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The book contains black-and-white illustrations.
|Introduction: It Can Happen to Anyone||1|
|1||Our Vulnerable Brains||15|
|2||Saving Lives: The Golden Hour||30|
|3||Hope on the Horizon||42|
|4||The Rough Road to Rehabilitation||64|
|5||How Families Become Victims||89|
|6||Facing Fatality--and Worse Fates||106|
|7||Protecting the Most Vulnerable||125|
|8||A Better Use of Resources||141|
|9||Policies and Priorities||154|
|10||Prevention: The Best Solution||176|
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Our Vulnerable Brains
During World War II, a Russian soldier named Leva Zazetsky suffered a wound from a bullet that penetrated his skull and severely damaged his brain. For the rest of his life, he experienced the world in a bizarrely fragmented way. Although he appeared to be normal, he could remember neither the names of objects nor the meanings of words. Although he could talk, when he tried to speak he couldn't find the words to communicate his ideas and feelings. Before the war he had been a fourth-year student at a technical university; after his injury he couldn't read or perform simple addition.
The unfortunate young man's sense of space and his physical orientation to the world were severely disrupted. He could see only out of the left sides of both eyes. He simply had no visual awareness of things on the right side of his field of vision. He would see only parts of objects or sometimes not see them at all. For example, if he had a bowl of soup in front of him, he might be able to see merely a bit of the spoon, or he even might lose the spoon entirely if it was on his right side. In addition to leaving him able to see only parts of objects, Zazetsky's brain injury also caused him to have hallucinations. Ugly faces and rooms with odd shapes would appear when he closed his eyes, so he would open them immediately. This made it very difficult for him to sleep.
Neuropsychologist A. R. Luria worked with Zazetsky as he struggled valiantly to piece back together his disintegrated life. For twenty-five years, Zazetsky kept a journal, using it to try to recapture the thoughts, experiences, feelings, and memories that had been ripped away by the bullet that tore into his brain. In The Man with the Shattered World: The History of a Brain Wound, a book first published in Russian in 1972, Dr. Luria explained: "His only material consisted of fragmentary recollections that came to mind at random. On these he had to impose some order and sense of continuity though every word he recalled, every thought he expressed required the most excruciating effort. When his writing went well he managed to write a page a day, two at the most, and felt completely drained with this. Writing was his only link with life, his only hope of not succumbing to illness but recovering at least a part of what had been lost. This journal recounts a desperate fight for life with a skill psychologists cannot help but envy."
Dr. Luria tried to comprehend as a neuropsychologist what Zazetsky described as an existential trauma. At their first meeting, three months after the bullet wound, Zazetsky couldn't recall what had happened at the battlefront where he was injured. Finally, he remembered that it was the month of May. Then he was able to retrieve the names of the other months, but he couldn't remember, for example, which month came before September, and he couldn't remember the seasons.
Although he could see, Zazetsky couldn't interpret the things he saw. In order to learn how to read again, first he had to relearn the meanings of letters. Because he saw the visual world in shattered fragments, he could read only a few letters at a time. He had to retain these as he moved across the page, picking up other letters to combine into a single word.
Writing was easier, especially after Zazetsky realized that he could write quickly and automatically, getting a whole word down without thinking about the letters that made it up. Apparently the part of his brain that allowed him to write hadn't been destroyed. Eventually he could write as well as he had before his injury, even though he remained unable to read what he had put on the page.
Zazetsky's confusion about spatial relationships caused him to get lost even a short distance from his house and made him unable to comprehend directions. He didn't recognize places with which he'd been very familiar before his injury. In his journal, Zazetsky described how his visual problems and lack of spatial orientation would cause him to lose track of whole parts of his body: "Often I fall into a kind of stupor and don't understand what's going on around me. I have no sense of objects. One minute I stand there thinking about something; the next I lapse into forgetfulness. But suddenly I'll come to look at the right of me and be horrified to discover half my body is gone. I'm terrified. I try to figure out what's become of my right arm and leg, the entire right side of my body. I move the fingers of my left hand, feel them, but can't see the fingers of my right hand, and somehow I'm not even aware they're there."
The details of Zazetsky's story are unusual. Certainly his determination and persistence are rare. But medical history is replete with cases in which traumatic brain injuries have robbed their victims of some mental faculties but not others, and there is a simple reason for this: different parts of the brain coordinate different functions.
The astonishing three-pound organ responsible for both our basic, animal survival and for all aspects of our personality and personal identity is fragile. Cars, bullets, fists, baseballs, and horses' hooves can damage it; indirectly, so can gravity--when we fall or when something falls on us. And because we live in a world filled with such hazards, we are all vulnerable. Who hasn't bumped his or her head or been hit in the head by some projectile? Maybe the bump caused only a momentary pain, or perhaps a tender swelling formed. If the blow was hard enough, it may have been followed by nausea or dizziness. Being smacked by something soft like a beach ball causes no harm, but if a baseball fouled into stands collides with a human head at forty miles per hour, it can mean serious injury.
Because traumatic brain injury has always been part of the human experience, healers have puzzled over the brain's workings since prehistory. "Head injuries must have been very common in the life of primitive people, given the harsh and dangerous conditions of their existence," neuropsychologist Harvey Levin observes, "and they must have been quite familiar with some of the consequences of these injuries." In the oldest known medical document, the Edwin Smith Surgical Papyrus, itself a copy of an older manuscript written about 3000 B.C., ancient Egyptians noted a correlation between left-side skull fractures and paralysis or loss of speech.
Surgical repair of traumatic brain injuries also dates back for millennia. Physicians in ancient Greece developed instruments for removing bone fragments from depressed skull fractures and for cutting holes in the skull to repair head wounds. As the centuries passed, surgical techniques evolved for treating skull fractures, intracranial pressure and swelling of the brain, and arrow, spear, and gunshot wounds.
Since Plato and Aristotle, philosophers have scrutinized the nature of human consciousness, thought, and reason. In the seventeenth century, the French philosopher Rene Descartes was preoccupied with the unique consciousness of self that seems to set us apart from other creatures. He also cleared the path for future research on how the brain functions by a style of analysis that threw out old dogmas and reduced complex concepts to their simplest components and by regarding the human brain and body as machinery. As his successors struggled to describe, classify, and explain consciousness, they established the branches of philosophy called philosophy of mind and epistemology, which together later spawned psychology.
Long before scientific evidence made the connection clear, astute observers began associating consciousness with brain functions. The ancient Greek physician Hippocrates suspected that the brain was the source of awareness, thought, and feeling. Apart from his followers, few agreed. For centuries, the heart, spleen, and liver were considered more essential to human identity than the brain.
Modern brain research began in the nineteenth century. Although Sigmund Freud is best known for his work on dreams, suppressed desires, language, and reactions to emotional trauma, his earliest theory concerned a biology of the mind. Like other scientists of his day, he believed that human psychology ultimately rested upon the complexities of the brain.
Half a century earlier, in 1837, Marc Dax, a French physician who was examining patients who had lost the ability to speak, noticed a link to paralysis on the right side of the body and injury to the left side of the brain. During an autopsy of a stroke victim who could utter but a single word, Parisian surgeon Paul Broca discovered that the only part of the man's brain that was damaged was a specific area called the posterior frontal cortex. Later he checked out eight other patients' similarly impaired speech and found that seven of them had suffered damage to the very same region. Subsequent research sought to map the parts of the brain that controlled various functions--sight, consciousness, memory, learning, language, and even moral sense. The concept known as "localization" was now firmly established.
One case that drew considerable attention was that of Phineas Gage. In 1848, Gage was a twenty-five-year-old construction foreman for the Rutland and Burlington Railroad. His job included supervising the setting of explosives for leveling the Vermont terrain so that the work crew could lay track. Typically, an assistant drilled a hole in the rock, filled it with blasting powder, and covered it with sand. Then Gage would tamp it all down with a three-centimeter-thick iron rod and set the fuse. One September day, something distracted Gage, and he tamped the powder directly--before his assistant could pour in the sand. In the resulting explosion, the rod went straight through Gage's skull and brain, entering the left side of his face and exiting above his forehead.
Remarkably, with some assistance, Gage was able to walk away from the accident. Although he was stunned, he never lost consciousness or the ability to speak clearly. His left eye was gone, but otherwise he recovered completely.
Except for one thing: before the accident, Phineas Gage had been an exceptionally responsible young man who behaved in accordance with the strict social conventions of his day. After his traumatic brain injury, he became unreliable and irreverent. He peppered his speech with profanities, and he couldn't hold a job. When Gage died in 1861, no autopsy was performed, but twenty years later a scientist named John Harlow retrieved his skull, examined it, and posited that the key to responsible and appropriate behavior lay somewhere in the left frontal lobe of the brain--the portion devastated in Gage's accident.
The recognition that specific areas of the brain direct specific functions helps to explain why the unfortunate Zazetsky could write more easily than he could read, why he could view the left side of his body but not the right, and why he could display normal intelligence in some activities but couldn't find his way home from a few blocks away.
In her book The Broken Brain, psychiatrist Nancy C. Andreasen describes the brain as composed of tissue with the consistency of Jell-O. It floats inside the skull, encased in a protective sac, which is called the dura mater, and cushioned by cerebrospinal fluid. The brain's gray surface is a maze of ridges; beneath them, most of the brain is white. Its curious appearance gives few clues to how it operates.
Viewed from the top, the brain is arranged in two hemispheres, left and right. The large mass extending from the forehead to the back of the skull is the cerebrum, the part that directs language, learning, creativity, introspection, and all the higher functions that we think of as giving us a human existence. Scientists subdivide each hemisphere of the cerebrum into four lobes (Figure 3). Farthest to the back, the occipital lobe takes in and disseminates visual information. Jutting out to the side, the temporal lobe handles hearing, language, and memory. Immediately above these two, the parietal lobe deals with other sensory data and regulates spatial orientation. The cerebrum's frontal lobe is the least understood part of the brain. Part of it controls our movements; other parts are devoted to different aspects of thinking, feeling, and decision making.
Immediately under the cerebrum lie the diencephalon, the basal ganglia, and the pituitary, the tiny gland that regulates hormones. Within the diencephalon, the thalamus modulates emotions, sensations, and behavior, serving as a sort of switching center between the cerebrum and the body, while the hypothalamus oversees hormonal function. Working with the cerebellum, which is located at the base of the skull, the basal ganglia control movement. Hidden beneath the cerebellum is the most primitive part of the brain--the midbrain, pons, and finally the medulla, which connects directly to the spinal cord. Often referred to collectively as the brain stem, these structures are responsible for heartbeat, respiration, and other vital functions--in other words, for the most basic aspects of organic survival.
Whatever its function, each part of the brain is made up primarily of nerve cells. These come in two types: neurons, which do the work, and glial cells, which support and nourish the neurons. Neurons communicate with each other through axons--thin tubes that run like microscopic wires through the brain, carrying electrical messages. Axons serve as transmission lines for signals to and from the brain and between its various parts. When the head accelerates, stops, or twists violently, these delicate fibers can stretch, tear, or shear off. Such axonal damage can prevent sensory information from reaching the brain and keep the brain's commands from getting back to the limbs. On a smaller scale, it can interrupt the internal signals essential for the brain itself to function normally.
Scientists have yet to unravel how the brain's individual structures do what they do, let alone how they interact with one another. Some neurophysiologists look at the brain as a biochemical system; others see it as a complex web of electrical circuits similar to those of a computer. Like the nineteenth-century view of the brain as a machine, each of these models can be useful, but none tells the whole story of this complex organic system. Dr. Andreasen notes that the brain's "designer, if it had one, concealed it well from hostile forces, in addition to concealing well its organization and function." She goes on to describe one of the most helpful metaphors: the brain as a network of scattered information centers that use electrical impulses to communicate among themselves: "Different areas of gray matter are specialized in different functions, such as moving, seeing, touching, listening, thinking, or modulating physical functions such as eating or sleeping. Often these areas are redundant--that is, several areas can perform the same function. Thus, when one communication center is knocked out, another may be able to take over in its place."
Another of Dr. Andreasen's insights is crucial to understanding traumatic brain injury. Inside its bony case, its tough dura mater, and its cushion of fluid, "the brain itself is soft, delicate, and easily damaged. If you touch it too hard, it may bleed."
Although many blows to the head are inconsequential, some have significant, if not permanently disabling, effects. For example, while my younger daughter, Marcia, was doing a flip during gymnastics practice, she landed on her head. She had headaches for weeks afterward. Fortunately, they eventually ceased. A few years ago, my older daughter, Joanna, was hit on the head by a fifty-pound barbell while she was exercising before swimming practice. At first, she denied that the blow had caused any harm, but soon a large swelling arose. Then she experienced double vision and a severe headache. To our great relief, a visit to the emergency room followed by a CT scan revealed no serious damage.
Joanna was lucky. One of my former colleagues at UCLA was in a traffic accident and smashed her head on her car's windshield. Medical examinations revealed no injury to her skull, and various kinds of high-tech imaging showed no visible damage to her brain. Yet for months afterward she couldn't think clearly or concentrate, nor could she keep track of multiple intellectual tasks. She found this particularly frustrating in her job as a high-level university administrator.
At first, my colleague denied the problems. Some of her associates thought she might be malingering. Eventually, however, a neurologist explained that so-called minor brain injuries like hers--those not visibly discernible even through high-tech diagnostic procedures--can cause symptoms serious enough to disrupt the victims' lives, at least temporarily. In time, these symptoms often diminish or disappear, but meanwhile, the neurologist advised, my colleague would have to compensate by reducing the number of tasks that she undertook simultaneously or keeping careful lists to remind her of what she should do next.
Many things can damage the brain. Tumors, strokes, drug and alcohol overdoses, fever, and Parkinson's disease all kill brain cells; so do cardiovascular and respiratory disorders or anything else that deprives those cells of oxygen. But my focus here is brain damage that results when the head is hit, is penetrated, strikes a stationary object, or is violently shaken or twisted. Unlike brain damage caused by chemicals or disease or the failure of some other body system, such as the lungs or heart, traumatic brain injury occurs suddenly and immediately produces varying and often multiple functional deficits. With the possible exception of chemical insults, traumatic brain injury is the most preventable cause of brain damage. Because of this, and because so many of its victims are young and therefore face decades of disability, brain trauma is also the most crucial for us to examine as a society.
Traumatic brain injuries fall into two basic categories: penetrating and closed. Penetrating wounds often look the most serious. The sight of someone with a sharp object sticking out of his or her head is among the most horrifying imaginable. Yet, depending on the missile's speed and trajectory, on the exact areas of the brain it damaged, and on many things that scientists have yet to discover, such wounds can result in anything from death to little or no impairment. Phineas Gage walked away, dazed but talking, after having an iron rod shoot through his skull; Zazetsky spent his life struggling to integrate his shattered world after a much smaller bullet entered his brain; President John Kennedy died a few hours after a gunshot wound to the head.
Amazing as they may seem, penetrating head injuries with few lasting effects are not as rare as the often bizarre particulars of individual cases might lead us to believe. Provided that infection is prevented, the brain breached by a sharp object can sometimes reorganize itself, circumventing the injured portion.
Consider the man who was admitted in a drunken stupor to the emergency room of Massachusetts General Hospital. He suffered from a slight limp, and the right side of his face drooped. Other than that, nothing much seemed wrong with him once he sobered up. But a CT scan taken while he was still semiconscious revealed the clear image of a three-inch nail inside his brain, its point touching the back of his skull. Asked how it got there, the patient explained that twelve years earlier he had tried to commit suicide by shooting himself between the eyes with a nail gun.
Closed head injuries, on the other hand, may look less serious on superficial inspection but may cause far more harm. Ironically, that's because the bony case that protects the brain also can damage it. The inside of the human skull is a mass of hard ridges. During normal movements, such as nods or rotations, and even light impacts, these ridges help keep the brain floating in place. But because the skull, the cerebrospinal fluid, and the brain all have different densities, when the head accelerates suddenly, as it does when a boxer takes an uppercut to the jaw, or decelerates quickly, as it did when my colleague's head hit her windshield, these three don't move at the same speed. This makes the brain bounce around against the hard, rough surface of the skull, causing abrasions and bruising that can extend all the way to the brain stem. Violent twisting and vibration can produce similar diffuse damage, which is why shaking a child--especially a very young one--is a potentially disastrous form of discipline.
The elderly have their own special vulnerabilities to head injury. Owing to osteoporosis and problems with balance, the latter often exacerbated by alcohol and prescription drugs, people over sixty-five suffer a disproportionate number of falls, and because their reflexes have slowed, they have trouble protecting their heads as they tumble. Moreover, our brains shrink as we age, leaving more space for the brain to travel inside the skull; a bump on the head that would barely faze a twenty-five-year-old may cause his or her grandfather lasting damage.
Blows to the head are among the most common causes of closed brain injury. Rocks, clubs, baseballs, and countless other hard objects, whether dropped, thrown, or wielded, are capable of shattering the skull without breaking the skin. The potential sources of damage vary from place to place (for example, falling coconuts cause many head injuries in Micronesia but few in the continental United States), but the results are similar. A single sharp thump can produce several types of immediate damage. If blunt trauma crushes the skull, bone fragments may bruise, cut, or penetrate the brain, causing injury. If the impact comes from the side, rotating the head suddenly, nerve fibers and blood vessels can be torn.
Among the most devastating effects of head injury is the secondary damage that can follow hours and days later. Like other parts of the body, the brain responds to bruising by swelling. But unlike the skin-covered leg or wrist, the bruised brain has nowhere to go once it reaches the inelastic skull. When this happens, pressure builds, and arteries and veins can be squeezed so tight that circulation to the bruised portion of the brain shuts down. The resulting oxygen deprivation can cause death or irreversible damage. Blood leaking from a wound inside the skull can form clots, or hematomas, that compress the area of the brain beneath them. The fluid that collects as a reaction to the initial injury can cause hydrocephalus. Draining it off lowers the intracranial pressure that may cause more devastation than the original impact. The higher the intracranial pressure and the longer it lasts, the more irreversible damage the brain suffers. That is why closed head wounds often wreak more havoc than nastier-looking penetrating wounds, which provide their own drains. (And that is why the shunt that Dr. Bernauer inserted in my skull and the speed with which he placed it were essential to my recovery.)
Scientists still don't understand how the brain heals itself, so long-term recovery from any traumatic brain injury is uncertain, and its course is difficult to predict. Some victims recover spontaneously. Until recently, neuroscientists thought that much of the loss of capabilities due to brain damage was irreversible. We now know that rehabilitation sometimes can restore cognitive and functional skills and emotional and experiential capacity, at least in part. Physical, occupational, recreational, and educational therapies may have significant short- or long-term benefits in certain cases. Although a good deal of rigorous evaluation must take place before we will know which of the various therapies currently available or under development will work in which kinds of cases, preliminary research suggests that for many victims of traumatic brain injury, the potential for recovery is much greater than previously believed.
Recovery from traumatic brain injury may be quick or slow; it may be complete, partial, or absent. It may come easily or require immense and intense effort. The anguish felt by the patient and his or her family may give way at last to success, or their hopes may end in despair.
People who do recover from traumatic brain injury must be highly motivated and persistent. Supportive families, skilled therapists, and protective environments in which to relearn the tasks of living and make the transition from hospital to outside world play an essential role. Treatment and other resources must be available and affordable, but a certain amount of physiological luck also comes into play. So does a constellation of factors and forces that currently lies beyond the reach of science yet cannot be fully explained by faith and hope.
The most comforting stories about recovery from traumatic brain injury have the timeless power of great myths. We love both the tales of miraculous escape, like Phineas Gage's, and the epics of valiant persistence and strength of character, like Russell Moody's. But we should not let these individual accounts obscure the fact that the broad spectrum of outcomes goes from full recovery to death, with a range of disabilities, many of them horrendous, in between. As we formulate our public policies and conduct our own lives, we must bear in mind that many individuals with traumatic brain injury never recover enough to lead independent lives. Their need for chronic care poses haunting challenges to our society.