Called to Account

As my student queries the 15 year old about her symptoms, it happens: she turns her head and gazes towards her mother.  Just as we invite her autobiography, our patient—she for whom we would advocate—abdicates. Sometimes, the parent will rightly recuse themselves. “Don’t look at me, he’s asking you.” Or, without a flinch, as in this case, the parent makes themselves the culpable messenger of their teenager’s history. As the parent delivers one response after another, my student persists in addressing the patient. But her head turns, and turns, … she disavows.

This is a characteristic moment, this turn of the head. For the relinquisher of accounts, the problem is often pain—headache. I wonder if their pain is tied up with the emergence of their vibrating, fledging, wings: their autonomy. In a way, the patient is wise to be wary. Questions carry hidden assertions on their backs, with un-intended side effects, yielding what one of my colleagues has learned to call an AEU—adverse event unit. You see it with interviewees who obligingly engage all those hidden assertions with enthusiasm, careening past their questioners in apogeic zig-zags of suggestibility.

As I caution my student, I flatten myself up against the hallway wall. Bring on the cascading narrative. Let it run like the bulls through Pamplona in July; count and record all the frenzied runners, words, pacing the hoofbeats. Drop your checklist, and let your eyes peer beyond that clinical architecture. Then, salute your interviewee at the finish line, bringing their words back with a flourish. It’s a way of inviting them over to the far side of that nice aphorism, “instead of waiting to see how the world will treat you, tell the world how you want to be treated.”

But this one won’t talk. How to disturb this alexithymia, awaken her, call her to account? A little firmness, a little playfulness, may loosen things up, as we strive to empower her to take charge of her own autobiography. Suddenly, she surfaces, contradicting her mother’s account of her symptoms. She’s protecting her story—hurray!

So often our wishes and fears scatter us, as though we spoke a different language, when we really don’t. When I lose the thread, I remember what that one we sometimes call God can do: collaborate with me to secure my history, the one I know now, against marauders, revisionists, inadvertent purveyors of lexical adverse events.


Sound of Wind

Sound of Wind

I walk down to the hive with my smoker and hood, a box of matches to light the pine needles. I’m listening for my usual optimism, borne of that light notion–if I get stung, I’ll get over it, they’re just doing their job, my bees, defending the hive, so they can make more honey—for me! As I arrive at the hive, a vague feeling that I’ve neglected my bees for the past month mutes my optimism. It’s the first week of October, and when it gets cool, there’s a responsibility to feed a first year hive with sugar water, to tide them over, to respect their callow vulnerability.

The porch is empty. There’s a silence surrounding the hive, and as I dis-assemble the boxes, it’s silent within. My eye wants to see them, crawling atop the frames, maintaining city. But it’s a ghost town, the cells are empty of all that sweetness. They’ve gone. Took their stuff straight up and out of here, levitated by salvational groupthink.

bee-cityI look up and through the air they’ve flown, site of the rescue of their prize, their queen. Whether I’m annoyed at the silence, or I just miss their company, I can’t tell. My son is looking down at me from the barn foundation wall. “They doing okay in there?”  “They’re gone … hopefully they’ve got another story.”

At night, the un-expected stillness of the empty bee frames comes back to me. They passed through this place like wind, rippling across the floor of the atmosphere. The wind makes no sound on a stoney island shore, where the rocks don’t move, or vibrate with the waves, unless I’m there for it to clatter across the porches of my ears.

I like the sound of wind rolling over grass-blades, those green throngs holding on to this sea-floor, our stage. By now the sound of the wind has gone some place with those bees. Waves of air ruffle their diaphanous wings, and bring green plaits to song.


The Future is Already Here

future-is-already-hereJyväskylä University—Meeting with 40 graduate students in the music department at Jyväskylä, Finland, we’re talking about noise: the kind, entropic kind, that helps you tune in, get centered. Waves at the ocean, water in a brook. By now over a dozen publications draw the paradoxical conclusion that a certain amount of noise improves brain performance, signal detection. This research bears out the predictions of stochastic resonance, the only theory to have come to neuroscience by way of meterology.

A hand shoots up. Great! I live for curiosity, its humble courage. “Are you talking about pink noise, or white noise?” I dunno. Wiseacre.

“The future is already here–it’s just not evenly distributed”–William Gibson, cyberpunk novelist. And there’s a lot of it in Finland.


I rode up to Jyväskylä in the pet car. The dogs were very well behaved.


Jyväskylä University is one of the few Music Therapy capitals in the cacophonous world of biomedicine, and in this market, I’m going long on music therapy. Not only do they have sophisticated graduate students who are way ahead of me, they’ve got toys: magneto-encephalography, functional MRI, EEG, motion lab.


Of course there are different kinds of noise—I’m still sorting that out. But I know that in the right measure, noise means variability, joy, a sense of humor, childlike innocence, naïveté, clowning, health. It’s how I know you’re really there.

Before you were born, the obstetricians studied the variability of your heart rate—that’s good noise. Monotony, by contrast, connotes stern-ness, joylessness, illness. Horror movies use this rhythmic principle a lot–think of the theme music of classics like Jaws, Hitchcock films.

To Jyväskylä I imagine I’ve brought a little chunk of the future. A speculation, the timorous lovechild of my courage and my vanity:  it’s the noise, the randomness in music, that improves self-knowledge, by helping us out with a royal signal detection problem–interoception. Interoception is bodily awareness, like the ability to sense your own heart beat, your breathing. Interoception links in turn to empathy: how can you “feel for” another being if you cannot feel your self? To tune up your interoception, to be present, admit some noise, the underwriter to silence, that golden child who’s always pointing towards the future. A little chatter, a little static in the back. Helps you think.

The hotel offers a jazz ballad on the overhead speakers. Leaning in on a long flat note, the trumpet just crossed over to self pity. Music evokes pre-history, childhood memories, and now, pre-adolescent whining. At the front desk, they loan me a bicycle with disc brakes, and an automatic transmission. (Do we have these back home? Am I in the future?) I take the helmet—a cycling neurologist without one is a jarring sight—and find the museum of Central Finland, which says that history is pretty new around here: the pre-historic age didn’t end here until 1500.


Helsinki At the Harald Anderson Chamber Choir Competition, I’m glad I’m not judging, because I can’t tell who’s winning.


The choruses came from all over–Estonia, Latvia, Sweden, Ireland. One of the four Finnish finalist choirs has arrayed itself all over the hall, and they’re coherent, on the beat, wired together. They’re singing with emotion, but they’re also predicting the future, so as to keep in synchrony, their auditory and motor cortices teaming up to compute the arrival of the next beat.

We Homos think we’re so visual, but everything comes down to timing. Forget our precious eyes. The ears have it. Neuro-philosophes love to ask, which came first, music or words? If you ask a book, it’ll say in the beginning was the word. And the songwriter says it’s the contract. One theory says that to keep the beat, you have to have a brain capable of speech. So if you want to jam with someone from another species, try a cockatoo. They got rhythm:

But sea lions don’t have much vocabulary, and they’re dancing machines:

Did you ever wonder why your dog won’t dance? It’s because she can’t. She can sing rubato till the cows come home, but she can’t dance to save her soul. And don’t ask me why it takes so long to teach chimpanzees to tap along with a rhythm. Even at their best, their timing is all over the place. They just don’t have it.

My trip is over; it’s been just a short journey towards the future, and I’m bringing it back home. There’s a massive orchestra of maple trees, synchronized colors, waiting. Then, come June, I’ll hear that ever-loving buzz of fireflies, and hum along to their neon beat.


The Real Thing

Stepping on to the boat, I think how fragile, how ephemeral, is autonomy. The regular ferry off Canna was cancelled (wind), but then my host wrangled a private boat, so I’ll get back to mainland, Maillag, on schedule. I pass a small gift—an authentic shot glass emblazoned with a covered bridge, and the word “Vermont”—to Gordon, the island coast guard/toilet-cleaner/bird-guide. He has a positive way about him. His term for the dog barking at 4AM in the resonant tin shed next to my caravan: “a Canna lullaby.”

Between tune-swapping with other isle folk at Canna Cafe, Gordon told me about the birds of Canna. He once sighted “amateur” [Scot for immature] Golden Eagles talon-grappling in the north sky. Talon-grappling is normally a courtship dance, and Gordon was surprised that amateurs were doing it. Two eagles join, talon-to-talon, drop hundreds of feet, swiveling with abandon, then catch the air again, un-folding their wings to save their lives. Teenagers.


With an inscrutable twinkle, Gordon conveyed a bird-guide’s power: “At the end of a tour, if we haven’t seen any Golden Eagles, and someone’s especially determined to see one, I’ll point to a buzzard and say ‘There’s one, a Golden!’ and they’ll believe me.” Such a betrayal! Does he lie to his birdwatchers out of kindness, or to be thought of as the best bird-guide ever? You can’t tell if he’s kidding—perhaps neither can he. It’s now an experimentally demonstrable fact that, as Lord Acton said, power corrupts, weakens our empathy, our scruples; I guess that’s as true of bird-guides as it is of the rest of us.

In Izmir, Turkey, I once had the temerity, or the innocence, to ask a merchant whether a stone he was selling was really the kind of gem he said it was. “What does it matter?” he responded. “If you like the stone, you can call it whatever you want.” What did I really want, he seemed to say, value that I recognized for myself, or that others recommended? Was I so dependent on social currency that I would deny my own senses? I remember my father’s enthusiasm when he took me bird-watching—“Oh look!” he said, pointing. How I strained to see what he saw.

The boat landed us in Maillag, where I found the Steamer Bar and B&B. At the bar, another customer approached me. “Aycheldach” I think he said, with an expectant look. I’m just off the boat, scruffy jeans, bristled, toting a guitar; must look like the real thing. Others at the bar look on with curiosity. “Aycheldach” he repeated a few more times before figuring out I don’t get Gaelic. “Sorry, I don’t get it.” “Not many people do” he consoled me.

Soon they’re slapping me on the back, asking me if I’m good enough to play a song. I tell them I am. Right now I’m neither Scottish nor American, and don’t have to live up to anyone’s expectations. The barman turns down the disco, and as I start singing, about 20 people in the adjoining restaurant attend. They applaud, they like the songs. I tell them I’ve been to a Headache Meeting. They all want to buy me a pint. I wrap up—I’ve got an early train to catch.

Back in 6th grade, I learned from my dad one of the wonders of the world, that a writer could make up his own name. His friend Whittaker was “E.L. Frimbo” when he wrote about trains for The New Yorker, and I’m sure Frimbo wrote about the Scottish West Highlands train, the one I’m on now.


Through its magical windows you can see stags run over the heath, sunny glacier-carved mountain tops crest over fog horizons, lochs, sheep. This line was used to film Harry Potter movies, so there are usually one or two Harry Potter aficionados riding it. I’ve heard they’re quite willing to scold the innkeepers in towns like Crianlach and Glenfinnan if they’re not up on their Harry Potter trivia.

The passenger across the table from me, a young scientist from Oxford, has a remote look. He’s been hiking, hoping to find some remote places in the highlands, but there were always other hikers. I found a place though: up on Canna’s high hillsides; I kept my eyes on the sky, looking for eagles. Oh look—two eagles, square dancing at 300 feet. Just as they come together, they sail behind the mountain top. Or were they buzzards? I look down at what seem like a million little cow-paths, evidence of cow-autonomy printed on the angelic sedge. I meander back to my caravan; so many beautiful ways to get back home.


Lost & Found

I’m in Scotland, and I lost my hat. The one that was supposed to do for me what my father repeatedly suggested to me when I was young: “Get your head screwed on boy!” I took it kindly. It was an encouragement towards mindfulness, or core strength. And now, the screwing entails some deduction: by now, if I’d left my hat in the cab, the Glaswegian taxi driver would have turned it in to the Convention Center where he dropped me off, so I must have left it at the ticket counter at the Queen St. Railway Station. Two days after losing it, I’m here, hopeful, making a precise description of a non-descript black hat to the lady at the station’s Lost and Found desk. She disappears for an intolerable number of seconds into a room full of lost things, then re-appears with .… that’s it! We smile at the hat.

And now I’m sitting on the West Highlands train, rolling headlong into the mountains, delighted how things come around. The ferry connection will get me to a lodging gracefully called a “caravan,” Scottish for a corrugated rectangle containing some of the comforts of home.


the caravan


view from the caravan


Surrounding the caravan, the Isle of Canna, which may be too small to be a Hebride, though I shouldn’t second guess it. It has, in any case, a similar density of sheep, lichen, and off-shore seals embracing its polygonal coast.

The weather in Scotland, like in Vermont, strikes one pose after another.



Maybe it was the fog blurring their horizons that made the Scots such persuasive, persistent scale makers, meting out this spectral, mysterious world in numbers and categories, all the way back to Lord Kelvin with his Absolute Zero Temperature scale. More recently, the head trauma cases coming in from the local highways gave neurosurgeons Teasdale & Jennett the idea for the Glasgow Coma Scale.

I have a bit of that ornery, Scottish measurer/categorizer in me, and come by it honestly, from the McQueens and McPhedrans in my ancestry. (McPhedran—in fact it’s not the name for a Scottish herbal stimulant.) I felt their presence when I stood at the microphone with a question for the speaker in a large, dark Glasgow auditorium, and the moderator was about to pass me over for a second time. “Hellow!” blurted my inner Scot. The moderator heard the W, and promptly apologized.

“Do you think the disposition to placebo and nocebo response resides in the same person? Or are they in different people, as though we’re either optimists or pessimists?” I don’t remember the response, which probably means it was 65 seconds of polysyllabic gesticulating, academic for “I don’t know.” Aykhh. When it comes to reviewing medication side effects, clinicians would like to know which among their patients is prone to side-effect-by-suggestion, nocebo.

I used to think I’d avoided “social infections,” but since I’ve attended the “European Headache & Migraine Trust Conference,” I’m not so sure. Here, a social infection is something like what the Italian experimentalist Benedetti caused when he sent over a hundred students, clambering guinea pigs, up a 10,000 foot Alp. And now, the bad magic, the sorcery: simply by whispering into the ear of one of the climbers “You will very likely get a headache during the climb; it’s from the high altitude, …” Benedetti increased the headache rate at the mountain top from 52% to 86%. That’s social primates for you, spoiling the picnic with a contagious headache, algesia-by-suggestion. I wanted to ask if Benedetti, like any good experimentalist, ran the study twice, to reproduce his results. Recruitment could be a problem … But I forgot to ask him, as I was missing my hat at the time.

The nice thing is, it seems you can save the picnic with a placebo, though only the nocebo headaches respond to it; it won’t touch those original, 52% of headaches. There is a way, however, to fortify a placebo. It’s all about expectation: tell the consumer that there’s a very low chance—one in ten instead of the usual 50-50—that he’s swallowing a placebo. He thinks, correctly, “this is most likely the real stuff,” and so, even when it’s a fake, it works, better than a work-a-day, 50-50 placebo; or Prozac; or molasses.

Wrangling expectations can be a social thing. Or not. Now that I’ve got my hat again, I’ll carry it in my hand, and ask my expectations to be nice. They’re bound to listen.



Getting Over It



I’ve returned to Vermont, but I’m not letting go of Yerevan. There’s something about this city, at once wide open to imagination, and rife with wicked problems. It’s responsibility, not disaffection, that drives the breakup–I’ve got to return to my post.  But I don’t want to get over Yerevan.

Case. 5 month old with recurrent intracranial hemorrhages–can you help us with this problem? The neurosurgeon opens up the CD for us. The hemorrhages are sub- and epi-dural, bilateral, of varying ages. The collections undoubtedly explain the child’s hypotonia, even as he looks alert, tuned in. Whatever the cause, there is no fix, other than tender loving care. The child’s brain will have to heal itself up. “Hypotonia is the least of this child’s problems” says the surgeon.

Why these hemorrhages? No known trauma or bleeding problems. But “non-accidental trauma,” as the euphemism goes, typically presents with the history “no trauma.” I suggest long bone films, an eye exam, for evidence of mistreatment. My colleague looks doubtful. “No, we don’t see this … because in Armenia, children are gold” she responds. They are gold everywhere, I think, even if parents, in non-accidental fits of physical rage, sometimes forget.

Brain injury in abused infants stems ultimately from an interaction that, while not accidental, has lost track of its intent. The caretakers’ anger blinds them to their responsibility to get over frustration, to not let a tempest in their brain’s limbic system shut down their restraining frontal lobes.  I’m sorry for the jailed parents who lost their moral compass in an emotional storm, and for their battered children.

Gohar Droshagiryan's Drawing for Like Water On Stone, animation of Dana's novel.

Gohar Droshagiryan’s Drawing for Like Water On Stone, animation of Dana’s novel.

Getting through such a storm, autonomically speaking, is a journey through some woolly peaks and valleys, and it’s a little different for each of us. You can divide us according to the alacrity with which our stress responses erupt with sweat, fear, and pounding heart, and how quickly they simmer down. If we quarrel, I may have thought things through (all right, you apologized, I accept …) before you’ve really settled down (but I’m still upset about it and we’ll both just have to deal with that until …“)? Reconciliation doesn’t happen all at once.

Case 3 year old boy, losing weight, and hakarak, aggressiva–increasingly contrary and aggressive. But his weight seems OK, and he won’t let go of the doctor’s chocolate snacks for the gait examination. Off to play therapy. Play, among other things, is a good way to learn how to go in and out of frustration in peace.

Neuro-responsibility. At what age do we lose that gold, that innocence that should assure us respect as children? And how can we verify the capacity for knowing intention that makes us responsible, culpable for our mistakes? In the 19th century, there was a trend for some poor mothers to plead temporary insanity when their babies were found murdered. And the juries were sympathetic.

Temporary insanity was a well-established legal defense in Europe–a gift of the psychologists to the lawyers you might say–when, in a Berlin street in 1922, an Armenian shot and killed Talaat Pasha, one of the primary architects of the Armenian genocide. The assassin was acquitted–temporary insanity. His defense lawyers made the case with photos and narratives of a horror whose legacy was still in its infancy. That trial brought Armenia as close as it ever came to a proper public disgracing of its frenzied murderers. The evidence gathered became a study guide for Raphael Lemkin, who later coined the term genocide.

Music. Aram, my oud teacher, has brought his duduk-playing friend Sevada so that I can purchase one of his duduks for Jeff, back home. A flute made from an apricot tree, and resonated by a bamboo reed, the duduk makes one of the most soulful sounds you can hear. Before we close the purchase, Aram and Seva play Hov Arek, Come Breeze, by Komitas, who is said to have been driven insane following his imprisonment in Istanbul in 1915. It pulls my heartstrings, this tune, and I pull back. I keep re-playing it, but I still haven’t gotten over it.

Zoom Out



Dance Dana shoots her left foot out 3 feet behind her and the young man passing by almost trips over her leg. He better watch out, the women are dancing Madzoon, “stirring the yogurt,” in a circle at the Naregatsi Center, where a hundred dancing bodies are heating up with Armenian rhythms. We greet our dancing buddies, who take our hands again.

Intensive Care. A one month old with seizures, absent corpus callosum–the problem is ultimately genetic, though chromosomes were normal. What about a DNA test? In clinical work, genetics presents a jagged coastline–the closer you come, the longer it gets. You couldn’t explore all its fjords in a lifetime.

“We have one more case for you.” This 12 year old girl’s delicate face is marred by a naso-gastric feeding tube-she has been vomiting for 20 days. No other symptoms–“the story is long, and yet with nothing else to tell” say my colleagues. I find a watchful, thin girl with no nystagmus, a normal exam. This can’t be labyrinthitis. GI workup was extensive, negative. As I coax her to sit she abruptly falls back, eyes close, pulse steady. In 3 seconds, she wakes up, fluent. “What is this?” asks the intensivist. Conversion Disorder–psychosomatic. One doctor says this is rare in Yerevan, but I wonder if he’s really stepped back to measure.

Performance Review. To teach, alas, is to judge. When a trainee seems weak, our responsibility to her future patients demands that we single her out, as we say “we don’t want you to feel singled out.” Is she over-confident, self-abnegating? It’s a Goldilocks thing, medical confidence.

We strive to pool perspectives to get the best view. Often, our impressions scatter with the coherence of bugs on a windshield–a good sign of reviewers’ independence. Wisdom of Crowds (Surowiecki) makes the point that it’s often better to trust the pooled opinion of 100 independent lay folk than that of a few experts. Can we be both?

Clinic. The parents, sitting opposite my colleague, each hold a twin. The 5 month old brothers study their doctor intently over the pleasant bodily wobbles common to their age. When their head ultrasounds were done, as premature newborns, both showed the ominous echo pattern of white matter injury that strongly predicts cerebral palsy. But their neuro exam doesn’t yet show definite signs.

So put down that reflex hammer and step back, take a look at their General Movements. This is a kind of gestalt impression of spontaneous infant behavior, introduced around the same time as the head ultrasound, though much more melodic. See the fidgety movement–good sign! The GM assessment was devised by Heinz Prechtl, an Austrian ethologist and bird-watcher, whose baby-watching methods are catching on. One brother shows ominous cramped, synchronous movement. But I’m un-sure if the parents would welcome this long view. I don’t let on.

Martyrs Day. This week the Armenian nation commemorates one of a series of massive stuttering slaughters of its people in what is now western Turkey–1895, 1909, 1915. These were the serial genocides conducted by Ottomans, who deployed some of their cruelest citizens, some even released from jail for the purpose, to kill Armenians, or lead them into the desert to starve. Frustrated by governments’ denial, historians went pointillistic, bringing thousands of accounts to international tribunals. Though you can hardly meet someone in Yerevan whose family wasn’t affected, the Turkish government dismissed these histories, as though the Armenian people were suffering an epidemic psychosomatic disorder, a confabulated Freudian memory of childhood abuse. I wonder how often in history, if ever, has an ethnic group’s sub-conscious produced confabulations of murder, persisting over 3 generations? Do nations cry wolf in this way? Meanwhile, “1915: I Remember and Demand” say the street signs. Agreeing on history sometimes requires a long hard look at the big picture.

Cameraman and Mt. Ararat at Tsitsernakaberd, the Armenian Genocide Memorial

Cameraman and Mt. Ararat at Tzitzernakaberd, the Armenian Genocide Memorial

"I Remember and Demand"

“I Remember and Demand”