There was a very large lesion in his left frontal lobe, and no one knew what it was.
He had been admitted earlier that day, after a neighbor found him in the hallway, confused and covered in urine. Now he sat in his bed quietly, while we stared at his brain and the bright spot that didn’t quite resemble something.
It can’t be tissue death from a stroke, insisted one resident. It was too big, and its geography flouted any one area supplied by any one blood vessel.
But if it were a cancerous mass, argued another resident, its size would cause other areas of the brain to compress. No structures were misshapen, and none were off-center.
I looked at him, as though he could tell me why his brain had been painted with what looked like an arbitrary splotch of white.
“Do you know where you are right now?” I asked, while he returned my gaze.
“I know where I am right now.”
“Where are you?” And what’s inside your skull? my unspoken words resounded in my own.
“I am in the place where I am.”
His echolalia was profound. He repeated empty words and phrases because his damaged frontal lobe compelled him to.
“You’re in the hospital.” And you have an MRI that looks like someone spilled coffee on it.
“Do you know why you would be in a hospital?”
“I do not know why.”
‘“Are you worried that you are in a hospital?” I am.
“I am not.”
We tapped into his spinal fluid to look for cancerous cells. The results would not be back for a week, and even then, a negative result would not necessarily mean a cancer-free brain. Definitive diagnosis only comes from tissue, but no one was ready to take a drill to this man’s brain yet.
The doctors came up with a plan. While we waited for clues residing in his spinal fluid, we would carefully monitor his mental status. Strokes get better. Cancers get worse. Over the next few days we would interrogate his brain, looking for small changes that would tip us off in one direction.
Within a few mornings he began to answer my questions slightly differently.
“Do you know where you are right now?”
Sometimes it was a “large academic institution,” sometimes it was a “hospital” by the wrong name, and sometimes it was a “department of a sort.” But it was an answer, and sometimes it was close to accurate.
I became obsessed with his responses, memorizing them, comparing them to the previous day’s.
“Are you worried?”
“I am worried.” Expression of emotion or echolalia? Every day I hoped he would worry. Worry meant emotion, and emotion meant that his frontal lobe was healing.
“Why are you worried?”
“I do not know.”
Every day was Groundhog’s Day with a touch of additional groundwork. Every day I hoped he would worry and mean it.
“Why are you worried?” You don’t look it.
“I am worried because I am sick.”
“What do you think is wrong with you?”
“I do not know.”
He still never spoke unless spoken to. He never asked a question. Abulia — lack of motivation — stemmed from his lesioned frontal lobe.
Then one day he spontaneously said to me, “Something is wrong with me.”
I was elated. “What’s wrong?”
“I do not know.”
“How do you know something is wrong, then?”
“Because something is wrong with me.”
He was sick, he knew he was sick, and he was worried. Tiny steps toward insight meant he was getting better. The doctors were optimistic. The nurses weren’t so sure. He was still wetting his bed because he did not have the initiative to go to the bathroom. Still, he was wetting his bed less than before.
On the day he could finally name the hospital he was in, his spinal fluid culture came back with malignant cells.
I went back into his room. Without diagnosis as an excuse, suddenly I saw my intellectual exercise as something I hadn’t before: cruel. How many words had I planted in his brain and mistaken as his own?
“How do you feel?”
“I feel okay.”
“Do you need anything?”
“I do not.”
“Let me know if you do.” I knew he wouldn’t. He never did.
How much had he really changed his answers over the past few days? I had changed my questions, and I had changed his goalposts. Hungry for meaning, I heightened every ripple of insight into a wave.
A good friend of mine espouses the philosophy, “Life is an ocean.” When we’re sailing across its surface, we tend to overlook its depth. Instead, we focus on eddies that propel us in a particular direction. The small surface changes are often what we feel most.
This man’s eddies of progress were tiny compared to the profundity of his losses. But his eddies were what I fixated on, because they were changing for the better. Following them, I lost sight of an illness that ran miles deep.
I stopped asking, “Do you know where you are right now?” because I looked down and finally saw the answer.
I hoped he wasn’t worried.
Shara Yurkiewicz is a medical student who blogs at This May Hurt a Bit, where this article was originally published.