Mrs. Posner's Smile

• Cerebrovascular accident
• Neurobehavioral manifestations
• Cognition disorders

She arrived like the others—fasciculating eyelids, cyclic moaning, odor of stale urine. You come to regard them in a certain way. You roll them like logs, reaching in to place your stethoscope over bags of papery skin. You offer them too-loud, semi-facetious greetings, as if their ailment were deafness rather than coma. You identify them by their numbers—sodium, white blood cells, oxygen saturation—and they stand out as notable individuals only by the salient aberrancy of their counts.

The night of her admission, she was a sodium lady. I drew my first blood gas on her. How fortunate I was to do my first on a sodium lady—no questions like “Now, how many times have you done this before?” My resident easily immobilized the woman's arm, which her brainstem made a reflexive attempt to withdraw. Only a slight groan bore witness to the quiver of my hand as it searched for the radial artery. With the flash of red in the syringe hub, she blipped into my medical school history book—“first blood gas.” And her entry would have remained at that if it weren't for what awaited us the next morning.

When the team entered her room, she was perched in the bed, her hair matted into a hoary cockscomb. A bland expression hung on her face. The chief resident boomed, “How—are—you—today, Mrs.—POSNER?” I don't think any of us expected the metamorphosis that the question elicited. Her half-mast eyelids drew up, revealing a pair of lively blue eyes. She smiled at the chief in a familiar way, as if he were her grandson. Then she pursed her lips and gazed toward the heavens in contemplation. After a moment she sighed, engaged the chief again, and in a voice that was surprisingly robust, began to respond. Her words were well articulated and carefully chosen, her speech exceptionally fluent.

But it made no sense. A rift gaped between the form and content of what she said. Her statements swung from the illogical to the fictitious. She had lived in this building (the hospital) for years, although she couldn't recall its name. She claimed to have been born in the early 19th century, yet she said that she was 29 years old. The team started to giggle nervously. Her leprechaun eyes seemed to laugh along with us. Perhaps she was toying with us, I thought.

Later that afternoon, the nurses propped her up in a vinyl recliner in the hallway. As I passed her, I stopped—as only a medical student is able—to chat. I explained my role on the team. She seemed interested and even asked a couple of appropriate questions. I left to talk to another patient. Five minutes later, I walked by her again and said hello. A few paces down the hallway, a mischievous thought came to me. I backtracked and asked her if she knew who I was. She scrutinized my face, scanned me up and down, and pronounced, “I have never seen you before in my entire life.” After another 5 minutes, I returned and asked again if she knew me. “Sure, we met in 1949 at the Kit Kat Club.”

I had seen stroke patients who couldn't speak or understand, but I had never encountered anyone with a deficit quite like Mrs. Posner's. Even after seeing her severely atrophied brain on the CT scan, I still wasn't sure whether her glib untruths were cortical reflexes or deliberate fakes. I noticed that she used several strategies of engagement. One was outright confabulation. A question such as “What floor are you on?” would be met with an elaborate zigzag involving a brass-plated door, two elevator rides, turning right, ascending 12 steps, and then turning left. At other times, she could stymie you with concreteness.

“Where are you?”

“Here.”

“What type of building is this?”

“This kind.”

Then, on other occasions, your question would produce a furrowed brow and a pensive stare, as if you had just laid the weight of some unsolvable metaphysical question on her. For instance, once I asked her about her parents. She proudly stated their identities as “Melvin and Myrna Cantor … and I was Sheila Cantor.” I asked her why she had changed her name to Sheila Posner. A quizzical pucker usurped her smile. For a long minute, she pondered. Then she locked her eyes onto mine and with a resigned sigh acknowledged, “That … is a really good question.”

During the week of her hospital stay, I visited Mrs. Posner often. Our conversations would slip away from her within minutes, but she really did seem to enjoy them while they were happening. When she was alone, the expression on her face fell into the blank mask we had observed on the first morning. Yet, when she was spoken to, some switch would click on and she would become cheerful, participatory, and always amusing. I think she knew she was funny. Despite the holes in her memory and logic, she retained an instinct for appropriate context and delivery. One day while I was talking to her in the hallway, a squat janitor approached, pushing a vacuum cleaner. After he passed, Mrs. Posner turned to me and in a completely earnest voice said, “I have known that man for years. And he keeps getting shorter and his butt keeps getting fatter.” After pausing for a moment she let out a cackle that made me laugh all the harder.

I can no longer recall Mrs. Posner's sodium level when she arrived at the hospital. I still remember, however, that the morning she left for the nursing home she wore a pink sweatsuit and gold-sequined slippers. Seeing her in that getup made me smile. She smiled back. The world she inhabited was fleeting, stitched together extemporaneously from some retained repository of information. Yet, something essentially human had been preserved. So much so that she kept me guessing right up to that last day. As we smiled at each other, I wondered who was smiling at whom. I think now that enough was still there that we were smiling together.

• Copyright ©2004 by the American College of Physicians