Urology Pearls

Stream of consciousness ebbs and flows

Shahar Madjar, Journal columnist

There are two stories I wanted to tell you. The first story is about Mr. Ralph A., a 65-year-old school principal in New England who suddenly lost his stream of consciousness. The other story is that of Claude Bernard, a 19th century French physiologist, who was described as “one of the greatest of all men of science.” Despite the time difference, and the vast distance between the two men, their stories intersect in my mind, for Claude Bernard’s observations are the basis for understanding, and solving Mr. A.’s medical mystery.

It was early summer in New England, and Mr. Ralph A. was busy running the local high-school: There was an urgent need to investigate who threw a stone at the teachers’ lounge’s window; Bob’s mother wasn’t happy about Mrs. Johnson grading policy (“Bob deserves an A+,” she protested); Mr. Peterson, a Math teacher, called-in sick at the last moment; and there was no money in the budget for the graduation ceremony. “I am so ready to retire,” Mr. A. thought to himself. He felt exhausted. His head started to ache.

Over the next three weeks, Barbara, Ralph’s wife, noticed that something was the matter with him. With each passing day, his fatigue intensified. “True, his morning headaches are mild and they do slowly disappear after he takes a couple of pills, but who has a headache every single day?” she asked herself. Then Ralph became forgetful (“Is it really your birthday today, Honey?” he asked her). A week later, Ralph became progressively confused — one early morning, she found him stretched, face down, on the loveseat in their living room. He was fully dressed in his suit and shoes, hugging his school briefcase under his chest, his snoring was interrupted only by incoherent mumbling that sounded something like “Banana! … Umbrella! … Ba-na-na!” It was a Sunday morning, she knew, and Ralph never went to work on Sundays — and Barbara realized that it was time for them to go to the Emergency Room.

“There is something wrong with my husband,” she told the doctor, “it seems that he lost his stream of consciousness.” The doctor asked Ralph a few questions, like “Do you know where you are?,” and “Do you know what is today’s date?” And, “Do you know who I am and what I am doing here?” Ralph answered correctly, he was oriented in time and place and he understood that he was in a hospital for a good reason.

“Consciousness forever changes,” the doctor told Barbara. “It can ebb and flow.”

“It may be,” Barbara said. “But lately, doctor, my husband’s consciousness only ebbs, it doesn’t flow!”

The doctor found out that Ralph’s blood pressure was very high (203/102 mm Hg), that his heart was pounding hard and fast and that he was breathing fast. Nothing else in the physical examination was wrong. Perhaps something was amiss, the doctor thought. But when Ralph’s blood tests came back, it became evident that his kidneys were failing. And an imaging study, an MRI, of his brain showed patches of cerebral edema, or, to put it simply, swelling of Ralph’s brain. The swelling affected Ralph’s white matter and gray matter.

The doctor believed Ralph’s wife from the beginning, but now, that he saw the images of Ralph’s brain on the monitor, he didn’t have even a shred of doubt that her story, that of her husband’s impaired cognition, was true–for if the brain is the throne for a man’s consciousness; a swollen, suffering brain would be a reason for a mind lost.

“The findings in the CT scan,” the doctor told Barbara, “indicate that your husband has PRES, or posterior reversible encephalopathy syndrome. It means that his brain doesn’t look, or function the way it should. It could be related to your husband’s high blood pressure, but also to other conditions. We just don’t know yet. We will run a few more tests, and we will start treating him with medications for hypertension. We believe it might solve the problem.”

The blood pressure remained high, and Ralph’s consciousness ebbed, it didn’t flow.

Barbara was sitting besides her husband’s bed. Her mind was swirling with questions: Why did Ralph’s kidneys fail? Why did his brain suddenly swell? Will he ever again be the Ralph she knew? Will he ever regain his stream of consciousness?

The answers to these questions are based on the observations Claude Bernard, a French physiologist, made more than 150 years ago. But this is a story for another day. I shall return.

Editor’s note: Dr. Shahar Madjar is a urologist working in several locations in the Upper Peninsula. Contact him at smadjar@yahoo.com or at DrMadjar.com.