We Are Our Brains (23 page)

Not that alcoholism is confined to presidents, of course. The American Communist hunter Senator Joseph McCarthy, who destroyed many lives, had a serious alcohol problem and died in 1957 of cirrhosis of the liver. And alcohol certainly isn't the only substance abused by world leaders while carrying out their duties. In 1956, during the Suez crisis, British prime minister Anthony Eden, who was suffering from severe pain, took pethidine, an opium derivative, shortly before chairing a cabinet meeting. He took barbiturates to sleep and amphetamines to stay alert. Indeed, in the final weeks before his resignation he lived on amphetamines, a fact that he didn't conceal from his cabinet.

Some leaders have been successful despite mental health problems and substance abuse. Winston Churchill not only suffered from severe depression but also had hypomanic and manic phases (see
chapter 5
) in which he drank phenomenal amounts of champagne, brandy, and whiskey. John F. Kennedy had numerous health problems, including Addison's disease, caused by the failure of the adrenal glands, for which he had to take cortisol. At some point during his election campaign he forgot to take his cortisol tablets with him and fell into a coma. In 1938 he was involved in a car crash, after which he suffered from back pain. His treatment involved procaine injections that were administered three times a day or more. (Procaine is a synthetic cocaine derivative that can leak into the brain, causing central effects.) Kennedy was also a recreational user of substances like amphetamines, whose effects he described as delectable and euphoric. He took cocaine both before and during his presidency. He was also being given testosterone, allegedly because of his adrenal gland problem, but you might wonder whether that could have contributed to his irresponsibly macho behavior during the Bay of Pigs invasion of Cuba in 1961. He experimented with marijuana and LSD in the company of his mistresses at the White House. Kennedy also took sleeping pills, painkillers, and phenobarbital, a sedative. On top of that, he was given injections of a mixture of corticosteroids and amphetamines concocted by a doctor. Various doctors prescribed medication for him without knowing what other treatment he was receiving. It has been said that Kennedy played around with doctors even more than with women!

Shouldn't we at least impose the same requirements on those who govern the country as those who drive a car or fly a plane? When are we going to test politicians, on whom we're so dependent, for alcohol, drugs, and medication?

We are conscious of our surroundings and of ourselves. Some brain structures are crucial to consciousness, like the cerebral cortex, the thalamus (where we receive sensory information), and the white matter, the nerve fibers linking these structures (
fig. 20
). After a brain infarct on the right side of the brain, both self-consciousness and consciousness of surroundings can be impaired. It's possible for a person not to be aware that they are paralyzed on the left side and to ignore everything on their left, not just in terms of their surroundings but also of their own body. This is known as neglect. If you approach such a patient's bed from the left, even though he can turn his head and see you, he won't notice you. When reading a newspaper, such patients will look only at the right-hand page, and when drawing, will draw only the right side of an object. They eat only what is on the right half of their plates. If you then turn the plate around 180 degrees, they will eat the other half. Neglect can extend to the left half of their bodies. They no longer regard their left arm or their left leg as part of themselves. They will
dress or wash only their right side, and comb their hair only on the right side of their heads.

Neglect patients frequently make up extremely imaginative stories to explain the bizarre situation in which they find themselves. Some claim that the hospital is their home and that they have chosen the furniture themselves. One patient remained convinced that her left side was fully functional and that she was physically independent. Yet in her drawings, the left half was completely lacking. “If it isn't there, then I can't be ignoring it,” she countered. When she was asked to move her left arm, she answered, “I could do that, but it would be better if I rested it now.” When she was asked to walk a few steps after she had claimed that there was nothing wrong with her, her response was, “Of course I could, but the doctors said I should rest.”

The mother of a good friend of ours suffered a severe brain infarct on the right side when she was eighty-five, being left paralyzed on the left side. Her mind was still sharp, though, and she hadn't lost her sense of humor. Indeed, her conversations with relatives, friends, and the nursing staff were perfectly normal, with one striking exception. One day she told me that she'd had a really odd dream in which she had a third arm. I carefully took hold of her paralyzed left arm and asked her, “Is this that third arm?” “No,” she said, “of course not, that's Kees.” Kees was her fifty-five-year-old son. “What is Kees doing here?” I asked. “He's sleeping in my bed, as he always does.” This was nonsense; I knew the family very well. “But tonight I needed him,” she went on, “and I couldn't wake him up. The same thing happened the night before, when Kitty [her daughter's friend, who visited her nearly every day and was very close to her] was sleeping here, and I couldn't wake her up either,” she continued somewhat huffily. She asked if she could have something to drink and went on to speak perfectly normally about all kinds of matters that she wanted to arrange.

The fantasies that arise in the case of neglect in fact spring from a
very general principle. If something gets in the way of the brain's information supply, it starts to make up information to fill the gaps. A damaged brain deprived of its customary input invents bizarre stories. It does similar things to compensate for the lack of oral or visual information or information from the memory or limbs (see
chapter 7
). Unconsciously filling up the little holes in our memory is something the brain does on a daily basis, even when it's intact. We're convinced that events happened exactly as we remember them and will state as much under oath in court. In fact, our brains are just knitting neat stories out of the countless scraps of information they receive, leading to all kinds of consequences.

FIGURE 20.
Three intact and properly functioning structures, shown here in black, are crucial to consciousness: an intact cerebral cortex (left), the thalamus (right), and the white matter (center), with pathways connecting the cortex and thalamus.

A coma is a situation in which a patient can't be woken and doesn't respond to external stimuli. It can result from damage to the cerebral cortex, the thalamus, the connections between these two brain structures
(
fig. 20
), or the brain stem (
fig. 21
), which activates the cerebral cortex and the thalamus. But it can also be caused by a metabolic disorder, drugs, or an excessive amount of alcohol. Some people recover from comas. One boy was driving back from a night out with friends when he crashed into a concrete post at high speed; the accident left him in a coma for six weeks. His family had already been approached about the possibility of his kidneys being donated for transplant. But they thought they detected slight signs of a return to consciousness, so they put off the decision. They were right, because he came out of his coma and completed his education at technical school. He wasn't quite the whiz at math he had been before the accident, but otherwise he was his old self. He got a good job, married, had children, and is now a grandfather. But things don't always go so well. People regularly awake from comas with serious and permanent brain damage or don't awake from them at all.

Vegetative State

Functions crucial to survival, like breathing, heart rate, temperature, and sleep-wake cycles, are regulated in the brain stem (
fig. 21
), which also contains the centers for coughing, sneezing, and vomiting reflexes. So, as long as your brain stem is still intact, you still go on breathing, even if the rest of your brain no longer functions. This tragic situation arises when people wake up from a deep coma after a serious brain injury, but instead of gradually getting better, they merely exist, like a vegetable. The same actually applies to patients in the final stage of Alzheimer's. They lie in a fetal position, their cerebral cortex no longer functions, and they no longer respond to the world around them (
fig. 31
).

We need the cerebral cortex to think, speak, hear, feel emotion, and move our limbs. When someone is in a vegetative state, also known as a coma vigil, their brain stem functions are still intact, while the rest of their brain, particularly the cerebral cortex, no longer
works. Most patients in this situation gradually regain consciousness after a few weeks, but if the cerebral cortex has been irreparably damaged, they merely progress to a “persistent vegetative state.” They can breathe independently and their hearts function normally, so according to the classic definition, they are “alive.” Their eyes may be wide open, and they may groan, cry, or laugh, but without the attendant emotions. They appear to be “awake” but don't show physical responses demonstrating any level of consciousness, either of their surroundings or of themselves. Since they seem awake and occasionally grimace or make a sound, it's extremely difficult for their families to accept that they aren't conscious. Parents of newborn children who have had a massive cerebral hemorrhage face the same terrible problem. The child looks normal, but most of its brain has been destroyed.

As long as they are hydrated and fed, patients in a vegetative state can be kept alive for years, as was shown in the case of Terri Schiavo, a brain-damaged American woman who entered a vegetative state in 1990. In 1998 her husband (who was her legal guardian), believing that recovery was no longer possible, petitioned for her feeding tube to be removed. Her parents, however, opposed her euthanasia. For many years the case went from one court to another with much legal saber rattling, while the pro-life movement made the husband out to be a murderer. (And that kind of threat needs to be taken seriously, because most pro-lifers are in favor of the death penalty, and the movement has murders on its conscience.) It took seven years before she was allowed to die, after her feeding tube had been removed by order of the court. The subsequent autopsy confirmed that there was little left of her cerebral cortex and that all that time she had indeed had no prospects at all of a dignified existence.

Eluana Englaro was an Italian woman who entered a vegetative state in 1992 after a car accident in which she suffered irreversible brain damage. Seven years later, her father started a legal battle to have her feeding suspended, because his daughter had expressly said that she would never want to live like a vegetable. On July 8, 2008,
nine years later, the Italian Supreme Court awarded her father the right to have her feeding stopped—a remarkable ruling, as euthanasia is illegal in Italy. Eluana was transferred to a clinic that was prepared to receive her and allow her to die, but the Vatican and the government tried to prevent it. “Stop this murderer!” was the predictable reaction of the cardinal who was acting as the Vatican's health minister. The decree issued by Prime Minister Silvio Berlusconi to force the continuation of her treatment wasn't signed by the president, causing Berlusconi to seek an emergency decree. Fortunately for those directly concerned, Berlusconi's decree wasn't approved in time, because several days after the tube was removed, Eluana died.