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Monday, April 01, 2002  Shock Waves:   A Scientist Studies His Stroke  By: J. Allan HobsonM.D. [continued]

CRASH 

On a Friday in October, eight months after my initial stroke in Monte Carlo, I drove my sons, Andy and Matty, to Vermont. Lia was still in Europe. We left early in the morning, when I normally would feel perfectly refreshed. Instead, I was so drowsy that I stopped at least three times to keep from driving off the road. I assumed this was a hangover from Ritalin withdrawal.

Arriving in Vermont, I hooked up with a friend, Nick Tranquillo, and spent a lovely Friday afternoon and evening with him. I enjoyed Saturday, too, as friends from Boston joined us. This was the legendary Columbus Day weekend retreat of the Harvard Laboratory of Neurophysiology staff, which had been canceled for two years owing to the death of Lia’s parents. For me, the gala was particularly exciting because I felt that I had been granted a second life. Work was going well at the lab and the Vermont foliage was glorious. 

One of my schemes for the weekend had been to dragoon visitors into picking up small branches from wood lots that had recently been cleared. But when I walked across the fields to check things out, I was aware of feeling not just tired, but tired in a specifically cardiac sense. Something about fatigue is distinctive when the heart is the culprit. You know that your cardiovascular system just won’t deliver the energy to move. I only felt better sitting on the ground, not moving. I quickly abandoned the woods project, knowing I wouldn’t be able to supervise it, much less participate. I dragged myself back to the house, determined at least to be a jovial host. 

That was easy. My guests were delightful, and people kept arriving until a total of 17 sat down for a splendid dinner on Saturday night. I felt giddy and wonderful, not a bit tired. I did have a cough, but no fever, malaise, chills, or other signs of being ill. After dinner, I went to bed but slept poorly and the next day, for the first time in my life, didn’t want to get out of bed. Venturing downstairs, I saw that no one else was up. I went back to bed and stayed there most of the day. I ate no breakfast, fixed my guests a lobster bisque for lunch but ate only a token amount, and skipped dinner. 

By then, I admitted to myself that I was sick, but didn’t know with what. Monday, I was so weak that I asked Ed Schott to drive me back to Boston. When we got there, he called my doctor, Jamie Winshall, who told me to go to Brigham and Women’s Hospital by ambulance the next morning. We then telephoned Lia, who began a hasty return from Sicily. 

INTENSIVE CARE 

On Tuesday, October 9, an ambulance took me to the emergency ward at the Brigham. When a chest x-ray revealed that at least three lobes of my lungs were infiltrated with pneumonia, I was put on massive doses of intravenous antibiotics. 

Because it is not isolated in a single lobe, this type of pneumonia is called “atypical.” It doesn’t come on quickly or give you the chills, fever, and intense sense of illness that typical pneumonias do, but it was nonetheless malicious—probably caused by many episodes of breathing food into my lungs as, over the summer and fall, my dietary indiscretions had multiplied. I didn’t like being in the hospital, but two days on antibiotics made me feel better. I hoped to be discharged in a week to resume my life. 

Instead, on Thursday night, October 11, apparently while asleep, I suffered acute cardiovascular collapse, with blood pressure readings of 60/0. I did not respond to attempts to rouse me. The hospital immediately put me in the intensive care unit, where for five days I lay near death. 

I have no memory of those five days, but am told I was conscious much of the time. According to Dr. Winshall, I may have had an acute “aspiration event”— breathing food or fluids into my lungs— or perhaps the acute toxic state of the pneumonia precipitated this major setback. I accept neither of these theories. I will discuss my own hypotheses later. 

Dr. Winshall describes my first two days on intensive care as “touch and go” with death. When I finally regained consciousness in the morning hours of Tuesday, October 16th, my hands were tied and a tube was in my trachea. In my delirium, I had already forcibly removed two of these infernal devices; but, although I was breathing on my own, now, the nurses waited until dawn to remove the incredibly uncomfortable breathing tube. 

BIZARRE PSYCHOLOGICAL EXPERIENCES 

From this point on during my hospitalization I suffered from the same insomnia that I had experienced during the original post-stroke period in Monaco: total, wall-to-wall, bolt-upright waking through the entire night. This drove me to seek relief through various sedatives, but I found little. Instead, I experienced bizarre psychological side effects. 

Taking these drugs provided a series of natural experiments, visited on me by unwelcome circumstances, but which I knew how to exploit. Writing my book The Dream Drugstore (MIT Press, 2000) over the past two years had led me to ask myself why, given my intense, lifelong interest in dreaming and hallucinatory experiences, I had never taken psychedelic drugs. My honest answer: fear. Now that I had an opportunity to take them for valid medical reasons, I was astonished at the range and intensity of effects. 

Serax (oxazepam) is a short-acting benzodiazepine with sedative hypnotic properties. Over the years, I had prescribed it for patients without knowing the effects it might have on consciousness. In me, Serax induced a sleepy state with confusion and an extraordinarily disturbing symptom.

Thinking myself awake, I would reach for a glass on the bedside table—only to find that it did not exist. My hand would pass right through it.

The same unnerving insubstantiality characterized many other objects. This must have resulted from my hallucinatory construction of an unreal glass, but I do not have a clue about what causes this disturbing effect, which was neither normal sleep nor normal waking, but a hybrid state with elements of both. I was in a robust mini-delirium. 

Ambien (loroazpam) is associated with confusional states in the elderly, and it certainly confused me. I took it twice and both times had similar reactions: I was convinced that I was sleeping not in the hospital but in an attractively designed summer camp.

There were families there that I might or might not know, but I sensed that I should know them. There were women talking, in what I took to be a kitchen, about making provisions for the other campers. Later, I realized that these were the voices of nurses outside the door of my hospital room. 

During these long episodes on Ambien, my sleeplike transformation of consciousness was almost euphoric.

Far from being in a hospital bed, I was atop a huge pile of mattresses, perhaps rolled and stacked on end, but very soft. I could sink down in them to any level, then have my consciousness follow me through these lovely, deep folds.

Reality, of course, was my plain hospital bed, but it didn’t feel that way. My conviction that this was a very special camp was total. It was pleasant and reassuring to hear the women talking outside my door, in part because many spoke in accents that sounded Latin, as does Lia. Many of the nurses were Latinas. 

“In the intensive care unit, sooner or later everyone becomes psychotic,” said Dr. Lowenfeld, its director, after my initial episode of delirium. I had begun to reexperience hallucinations at the onset of sleep, but here I want to describe the more distinctive effects of yet another drug, Benadryl. 

On Wednesday, the night after my recovery from shock and respiratory failure, I had been sleepless despite taking trazadone and oral Ambien. On Thursday night, Bob, my nurse, reminded me that I should not be taking medication orally. He suggested sedating me with morphine through the intravenous line in my arm. Seeing this as an opportunity to describe the subjective experience of narcotics, I readily assented, but the morphine had no effect whatsoever on my perceptions—or my sleep. Even a second 25-mg dose left me awake and lucid.

Bob then suggested an antihistamine, Benadryl, a popular over-the-counter drug used for years as a clinical sedative. Here was a good chance to test a theory. Blocking histamines in my cortex ought to produce a dreamlike experience; indeed, my colleague Clifford Saper had identified the specific arrest of histaminergic neurons in REM sleep. His report put histamine cells in the same category as the serotonin- and norepinephrine-containing cells that turn off REM cells, a discovery I and my colleagues had made 25 years ago. We had also suggested that the specific features of dream consciousness were invoked by the demodulation of the cortex. By taking Benadryl, an antihistamine, I might thus learn more about the sudden, acute impact on perception of blocking my histaminergic cortical-activating system. 

Admittedly, this was a messy experiment. My inferences about the drug’s mechanisms are tainted by what researchers would call the dirty chemical conditions of the experiment, not least my prior doses of morphine. But the effects of the Benadryl were so striking and specific that I note them here. 

One advantage of administering Benadryl intravenously is that the subject has immediate awareness of the drug entering his circulatory system; it feels as though the injected vein is warming.

No sooner had my right anticubital vein begun to heat up than there appeared the first in a succession of images on the ceiling over my bed. They were computer-animated sketches of imaginary reptiles, a show that came complete with the catchy title “Thalamo-Saurus” rendered in elaborate artistic computer graphics. Four characteristic reptiles trundled past in a specific sequence. The one I recall best was a blue-and-red crocodile, but a green-and-yellow lizard typically followed him. There were at times butterflies, birds, and fish. With my eyes open (and only then), these images would muster up on the right side of the ceiling over my bed, and then, as I watched in wonderment, march diagonally to behind my head on my left. I realized that I was having visual hallucinations. 

By and large, these hallucinatory reptiles were friendly. I enjoyed them, especially when I realized that I could alter their speed and location by making eye and head movements. Otherwise, however, their trajectory was consistent, their appearance repetitive and clear, and their artistic characteristics harmonious and even beautiful. Amazingly, there was even a credit for the studio in Tokyo that had made this show. The show’s apt and imaginative title, “Thalamo-Saurus,” suggests imaginary reptiles conjured up by my drug-soaked thalamus. 

I said that the creatures were friendly, but occasionally they became unruly. The ceiling would assume a parachute-like, filamentous character and appear to float down toward my bed. The images would distort on the falling ceiling and sometimes even break away from it. This happened particularly to a menacing goldfish and butterfly combination that threatened to fly off the projection surface and enter my room space. This made me anxious and fearful.