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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”

Filling the Silence

 

 

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On the eve of April 24, Martyr’s Day, we join a few thousand 20-somethings on a 4 kilometer march from Opera, at Yerevan’s center, up Baghramian Street, past the President’s House, past the American University of Armenia, past the old Soviet Military Hospital, across the Kievyan Bridge, and up to the Genocide Memorial. Perched on a promontory, separated by a large stone slab from the Genocide Museum below ground, the memorial is two sharp stone spires, nested next to a circle of trapezoidal granite obelisks that lean protectively over a sanctuary, open to the air, a fire within. Halfway there, some young men’s hate chants are crashing on our backs and ears; we hurry forward to the parade’s clearer heads–some bishops in black, and bearers of an enormous flag.

“Some wounds never heal” reads one button. “Why won’t the Armenians give up their fixation on genocide?” I once heard an American ask. Try asking the bereaved parent to overlook his child’s murder.

In my own experience, the inflicted wound, pound for pound, always hurt more than an accidental wound. For better or worse, the brain’s pain system takes social factors, like apparent intention, into account. Then there is the social kind of hurt–feeling ignored, snubbed, rejected. Our brains register social pain using the same networks as those that perceive physical hurts. Despite all this fancy equipment, it often seems that we acknowledge and comfort the accidental hurt (earthquakes,tidal waves, hurricanes) more readily than the inflicted hurt.

We cross the bridge and head up the stone walkway along the far side of the Hrazdan River Gorge. Every year, along these last 300 meters up to the Memorial, walks the greatest confluence of Armenians that the world knows. They walk mostly in family groups, and they carry lilacs, tulips, roses. We arrive, and lay the flowers down. Before the day is done, there will be a 64 foot circular wall, six feet high, under the sky and the stones.

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If you talk to Barack Obama, or your American Ambassador in Armenia, or the leaders of Turkey, you will not hear the term “Armenian Genocide.” In this silence, for some, the perpetrator’s original message, “you are not of us, you deserved this,” may continue to echo. Perhaps, among other things, this ritual serves memory by correcting other cognitive errors–shame, or guilt, emotional scars of a historical monstrosity. This is what I see most clearly about Martyr’s Day–a will to fill the silence with better understanding.

 

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I Don’t Forget You

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click to hear: I don’t forget you

Russia Hotel, Tzaghkadzor, Armenia. ┬áThe guests line up for the nice buffet breakfast. Queuing up is not such a strong tradition in Armenia, and I don’t want to step on anyone’s toes. “Sorry, were you next?” “Voch-eench,”–“it’s OK, whatever.” “Voch-eench” is a kindly, assertive caption to a small favor. The closest translation may be “forget-about-it.”

Tell me about it–I’m wired to forget no less than most folks I know. There is some comfort in a handful of neuroscience papers attesting that my brain has a dedicated, calorie-consuming, forgetting system, somehow promoting my survival. So it’s not just entropy: every day, on some sub-conscious bridgehead in your brain, without so much as a “Let it be so,” a switch gets thrown, another memory is jettisoned. image image

Emotions, especially strong, negative ones, have a way of tying a double-knot on memories. Perhaps the trickiest memories our forgetting system has to deal with are the ones laced with fear. In neurology, we get to meet people whose forgetting system has gone haywire tangling with fear-laden memories. These are people with Conversion Disorders–apparently neurologic incapacities that are based in “psychological problems.” Back around 1880, the French neurologist Charcot couldn’t show Freud where the brain lesion was in patients with “hysteria,” which seems to have been a similar condition. Like twins separated at birth, the two parted ways, and left two schools in their wake: neurology and psychiatry. We neurologists still commemorate that historical split by drawing an imaginary line around Conversion disorders, saying “that’s not neurological, that’s mental, that’s a case for Freud”–we somehow forget that Conversion Disorder is still a brain disorder.

People with Conversion Disorder are not fools, and they are not lying. In a contest between some horrific memory (or in some cases, some dreadful prospect), and forgetting, their brains are simply unable to announce a winner. The inner waffling short-circuits volition, self-control. The prescription: remember history, what you dread, lest it repeat itself, ever biting back.

History can be a difficult topic in Armenia. After a month here, it’s clear that the citizens don’t forget the massacres and atrocities to which their hundreds of thousands of grandparents, aunts, uncles, cousins, were subjected in 1915, just a few generations ago. Next door, in Turkey, denial of this genocide is wired into national policy. Meanwhile, an increasing number of vocal Turks are challenging this systematic forgetting.

Perhaps you’ve heard the joke that for some people, denial is a river in Egypt. How to paddle up that river with the deny-er? As a neurologist, I tread lightly, and try not to confront my patent’s denial too forcefully: some deep instinct to forget is at work. We neurologists are all over the place in how effectively we respond to the blunt inconsistencies of patients with Conversion Disorder: we disdain, we lose trust, we dismiss, we condescend, we stumble. We somewhere wish that memory was all-or-nothing, forgetting the kaleidoscopic, incremental thing that it is.

Perhaps some day the writing of history will be a joint venture, and the authors will reconcile their varying needs to forget, to remember, to celebrate love, to reckon with dread. Such collaboration doesn’t come easily. One neurologist had a suggestion for how to help the person with Conversion Disorder: gently point out inconsistencies. “Look, you moved your leg just now, when you couldn’t move it before!” As though we could guide reconstruction, support bridge-building back to integrity. But even with the best intentions, we often lose these patients, having again, 130 years since Charcot, failed to find the lesion in our clinical laboratory. We see their anger as they walk out the door, feeling misunderstood, judged. A sad little microcosm of misunderstanding, we make. Forget the damn lesion, Charcot.

Once, I heard someone’s intelligence complimented with the backhand: “that guy forgot more than I ever knew.” I am still working on my forgetting skills. They lack a certain … je ne sais crois.

Sides’chun for now!

Song: I don’t forget you (recorded at Russia Hotel, Tzaghkadzor, 2/22/13.)