aphasia and back

Daniel's voice

Sarah's voice

Daniel and I were conversing about a paper he had to present
when something I said caused him to laugh.  I don't remember what I
said, and I don't remember it being funny; the laughter seemed
intensely inappropriate.  He threw his head back in convulsive,
maniacal laughter that went on for many minutes, then suddenly lay his
head down on the desk. I snorted, asking what was so funny, but got no
response.  I kept talking irritably for a few minutes with still no
response and then began to worry. Crouching next to him I pushed him
upright off the desk; he immediately put his fingers to his forehead
as if thinking.  "Hurts." "What's wrong with you?" Still no
response. I understood he must have a headache and tried to pull him
upright to get him to lie down in bed. He offered no physical
resistance but also did not make any attempt to move himself, so I
left him there. I kept prompting him until almost hysterical: "Goddamn
it, get up! Talk to me!" "Do you need a doctor? Do you need me to call
an ambulance?" He made no response but to say "Bright." Thinking the
light was hurting him, I turned all the lamps off and fumbled in the
dark for my phone. I screamed at him again in fear and anger - at this
point I was still holding out the possibility that he was playing a
very unfunny game of possum.  I pinched him hard on the arm, but he
made no response to the pain, not even a blink.  Finally I dialed 911.

It's odd to describe and remember all these things in fluent language; I experienced most of them as images and ideas, divorced from words,
all run together.

The first thing I remember is the bright yellow pain. That's all there
was in the world. No sense of self, no sense of confusion or time or
fear; there was just brightness, which hurt, and was yellow - searing
yellow, platonic yellow.

After a time, the yellowness started to contract and lateralize to the
left, and vision returned - people were looking at me, and I was
looking at an analog clock. I recall finding this funny, but not
understanding quite why. People were talking to me, but I couldn't
understand anything they were saying. I understood that something was
wrong, that I was hurt. Someone put an IV in my arm; I didn't feel it
go in. Everything on my left was still yellow - not visually tinted
yellow, but simply yellow in fact, in the way that if you close your
eyes, you know that an object is still there where you last saw
it. Yellow was a property of the world on the left.

Daniel sat upright easily in the stretcher, eyes wide open.
His face was not creased with pain or confusion - or recognition when
I called his name.  He was conscious but his only apparent emotion was
a profound disinterest.  He only spoke to say "hurts" or "bright" and
the words were always spat out angrily and insistently in isolation,
almost like a curse.  He didn't blink enough.

During the ambulance ride, I started to understand a little more of
what was happening; fear started to intrude, and the pain started to
recede enough so that I actually started to notice it; before, it had
been so intense that, I think, it'd seemed like air, something always
there and thus not noticeable. I couldn't hold on to thoughts; they
felt slippery.  I knew I should be able to understand what people were
saying, and I knew that the symbols on the walls were meaningful. I
knew what was missing. They seemed to hold meaning if I didn't look at
them directly; but when I tried to read them, nothing happened; they
were just squiggles. I understood that the EMTs were trying to ask me
questions, and I even knew what sorts of questions they were trying to
ask, though I couldn't put those questions into words inside my head.
I realized they'd be trying to see if I was awake, alert and
oriented. I tried to talk to them, to tell them I was conscious, that
I was awake, but something odd happened - the same words kept coming
out.

Not just any words, though. I was trying to tell them that I was
awake and that my head hurts a lot and that I can't seem to
understand what people are saying very well and that for some reason
everything on the left side seems to be bright yellow … but all that
I managed to say, over and over, was "hurts" and "bright".

We arrived shortly to the Lankenau ER and Daniel was moved to
a bed.  Two nurses took his vitals while a third questioned me again
about his medical history.  One of the nurses eventually said to him,
in that voice reserved for puppies, infants, and foreign speakers,
"We're going to do an EKG now, okay? Do you know what that is? We're
going to attach some wires to your chest here and see if your heart's
okay." Daniel didn't respond, but did again look at her as though he
realized he'd been spoken to. The EKG ran and she made some notes on
her chart, then asked, "How do you feel now, Daniel?" "Yellow." "You
feel yellow?" "Yellow." This was the first new addition to his
apparent vocabulary in the 40 minutes or so since onset.

The doctor arrived and started to question Daniel; he was a
gruff, rapid speaker, and even I had trouble understanding him
occasionally.  He got no verbal responses other than "bright," but
Daniel furrowed his brow in confusion and concentration and followed
the doctor with his eyes.  The doctor held up two fingers and asked,
"How many?"  Daniel could not answer, but after a few long seconds,
held up two fingers of his own.  His reflexes were normal and he was
able to grasp with both hands.  The doctor left to schedule the CAT
scan.  Since Daniel was now at least acknowledging speech directed at
him, I asked if he knew my name.  He looked at me hard, then his lap,
then the wall, then back.  "Sss. Ess. Sarah."  "Yes!  That's very
good!" I tried to keep my voice out of puppy-register but failed.

Events in the ER all run together for me; it's difficult to tease them
apart without time or verbal memory as a guide, but I remember a few
of the early ones. I remember the CT scan in particular. By then I had
actually recovered enough comprehension that I was starting to really
grasp what had happened - I understood what a CT scan was, why I was
getting one, understood that I might have had a stroke. I was
confused, because I knew I was perfectly capable of using both sides
of my body.

When the doctor started to give the neurological exam, I had no idea
what was being asked of me - I heard him asking me to do something,
looking at me expectantly. Enough of what he was saying was getting
through that I understood he was asking me to do something with some
part of my body, but I didn't know what, or what part. When he finally
showed me what to do, by taking my finger and touching it to my nose,
then his finger, I was able to show him I could do the task
perfectly. Similarly with squeezing his hands and raising my legs -
once he demonstrated what I was to do, I could do it. Once I realized
he was doing all the standard neurological tests, I think I got better
at anticipating what he was after - I think I was lifting my legs as
soon as he glanced towards them.

He came back from the CAT scan noticeably improved; this was
about an hour after arriving at the ER, and 90 minutes from onset. As
soon as he was wheeled back into the room and we were alone he looked
at me wide-eyed: "CAT fast!"  "The scan was fast?"  Nod.  I was very
encouraged, first that he had noticed such a thing, and was able to
report it, but moreover that he found this interesting - he clearly
knew at that point what a CAT scan was and why it was being done.  I
kept prompting him over the next half-hour and he was able to retrieve
single words fairly well and was aware of his surroundings.  "Do you
know where we are?" "Hospital."  Sometimes he made two-word sequences
like "hurts left" or "left yellow." He still had no syntax to speak
of.  The very first structural utterance he gave was when I asked him
about the pain for the dozenth time.  "Hurts." "Your head still
hurts?"  He nodded, then shook his head.  "Hurts."  He shook his head
violently.  "It hurts."  At one point he noticed his hospital
bracelet and tried intensely to read it, with great difficulty.  He
pointed to his name: "Drucker Daniel," then shook his head, "Daniel
Drucker. Me." He pointed to the date: "Today."  I pointed to the date
for his birthday and asked if he could read that; he stared for a
while and got frustrated.  I pointed out the column with his age.  He
concentrated a moment, then got very excited and waved me over to see:
he pointed at the date, then his birthday, then his age in sequence.

Two hours or so after getting to the ER, I'd recovered enough language
to say a word or two at a time - nearly any word or two, but no
syntax, and only with great difficulty. I tried questioning about what
had happened. People were still talking too fast for me to
understand. Slow. Again. Slow. I managed to understand that my CT scan
was normal. CAT plain. Normal. Plain. Stroke??? I said stroke with
my hands on one side, then made a wiping out motion on it. I
understood that I hadn't had a stroke. What?!  Then, what had
happened? I raised one hand, then the other. Symmetric! I was
retrieving more and more complex words, but still couldn't tie them
together with syntax. I was also still puzzled about yellow left left
language hurt left left left. I thought it was odd that this percept
of "yellow" appeared ipsilaterally.

The doctor returned to tell us that the CAT scan had been
perfectly normal.  Daniel was clearly trying hard to understand but
failing; he balled his hands in frustration and kept telling the
doctor "Slow. Slow!"  The doctor turned to me, "Are you married?"
"No."  "Hmm.  I want to do a lumbar puncture - since the CAT was fine,
I'd like to make sure there's no other bleeding or infection.  Do you
think you can make him understand what that is?" "I'll try."  As soon
as he left, Daniel turned to me expectantly.  "Do you remember the CAT
scan?" Nod. "The scan was fine.  They didn't find anything wrong."
"CAT… plain" "Yes. Normal." "CAT plain."  He squinted.  "No stroke."
"That's right, not a stroke."  "Then. What."  I was thrown by this,
had no idea what he was trying to say.  He tried again: "No stroke,
then - What." If it wasn't a stroke, then what's wrong? He was
unable to produce anything other than a flat intonation, and so it
took me a few repetitions to realize that he was asking a question.
"The doctor doesn't know.  They want to try something new.  They want
to poke you in the back, with a needle, to make sure there's no
infection.  You understand?" "Spine." "Yes." "Needle." "Yes." "Oww."

Trying to understand the concept of the lumbar puncture was
difficult. It was obvious to me that Sarah and the doctor were trying
to convey some extremely serious piece of information, but the harder
I concentrated on trying to understand each word, the more the meaning
seemed to slip away. I changed strategy and tried to let my mind
wander; this helped tremendously. The words people were saying started
to give rise to ideas in my own head, without me having to really
think about it or try to pull them apart from other ideas they might
possibly be. Suddenly I had a very strange feeling, though; for a
while, I couldn't always tell which ideas were my own, and which ones
were coming from what people were saying, perhaps because I still
couldn't really map on to individual words in real time.

The next time the doctor returned he had spoken to a
neurologist, who believed that Daniel's symptoms were just the result
of a migraine that had presented abnormally, so he left us to wait it
out.  Daniel took the news skeptically.  "Headache? This?"  He touched
his lips, "Talk… speak.. hard!"  There was much more affect in his
voice now, and he could express more complicated sequential ideas.
This was about three to four hours after onset.  Something in
particular was bothering him.  "Symmetric."  "What is? What do you
mean?"  "Hurts left, yellow left."  He tapped his left temple, then
reached out into the space on his left side.  "Why?"  I understood
immediately, probably because I was curious myself: shouldn't the
symptoms manifest contralaterally to the site of the trauma?  "You
think that's odd.  It hurts on the left, and it's yellow on the same
side.  That's weird?"  Nod.  I wanted to know more about the
yellowness, whether it was a hemifield or the left eye or just a
region. I tried holding my hand in various places in his field of
view, asking whether it was yellow now, but either he didn't
understand me or the form of questioning was inappropriate to what he
was experiencing.

By the fourth hour Daniel could express mostly anything he
wanted to, though slowly and with difficulty, and he frequently
dropped function words.  He could read the clocks in the room and the
words and numbers on his bracelet, even the arbitrary patient numbers.
A nurse came in and asked him if he knew where he was; he dutifully
answered her "Lankenau emergency room," then turned to me to whisper
conspiratorially, "the nice hospital."  At that point I finally
relaxed.  He started trying to explain what he had been experiencing
the past few hours.  He claimed to remember nothing before the CAT
scan, and progressively more since then.  "Everything was yellow on
the left?" "No… yellow just… was on the left."  "What was bright?
Did the lights hurt you?" "Bright yellow.  Yellow was bright."  He
insisted that this did not feel like any migraine he had ever had.
"Left only.  Usually… both.  No aura.  I get strawberry aura."  His
speech became rapidly more and more fluent as we conversed.  I asked
him unique questions but also did a lot of shadowing, to which he was
very attentive.  "Hurts less." "Your head hurts less now?" "Yes. My
head hurts less now."  He corrected himself and repeated things more
and more frequently until he no longer needed to.

As I became better able to express ideas in language, I became better
able to hold onto ideas and manipulate them. Before, ideas had felt as
if they were all run together, barely differentiated sometimes. Words,
especially, in the sort of dawn when I had just begun to remember
again what words were; I couldn't pick out one word from another
because they seemed to be all overlapping in meaning, hundreds of
thousands of overlapping shapes only just barely separated. As
language returned, the shapes drifted apart, the boundaries became
firmly defined, and the tip-of-the-tongue feeling departed; when I
wanted to speak, I no longer had to try to pry one word from another;
the right word simply was the right word, rather than having to be
sifted from all the others.  In spite of these difficulties, I never
used the wrong word. I often used a word that was less precise than
I had intended (the message I was constructing was always more precise
than what I was able to produce), but I never said "apple" when I
meant "banana".

I think understanding what was happening helped tremendously in the
rapidity of my recovery. From very early on, I was very self-aware and
constantly attending to my mental state, trying to the best of my
ability to probe out the new shape I found my mind to be in. I felt as
if a lamp had gone out, but I'd been expecting it - I knew where
everything was, and I just had to feel around long enough in the right
places, and the light would come back.

when the darkness takes you, with her hand across your face
don't give in too quickly, find the things she's erased
find the line, find the shape through the grain
find the outline and things will tell you their name

Suzanne Vega

The ER doctors in consultation with their and my own neurologist
eventually came to the conclusion that I'd had a partial complex
seizure. Unknown cause. I'd recently started a new migraine
medication, but one not known to have any side effects that could
cause anything like this. Essentially, they decided that this was a
fluke. A random event that just happened to present in a very abnormal
fashion.