Book extract: The Truant From Medicine – Three puzzling patients

Ivan Donaldson had earned an international reputation in medical circles before he retired from clinical work at Christchurch Hospital and as professor of neurology at the Otago School of Medicine, Christchurch, aged 60. By then another interest had overtaken his medical career – winemaking. He and his wife Chris established the Pegasus Bay winery and restaurant at Waipara in the 1990s. In this second of two extracts from his memoir, he describes three of his many puzzling patients.

‘It’s when I run, doctor, that’s when it’s worst. It’s really starting to drive me crazy.’

Keith did not strike me as a crazy type, but then you could never tell. He seemed to be obsessed with sport, so maybe his outdoor he-man appearance was just wallpapering over cracks in a fragile personality. He came off a dairy farm and had a somewhat suntanned, bullish look.

‘And within a few minutes of it starting I begin to get a headache. Unless I stop, it becomes a pounding headache. I can’t allow it to continue like this, you know. I’ve got an important game in a couple of weeks and I have to train. As I am I couldn’t even do the first 10 minutes; I’d be sidelined!’

‘Tell me more about the headache,’ I prompted. ‘Where does it start and what exactly does it feel like?’

‘All over my head and it’s bloody awful! It feels as though my head will explode. It’s worse than a dozen hangovers. I thought it might be the piss so I gave it up. It’s made no difference.’
‘How long does it take to settle down if you stop running and just rest, Keith?’ I asked.

Keith had seemed uncomfortable from the time he had entered the consulting room. I had put it down to the unfamiliarity of the situation, but now he looked on the verge of tears, possibly due to reliving the experience of one of his bouts of head pain. He sniffed loudly through a nose that proudly bore evidence of previous battles, lost or won on the rugby field. He sniffed
again and looked about in embarrassment so I pushed a box of tissues across my desk towards him. He gratefully pounced on it.

‘About five or 10 minutes, I guess. It doesn’t last long, but then it never really goes away. I always seem to have a dull head these days. I never had headaches until a month ago.’

In my mind I had been running through possible causes of Keith’s exercise-induced headaches. At 28 years of age he could easily have developed his first migraine symptoms, and in some people attacks can be precipitated by exercise while, somewhat perversely, in others physical activity will relieve them. It is all very much an individual thing. Then there is a condition called cough headache, in which a cough or straining, such as at the toilet, can cause a severe generalised headache. It can be a symptom of blockage to the flow of the cerebrospinal fluid from the head to the spinal canal, which normally occurs at these times. This can also be triggered by sudden exercise. But then there are a hundred and one causes of headache. I needed more details before I got carried away trying to make a diagnosis prematurely.

‘Do you get any other symptoms with the headaches?’

‘Only splashing.’

‘Splashing?’

‘Yes, but I get that at other times as well. I told my doctor about it, but he said I must be imagining it, or perhaps it was coming from creaking in the joints in my neck.’

‘What do you mean by “splashing”?’ I asked, thinking that Keith must have gone soft in the head. ‘Perhaps his brain has turned to mush and is just slopping about inside his skull,’ I thought to myself uncharitably.

‘It’s just ordinary splashing, like you might hear if you shook a can of paint that was only half full.’

‘Do you mean that you hear it?’

‘Yes, and it comes at other times, such as when I shake my head. Sometimes when I turn over in bed I can hear a bubbling, but it doesn’t last long. I guess I must be imagining it and I have stopped paying it any attention. It’s not the noise that bothers me or prevents me from playing rugby, it’s the headaches, and I need to get rid of them before the next game!’

‘How long have you had these splashing noises?’ I persisted gently, trying not to irritate him by harping on about something that he thought was irrelevant.

‘About three weeks. Not as long as the headaches. I’ll show you,’ Keith said, shaking his head vigorously from side to side. ‘There, you see, that’s what it’s like. You must have heard that.’

‘No, I’m sorry but I didn’t hear anything.’

I might have heard the bubbling,’ volunteered Eva, who until that time had sat silently; ‘I’m not sure.’

I was uncertain whether the buxom Eva, who was oozing cheap perfume, was Keith’s wife or partner, but it was irrelevant. The concerned young lady seemed absolutely genuine and was corroborating what Keith had said.

‘Yes,’ she continued, ‘sometimes when it is quiet in the night and Keith turns over in his sleep.’

‘Keith, could I listen to your head with my stethoscope while you do that shaking?’ I asked, assuming permission and moving behind him to put my stethoscope in the centre of the top of his head, at the vertex.

That was how I heard the splashing, which could mean only one thing: Keith had air in his head as well as cerebrospinal fluid.

‘Did you suffer a bad head injury not long before these headaches started?’ I enquired.

‘I did get a fair knock during my last major game. It was a sort of a head butt, done on the sly while the ref wasn’t watching. It made me see stars, but I’ve had worse so I didn’t think much about it,’ Keith said, blowing his nose vigorously on another tissue. ‘Damn cold, don’t seem to be able to shake it off.’

‘When did it start?’ I asked with rising excitement.

‘About the time the headaches kicked in. I thought they must be due to sinusitis and the doctor gave me a course of antibiotics. It didn’t do any good.’

‘You mustn’t blow your nose, Keith. Just wipe it. It’s dangerous to blow your nose because you must have a fracture high up inside it. This crack in the bone is between the inside of your nose and the space below your brain. It’s the cerebrospinal fluid that surrounds your brain that is leaking out and air must be replacing it inside your head. If you blow your nose it might force germs into the cerebrospinal fluid and cause you to get meningitis. It is surprising that you haven’t had that already.’

I saw Keith in the days before brain scanning had been invented, but a simple x-ray showed that the top half of each of the large fluid-filled spaces inside the cerebral hemispheres, the lateral ventricles, were filled with air, with cerebrospinal fluid below this. There was also air over part of the surface of the hemispheres. He had adroitly performed his own air encephalogram!

A neurosurgeon opened the front of Keith’s skull and carefully eased the right frontal lobe of the brain upwards, exposing and then blocking the leak. This solved the problem of the air-head rugby player – well, almost solved it. Keith missed his important match. Neurosurgeons can work wonders, but miracles take extra time.

It may seem surprising that Keith’s skull had been fractured without his losing consciousness, but this is not a rare occurrence. Fortunately, Keith had no evidence of brain injury, but it is possible to sustain considerable brain damage from a blow to the head without blacking out, and significant persisting disability can follow an apparently simple concussion. All head injuries are bad news; well, almost all. They say it takes the exception to prove the rule, and on rare occasions a patient may appear to be improved. Such was the case with Thomas Peters.

Tom was not a big man, in fact, he was puny, but he was feared by his wife and children, even though they were physically larger than him. When he was not laying bricks he spent his time laying into them, often boozed to the eyeballs. After he knocked off work each day he headed straight to the pub where, although he was a bricklayer, he generally got plastered. When he arrived home half-sozzled, dinner had to be on the table and woe betide anyone who spoke while he ate his meal, watching his favourite soap opera with the volume knob turned strongly clockwise. Industrial deafness was said to be the problem, but it was an industrial accident that turned out to be his making, or his undoing, depending on your point of view.

A load of bricks was being swung by a crane onto a building site when the pallet hit the side of Tom’s head, sending him sprawling in an ungainly heap. If he was unconscious, then it was only for a brief period; perhaps not more than 30 seconds. By the time the crane driver reached him, Tom was rolling on the ground groaning and clutching his head. Shortly afterwards, he was able to stagger to his feet with assistance. The dutiful husband and respected father was kept in hospital overnight and then returned to the bosom of his concerned family.

After a few days he went back to his job, but within a week he had been laid off because he seemed incapable of doing the task. In spite of several further attempts at rehabilitation he proved to be unemployable and spent his days at home. He could still lay bricks, but he was slow, slapdash and unreliable. Now Tom sat for much of the day watching television, not the soaps but sport.

‘His memory’s no good and he forgets what’s been happening during the programme, so he can’t follow it. Before long he becomes bored and changes the channel. But sport, that’s perfect. It’s full of action, there’s no plot and you don’t have to remember anything because they keep telling you the score. Sport on TV is great for brain-damaged people,’ enthused Maud, Tom’s rather frumpy and overweight wife. ‘And Tom’s a changed man. He’s so placid and quiet; no more arguments. He does what I tell him and he’s become a thinker. He often just sits in one place for an hour or two at a time, staring into space. Don’t know what he’s thinking about ’cause he never says, but he must be thinking deeply to keep occupied that long.’

Tom had clear evidence of major frontal lobe damage causing a personality change, in addition to his faulty memory, but this seemed to suit everybody, including Tom; everybody, that is, apart from the taxpayer, who had to foot the bill for Tom’s early retirement.

But if there are persisting sequelae following apparently mild head injury the clinical picture is usually quite different. The patient is discharged from hospital with a clean bill of health and returns to work within days or a week or two. It is often months and sometimes years before they are referred for further evaluation. Their story is just about always the same. Joe’s memory for new events is defective so that he now forgets things at work, leading him to make mistakes. He is more irritable and has difficulty controlling his temper, especially when his mistakes are pointed out to him.

Because of arguments he has lost his job. Joe’s personal life has become a mess. He shouts at his wife and kids and may be physically violent. He intermittently feels light-headed or dizzy and suffers from headaches. His headaches may be triggered by noise, so the family have to keep quiet. No one, apart from those with whom he is closely associated, realises that Joe has a problem because he looks fine and on casual acquaintance he behaves perfectly normally.

Joe’s life may be completely ruined, without recognition or compensation. His wife and kids have taken off, he cannot hold down a job, he has fought with his best friends and he has been in court for assault. If he had lost an arm in a work-related accident he would have been handsomely compensated and could get on with his life; by comparison, the amounts handed out for Joe’s type of brain injury are trifling. Like diamonds, Joe’s brain damage is forever, but unlike them it is worth peanuts.

Even if Joe had sustained relatively mild concussion and did not have the persisting problems mentioned above, he probably would have shown some transient evidence of brain dysfunction on careful neuropsychological testing. In other words, he would not have been able to think so clearly for some days, weeks or months after the event. If he was lucky the test results would return to normal and his symptoms would disappear.

Now, should Joe be unlucky enough to have similar mild concussion at a later date, it would take longer for his neuropsychological test results to return to normal than on the initial occasion. In other words, there was some persistent brain damage from the first incident, even though it was so subtle that it appeared to have cleared completely on the highly sensitive neuropsychological tests. Repeated concussions can be additive and lead to gradually accumulating neuropsychological defect, which is why neurologists take even repeated minor head injuries in contact sports seriously.

© Extracted with permission of the publisher, Random House New Zealand