When Mr. Essem was twenty-eight years old, a blood vessel burst in his brain. He collapsed and went into a coma, but then through the miracles of modern medicine, he was saved. He was rushed to surgery; the bleeding blood vessel was clipped; and the blood in his brain was removed. He was sent to the intensive care unit, where he remained in a coma for weeks. Then he woke up. He was bright and alert, and could move all his limbs, but he didn’t speak, and no one could tell how much he understood. So he was sent for rehabilitation, but didn’t improve. He was pleasant and cheerful, but if left alone, Mr. Essem simply sat. Finally he came to us, and by the time I met him, he’d been on E6 for more years than I’d been at the hospital. Each morning the nurses got him out of bed, shaved him, dressed him, fed him, and put him in his chair. And there he sat all day long, with his round young face, his round ears, and his round, attentive brown eyes. He never spoke, but he did smile, a tiny, pleasant smile, as he watched the ever-changing, mysterious scenes on his ward. He was demented, but he didn’t have Alzheimer’s. He had a traumatic brain injury.
The oldest patient on E6 was Mr. Hernandez, who, when I met him, was ninety-eight years old. He was short, stocky, and well muscled, with thick, slightly graying hair, all his teeth, and a raspy voice. Whenever I pointed out to him that he was my oldest patient, he would reply defiantly, “No, I’m not!”
“Yes, Mr. Hernandez, you are.”
“No, I’m not,” he would repeat. “Bring me a woman, and I’ll show you how old I am!”
Although we never did bring him a woman, on his 104th birthday the nurses arranged for a stripper—mostly dressed—to come to E6 and present Mr. Hernandez with a bouquet of balloons. He was very pleased. Mr. Hernandez was old enough to have real Alzheimer’s as a cause for his dementia, but I was skeptical of that diagnosis because in the years I knew him, he never deteriorated. He didn’t get better, but he didn’t get worse. His son told me that his father wasn’t much different from how he’d ever been, so perhaps Mr. Hernandez was just being Mr. Hernandez, only older.
Between Mr. Essem and Mr. Hernandez, there were examples of just about every other cause of dementia on E6—except Alzheimer’s. There was Mr. Richard Temkin, for example. Mr. Temkin was a depressed alcoholic who, one evening when he was fifty-four years old, left his usual bar, went back to his single room above the bar, took a loaded gun out of his bedside drawer, opened his mouth, and put a bullet through his head. Right through it—through his hard palate, and then through those frontal lobes that neurologists say we need in order to have “executive power”—to think and to plan.
Apparently we don’t need them; at least Mr. Temkin didn’t, although it did take him quite a while to get used to life without them.
When he first arrived at Laguna Honda, he was just waking up from his coma. It took a few months, but he did wake up, and eventually his Self—morose, insulting, and irritable—came right back to him uninjured, despite those missing frontal lobes, along with enough executive power to insult the other patients and order his own meals from the cafeteria. He continued to improve, and a year later was able to go back to his room above the bar, the only apparent difference in his mental state being that after his attempted suicide, he was no longer suicidal. He, too, had a traumatic brain injury and not Alzheimer’s.
There was Mr. Bailey, a diabetic who had been obsessive about treating his blood sugars. He’d kept them so low that he’d had many episodes of hypoglycemia—when the blood level of sugar is too low for the brain to function. Which was how, over time, he, too, had become demented—from recurrent episodes of hypoglycemia.
Then there was Mr. Powell, whose dementia had been caused by a series of small strokes. He was also a diabetic, and his right leg had been amputated in consequence. He was none too bright to begin with, and now demented, too. I was all the more impressed, therefore, when he showed me how, lacking any locking drawers in his bureau, he used the space inside his artificial leg to keep his money, cigarettes, and contraband matches.
Of all the patients on E6, only Mr. Stembel seemed a candidate for real Alzheimer’s. His dementia had started when he was only thirty-eight and had progressed so rapidly that by the time I met him he was mute, unable to sit up in a chair or swallow his own spittle. So he did have a rapidly progressive, presenile dementia. I decided to try Aricept, therefore, one of the few medications we have for Alzheimer’s. Aricept interferes with the body’s ability to break down acetylcholine (ACH), an important neurotransmitter in the brain. This lack of acetylcholine was, at one time, thought to be the cause of Alzheimer’s dementia, although the fact is that Aricept works well in only a few patients, perhaps because of our redefinition of the disease. I started Mr. Stembel with the very tiniest dose, and I was shocked the next morning to find him sitting up in his chair, smiling, no longer drooling, and trying to walk. So perhaps he did have Alzheimer’s. Although our neurologist thought not. Mr. Stembel’s reaction to Aricept was so exaggerated that it was more likely he’d stroked out the part of the brain that modulates the response to ACH, he hypothesized. In any case, there was no long-term effective medication for Mr. Stembel. Just those few minutes every day when he suddenly sat straight up, swallowed his own spittle, raised his eyebrows, and opened his eyes wide, with a broad, delighted smile.
These six, and the other twenty-eight patients on E6, had just about every cause for their dementia except Alzheimer’s—and usually a mix of many causes: stroke and alcohol and head trauma, drugs, deprivation, disappointment, and want—all the causes that Dr. Esquirol had described almost two hundred years before.
Although the patients on the dementia ward did not have the feared diagnosis of Alzheimer’s, they were certainly “de-mented”—deprived of parts of their brain and mind. Now, I’m an optimist; I believe that there is meaning to life and that this meaning has something to do with soul or spirit; and the men of E6 worried me. Death is one thing. When a vibrant, intelligent being dies, it is devastating, but it is not difficult to believe that his anima, his spirit, survives that sudden loss of body, the difference between the living and the dead being so bright, so clear, so distinct.
But the demented men of E6 gave me pause. They weren’t all there, and they weren’t all not there either. They were demented, but not de-souled or de-spirited. They certainly had the “impairment of memory” and “enfeebling of intelligence” that Maudsley used to define dementia. I’ll grant, too, that many had Dr. Esquirol’s “weakening of the understanding.” But they did not have “a quenching of feelings” or “weakening of the will.” Indeed, I learned a lot about sensibility, feeling, and will from those demented men of E6.
Still, Alzheimer’s or not, dementia is challenging. It challenges what we think of soul, spirit, and personality. Which was why, when I saw Mr. Bramwell dancing to the tune of Glenn Miller, I never forgot it.
I met Mr. Bramwell for the first time on the day he was transferred up to E6 from the admitting ward.
He was sitting in the chair by his bed, dressed in dark blue pressed chinos and a green plaid shirt with the collar buttoned all the way up. He was African-American and dark brown, with a wide face, slack jaw, and incurious eyes, which stared at his own hands tapping softly on the table in front of him. Mrs. Bramwell was standing next to him. She was beautiful. Tall and statuesque, she was calm and confident in high heels and nylon stockings, a maroon skirt-suit, and an elegant green wool coat. Which sounds like it would clash, but against her dark, clear skin, did not. She was probably the same age as Mr. Bramwell, which was seventy, although she could have been ten years younger.
She just couldn’t manage Mr. Bramwell any longer, she told me. The Alzheimer’s was just too hard. Her husband had been a family man, and they had six children, three boys and three girls; he’d worked in construction and had a business with his son and son-in-law. He drank too much, yes, but they hadn’t noticed much wrong with him until the time he got in an argument with his son-in-law and took an ax to him. That was six years ago. Aft
er that, he stopped drinking, but gradually, maybe four years ago, they started to notice he wasn’t quite right. Didn’t talk as much. Seemed slowed down. Then a year ago he began to act really crazy. He got lost in places he knew, and then he started to soil himself.
So she took him over to the County Hospital, where they told her he had Alzheimer’s and sent him to Laguna Honda. He stayed for several months, and he got better, and she took him home. But now she just couldn’t manage him anymore, even with their children’s help—the wandering, the sleeplessness. If he got better again, she would take him home. She wanted to take him home; they’d been married fifty years, and he’d been a good husband, a good father, a good provider.
While Mrs. Bramwell was speaking, Mr. Bramwell sat quietly, with a faint smile on his face, his eyes not blinking much, and his fingers tapping on the table. When I introduced myself and asked him how he was, his eyes turned to me, but he didn’t answer, and then they went right back to the spot he’d been looking at before I spoke.
He’d already been examined and worked up by Dr. Dan, the new doctor on the admitting ward, so I went back to the nursing station to sit down with his chart, his old tests, Dr. Dan’s examination, and his previous admissions to us and to the County Hospital. I would examine him myself later on.
Mrs. Bramwell had the story exactly right, although when I went through the records, they provided more detail and a different emphasis on the facts. Mr. Bramwell had been a very heavy drinker, although he had stopped three years before. He’d had some kind of head trauma, too, in a car accident many years before. Also, he had a psychiatric diagnosis; he was “schizoaffective,” a handy diagnosis that meant whatever we wanted it to mean—a mixture of schizophrenia and manic depression or just depression. What made that diagnosis interesting was that untreated schizoaffectives sometimes use alcohol to self-treat their mental illness. Though I doubted that Mr. Bramwell was schizoaffective. Not many schizoaffectives have construction businesses, houses, six children, a fifty-year marriage, or Mrs. Bramwell, for that matter, and it was more likely that the diagnosis crept into his chart thanks to some overenthusiastic intern who had just heard a lecture on it.
As I went through his records, I was trying to determine the basis for Mr. Bramwell’s profound but rather static dementia. He did have the diagnosis of Alzheimer’s, of course, passed along from doctor to doctor, but real Alzheimer’s didn’t seem likely. Not the Alzheimer’s defined by Dr. Alzheimer, with its neurofibrillary tangles, extracellular plaques, and rapid progression, nor even the new Alzheimer’s, which required only that no other causes for dementia be present. Mr. Bramwell had many causes for his dementia. There was his heavy drinking, which pickles the brain and causes a specific dementia called Korsakoff’s dementia. He had head trauma from his car accident, which can cause the traumatized part of the brain to deteriorate into the encephalomalacia of post-traumatic dementia. If he really was schizoaffective, then he might have the “pseudo dementia” of a psychotic depression, which can look like dementia. Almost certainly, he had some component of multi-infarct dementia, where patients with high blood pressure suffer small, silent strokes that gradually damage their brains. Given his rigidity, lack of blinking, and slow movements, he might even have Parkinson’s disease or its relative, Lewy body disease, both of which can also cause dementia.
But what was most likely, I thought, after I finished going through his records, was that Mr. Bramwell had what so many of our patients had—a mixed dementia from a combination of causes. Indeed, I was beginning to think of dementia as a kind of polynomial equation, or as some kind of weird recipe: three parts multi-infarct plus two parts alcohol, and one part each head trauma, depression, and the side effects of medication.
What was important about this recipe was finding the ingredients in it that were treatable. A medication the patient was taking that caused confusion; an underactive or overactive thyroid; a vitamin deficiency, an imbalance in the blood, or a depression; all these can be treated, and doing so often improves the dementia enough to make a difference—to send the patient home, for instance.
Mr. Bramwell did not have any of the unusual but correctable causes of dementia, though he did seem depressed, and he was on quite a few medications. We could try decreasing or even discontinuing some or all of them, and we could try treating depression. We would see, I told Mrs. Bramwell, how well he would do.
It took more than a year to get Mr. Bramwell off his medications and to treat his depression. And I wish I could say that he had a remarkable improvement. But he did not. He continued to be kempt and shaved, with his little smile and his tapping hands; and Mrs. Bramwell continued to visit him every day, bringing in home-cooked food. She did take him home now and then, but only for a few days; and every time she had to bring him back. Partly because she had kidney failure herself and went to dialysis three times a week, and partly because, well, he just didn’t get better. He didn’t get worse either, which made Alzheimer’s all the less likely. He simply stayed the same, a sad shadow of his former self, a warning that time is short, that we must live our lives to their fullest while we can.
Then one day Mr. Bramwell demonstrated one of the oldest observations about dementia: that even when a patient is de-mented—deprived of mind—his soul, his anima, is still … somewhere.
Now, every ward at the hospital had an activity therapist (AT), and so did E6. The ATs had a hard job—to come up every day with an activity that would engage the demented and the disabled, who were also mostly very sick; an activity, too, that would work the joints and muscles, stimulate the mind, and encourage social interaction. I don’t know what their training was, but, as with all of the new health-care professionals, it was, doubtless, long and rigorous.
The ATs were mostly women; kind and intelligent, they loved their patients; it was easy to see by the passion they put into their wheelchair dodgeball, their bingo games, newspaper readings, poker, blackjack, and baking in the portable ovens. I didn’t like their title though. It was too bland, too nondescript for what they were trying to do. The French is better: Activity therapy is called animation and the activity therapist an animatrice, as in anima—that which animates the body, which makes it come alive and stay alive, and which leaves the body after death.
Activity therapy had replaced the previous activities at the hospital that had been called “work.” Along with giving us the word dementia, Dr. Pinel had also observed that work was therapeutic for the demented, and he had assigned his patients chores—gardening, sewing. At the early Laguna Honda, too, patients had been expected to work if they could. And they did work, farming its sixty-two acres, weaving the cane chairs they sat in, sewing the bandages they used. As late as Miss Lester, the head nurses still assigned patients to feed other patients, read to other patients, and push the wheelchairs of other patients, if they could.
But by the time I arrived, that system of work had been discontinued. It was too complicated; it had too much liability; it took away union jobs. All that was left of it were two patients who worked in the little store, selling candy and shaving supplies, and Mr. Sanchez. Mr. Sanchez was a diabetic who’d lost a leg from his diabetes. Nevertheless, leaning on his wooden cart, he still delivered newspapers to all of our 1,178 patients. He didn’t get paid, but he loved his job, and smiled his way into many an illicit Coke on the wards he visited every day.
Except for those three patients, however, paid workers had replaced the rest of the worker patients, and activity therapists had been hired to provide activity therapy instead.
One of their most popular activities was dancing. There was the Valentine’s Day Dance, a formal affair for the whole hospital; and there were the weekly dances on each floor. Three wards would participate in a weekly dance—ninety patients sitting in rows of folding chairs or in their wheelchairs. There would be music, and the nurses would dance and try to cajole the patients who could to dance with them.
And so it was on this day, when I came around the c
orner on my way to E6. A volunteer was playing the piano, boogie-woogie and jitterbug, and three of the pudgy, youngish Filipino nurses were dancing by themselves.
They were not very good dancers, kind of stiff and slow, but they were enthusiastic, and I stopped to watch. The patients sat in various attitudes of attention and slumber, and none was brave enough to join them. Suddenly one nurse threw out both arms and pulled up a patient to dance with her. It was Mr. Bramwell.
He stood for a moment in front of her, confused and uncertain. He swayed a little, and I was afraid he might fall. With his slack jaw and open mouth, he stared at the nurse, puzzled. Then, slowly, he lifted his right hand and took her left hand, and her right hand in his left, and he began to dance. And though he no longer remembered how to talk, how to clean himself, and barely how to eat, he wasn’t a bad dancer.
Actually, he was a very good dancer. After a few turns with the first nurse, he held out his hand in a gentlemanly way to another nurse, and she obliged him and stepped up. And then he was spinning her under his arm, twirling her in and out and smiling—just a bit, not too much. He was manly, in control, and suddenly young. Though he’d forgotten everything else, he still did know how to dance, and with the dancing, he remembered not only his steps but his style, his manners, and his charm.
The music stopped eventually, and Mr. Bramwell stopped, too. He slumped, he stooped, he came to a halt; he forgot the dancing and shuffled with the nurse back to his ward.
But I didn’t forget. And ever after on my morning rounds, when I came to Mr. Bramwell sitting so stiffly in his chair, with his left foot tap-tapping on the floor, and his hands drumming out a little tune on the table in front of him, I read him differently. With that slight smile as he stared at his hands, he was waiting, I thought, for those first strains of Glenn Miller to sound in the hall.
Ever after, too, when I passed the other patients on the dementia ward, I wondered: What tunes would get them dancing? What did their blank faces hide? What worlds of talent did their eyes shutter?
God’s Hotel: A Doctor, a Hospital, and a Pilgrimage to the Heart of Medicine Page 18