side had grandchildren. That these two urchins – for that is what they looked like to Harold – were wearing clothes that would not have been out of place in a Victorian novel was even more unusual, he would think only later that evening. A most cordial and benign man of seventy-three years, Harold concluded that these young boys were not causing any trouble and so he would leave them to his garden, and went about his day.
Over the next few weeks he became only faintly unnerved when the two boys returned to his garden more regularly. As time wore on they were now often accompanied by young girls, also dressed in noticeably drab clothes of a different era. When he would try to gain their attention by gently knocking on the kitchen window, the children seemed oblivious to his presence. In fact, it dawned on him that the strange children dressed in grey were playing noiselessly together.
His interest was further piqued when a group of ten or more children gathered in his garden on a dull London morning dressed as medieval knights. They looked like a children’s version of an old Monty Python sketch, he laughed to himself. While they were not disturbing him unduly, and had made no mess of his well-kept lawn nor caused any damage to his vegetable patch, he decided to approach them. He unlocked the back door that led to his garden. By the time he had shut the door behind him and turned to face the mini-medieval knights, they had disappeared.
Harold’s wife, Edith, had passed away two years previously, and the last three years of their time together had been tough on both of them. Edith’s lost keys and misplaced scarf had evolved quickly over a single year into an inability to find her way home from the local Tesco. Harold had tried his best to cover poor Edith’s tracks, but eventually he could no longer trust himself to protect her from herself. He had visited her twice a day for the next two years in the local nursing home.
Just One More Question Page 2
