Chapters 21–25 Summary
A routine of love holds Susannah Cahalan together as her mind and body unravel. As doctors chase a vanishing diagnosis, a new voice—Dr. Souhel Najjar—reframes her illness and points toward a way out. A second spinal tap finally confirms the invisible war raging in her brain, turning terror into a solvable case.
What Happens
Chapter 21: Death with Interruptions
Nearly a week into her hospital stay, Susannah loses all sense of time. Her family builds a daily rhythm to anchor her: Tom Cahalan brings breakfast and reads in the mornings, Rhona Nack monitors her care at lunch and after work, and Stephen stays late into the night, looping a Ryan Adams concert she greets each time as if new. Her short-term memory is erased—damage to the hippocampus leaves her stuck in an eternal present. Drawing on the cases of H.M. and Clive Wearing, she explains anterograde amnesia and foregrounds the theme of Memory and Unreliable Narration.
Compulsions bloom: apples, cleanliness, order—rituals her family reads as the body trying to purify itself. When her cousin Hannah visits, Susannah cannot unwrap the gift she brings—José Saramago’s Death with Interruptions—and no longer recognizes the author she once loved. An EEG video captures the stark reality: Susannah sits disoriented, hair threaded with wires, while her mother keeps vigil. Both patient and caregiver appear trapped, helpless before a nameless force.
Chapter 22: A Beautiful Mess
By week two, Susannah’s body betrays her: slurred speech, drooling, incessant chewing motions, arms rigidly posed in front of her. The team suspects brain stem or limbic system involvement—primitive circuits misfiring. William F. Allman’s description of the brain as a “monstrous, beautiful mess” frames the central puzzle and sharpens the tension of The Diagnostic Mystery. The visible deterioration forces a shift: this is not purely psychiatric, an insight that crystallizes The Mind-Body Connection.
A small breakthrough arrives: a spinal tap shows a slightly elevated white blood cell count, suggesting inflammation or infection. Rhona feels relief—finally, evidence. Friends bring bittersweet relief: Katie coaxes a laugh and a clumsy Irish jig; work friends Angela and Julie visit, and Julie’s crude joke about a photo of her own poop sends Susannah into hysterics. But after these flashes of connection come paranoid troughs—she insists the blog Gawker is attacking her—and long stretches of silence that leave her exhausted.
Chapter 23: Dr. Najjar
Hope flickers, then dims. Tests for Lyme disease, multiple sclerosis, lupus, and other culprits all come back negative. The family fears she will be sent to a psychiatric facility. In a crushing blow, Dr. Siegel—Rhona’s most trusted doctor—abruptly bows out, leaving them feeling abandoned.
Then Dr. Russo introduces a new possibility: Dr. Souhel Najjar, a neurologist known for solving baffling cases. He rejects the psychiatric label and suspects either viral encephalitis or a rare autoimmune response. When viral tests come back negative, he pivots to an autoimmune theory and recommends intravenous immunoglobulin (IVIG), an aggressive, experimental treatment. His arrival reshapes the case: at last, a coherent plan.
Chapter 24: IVIG
Susannah begins IVIG—antibodies from thousands of donors meant to neutralize the “bad” antibodies attacking her brain. Listening to a Ryan Adams concert through headphones, she feels transported into the show. When a nurse interrupts to take her vitals, she lashes out and punches the nurse—an eruption that dramatizes the Loss of Self.
She continues to slip. On the phone with her brother James, she can only repeat his name. Dr. Arslan documents catatonia—waxy flexibility, mutism, rigidity. After a nurse asks, “Has she always been so slow?” Stephen’s anger hardens into resolve. He and Tom find common cause: the real Susannah is still inside, and they will not stop fighting for her. Their alliance embodies Love and Family Support.
Chapter 25: Blue Devil Fit
By April 9—eighteen days in—Susannah is at her worst and undergoes a second lumbar puncture. An overnight EEG records a terrifying episode: she bolts upright, stops breathing, arms curled with wrists bent—Stephen calls it a T. rex pose. A nurse dismisses it as a “blue devil fit,” an antiquated term for a hysterical tantrum. Stephen refuses the label. Similar episodes recur almost nightly, curiously only when Stephen is present.
The second spinal tap finally delivers the decisive clue: her white blood cell count quadruples from 20 to 80—undeniable proof of severe brain inflammation. Her diagnosis shifts from psychosis to “encephalitis of unknown origin.” Even as the medical picture clarifies, her language collapses. She strains, “I . . . want . . . to . . . speak!” babbles at her cousin, then, in a controlled flash, slaps a blood-draw needle from a nurse’s hand with a sarcastic smile. The madness remains close to the surface.
Character Development
The crisis strips characters down to core roles—fighter, guardian, detective—and forges new bonds in the crucible of uncertainty.
- Susannah Cahalan: Catastrophic cognitive and motor decline culminates in catatonia, violent outbursts, and near-total mutism. Brief flashes of humor and intention hint at a self still trapped beneath the inflammation.
- Stephen: Becomes her fiercest advocate, confronting dismissive care and forming a united front with Tom. His presence both witnesses and activates crucial turning points.
- Rhona Nack: Vigilant and exacting, she endures the devastation of losing Dr. Siegel’s support, then channels relief and resolve when new evidence points to a physical cause.
- Tom Cahalan: A steady anchor whose routines and journal entries preserve the family’s timeline; his growing respect for Stephen underscores the family’s reconfiguration under stress.
- Dr. Souhel Najjar: The diagnostic pivot—he reframes the mystery as autoimmune encephalitis, champions IVIG, and restores a path forward.
Themes & Symbols
The diagnostic mystery tightens as negative test after negative test raises the stakes. The second spinal tap breaks the stalemate, proving inflammation and shifting the narrative from speculation to treatment. That pivot embodies the mind-body connection: as symptoms move from “psychiatric” to visibly neurological—slurring, rigidity, seizure-like events—the system can no longer ignore the biology behind behavior.
Identity erodes as illness advances. Catatonia, volatile outbursts, and memory loss fracture Susannah’s sense of self; her choked plea to speak dramatizes a consciousness barricaded by inflammation. Against that erasure, love and family support become lifelines. The routines, jokes, and bedside vigils do not cure her, but they preserve the idea of her—fueling advocacy, insisting on another explanation, and keeping momentum until science catches up. The storytelling itself—braiding journals, EEG logs, and lab results—answers the problem of memory loss by building an external record to replace what the hippocampus cannot.
Key Quotes
“Monstrous, beautiful mess.” This line captures the brain’s paradox—elegant in design, chaotic in function—and frames the story as a puzzle whose pieces resist tidy assembly. It justifies the team’s wrong turns while underscoring why a single clue (the spinal tap) can suddenly make the picture cohere.
“Has she always been so slow?” The offhand cruelty exposes systemic bias toward psychiatric explanations and the dehumanizing effect of stigma. Stephen’s reaction crystallizes his role as protector and accelerates the family’s insistence on a biological cause.
“I . . . want . . . to . . . speak!” A raw cry from within catatonia, this moment turns abstraction into urgency. It proves there is a coherent self struggling beneath the symptoms and reframes treatment as a rescue operation, not simply symptom management.
“Blue devil fit.” The archaic label reveals how quickly women’s neurological symptoms can be misread as hysteria. Stephen’s refusal to accept it becomes an ethical hinge in the narrative, pushing the case back toward rigorous investigation and away from dismissal.
Why This Matters and Section Significance
These chapters mark both the nadir and the pivot of Susannah’s illness. The collapse into catatonia and the abandonment by a trusted physician drain hope, while the second spinal tap and Najjar’s autoimmune theory rebuild it with evidence. The confirmed encephalitis transforms the book from a nightmare of “madness” into a medical fight with a name and a plan.
Structurally, this section shows how the memoir compensates for lost memory: family routines, journals, EEG video, and lab numbers reconstruct a life the narrator cannot remember, turning unreliable narration into an investigative method. The result is a powerful claim about identity and illness: when the brain inflames, the self blurs, but advocacy, patience, and the right detective can bring the person back into focus—and begin the true battle for recovery.