Another Day in the Frontal Lobe (15 page)

With his characteristic enthusiasm, he dropped everything, sprang from his chair, and led me to a room down the hall where a cardboard box contained numerous half-inch-thick slices of human brains that had been prepared during autopsy. The slices had been preserved in a formalin solution and were packaged in neat vacuum-sealed plastic pouches, similar to what you might find in the meat section of a grocery store. He had saved illustrative examples of a variety of different diseases: Alzheimer’s, stroke, tumors, hemorrhage, infections. It was a real treasure trove, for those inclined to view perfect examples of diseases as treasures.

He held up different slices one at a time and gauged my level of interest in each, setting aside a short stack of the ones I liked best. I only wanted four or five, as more than that would be a tight fit in my book bag, and I knew I would have other things to carry across campus. I had reached my limit when he came across a final one that he urged me to consider.

This last one looked familiar for some reason. Within this particular slice was a section of a brain tumor, an unusual brain tumor, and I recalled having seen the exact tumor—size, shape, location—on a patient’s MRI scan not long before that. As a neurosurgery resident, you develop a good visual memory for brain scans, and can remember them almost as you would a face. Often, when I see a patient in follow-up in the office, an image of their scan will pop up in my mind as I greet them. (What I might say: “Hello, Mr. Garcia. How are you feeling?” What I might see: the real Mr. Garcia, and a flashback of his scan from two weeks ago showing a small collection of blood in the right thalamus.)

My neuropathologist friend detected a puzzled look of recognition on my face. “You know who this is…right?” He paused, waiting for me to complete the picture, to match the face with the brain. “Oh…yes,” I answered, somewhat disturbed, and added the slice to my stack after some hesitation. I had to agree, it was a choice specimen for teaching purposes, and I vowed to preserve its anonymity.

The next day, I left the hospital mid-morning and started walking across campus on the way to give my lecture, the brain slices neatly arranged in my book bag. I walked past building after building where university professors were teaching, holding court, enlightening their students, and living their lives. I wondered how many were taking it all for granted.

I continued my walk past one building in particular, where one professor in particular, whose life had been cut way too short, had taught before his neurological symptoms crept up on him. I knew that it was
his
brain I had recognized, that I was now carrying in my book bag. His brain would continue to enlighten students more than his mind could have guessed.

I felt privileged to use his final, invaluable gift in the name of teaching, but I couldn’t help but perseverate on a strange feeling similar to what I experience whenever I see Shel Silverstein’s book
The Giving Tree.
The book is ostensibly a children’s book, but probably too weighty and disturbing for kids, judging from my own experience of reading it for the first time. I don’t even have to flip through the pages to get this feeling. Just catching a glimpse of the cover in a bookstore will do it.

In this book, a man uses his generous tree-friend for every imaginable purpose, starting in his early years: picking apples and climbing the branches as child, lying in the shade and carving his initials (and girlfriend’s) in the bark as a teen, cutting down the branches to help build a house as an adult, taking down the entire trunk to make a canoe and get away from it all in middle age, and, finally, coming back to rest on the stump as a frail, emotionally spent, elderly man. The tree keeps giving of itself, selflessly. It is the humble and humanlike personification of this tree, combined with the primitive line drawings, that practically has me in tears by the final page as the tree offers the only thing it has left—the stump of its former self—to the man who has taken everything else.

In working with the brain as an object, especially one dissected free of the body, I can’t help but turn my thoughts to the philosophical once the anatomical and pathological requirements of the job are out of the way. Frank Lloyd Wright, when asked about his core religious beliefs, once answered something to the effect that he believed in “nature with a capital N.” I like that answer. I know what he was getting at. I fundamentally believe in Nature, too, with the human brain as a key part of it.

To my way of thinking, there’s really no role in this simple “religion” for the supernatural or the mystical. A pure nature-based outlook on life, I think, can be refreshingly straightforward: our brains, which make us who we are as individuals, function while we are alive. Once dead, brain function ceases, and the individual is gone. Figuratively, of course, the person does “live on” in a sense, but only because he is represented in the memories of the living and in whatever else he leaves behind: writing, photos, videos, artwork, donations, the DNA within his offspring, and so on. There is nothing mystical about this; no ethereal “soul” that floats around in the stratosphere or beyond.

I do have to admit that the supernatural elements of traditional religion offer a protective layer of comfort that a Nature proponent might miss out on. Take, for example, the idea of an “afterlife.” Wouldn’t it be comforting to think that you could mess things up in this life but make up for it all after death? Or, that you could make the tragic mistake of forgoing simple pleasures as a human on Earth, yet look forward to enjoying yourself more after burial or cremation?

Most people believe in religious teachings simply because they were brought up with them from an early age, not because they critically examined the fundamentals and concluded that they made sense. Culture and tradition often trump good common sense. From the viewpoint of a Nature-based believer, then, traditional religion can lead to a false hope or false comfort starting at an early age. Think of the ramifications. How many people sell themselves short on life because they expect great things after death? Life is not a dress rehearsal. You have to enjoy it, make the most of it, while your neurons are still buzzing with live connections. It’s amazing how holding a human brain can emphasize these points, at least for me.

I don’t want to give the wrong impression. I have the utmost respect for people’s religious beliefs. I am, in fact, fascinated by those beliefs (in circumstances when it’s not impolite to ask). I understand why religions were created and why they persist. The benefits of affiliating yourself with a religion are without question: a ready-made framework for morals, a welcoming social network, comfort in times of duress, and a repeating schedule of events (weekly worship, yearly holidays) that strengthen belief and bring order to one’s life. Those are very nice benefits. The not-so-hidden downsides, though, can sometimes put a damper on these benefits: dividing humans along religious lines, encouraging war, discouraging marriage between otherwise perfectly compatible individuals, inhibiting free thought, and invoking guilt in those who stray from the flock.

I remember attending Sunday school as a youngster and feeling distinctly unsettled one day. I had just been taught, in no uncertain terms, that heaven was reserved for people who believe in Him (with a capital H). Most kids in the room felt pretty good about that. They were safe; they could laugh at the devil (lower-case D?) with impunity. I, on the other hand, felt awful. I asked the teacher about all the kids who happened to have been born in China. What about them? The teacher assured me that they, too, could be accepted into heaven as long as they found their way to Him as well.

Found their way? I imagined all the potential roadblocks to proper access and conversion: no churches in the province, no Bibles in the libraries, no soft-spoken Sunday school teachers to clue them in. I imagined a fiery subterranean hell with a sea of perplexed Chinese faces. I knew that just couldn’t be right.

Ever since, I have remained the questioning sort, but I still thoroughly enjoy Christmas morning, Easter baskets, and religious wedding ceremonies. I’m not a spoilsport. I can appreciate the cultural traditions of any culture (particularly when good food is involved) and I do have a soft spot for the traditions I grew up with. The trappings of religion are not the issue as far as I’m concerned, as long as they’re not taken too seriously. It’s the dogma behind them that can sometimes be confining or divisive.

Sometimes, when I’m not exactly rational, like during the odd period between being awake and asleep, I worry that someone, somewhere, will force me to fill out the “religion” blank on a form, like on admission to a hospital, and won’t accept N/A as an answer. “You have to pick one!” the persnickety lady behind the counter will say, handing the form back to me. I think about the world of possibilities. There are so many religions to choose from, how can there be just one “right” one? Could all the others be dead wrong?

Lutheran would be an easy choice for me because that is my family background, and nobody would question it. But which religion is really most in tune with my more brain-centric Nature beliefs? There’s no particular option that’s just right, but I think the basic ideas behind Buddhism are probably the most true to life and, one could argue, perhaps the most sophisticated. Along the way, as it evolved through different cultures, different forms of Buddhism picked up many colorful and supernatural elements that are a tad far-fetched (humans can’t help it), like the idea of reincarnation, but the fundamentals are solid. (Unfortunately, I think the more colorful and supernatural elements are what can turn people off—so that they throw the baby out with the bathwater—and prevent them from taking a look at the basics, which are both ancient and very modern.)

A key idea in this philosophy (more a philosophy than a religion, per se, because no god is involved) is that suffering is a natural part of human life, and the only sure way to overcome suffering is to develop control over your own mind. That’s what I like: it puts the locus of control in the individual, the individual mind, and not in any external power. That’s a refreshing concept. You can enjoy the here and now because your thinking is clear, you don’t have to look through the smoke of the mystical, and your mind is not the passive victim of whiplash in the turbulence of external events. The comfort you get from being in charge of your own happiness does not rely on any false hope.

I once toured the Asian gallery of an art museum and learned the meaning behind a common ancient Buddhist figure with dozens of small, uniform, individual clumps covering the head, almost giving the appearance of cornrows. The expert explained that these were meant to convey the numerous accessory brains of a highly enlightened individual. However far-fetched the idea of numerous accessory brains (clearly meant in a symbolic way), I was happy to see the brain represented so prominently in a religious icon. So many other religions downplay the brain, as if to deny that human minds, working collectively, are what created religion in the first place.

I volunteered to be a research subject several years ago, partly to help science, but equally to get a free MRI scan of my brain. As a neurosurgery resident and witness to a variety of intracranial catastrophes, I was curious to see if I might have any ticking time bombs of my own, or maybe a congenital cyst quietly taking up some room. It wasn’t part of the protocol to let the subjects take home their own pictures, but I begged the MRI tech, nicely.

My first thought, on seeing my own images, was relief to see everything in order, and nothing that didn’t belong. My second thought was surprise and almost a twinge of disappointment at how it looked exactly like everyone else’s normal brain. I’m not quite sure what I was expecting, but I must have felt subconsciously, however irrational and illogical, that the image of my brain might somehow be a reflection of me as an individual, like a face. In retrospect, the tech could have handed me pictures of anyone else’s brain and I wouldn’t have known the difference, except that I could identify my long, straight nose in the profile shot of my own.

Even logical minds are prone to illogical, mystical thinking sometimes. Luckily, though, it doesn’t take much for me to reconfirm my more realistic, Nature-based outlook. Another day on call might present another brain at risk, with gradations of injury compromising gradations of the individual. Then instinct sets in: minimize the damage and maximize the individual. The brain is the mind is the individual, and it’s our only hope. That’s what I believe.

THIRTEEN

Fragments

Andy Goldsworthy appreciates the fragmentation of nature over time. I first saw Goldsworthy’s work at the Museum of Contemporary Art San Diego, a small fine museum in La Jolla, California. I had been a fan of this artist’s books for years. His books feature photos of his ephemeral creations, assembled with unprecedented creativity from objects in nature, like fall leaves carefully chosen along a color spectrum, fastened together in line with twigs or thorns, and allowed to float down a river. The leaf line eventually falls apart by the force of the river.

I was eager to see his work in person. The La Jolla exhibit featured organic objects, like large stones covered in a thick layer of clay, displayed right on the museum floor. The clay was applied while moist, and as these structures became drier and drier over days and weeks, they started to develop deep cracks along their surfaces. Over the period of the exhibit, the cracks extended all the way through, fragmenting the clay and further exposing the stones underneath. It was a haunting demonstration of impermanence.

Goldsworthy played to a similar theme in his various series of snowballs. He created larger-than-life snowballs with various other media, like sticks and stones, embedded within the snow, similar to bits of candy within a scoop of ice cream. He deposited these massive snowballs in various places, including in the middle of busy urban spaces. He photographed the melting process over time, recording not only the slow revealing and settling of the sticks and stones, which ended up in a neat pile on the ground, but also the puzzled looks of passersby on the street.

Much of Goldsworthy’s art is not meant to last, except in photographs. This sets it apart from most other types of art I can think of, except for the Tibetan sand mandala, Christo’s projects (like the Central Park Gates installation), and, I guess, urban graffiti, as these artists expect their work will get cleaned up, eventually. I first saw a sand mandala in college when a group of Tibetan monks was invited to create one at the Johnson Museum of Art at Cornell University. I’ve sought out several others since. Creating a sand mandala is a painstakingly detailed task, performed from memory by letting fine, colored sand sprinkle out of the end of a thin metal funnel onto a flat surface.

Museumgoers get to see not only the completed work, but even better, the work in progress. The sand sprinkling is carefully controlled by running a stick up and down along the rough surface of the funnel, held sideways, allowing the vibrations from the stick against the funnel to agitate the sand. These mandalas are quite large, and the monks have to work, logically, from the center out; they would end up messing up the edges with their robes if they worked from the outside in. They are very careful to preserve their fragile work during its creation, and most visitors naturally have the sense to keep a safe distance, in case they have to sneeze or cough, which might scatter the sand.

The final result is a masterpiece, an unbelievably intricate, multicolored, circular design, full of symbols and complex geometry. Once the mandala is fully complete, the monks destroy it. They sweep up the sand and carry it out to the nearest natural body of water, in a ceremonial fashion. You have to enjoy the mandala while you can, just like everything else in life. Some things last longer than others, but nothing is permanent, and this is the whole point.

Nature can fragment over time. The brain is part of nature. Degradation and disease are natural processes. Even so, it’s hard to develop a calm acceptance of the fragmentation of the human mind. It’s hard to find any beauty in it. The Japanese term for the beauty of things that are incomplete, worn out, or impermanent is
wabi-sabi,
and although I can appreciate the
wabi-sabi
nature of an old piece of furniture, with its chipped paint and random dents, or the natural, wrinkled face of a well-aged man or woman, I still have trouble with the wearing out or fragmenting of the brain, as most people do. I sometimes wonder if a good deal of suffering could be curtailed if a brain, like a Tibetan sand mandala, could be swept up and sent out to sea, in a thoughtful and respectful ceremonial fashion, before the intricate design has a chance to fragment too far, before it is degraded by the equivalent of drafts, clumsy feet, and curious hands.

As a neurosurgeon, I am often positioned at the end of the line. Similar to a police officer, I have often thought, who tends to meet people at their lowest ebb, as when a family relationship has degraded to the point where violence ensues, I often meet people at their lowest point, too, as when their minds have fragmented past the point of no return. I am then standing there, at the end of the line, asked to clean up what I can. It can be hard to shake the feeling of futility at times.

There are the fairly common scenarios, like the elderly woman with Alzheimer’s disease who falls down the stairs and ends up in the emergency room with bleeding into the brain. How aggressive should I be for this poor woman whose mind has already been moth-eaten by disease? Should this be the final straw? What would she want me to do, if her mind were intact enough to offer a thoughtful opinion? It’s at times like these that I might daydream of a career with a more upbeat focus.

(This reminds me of an idea I’ve had off and on during late-night treks to the ER. Everyone past a certain age—it’s hard to be exact here and I’m not being ageist, really—should consider sleeping on a traditional Japanese-style futon, the real kind, frameless, right on the floor. I can’t tell you how many ER visits for injuries to fragile parts—heads, necks, backs, limbs—could be prevented if simple falls out of bed were curtailed. It might also help maintain flexibility, with the daily getting up and down from the floor. One reason that some elderly can’t get up after a fall is that they actually haven’t been down on a floor for years!)

Difficult management decisions are made all the more taxing when family relations have fragmented along with the patient’s brain. Understandably, it can be difficult to keep a relationship going strong when one person is barely there. I remember seeing a woman with advanced Alzheimer’s disease who developed significant bleeding into an area of the brain that had already suffered a stroke. She was brought by ambulance to the ER, and the search was on for a responsible family member. The social worker eventually tracked down one of the daughters, who was kind enough to drive to the ER, check on her mother, and help us out.

I returned to the ER to meet the daughter. She was there with her somnolent mother, behind the curtain, and she had brought her own daughter as well. They had stopped at McDonald’s on the way, and both were seated in plastic chairs at the bedside, dipping their fingers in and out of their paper French fry bags as I explained the gravity of the situation. I paused as they took the briefest of breaks to lick their fingers and sip on their Cokes. They continued, like metronomes, with their repetitive in-and-out pincer grasp motions as I explained that the bleeding could be fatal if nothing was done. They nodded their heads in understanding, their mouths full and lips glistening. I left the room to let them think things over and finish their fries. Typically, I would have shaken hands at this point, but I decided against it. I walked away wondering who, in this situation, would be grateful for the fruits of our labor: the patient? the family? no one?

In addition to Alzheimer’s disease, serious mental illness is a particularly distressing sort of fragmentation. From my vantage point at the end of the line, the most extreme situations I’ve encountered have involved mentally ill patients. The situations have been extreme in many ways: the most gruesome presentations, the most marginalized members of society, the most convoluted ethics, and some of the longest hospital stays. After a patient has been in the hospital for more than a few weeks, we may refer to their stay as a “hostage crisis” on rounds, as in: “Mr. Doe, hostage crisis day number thirty-seven, self-inflicted gunshot wound to the head.” It can be hard to get a person out of the hospital and placed in a facility when there’s no insurance, no family, and no hope.

Gunshot wounds to the head—as accidents, attempted homicides, or suicide attempts among the desperately depressed—tend to fall into two opposite categories, like a dumbbell, with few cases falling into the gray zone of uncertainty: there are people who will survive and people who will not survive. It’s usually easy to figure out which category a patient belongs to, and you can often tell the second they hit the ER. Breathing? Eyes open? Moaning? Moving? If none of the above then things look bleak. Their stat head CT seals the distinction. If a bullet has violated both sides of the brain, clipping off the deep vital structures (not just grazing across the tips of both frontal lobes, for example), then there’s nothing that can be done, and the neurosurgeon’s role is more counselor than surgeon.

Early on in my training, I learned a critical lesson in managing these patients: if a person is not going to make it, and you’re sending him up to the ward for his final hours of existence, you still have to stitch up the bullet wounds in the scalp. Here’s why: death is often precipitated by a buildup of pressure inside the skull. The pressure is due to the sheer volume of damaged, swollen brain tissue. Extreme pressure will eventually lead to one of two fatal events. Either blood flow to the brain will be shut off, or the brain stem—which harbors the control centers for breathing and heart rate—will become compressed and rendered nonfunctional. If the holes in the scalp remain wide open, the swollen brain “pulp” will naturally make its way out through these paths of least resistance, relieving the intracranial pressure, at least temporarily. A normalization of intracranial pressure can delay death.

One day on call, when I was still in the early stages of the learning curve with this clinical entity, I neglected to suture up the holes in a chronically depressed man who was nearly dead on arrival, but still breathing, his brain capable of coordinating normal rhythmic breathing but not much else. Out of ignorance, I elected to simply wrap his unsanitary head with gauze, as quickly and as neatly as possible, so the family could hold vigil at the bedside. I assumed he would expire before too late in the evening and I hoped that his family might be able to get some much-needed rest after a nightmare of a day. At that point, I was treating the family, not the patient, and thoughtfulness was the only thing I had to offer.

The following morning, on rounds, I was horrified to see that the patient’s breathing was still going strong. A few family members had spent the night, half-asleep and distraught, on chairs and recliners in his room. I reported his condition to my attending, who asked me if I had sutured up the bullet holes. When I answered no, he put up his hands as if to say “What did you expect?” and recommended that I go back to the patient’s room to finish my job.

I asked the family to leave for a few moments, for reasons I didn’t feel obligated to explain, and sought out a nurse’s help in gathering supplies, feeling like an idiot as I listed out the things I needed, all the things that I should have asked for the previous day.

I unwrapped the gauze and cringed on seeing that his hair had become matted down with brain tissue that had followed the simple principles of pressure dynamics. I stitched up both the entry and exit holes, the only truly thoughtful act I had performed for this family, and the patient expired a few hours later. Since then, I have vowed never to put a family through such prolonged torture. I’ve only made that mistake once.

Now take the opposite side of the dumbbell: an attempted suicide patient who
will
survive. This is an awkward and crushing situation. Survival is exactly what the patient did not want, but survival is what he gets, often a neurologically blunted survival, and often because of the position he held the gun in. I won’t go into detail. I don’t want this to be misconstrued as a how-to, but suffice it to say that the frontal lobes are quite forgiving, which I’ve said before.

The most disturbing mentally ill patient I ever took care of was sent to us “from the hills” of a neighboring state. During my training, I saw many unusual patients who came from those hills. Maybe it was because some of the communities out there were appallingly destitute. Illnesses sometimes presented themselves to us in quite advanced stages, having been neglected in their earlier stages due to ignorance or inadequate medical care. Add a fragmented mind to the extremes of socioeconomic misfortune, and the results can be disastrous.