The Brain is a Woolly Beast

By Colette DeDonato

The woman seated in the neurologist’s office is here for two reasons, the first of which is that the woman has implicated herself as a victim of brain deterioration which she believes to be either 1. Remnants of a head injury from a car accident in 1987. 2. An inherited handicap involving left-brain right-brain malfunctioning or 3. A high-sugar diet combined with middle age and a tendency toward alcohol overuse. In either case, the neurologist, having viewed the now antiquated X-rays from an MRI circa 1987, has ordered tests to be administered in the event that the memory problems the woman has reported are in fact the result of a prior head injury. Since there is no way to actually prove that the inherited handicap the woman speaks of is not simply a psychosocial issue, i.e. that members of her family weren’t representatives of outstanding mental capacity, e.g. a Noam Chomsky-like facility with language and intellectual prowess which the woman seems to believe she once had a shot at despite any tangible evidence to support this, the woman would be wise to have prepared herself for a considerable range of outcomes.

The examining doctor assigned to the 1987 incident had only offered the woman a vague prognosis, something like you’re probably going to have memory problems as you get older, which most of us know we don’t need a doctor to tell us, and the nonspecific nature of the doctor’s conclusions laid the groundwork for the woman’s ongoing affiliation with anxiety and the burgeoning fear that she might one day wake up and find herself a character in a daytime television drama with a sudden case of amnesia. Or worse, a person who forgets what she is talking about in the middle of a sentence. An additional point to consider is anxiety’s relationship to depression and the chicken-and-egg dilemma it presents: Does anxiety lead to depression which can then lead to atrophy in specific areas of the brain, or does a genetic predisposition for depression combined with the atrophic effects of a head injury increase the likelihood of debilitating anxiety. The brain is a woolly beast.

The second reason for the woman’s grossly overdue visit to the neurologist’s office some twenty-odd years after the aforementioned car accident is the woman’s on-again, off-again relationship with health insurance, which at present is good, substantial enough to see someone who knows what he or she is talking about, but over the course of the woman’s life has been recklessly inadequate. (Details of such are better suited for altogether different narrative.)

Aligned Particles That Produce Faint Signals
It is an unseasonably warm day. The woman is wearing an oversized navy blue sweater and gray argyle socks which are visible from the back of the woman’s heelless German shoes. She has two pairs, one oxblood, the other black, often confused with Birkenstocks, which the woman refuses to wear out of principle, a negative association with certain stereotypes attributed to her demographic/racial sub-type which she feels she is often erroneously aligned with. She follows a woman, an employee at the facility who, like many of the other employees is wearing scrubs, a matching top and bottom uniform made of thin material designed for comfort and wearability. Hers are pink, adorned with small red and white hearts, in anticipation of Valentine’s Day.

The two women travel down a long T-shaped hall, past a collection of abstract line drawings, the Ladies Room, and a junior-size, unoccupied waiting room in which there are various lifestyle magazines arranged in neat rows on a small table.

On the left is a door that leads to another door that opens out into a brief interlude of concrete patio between the buildings. The woman feels a brief rush of sun on the back of her neck. Once inside, the two enter a windowless room where they are greeted by three exuberant lab technicians who briefly explain the afternoon’s procedure in a non-threatening manner. A funny quip or two are exchanged in what appears to be an earnest gesture meant to put the woman in the oversized navy blue sweater at ease.

There are several questions the woman must answer, each of which will be used to assess her previous experiences with typical and atypical medical apparati and measure her comfort level with small spaces and loud noises. The woman has done this before, twenty-plus years ago, and is in fact mildly claustrophobic, five to six on a scale of one to ten, but should be fairly tolerant of a prolonged irritating noise — described as a loud hum, annoying but sustainable — and able to follow directions and communicate her apprehension throughout the course of the procedure. One of the technicians, a stalk woman with fuzzy gold hair, acrylic nails and a tattoo of Chinese origin on her right forearm, demonstrates several hand signals she will want to use in the event that the experience becomes so overwhelming that she is unable to continue lying still in a supine position.

Once tunneled into the Magnetic Resonance Imaging (MRI) device these hand gestures will be the woman’s only way to communicate with the technicians who will be operating the machinery behind a large sheet of glass at least twelve feet away. A diagonal mirror placed above the eyes will allow the woman to look down the tunnel or bore, rather than at the bore wall inches away from her face, although this is a more recent feature that was unavailable in older MRI systems.

Magnetic Resonance Imaging uses a large, powerful magnet to align the magnetization of atomic nuclei or water molecules in the body to distinguish pathologic tissue, such as a brain tumor, from normal tissue. The part of the body being imaged must lie at the center of the magnet. Radio waves cause these aligned particles to produce very faint signals, which are used to create cross-sectional MRI images, like slices in a loaf of bread. This particular procedure is performed on a GE 3T HDx system. No radiation is involved.

The procedure runs smoothly and the woman, who has taken the day off from her job, spends the remainder of the afternoon nursing a cup of coffee, and purchasing books that she probably won’t have time to read.

The Body’s Reaction to Sudden Contact
Perched on the exam table, the woman’s feet dangle like marionettes controlled by the knees. The neurologist taps each of them, first the left then the right, with a reflex hammer, a tomahawk-like instrument used for measuring the body’s reaction to sudden contact. He shoots a beam of light into the woman’s eyes and asks her to follow his finger as it moves toward and away from her face. Up and down, left and right, like he is making the sign of the cross. Up and down, left and right. The neurologist asks the woman to perform a series of physical tasks, the first of which is to stand balanced on each singular leg in what looks like a yoga posture, more skittish flamingo than tree pose. The woman is engaged in unnecessary chatter, dispersing wisecracks, which have become tics she has little control of anymore, and are likely to surface in situations that cause agitation. In this case, the neurologist’s face makes her nervous. Making the appointment over the phone, the woman imagined someone old, closing in on retirement, with splotchy skin and cranky hair, not the young and handsome man standing in front of her making her feel self-conscious and frumpy. She thinks this would have been a good day to wear socks that match.

I have to ask you some questions, he says as the two sit down at his desk. I’m sorry if they are insulting. There’s a hint of German in his voice. Big consonants and throaty tones that stand up straight. Perhaps he is Austrian, the woman thinks, and drives a German car.

She wonders if this is some kind of a test to measure a person’s response to various put-downs. Will she be combative and disrespectful, or apologetic and contrite? Will she grow indignant and want to leave the office? It’s a strange practice, neurology. Snake oils and Ouija board brain scans, insult centers. The questions, however, are routine, designed to evaluate memory, comprehension, and mental status. The woman likes the phrase mental status because of its neutral and unassuming tone. How is your mental status this afternoon? Due to my mental status, I won’t be able make it into work today.

Can you tell me what year it is?

It’s 2009.

Who is the president of the United States?

The woman makes a sarcastic remark about the Bush years followed by a gleeful disclosure of her affinity for Barack Obama. Neither of the woman’s comments elicit so much as a nod of recognition from the neurologist, which sets off another ritual behavior in which the woman begins to second-guess her better judgment and worry that the doctor, a serious man in a profession that requires sobriety and steadfast concentration, finds her cagey remarks annoying. Although the woman understands that far more serious cases, stroke victims, traumatic head injury survivors and the like, are seen by the neurologist, and that there is nothing funny about a malfunctioning brain or a faulty nervous system, she is unable to override the urge to amuse the neurologist who, one might have guessed by now, has far more troubling cases to attend to.

The woman’s own father had suffered a series of strokes that stretched out over a period of several years before he died. The attending doctors had been clear with the family about the difficulty in calculating the number of strokes he’d had since many of them were small, petit-mal seizures that he may have experienced in his sleep. On one occasion the father had collapsed in a parking lot and a passerby who discovered him lying on the pavement next to her car was able to call an ambulance. After the incident, his driver’s license was taken away and his car was replaced by one of those little electric carts that the father could drive around the neighborhood, but not to the store, where he might buy liquor.

Carbon Monoxide, Cellular Machinery and Chronic Negative Thinking
Can you tell me what the date is today?” the obnoxiously young doctor asks, to which the woman responds with an unsettling half-laugh that buys her a few more seconds to come up with an answer. As it turns out, she can’t remember the date. In her head, the woman draws a mind-picture in an effort to see the words as they might appear on a form — Date, colon, short line — or on the red and white calendar icon that provides this useful information on her smart phone. Her eyes travel up and to the left, a physical indication that the brain is attempting to retrieve visual memories or pictures. The eyes move down and to the right to connect with feelings, or kinesthetic sensations. Eyes down and to the left represents an attempt to recover one’s inner dialogue or “self-talk.” Up and to the right might indicate that a person is lying.

Suspended in a state of self-admonition for not keeping track of the date, the woman recalls many of the week’s activities, composing and dating letters at work, consultations with the school calendar to confirm the times and dates for the next round of parent-teacher conferences. The woman recognizes that if she were writing a check or signing an insurance form in the presence of a receptionist or store clerk, she would simply ask what the date was and it wouldn’t be a big deal. But on this occasion, she is distracted by the neurologist’s eyes, dexterous and green with shards of brown, and stuck trying to add four days to Monday, which is the last date she remembers. A Sesame Street whirl of numbers and figures and symbols appears, and the fetching German doctor is now a wall of expectation, a niggling face with solicitous fucking hazel eyes and unjustly thick eyelashes, and the woman wonders why he can’t simply move on to something else and stop making her feel stupid. She wipes her sweaty hands on her jeans and apologizes. She must be taking up his time. There are patients waiting to be seen, colleagues to consult with over lunch. A wife to call. He must have a wife. Thin, athletic, with long brown hair pulled back imprecisely in a chignon.

“I tell you what,” the neurologist says. His tone is forgiving. “I’m going to leave the room and when I get back you can tell me what the date is.” Left alone, the woman’s over-wrought imagination becomes burdensome. She pictures him in the hallway with one of his assistants watching her on a video monitor as she fiddles with her smart phone in search of the date. Just as I suspected, he says to his eager intern. The patient displays the kind of chronic memory deficit consistent with traumatic brain injury, which will only get worse as she ages. By the time she’s 50 she won’t be able to tell a 1099 from a taqueria menu.

It appears that in each act of forgetfulness the woman is unable to distinguish between her panic and the information she is attempting to recover. She is less likely to recognize these transactions as simple episodes of performance anxiety, and more likely to see herself being sucked into a tornado of emptiness that proves she’s irreversibly damaged. It is now understood that carbon monoxide, pesticides, smoking, chronic negative thinking, junk food, those adolescent Disney sitcoms with the mind-numbing laugh tracks, pollution, stress, cocaine, and paint huffing all cause brain damage. Punk rock concerts contribute to hearing loss. Alcohol disrupts the cellular machinery that controls the ability to form new memories. It doesn’t exactly kill, but it maims. Food additives, cleaning solvents and not getting enough sleep, all contribute to the death of brain cells. SpongeBob and video games damage the developing brain. Only recently have scientists understood the extent to which new cells have the ability to develop if given the right tools or circumstances to do so.

No longer stirred by anxiety, the woman is able to lean back in the chair, gaze at the spindly branches scratching against the window, and peruse the medical school diagrams of the brain some office tech has pinned to the walls. She finds these distractions relaxing. The neurologist returns in his white lab coat and shiny Italian shoes. It’s the 23rd.

1983 Four-Door Honda Civic
The woman had been driving a 1983 four-door Honda Civic to her parents’ house to do laundry when she was broadsided by a speeding car. It was later discovered that the offending driver was an employee of the hospital the woman awoke in after being unconscious for nearly eight hours. Rushing to work, the woman had run a red light. Except for a vague visual recollection of a laundry basket on the back seat, the woman in the 1983 four-door Honda Civic has no memory of anything that took place that morning leading up to the accident. The experience begins in the hospital, a nurse with a downy voice shining a bright light into her right eye, casually peering into her soul, asking if she knows where she is and what has happened to her. She remembers the moment quite well. She felt peaceful, well-rested, unafraid, as if she were lying on a warm patch of earth under a tender blanket.

Three witnesses confirmed the circumstances of the accident. The aggressive impact to the 1983 four-door Honda Civic had pushed the vehicle well out of the intersection into a parking lot which was once the home of Jimboy’s Tacos, but currently occupied by Jiffy Lube and a Chinese restaurant. Since the woman had never made contact with any of the three witnesses or the nurse whose car had totaled hers, the four individuals who had suddenly and profoundly altered the woman’s life would over time become specters, occasional visitors to the woman’s dreams. A man’s face, red hair, ruddy complexion, possibly the EMT, a frequent, recurring image that kept the woman wondering about the amount of unapproachable information that is potentially stored in the brain. No other details, being dragged from the car, bleeding from the head, the incredible pain caused by a blow to the cervical spine, the seven vertebra that move down from the bottom of the skull and connect to the thoracic spine located closer to the chest area. None such lodged themselves in her consciousness. Just a few questions: Did the employee of the hospital who ran the red light and slammed into her car complete her shift at work? If so, had she checked up on the injured woman out of some sense of guilt or remorse? Was she able to focus on anything other than the unfortunate accident that day? Was there any significance to the fact that the woman in the 4-Door Honda Civic was listening to Marvin Gaye on a Sony Walkman cassette player? Was the music still playing as the EMT pulled the ear buds from her ears? Would it have killed her to spend the eight dollars at the laundromat down the street from her apartment instead of traveling all the way to her parents’ house?

It was eight something in the evening when the woman finally awoke after being out for most of the day. Her head had been stitched up on the left side, but she was in no pain. It had taken the hospital several hours to locate and notify the woman’s parents, who arrived nearer to the moment she’d woken up from her micro-coma. The woman remembers the sound of Alex Trebek’s voice coming from the hallway, indicating that it might be early evening, perhaps even the dinner hour, and for the first time noticing that her father bit his nails.

The experience concluded with an MRI in addition to a CT scan, also referred to as a CAT scan, a somewhat outdated procedure that uses ionizing radiation, or X-rays, to produce images. CT scans are disadvantaged in that they expose the patient to harmful ionizing radiation, which has a small increased risk of cancer and can possibly damage DNA. It is estimated that 0.4% of current cancers in the United States are due to CTs performed in the past. Results of these two scans indicated no midline shift or subdural hemorrhage and nothing to suggest cerebral edema, though maxillary sinusitis was detected, which, as you can imagine posed no significant threat to the woman’s mental status.

There were also several follow-up visits to a neurologist who asked a series of standardized question and quizzed the woman’s idiomatic fluency. Did she know what these meant: no moss gathers on a rolling stone, people in glass houses shouldn’t throw stones? It was evident to the woman that even prior to the accident this kind of interrogation would have caused anxiety, since she had often wrestled with the presupposed logic of these statements. Why would a person live in a structure made of glass anyway? And what kind of person throws stones in their own house? As for the stone, she was less concerned. However, the woman found some small amount of comfort in these visits. It pleased her that someone was keeping track of her mental status.

The woman received a small settlement that enabled her to pay her college tuition for the next semester and skip the tedious work-study job she’d had the previous year. She continued to suffer pain in the neck, sought the help of physical therapists, massage therapists, chiropractors, meditative practices shown to reduce muscle tension and stress, and commissioned Ibuprofen to underwrite the remaining years of her life.

Intricate Patterns, a Gray Spot and the Area of Concern
Now that the pop quizzes are over, the woman and the striking neurologist are seated next to one another at a small desk facing an uninteresting, drably designed computer. The neurologist indulges the woman in his enthusiasm for the newly-acquired neuroimaging software, behaving like a nine-year-old boy playing Super Mario. The technology provides optimal viewing of the structure of the brain and has a greater capacity for diagnosing intracranial diseases and accurately assessing head trauma. The ability to quickly zoom in and out of view — right side, left side, up, down — is exciting for the neurologist and somewhat fascinating to the woman.

Frontal lobes. Thalamus. Anterior and Posterior cingulated cortex. Parietal Lobe. Occipital lobe. Temporal lobe. The sinus build-up on the left nasal cavity, always good to know. The eye sockets, empty and skeletal, a stark reminder of the fact that we are made of bones. The vantage point is remarkable.

The woman is eager to exchange information about the brain’s centers, where language comes from, where pain resides, and to test her pedestrian knowledge of neurons and neurotransmitters with someone who shares her excitement about the subject. Together they examine the slight asymmetry of temporal horns, and the hippocampus, mostly the right one, which in comparison to the left is slightly atrophic. Since that Tuesday afternoon when the administrative assistant named Naomi called her to schedule the appointment with the neurologist, the woman has been particularly interested in discussing the atrophy.

The hippocampus is a seahorse-shaped ventricle located in the cerebral cortex, responsible for spatial navigation as well as short-term and long-term memory. Like most humans and mammals, the woman has two, one on each side of the brain. This atrophic state is recognized in people with major depression and, oddly, with those who have undergone a life-changing religious experience, which it appears the woman has not. The atrophy is also likely to progress throughout the aging process. Again, there are no signs of edema, midline shift, hemorrhage or extra-axial fluid collection, and the paranasal sinuses continue to be an issue, one that might be better addressed by an acupuncturist or a diet free of dairy and gluten.

After the initial excitement and fascination with the centers of the brain has begun to wane, the conversation slows and the handsome neurologist pulls a pen from his coat pocket and points to a spot on the screen. It is a gray spot, no larger than a dime. He refers to it as “the area of concern.

The woman leans forward in her chair, her breath choppy and her shoulders pulled tightly up towards the neck, to get a closer look at the area of concern. The woman’s prolonged gaze looks to be an effort to take in the gray spot, acquaint herself with the gray spot, to become attuned to the nature of its hue. Her heart is pounding. There is activity in the brain. Neurons are firing. Facial muscles are motionless. Her language center has been aroused. It is a gray spot, the woman thinks, decisively gray, an inconvenient, oddly shaped noiseless void, around which the woman will construct several rhetorical questions. How intimately will she need to know this gray spot? Within the spectrum of gray, is there a better or worse end? It is conceivable that the spot is a mere irregularity, neither trifling nor commandeering, common as a mole that needs the occasional looking after, or a patch of broken blood vessels that might lead one to romanticize the skin of one’s youth. Or might it be a nonvariable truth, a terrible signpost that stands between the woman and her newly fraught existence.

Is it bad, she asks. Well, it’s not bad, the neurologist says, but it’s not really ideal either.

Since she had prepared herself for the worst possible outcome, which had opened the door for a considerable amount of anxiety prior to the appointment, by no means an uncommon response to an experience that holds great potential for psychological distress, the woman does not find herself significantly undone by the neurologist’s remarks. She appears to be in a mixed state, moderately reprieved and mildly rattled by the indistinctness of his comment.

The neurologist’s prognosis, that the woman will continue to have memory problems, though they are unlikely to have catastrophic consequences, is mitigated by the recent spate of discoveries about the plasticity of the human brain and its ability to rebuild itself, as well as other helpful counter-information which works as a kind of screen to keep the swarm of unnerving facts about the potential danger and inherent harm of everything from invading her consciousness. She should learn another language, take up crossword puzzles, practice breaking daily routines e.g., taking an alternative exit from the freeway, following a different path home, using the non-dominant side of the body for everyday activities such as teeth brushing, all of which support the recent studies indicating that brain, like muscle, needs variety, confusion, and continual challenges to maintain optimal performance.

Scattered small foci, hyperintensity in the doughy white matter, eyes down and to the left. She is going to have trouble with words and forgetting things, such as thoughts, but she should try to come to peace with that. The neurologist doesn’t actually say come to peace, but this is how the woman understands the point he wishes or perhaps doesn’t have time to make.

Colette DeDonato lives in Santa Cruz and is currently working on a collection of essays which she’d prefer to write under a nom de plum such as Mirabelle or Blaze. However, this is unlikely to happen.