Paresthesias, Guillain-Barré syndrome

It began in his toes. He sat in the brown leather armchair behind the couch, as his patient, head resting on a clean white doily, spoke to the ceiling above her about her father's lack of affection for her as a child. He tried to listen, doggedly recording her litany of paternal neglect on his yellow legal pad. But the pins and needles in his toes were distracting him. If it were just one foot, he could try to shake it awake; but this was different.

"Paresthesias," he thought, "What causes paresthesias? Diabetes? Multiple sclerosis? "Twelve years of specialization in psychiatry and psychoanalysis had dulled what had once been an encyclopedic capacity to rattle off differential diagnoses of medical conditions. "Perhaps it's hysterical," he wondered. "Am I having conversion symptoms?" He dismissed the notion that he was identifying with his patient's lack of love. His relationship with his parents had been warm and loving, and his warmth and affection for his daughters knew no bounds.

By the next morning, the tingling had moved up to his thighs. In his toes, he felt nothing; they were numb. He tripped several times, as his foot dropped aimlessly against the rug. Climbing stairs was a major effort. He felt like a marionette whose strings had gone slack. A sense of alarm began to gnaw at his insides, and he telephoned his internist.

After his body had been punctuated by pinpricks ("Sharp or dull? Sharp or dull?"), and his tendons tapped with the toy rubber tomahawk, he was relieved to hear his internist say, "I know what it is." The grave look on the internist's face did not concern him, for internists are always solemn.

"It's Guillain-Barré syndrome," pronounced the internist, "You remember, the ascending weakness and paralysis with numbness and paresthesias. I don't know what's caused it, perhaps a cold you had in the past few weeks. These things sometimes follow a viral illness. We'll put you in the hospital and have you seen by a neurologist. Geschwind is at University Hospital, and he's the best."

By the time I met him to do his admission history and physical, the pins and needles had reached his fingers, and he was having difficulty standing. He covered his anxiety with an engaging and sophisticated patter. "Guillain-Barré," he mused, "such a delicious mouthful, don't you think? Rather like a fine Bordeaux. 'Garçon, another bottle of Chateau Guillain-Barré '62, s'il vous plaît.'"

He told me of his good health and good fortune --- throughout life --- doting parents, a major in German literature in college, loving wife, darling young children, thriving psychoanalytic practice, a penchant for singing German lieder.

"How high will this thing go?" he asked with an anxious smile.

I had seen only one case before, but answered confidently, "No higher than your upper arms. Then it almost always remits, and in a few weeks you'll have your full strength and feeling back."

I was wrong. The following afternoon, he could not breathe. Sweat poured from his brow, his eyes bulged, and his pursed cyanotic lips panted, "What's happening to me?"

We passed a tube into his trachea, and a respirator pumped air into him.

It continued to climb, right to the top of his head. By the time he reached the intensive care unit, he was comatose. This was not the typical case of Guillain-Barré. Had we ordered the wrong Chateau?

§      §      §

We tended to him carefully, around the clock. He was one of us. Every hour, we would assist the nurses to roll his dead weight from side to side to prevent bedsores, adjust and restart his intravenous drip, clean out his feeding tube, flush and change his urinary catheter, and "suck him out," passing a suction tube through the tracheostomy in his neck to remove bronchial secretions. Every morning, bleary-eyed from lack of sleep, we would report to Dr. Geschwind, "The patient maintains fluid and electrolyte balance --- three liters in, three liters out."

The problem was, he was dead. His EEG was flat, showing no evidence of brain activity. His breathing was regulated by a respirator. A penlight shone in his eye raised barely a flicker of pupillary contraction. After ten days of this routine, we began to resent his plight, as well as our own.

"He's clinically dead, Dr. Geschwind," we would complain, "He meets all the criteria for brain death, We could harvest his organs (a lovely term, no?) for transplant to others. Why prolong the suffering? We should talk with his wife about removing life-supports."

Calmly, Geschwind reassured us, "I've seen this before. He'll come back."

Geschwind was not to be sneered at. He was Boston's, and some said the world's, leading neurologist. And he was right. After two weeks, the pens of the EEG began to show flickers of activity. The pupils reacted more briskly to light. When we would suck him out, he would break, like a beached whale, into paroxysms of reflexive coughing, spewing gobs of phlegmy spray out at his assembled rescuers, Wormy writhings of his muscles gave way to coordinated movements, and he began to respond to us with his eyes. The respirator was removed, and he breathed on his own.

§      §      §

He stayed in the hospital for several months more, and was transferred to the rehabilitation ward. By this time, I had begun my residency in psychiatry, When I was on duty at night, I would go up to visit him. In his wheelchair, he looked quite different from the urbane psychiatrist whom I had admitted to the hospital seven months before. His skin had the pale translucent quality of one who had not seen the sun for some time. It covered the soft infant-like flesh, so that he seemed to be wrapped in hairy dough.

His muscles were atrophied, and when I shook his hand, I could feel the bones crunch against each other. Most striking was his voice. He would cock his head to one side and crow, in a high-pitched voice, like a wounded rooster. His words were slurred, as his tongue fought to enunciate them. He spoke of the terrible plight he was in, estranged from his family, doubtful that he would ever work again. Tears came to his eyes, and to mine, when suddenly raucous laughter burst forth from him, his chest shaking, his arms convulsing.

"Inappropriate affect," I thought, reflecting on two months of psychiatric training. "He's unable to cope with his losses." A review of his chart, however, showed that the neurologists thought his outbursts of laughter came from an organic brain syndrome.

I continued to visit him at night. He became increasingly withdrawn, staring at the withered hands in his lap. One night, in desperation, I exhorted him to look up and talk to me. In a tremulous voice, he wailed, "I used to sing Schubert lieder!" His sobs gave way to gales of laughter.

In a final attempt to rekindle his interest in the world, I invited him to come down to the psychiatric ward and to sit in on patient rounds. The periodic grunts and whimpers he made from his wheelchair in the corner of the room interrupted the flow of information about the patient under discussion, but the staff averted their eyes and ears in deference to his obvious impairments. When, however, the psychiatrist-in-chief made a small joke to put a patient at ease during her interview, he broke into sobs.

In a few weeks, he was transferred to a VA hospital. A year later, I learned that his wife had divorced him and that he had died quietly from complications of a kidney infection. I wondered just when it was that his life had --- or should have --- ended.

--- Michael A. Ingall
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