How To Lose Neurons Quickly
I slowly realized what was going on. He seemed to forget what I had said almost as quickly as I was able to finish saying it. He had already asked me twice if I were really a doctor and a psychiatrist. I get that a lot, probably because of the bright colors I wear and my informal conversational style.
Slowly we got the part of the examination called the “mental status exam.” He did not know the date or the day of the week or even what city we were in. Apparently a “case manager,” one of those people who is assigned to work as an assistant to help low-functioning patients get to the clinic, had brought him in. He could only tell me that he had spent most of the past ten years in jail. As a matter of fact, he said jail was easier for him than the world outside. He said he always violated parole, because calendars were hard to read and he seemed to never show up on the right day.
When he finally had no parole left, and was done with jail, he scraped up all the marijuana he could find and called 911 to come arrest him, so he could get back to jail.
He never explained why, but told me that sort of thing would simply not work anymore, so here he was. Naive and still the academician, I tried to get what they call a medical history. About all that I was able to learn was that he had done drugs, and lots of them. He could not think of anything he had never tried, except heroin. He mostly had done crystal meth. This is a stimulant, and as far as I can tell, a “neuron burner.” People seem to feel very high on it, but also to lose a large number of faculties. Sometimes they lose really basic ones, like knowing who they are and where they are. Of course, there are other ways to forget who you are and where you are. All kinds of serious illnesses. But in the patients I see, the most common one, maybe as common as crystal meth, is head injury.
I asked him if he had ever had a head injury where he lost consciousness, maybe a seizure. What followed was a colorful if confused story of bar fights and losses of consciousness, finding himself draped over everything from a motorcycle to a bridge to construction equipment, never having a clue how he got there, never sure if he really had been there. “Maybe it was just a dream.”
I started asking myself if it really mattered how accurate the history was. I once worked with a French surgeon, a famous one, who had once found himself draped over the front of a steamroller. Now he had been quite drunk, and it had been an initiation ceremony for a sort of secret medical society. He had awaken to retrieve all of his faculties and become a brilliant surgeon, and had (among other things) sworn me to secrecy. This was not that. There had been a lot worse biochemistry involved.
This man may have remembered the circumstances of brief consciousness after a few exotic and dangerous bar fights. But aside from that, his mental status was indistinguishable, as far as I was concerned from that of Henry M.
My gentle reader may not know anything about Henry M., but any and every student of neurology would know about this person who had surgery performed in an attempt to control some very serious seizures. In 1927 at age 27 he was operated upon by Dr. William Beecher Scoville. Soon after he had required something called a “bilateral temporal lobe resection.” He was studied at the Montreal Neurological Institute, where Dr. Wilder Penfield had pioneered the operation. The patient lived for a long time, and was studied extensively, but his memory of events was largely disturbed, even though language remained. Although Brenda Milner and the team in Montreal did detailed studies and testing, I was bowled over by the resemblance of my multiple head injured multiple substance abuser to this classic case. The patient in front of me had recently shaved his head, so it was too easy to find the scalp scars above both ears that would easily have meant he had sustained injuries of some sort to both temporal lobes.
Then it hit me like a ton of bricks and a wrecking ball put together. The combination of poly-substance (and particular crystal meth) abuse, and the head and brain injuries which seem to accompany them in most cases, can reproduce pretty much all of the neurological tragedies of the past. I remember how as a neurosurgeon I had such reverence for preserving as much working brain as I could. Here, people were getting rid of pieces of working brain more efficiently than trauma and/or neurosurgery every could.
It is a well-enough defined medical syndrome that the NIH supports research and has an information page.
Then it occurred to me this is not the most frequent damage I see. I have plenty of patients who look and sound an awful lot like Phineas Gage.
Basically, this 25 year old railroad employee was working on the railroad and preparing an explosion (September 13th, 1848) near Cavendish Vermont when a “tamping” iron went through the front of his skull. He survived, but the frontal lobe of his brain was damaged, survived what seemed to be a “fungal” infection, and by January 1st 1849 he seemed to have “recovered.” He did, however, have an amazing character change. He became “fitful, irreverent, indulging at times in the grossest profanity…” and it sounds to me, not unlike many of my dear patients from public clinics, who have abused substances even they cannot completely catalog and succumbed to head injuries with losses of consciousness the length of which they can ill describe. I will never be able to convince the system to get enough MRIs and psychological testing to prove this hypothesis which is to me now self-evident. Even if I did, they would not prove such hypothesis as eloquently as these stories can.
I think there is one tiny class of society which includes me. People who love the brain, in classic and ancient study, and look at people and see their brains as magnificent machines and bags of chemicals that we cannot adequately describe, even with out highest technology. Then there is an overwhelming underbelly of humanity that takes substances of all sorts, that cannot or will not hear warnings about such behaviors.
We cannot transplant brains. The philosophical questions are even more dizzying than the practical ones. Do we articulate a wire of a computer with a brain cell (we can.) or train people with brain damage to use hand held computers (we can). We have no money for these things. We ought to be able to train whatever brain stem cells these people have left—and we all have them until the day we die—to replace at least some of these lost faculties. Lost faculties as horrible and as tragic at least as the lost faculties that are lost when hunks of brain are cut out and die.
I have offered patients, sometimes repressing tears, to get down on my knees and beg them to stop using drugs, if it would help. (This would be no mean feat, as my knees are not terribly strong and I am working hard to strengthen them.) I have turned heaven and earth and pierced seemingly unpenetrable bureaucracies to offer hope to those who believe there is none. Most of the time, I must live with my own heart-piercing pain, of knowing that what I do often is insufficient to change their lives. I am the one, by virtue of my training and mission, who must navigate between these two distant worlds.
I do not know how to beg harder. People who do drugs kill their brains and should stop.