Dr. John L. Turner Blog

Technical Note 1: TRANSIENT GLOBAL AMNESIA

The clinical entity of Transient Global Amnesia involves the sudden onset of memory loss. This condition typically lasts for 24 hours, rarely longer, and recovers to a near-normal state - the memory for events during the attack is typically absent.

Repeat episodes are estimated to range from a low of 4% to a high of 24%. The affected individual retains the ability for "immediate recall" of events but the ability to process and retain new information, and the memory for recent events are severely affected.

The neurologic and physical examination are remarkably normal, except for the mental status examination which reveals a striking alteration of memory as described above.

The condition, first recognized in 1956, is seen in patients older than 50, at a rate of 23.5 per 100,000 per year in the U.S. Most show increased risk factors for vascular disease. The condition may be triggered by physical exertion, sexual intercourse, exposure to cold-water, stress and pain. Something in common, noted in the paper by Sucholeiki, is an "increased venous return to the superior vena cava."

I have seen only one case,the step-father of my girlfriend at the time, Lucinda and, strangely enough, it struck him as he was driving past the medical building where I began my neurosurgical practice in Hilo.

Frank was an engineer, 72 years old, and one morning as he was driving his car, intending to deliver house plans to a customer, suddenly, he swerved off the highway, turning into the parking lot of the Hilo Medical Group. He managed to stop his car, banging the front fender on a light post. He found his way, with some trouble, into the building and asked for help. The ambulance was called and he was transported to Hilo Hospital.

Frank had no idea of how he suddenly turned from the road into the parking lot of the medical office building. He did not recall how or why he was transported to the hospital. He repeatedly asked where he was and why he was here. He could not remember driving other than the fact that he had "plans to deliver." Although he could communicate normally, his recent memory was shot and he had trouble following rather simple commands. He had no complaints of headache.

CT scan and blood work were performed - all studies were negative. He was admitted for observation. I saw him in consultation; the rare diagnosis of Transient Global Amnesia was made. His condition cleared within 24 hours and he was discharged without restrictions.
At the time Frank experienced an episode of TGA, MRI was not available.

Now, a MRI with diffusion weight imaging will show early ischemic changes in several areas of the brain associated with memory: left parahippocampal gyrus, splenium of the corpus callosum, left frontal cortex, and the CA1 regions of the hippocampi. The ischemic changes do not progress to infarction.

A good review of Transient Global Amnesia can be found here:
Author: Roy Sucholeiki, MD, Medical Director, Comprehensive Seizure and
Epilepsy Program, The Neurosciences Institute at Central DuPage Hospital

Question: Could this be what is affecting protagonist Dr. James Brock in The Edge of Madness?

We will have more clues as Chapter 1 continues . . .

Chapter One: Born Again

The sun was not simply bright, it was super bright and blinding on this refulgent morning.Trying to avoid its intensity, he turned his face away; covering his eyes with one hand and with his other hand, he began searching his pockets for sunglasses. He was barefoot! His silk shirt was adorned with large red, yellow, and orange flowers-the kind or shirt that tourists wear. His search was fruitless; he had no glasses. A pair of shades was something he needed more than ever on this brilliant morning. He wished he had a set of those Wiley-X Ballistics that everybody wants, then it would be just fine for him to lie here and . . . he pulled back a bit, getting his face out of the light.

Then, he took his first good look at his surroundings.

‘Something was wrong', he thought, ‘terribly wrong! Where . . . where the hell am I?'

He concluded that he must have fallen asleep, feet jammed up against a trashcan and his back wedged up against a very grungy wall. The brick surface was absolutely filthy, covered with a thick layer of grime and pigeon shit; his shoeless feet were covered in dirt. Even worse, his stomach started to churn because of the odor from a good-sized pile of garbage-plates of old lettuce, rice, cockroaches and dirty chopsticks-overflowing a large can just a few feet away.

Looking around, he cannot recognize any of the buildings or anything else in the vicinity. This is not only a scary way to wake up, to him it is unexplainable. His head is pounding; his back is stiff and sore.

Even in the shadows, away from direct sunlight, beads of sweat begin to form on his face and arms. He wants to jump up, to escape . . . but he cannot; his movements are extremely awkward and made only with a great deal of effort! He tries again, but his body is not willing to cooperate. He has to think carefully to initiate the most simple movement. Something really strange is going on. He is alone in the alley as far as he can determine.

A neon sign buzzes above his head and distracts him for a moment; in pink and blue letters, it flashes: "Wing Wah's Cantonese Cuisine." Seeing this, he feels like vomiting more than ever. Over twenty ears ago, a Guangzhou cook once told him, ‘Any animal, whose back faces the sky can be eaten.' They had been celebrating his marriage with Shaohsing wine and dried plumbs. He disliked Chinese food since that day.

Now, he was in a real mess. Could he have been a victim of violence? No, he had no pain other than a bitemporal headache, and he does not appear to be bleeding. A blackout of some type? That doesn't seem to work either; it does not explain his waking up in a filthy back alley. Yet, there must be a logical explanation, there just has to be; he had always operated based on logic and right now, nothing made any sense.

The morning wind picked up, bring a mixture of strange smells along with a vague freshness that seemed to indicate that rain is not far behind. Some ease of movement was returning to his legs and arms, but he continued to move as if in slow motion. He decides to rest a bit, gain some strength, and then try again. What he needs is a diversion, something to also let his mind, as well as his body, have time to recover.

As if on cue, at his side a battle-scarred yellow cat, unnoticed until now, begins to nuzzle his knee. He likes cats-at least he thinks that he does. This fellow must be a friend as there must be an important reason for his appearance. Some omnipresent force was responsible for delivering this cat to him. As he strokes the matted fur, he notices that the poor kitty has infected ears. Since he cannot seem to get moving this morning and the hot sun is bucking up the humidity, he pulls himself further back into the shadows. The cat follows. He is momentarily fascinated by moving shadows and forms on the ground, caused by the fan and inside light.

Hair begins to rise on the back of his neck and goose bumps form on his skin. And the cat nuzzles him again and gives a soft meow as if to say, "nothing to be scared of." Ok, if the cat wants to talk, he will oblige:

"I once had a cat like you, same ear problem. Either he loved to fight, or he was forced to fight and eventually, his scrached up ears filled with pus.They hurt him, much as yours probably hurt you. But I tightened him up in two swift strokes of the knife."

The cat looked at him as if he might be interested in what the man had to say.

"His name was Leapo. Mike bundled him in a towel to hold him still so that I could lance his ears and allow them to drain."

The cat doesn't say anything but appears to be thinking:

‘What an odd fellow. He looks like a mess. The stupid grin on his face makes me think of an imbecile, and he talks to cats as if we understand his gibberish.'

That thought makes the man laugh. He has a friend here, in the middle of what can only be interpreted as extreme chaos.

He turns his attention back to his plight and notices that the sweating has stopped; the pounding pain in his head is nearly gone, as is the chicken-skin feeling of goosebumps. However, a smoky exhaust now wafts from the restaurant, and when coupled with the morning winds, delivers a pungent grilled-eel smell to his nostrils. Bits of trash blow around him in a small cyclone-like vortex; some of the pieces whip at his face, causing him to move his body once again.

It is comforting to see cars and pedestrians at the far end of the alley. Beyond the street traffic, there is a familiar sight: the Ala Moana shopping center.
"I know that place well -I own a shop or something there," he mumbles. "Hey, this is Honolulu! That explains the shirt, and the flowers . . . but who am I? I can't remember my name or what happened."

Standing up for the first time, dizziness hits him . . . and hits hard. He feels stunned and giddy; everything is spinning. Using the wall for support, he tries to rest for a few minutes until the spell subsides. Suddenly, he has the sensation that someone is lurking in the shadows . . . watching.

'Aw come on, get a grip,' he thinks. 'Your imagination is going haywire but you can handle, you've been in tough situations before.'

Each time he moves away from the wall, he hears a jingle. Bracing his shoulder against the bricks, he feels about his pants. There are two keys in his front pocket, and a wallet in the back. He takes out the keys first. The smaller one has an embossed emblem of an animal -a bull or something- and the other one looks like a common door key.

Next, he checks the wallet. It is an expensive one, as judged by the look and feel -some type of soft dimpled leather. Inside there are several crisp one hundred-dollar bills and two fifties, along with some credit cards.

This is strange: Dr. James Brock. That's the name on all of them. But wait a minute, how did he obtain this wallet? Was it his? His keen mind is failing him and is of no help in solving this mystery.

To be continued . . . .

                                                     THE EDGE OF MADNESS

         Introduction       

On the surface of things, nothing appears as it is.

And yet, everything that appears unreal,

Is more real than the surface of things appears to be.

                                            – Psi Factor: Chronicles of the Paranormal

This is a place that many will avoid—a blind alley in the big city. Here lies a comatose man, sprawled among garbage cans, near a restaurant’s back door—chest barely moving, face exposed to the morning sun. A tomcat, favoring one hind leg, ribs adorned with scars on thin tawny fur, nuzzles the man as if trying to arouse him; unsuccessful, the cat retreats, lies down and watches. Trash litters the entrance; small pieces of paper fly by on spinning updrafts from winds momentarily trapped between buildings. Above the door, an exhaust fan’s large blades turn slowly, causing an eerie effect; the yellow light that shines through them from within, produces moving shadows outside, which sweep across the man like troops marching single file, slowly tramping over his chest and legs. We hear the sounds of distant traffic, the intermittent hum of an electric sign and from behind the door, a voice from a radio:

“Today’s National Weather Service forecast calls for a typical trade wind morning across the state. Light showers are expected to remain primarily in the windward and mauka areas. A weather system to the north of the Islands will keep moderate trades blowing through tomorrow, but likely diminishing during the weekend.” A quick muffled shout in Mandarin Chinese, and the radio stops.

Brown rats are in this alleyway, watching from secluded places with unduly curious eyes. A leisurely gourmet’s feast of human flesh is on their minds–they mistakenly believe the man is dead. They patiently wait for the cat to leave; this still-warm entrée will soon be theirs.

This man has all the appearances of the dregs of society. But be forewarned . . . It is easy to be fooled by the surface of things.

 To be continued . . .