George zeroed in on my eyes when I looked up from his neatly typed page of notes. In three paragraphs he had matter-of-factly described the skirmish that had taken place in the plane’s lavatory. We’ll immediately pursue all the tests you order, he said briskly. His wife nodded her assent, with a look of relief on her face.
Your notes are very useful, I assured him. But I’d like to get more of the flavor of how the episode unfolded. It might help us to decide how to proceed.
He pulled his shoulders back and assumed even more of a military brace. I asked if he had been in the service. A Hollywood casting director would have pegged him as a Marine colonel in his late 50s. Oh, George said, I was a bomber pilot in World War II, then a test pilot before becoming an engineer. At 70 he still ran his own consulting business as a troubleshooter for firms that sent him to military bases in other countries to solve technical problems with their aircraft.
He summarized his experience as precisely as he had written about it. On a commercial flight several days ago he had closed the door to a restroom cubicle and tried to pull down his pants zipper. His right hand could not seem to find it. While struggling to un-zip himself, he thought he heard someone trying to open the door behind him. Maybe it was just a little air turbulence, he conjectured. Suddenly he felt what seemed to be a hand pressing against the small of his back. Perhaps, he reasoned, it was just a chill from one of those tiny air jets by the sink.
But then he sensed that whatever had rattled the door was actually inside the cubicle. It slid like a snake around the right side of his waist. With his left hand he grabbed at something fleshy and hard and struggled for a few seconds to pull off the sinuous thing. It tightened its grasp around him, but he stood his ground over the toilet. Finally he yanked it up to eye level and saw what he had been wrestling with. He had been grappling with himself. His left hand was holding his own right forearm.
I finished the zipper routine and went back to my seat without a problem, he said.
He mentioned nothing to his wife about the battle in the toilet and resumed work on an expense account. However, he repeatedly jotted the numbers down an inch or so outside the column in which he wanted them. No matter how hard he concentrated or how rigidly he propped his right wrist against his notepad, he could not squarely hit the two-inch column. Figured it was just the shadows from the overhead lighting, he told me. He checked the angle of the light by blocking its beam with his right hand and realized that wherever he held it, he was missing the outer fingers. When he held his hand palm up, his right thumb disappeared. When he laid his hand palm down on the paper, the right thumb reappeared and the little and ring fingers vanished. About 15 minutes later, all the fingers gradually returned and he was able to place his accounting figures where he wanted them.
How did he feel about this bizarre event? I wasn’t frightened or especially concerned, but something wasn’t right, he replied. The incident reminded him of his experiences while training to be a high-altitude pilot. They’d put us into a decompression chamber and tell us to write until our skills deteriorated to the point where we could only scribble. I figured the plane lost pressurization while I was in the john and that had made my mind play tricks on me.
As a pilot he would have known that in an unpressurized aircraft climbing faster than 1,000 feet per minute (or in equivalent conditions in a decompression chamber) people can start to falter when doing simple arithmetic at an altitude of only 10,000 feet. By 18,000 feet most people respond slowly, writing becomes illegible, and intellectual functions start to grow almost delusional, until at 20,000 to 25,000 feet consciousness dissipates altogether.
However, George’s rationalization fell short. Had his symptoms really been caused by sudden decompression in the plane’s cabin, others-- perhaps his wife--would also have experienced them. It was not until he and his wife landed and waited in a terminal for the flight that would take them home that he even mentioned the incident to her. I asked her how he had behaved.
Nothing out of the ordinary, she remarked. She hadn’t noticed any difficulty with his speech or thinking on the plane. And his balance and strength seemed normal when he got up from his seat and maneuvered their carry-on luggage off the aircraft. He seemed a bit amused by it all when he finally told me, she said.
But she was clearly shocked by his admission. Not only was she now a psychologist, but she had previously been a nurse, so she could imagine all kinds of possible afflictions of the brain and mind, from dementia to psychosis to vascular disease, that might account for the events. She insisted that they see his physician the next day. The family internist, perplexed by his patient’s symptoms, ordered a magnetic resonance imaging study of his brain. The images revealed a white crescent of swollen tissue extending below the surface of the grayish left cerebral hemisphere, at the junction of the sensory and visual cortex. George had suffered a stroke.
His peculiar symptoms were easier to make sense of given this narrow wedge of cortical injury. Transiently, perhaps for only minutes, that portion of the brain had been robbed of blood, oxygen, and nutrients. The nerve cells in this area participate in appreciating what the right side of the body feels and where the right arm and leg are in space. When they faltered, George’s right chest and arm had been disconnected from his awareness of them. He thought he was using his right hand to unzip his pants, but actually it had assumed a life of its own beyond his conscious control and perception.
As blood drained away from these cortical areas, sensation ebbed like a shadow moving across his body’s right side, leaving behind a cool, crawling feeling. His right field of vision had also disappeared in its wake. He saw only what one might view through goggles with the right half of each lens obscured by tape. So his right arm, the expense account column, and his fingers came into sight only when they rested in the left half of his world.
That was apparently why George could not at first recognize that the invisible alien around his waist was his own arm. It wasn’t until he yanked the arm up to his left field of vision that he saw that it belonged to him. Although sensation soon returned to the right side of his body--he was able to zip up, leave the cubicle, and return to his seat as if nothing had happened--his vision took longer to recover. Another 15 minutes or so elapsed before he could plant his expense account numbers squarely in their column. Luckily blood flow restored itself to prevent permanent destruction of his faculties.
George had several risk factors for vascular disease. His mother had died from a heart attack at age 58, and he’d inherited her high blood cholesterol. This led to his own atherosclerosis (a building up of fatty plaque inside his blood vessel walls), resulting in two silent heart attacks within the past 12 years. He had never had chest pain, or at least he’d never paid attention to any discomfort at the time of the attacks. Some routine tests by his physician picked up the damage to his heart wall after each event.
The tests paved the way to two coronary bypass surgeries. After the second one, almost a year ago, an infection in his chest wall required a surgeon to reopen his chest, sawing through the bony sternum, so the wound could be treated and heal. On his back in a hospital bed for a week, with his heart exposed under sterile dressings soaked in antibiotics, George watched the pulsation of his muscular pump.
Perhaps the atherosclerosis that had plugged his heart’s arteries was now building up in one or more of the vessels to his brain, hampering blood flow there too. Or perhaps prior damage to the heart wall might have allowed jellied clots of blood to form on it, break free, and travel up to the cerebral arteries until they proved too fat to pass any farther.
I wondered whether his nonchalant attitude about his alien arm and disappearing fingers came from an indifference stemming from his stroke; maybe a brain region that contributes to insight and emotional responsiveness had also been involved. In patients with right cerebral strokes, apathy and denial that anything is wrong is quite common--even if the left side of the body is paralyzed. Some even imagine that the insensate arm was stolen or floated out the window.
But such strange perceptual twists are rare with a left brain injury like the one George had. Then again, he was obviously a disciplined, stoic fellow. As a pilot during World War II, he had held his course under fire until the moment his payload of bombs had to be dropped. As a test pilot he had often faced uncertainty and managed to suppress surges of adrenalized fear. As a patient, he had calmly eyeballed his heart pumping in his chest without getting upset. Alarm over a novel experience was just not in his psychic wiring.
We proceeded to the studies that might tell us why he had this stroke and how we could prevent another, more serious one. We found no obvious answers. An ultrasound test that bounces sound waves off the chamber walls and valves of the heart revealed no clots or debris. And an initial scan of his carotid arteries, which run up the neck and into the brain, showed no definite narrowing of the blood vessels. He agreed to an arteriogram, an invasive and somewhat more precarious test that allows us to see blood circulating through the brain. The test in itself carries a small risk of causing a stroke.
In the darkened arteriography suite late the next day, I wore an apron with a lead core that barricaded me from the X-rays aimed at George during his test. He calmly chatted with us and held still under his green sterile drapes. The radiologist poked a plastic catheter into a blood vessel in George’s groin and inched the wiry tube up the wide aorta in the belly and chest to the site where the carotids branch off and head for the brain. The one percent risk of a stroke comes from the chance that the catheter will nick an artery wall and flick off debris into the brain’s circulation.
Once the catheter was in place, the radiologist injected dye into the bloodstream to help visualize the brain’s vascular network. We could instantly see the images of each vessel and its serpiginous branches light up on a TV monitor. X-ray pictures, developed minutes later, revealed that several of his arteries contained irregular mounds of atherosclerosis that jutted into the bloodstream. We concluded that one of these plaques at the top of the left carotid, which extends two major branches into the brain, had probably caused his stroke. Most likely a piece of porridgelike material had spontaneously split off and briefly plugged a smaller, distant branch feeding into his cortical areas. But now, three days after the event, we could no longer see any sign of the debris. Presumably, it had quickly disintegrated, restoring flow to the injured but not-yet-destroyed patch of cortex.
As the radiologist pulled out the catheter, I told George that the odds seemed against another imminent attack. But he’d always be at greater risk than another man his age who had been free of vascular disease. The only course was to continue keeping his risk factors under control. (Surgery to clean the artery wall was not an option: the most irregular plaques had accumulated beyond the easy-to-reach carotids in his neck.)
You think I ought to retire and take it easy? George asked, still on his back. I do get myself into some stressful situations, he admitted, though the wife and I make each trip out of the country into a working vacation.
I left it to him and his wife to decide. For a man like George, inactivity might seem like more stress than working.
George sat around the house for a few days, then left with his wife to see a customer in Asia. He would not retire. He’d live with the uncertainty that even his best effort might not prevent a serious stroke or heart attack. Coming to grips with that notion was no more trying than the wrestling match in the lavatory.