The heart is in the brain

Cambridge University Press
978-0-521-03111-0 - Half a Brain is Enough: The Story of Nico
Antonio M. Battro
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The heart is in the brain
ubi enim est thesaurus tuus ibi est et cor tuum
For where your treasure is, there will your heart be also
m at t h e w, 6 : 2 1
This is a book about education and human nature. I would like to share a per-
sonal experience about our brains, mine and yours, so as to open up a debate
about the brain, education and human development from a new perspective:
that of brainpower and brain efficiency. In a sense, this book is an attempt to
become aware of the treasure we have inside our skull, “for where your treas-
ure is, there will your heart be also.” And the heart is in the brain.
The expression “the heart is in the brain” is not simply a metaphor, it can
be interpreted literally from the point of view of modern neurology, as
described by Antonio R. Damasio (1994):
there is a region of the human brain, the ventromedial prefrontal corti-
ces, whose damage consistently compromises, in as pure a fashion as
one is likely to find, both reasoning/decision making, and emotion/
feeling, especially in the personal and social domain. One might say,
metaphorically, that reason and emotion “intersect” in the ventrome-
dial prefrontal cortices, and they also intersect in the amygdala.
And the author continues,
there is a region of the human brain, the complex of somatosensory
cortices in the right hemisphere, whose damage also compromises
1
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Cambridge University Press
978-0-521-03111-0 - Half a Brain is Enough: The Story of Nico
Antonio M. Battro
Excerpt
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2
h al f a b rain is e nough
reasoning/decision making and emotion/feeling, and in addition, dis-
rupts the process of basic body signaling. (p.70)
But we shall see that when the right hemisphere is anatomically or function-
ally removed, as in the case we are going to discuss, the remaining hemisphere
compensates actively for the loss and no major problems in cognition, soci-
ability, and emotion appear.
New clues have emerged from this study of a child with congenital hemi-
plegia who was subjected to a right functional hemispherectomy because of
intractable epilepsy at the age of three years and seven months. This child,
Nico, has lost the use of an entire hemisphere but goes to school, where he
has been closely studied from kindergarten to third grade. These three years
in particular (five to eight), though only a short span of time, are so very
important in a child’s life. Moreover, I consider this research to be the start of
a longitudinal study which should be continued until early adulthood. It will
hopefully give me the opportunity to work on the foundations of a new field,
to which I propose to give the name “neuroeducation,” with the purpose of
bridging the gap between the science of education and the neurosciences.1 I
shall also try to show how to empower the brain (or half of it) with the “pros-
thetic” use of computers and how this might relate to the global distribution
of knowledge in the new digital society. It is an ambitious program but I am
certainly not alone in this voyage of discovery.
This book might also be used as a tentative guide to the education of a
half-brained child. It would give me great satisfaction if it could help those
families in which someone has undergone the ordeal of radical surgery, such
as a hemispherectomy. But I must stress the fundamental point that Nico’s
remarkable rehabilitation is partly due to the fact that the hemispherectomy
was performed on his minor right side at an early age. If the same operation
were to be performed on the dominant left hemisphere at a later age, the
overall result might be different, and certainly not always as satisfactory as in
the case we shall discuss here at length. This book is therefore based on the
fortunate case of a left half-brained child and should not be extrapolated to
other cases without due distinction.
I shall try to show how the scientific study and tender care of a single half-
brained child might shed new light on the understanding of the universals of
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Cambridge University Press
978-0-521-03111-0 - Half a Brain is Enough: The Story of Nico
Antonio M. Battro
Excerpt
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t he he art is i n th e br a i n
3
human nature. The opportunity to work with Nico has changed my intellec-
tual life, and has certainly enriched my affective experience. This remarkable,
intelligent, and affectionate boy has challenged most of my ideas concerning
the brain, the mind and the computer, and may possibly also shake up some
of yours. I can better understand now the profound impact that some pupils
can make upon their teachers or some patients upon their doctors. Such
unique cases produce a change in our views about man. Nico is certainly one
of these privileged persons and I am deeply indebted to him.
Medicine is rich in studies of extraordinary neurological cases. The one-case
style became popular in our time thanks to the writing talent of distin-
guished physicians such as Alexander R. Luria (1972, 1986, 1988), Oliver
Sacks (1987, 1995, 1997), Norman Geschwind (1987), and Antonio R.
Damasio (1994). Some patients have been monitored for decades, like “the
man with a shattered world” reported by Luria after thirty years of observa-
tion. Psychology too has a long history of one-case reports. Jean Piaget was
certainly a master of the detailed developmental analysis of individual chil-
dren. He published his celebrated research on his children, Laurent, Jacque-
line and Lucienne, in three complementary books: La naissance de
l’intelligence chez l’enfant, Piaget (1936); La construction du réel chez l’en-
fant, Piaget (1937) and La formation du symbole chez l’enfant, Piaget (1945).
I have a nice story to tell. The first time I had the pleasure of lunching with my
“patron” at his house in Pinchat, near Geneva, Madame Piaget, née Valentine
Chatenay, a psychologist by training, told me that she always wore a tiny
notebook attached to her necklace so that she could record her observations
of their children. These careful reports contributed substantially to her
husband’s research. To this maternal and paternal dedication I would add
Luria’s (1986, p. 147) comments: “romantics in science want neither to split
living reality into its elementary components nor to represent the wealth of
life’s concrete events in abstract models that lose the properties of the phe-
nomena themselves. It is of the utmost importance to romantics to preserve
the wealth of living reality, and they aspire to a science that retains this
richness.”
A permanent record of our beloved Nico’s works and deeds at school is
also kept by his teachers. I do not keep an equivalent register at home, but his
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Cambridge University Press
978-0-521-03111-0 - Half a Brain is Enough: The Story of Nico
Antonio M. Battro
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h al f a b rain is e nough
parents regularly share the most significant developments with me. What I
appreciate most is the loving care and commitment which support a long-
term observation, an attitude that has more in common with “romantic”
science than “classic” science, to use Luria’s terms. In sympathy with the
values of romantic science my friend Thierry Deonna, an expert child
neurologist, wrote to me, “an accurate neurological, scientific description of
deficits, compensatory strategies, etc. is perfectly compatible with a descrip-
tion of the ‘roman de vie’ in which such a unique experience unfolds and
which gives it its proper existential dimension.”2
As for the medical aspects of the surgery known as functional hemisphe-
rectomy, (I use the term hemispherectomy as a synonym for hemidecorticec-
tomy or hemidecortication), this clever technique was conceived and
executed by the neurosurgeon Jean-Guy Villemure and his team at McGill
University to solve the problem of intractable epilepsy. The essential details
on functional hemispherectomy are given in Tinuper et al. (1988), Smith et al.
(1991), Villemure and Rasmussen (1993), Villemure and Mascott (1995).
They have devised a new way of removing the damaged brain hemisphere
without risk of a neurological catastrophe. Instead of producing a whole and
complete anatomical recession of the hemisphere, which might have devas-
tating effects, they successfully tried a more physiological intervention. This
functional surgery increases the chances of a successful rehabilitation follow-
ing the removal of a significant part of the brain. In particular, it inhibits
hemosiderosis (iron deposit in cells) and hydrocephalus, the most serious
problems in anatomical hemispherectomies. Recent statistics show that most
patients react very positively to this intervention, the seizures disappear and
cognitive functions can even be enhanced.
Nico suffered a congenital left hemiplegia, but managed to walk before he
was one year and seven months old and started to speak in sentences shortly
before his second birthday. The first two epileptic seizures happened when he
was a twenty-two months old, but they then completely disappeared during
the following eight months, at which point they recommenced, with repeated
convulsions and loss of consciousness. Medication proved useless and a dra-
matic increase in epileptogenecity was observed. An EEG confirmed an
extended epileptic focus in his right cortex involving the right temporal, frontal
and parietal area. Finally, when Nico was three-years-and-seven-months old
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Cambridge University Press
978-0-521-03111-0 - Half a Brain is Enough: The Story of Nico
Antonio M. Battro
Excerpt
More information
t he he art is i n th e br a i n
5
the family decided to try a neurosurgical treatment. The operation was origi-
nally to be restricted to a limited resection of the right temporal lobe and a
disconnection of the right frontal lobe under corticographic control.
However, after the first ablation and disconnection had been performed the
corticography continued to show multiple spikes and discharges in the
remaining right areas. The physicians discussed the options with Nico’s
parents and they agreed to a functional hemispherectomy being completed.
The technique applied in this case consisted of the removal of the central cor-
tical region, the parasagittal cortex and cingulate gyrus, plus a complete tem-
poral lobectomy, including amygdala and hipoccampus. The remaining
portions of the frontal lobe and parieto-occipital lobes were also discon-
nected from the brain stem and the opposite hemisphere. The pathology
found was polymicrogiria of the right temporal and parietal lobes with mild
chronic meningitis. Nico made a remarkable recovery. The seizures disap-
peared, he never lost his speech and in a few days he started to walk. He is
now a healthy boy and a good pupil at school. The amazing fact is that
nobody would imagine this impressive neuronal loss from his overt behavior.
Indeed without seeing his brain images it is impossible to believe that Nico
has only half a brain left! Figure 1.1 shows a dramatic view of this functional
right hemispherectomy.
In order to take a further step inside Nico’s remarkable left brain we could
use other kinds of imaging technologies, such as functional magnetic reso-
nance images (fMRI). But I still consider that some experimental research
with non-invasive brain technologies is simply not justified, even with volun-
teers. I believe in the classic dictum: primum non nocere, even if the fMRI
does not hurt. I am sure that these technologies will improve significantly in
the near future, not only in image resolution but in friendliness, and the time
will come to proceed further in our description of the function of this partic-
ular half-brain. To sum up, it is difficult to correlate the “catastrophic” reduc-
tion of his gray matter with Nico’s normal cognitive, social and affective
development. His only apparent problem is that he limps and cannot easily
move his left arm. He also has a left hemianopia and has difficulty focusing
on a visual target, for instance when reading, but in some tasks, such as
spoken and written language, he is at the top of his class. How is this pos-
sible? How can half a brain sustain a full mind?
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Cambridge University Press
978-0-521-03111-0 - Half a Brain is Enough: The Story of Nico
Antonio M. Battro
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h al f a b rain is e nough
(a)
(b)
Figure 1.1
Two images of the functional right hemispherectomy. (Nico: three-
years-and-seven-months): (a) horizontal (axial) view, (b) frontal
(coronal) view. Only the left hemisphere is seen, most of the right hemi-
sphere has been removed.
In order to answer this question it is important to take a general view of the
problem. Hemispherectomy or hemidecortication are extreme surgical inter-
ventions in medical practice, and most of the publications on the subject are
clinical reports, follow-ups and statistics from neurosurgeons or neurolo-
gists. I shall not deal here with the medical aspects because there are several
good reviews which may be consulted.3
It is, however, interesting to note that hemispherectomy has not stimulated
as much fundamental neuropsychological research as split brain surgery has.
While the psychological literature on brain bisection is still growing, the
study of the cognitive, affective and social consequences of the excision of a
brain hemisphere is insufficient. This book is, in a sense, a modest attempt to
enrich our psychological and educational knowledge of the consequences of
hemispherectomy, but certainly much more should be done. In fact, neuro-
psychologists are somehow late-arrivals in the field. Previously the central
question concerned brain laterality and dominance. Now, and I think this is
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Cambridge University Press
978-0-521-03111-0 - Half a Brain is Enough: The Story of Nico
Antonio M. Battro
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t he he art is i n th e br a i n
7
progress, the problem is shifting to compensatory neural strategies and to the
related questions of brain efficiency and capacity.
We can start with a landmark in the new philosophy of the brain. The phi-
losopher Karl R. Popper and the neuroscientist John C. Eccles, in their classic
book The Self and Its Brain (1977) have analyzed the left and right excision of
the hemispheres. They reported that while the complete removal of the domi-
nant (left) hemisphere gives somewhat enigmatic results, “the excision of the
minor [right] hemisphere under local anesthesia gives rise to no loss of the
patient’s consciousness or self-awareness.” And from that crude observation
the authors reached the bold conclusion that a “minor hemispherectomy
gives a result in complete agreement with the postulate that self-conscious-
ness is derived only from neural activities in the dominant [left] hemisphere”
(pp. 330–2). They concluded that the right hemisphere was a “minor brain.”
The clinical observations of Obrador (1964) and Austin, Hayward and Rouhe
(1972) had already articulated this idea. Some years later, Michael C. Corbal-
lis (1983) analyzed the cognitive consequences of early and late surgical
removal of the left or right hemispheres, the so-called Margaret Kennard doc-
trine: “the earlier the brain damage occurs the less the behavioral loss.” The
time at which a brain injury occurs is essential to the making of predictions
and taking medical decisions. A detailed overview of the onset of the brain
lesion and its impact on mental development can be found in Elizabeth Bates
(et al. 1992). The issue being examined was the extent of brain plasticity in
children and adults, in particular the recovery of linguistic skills in the
absence of the dominant hemisphere. At that time the mortality rate was very
high in this kind of neurosurgery, especially in adults, and it was difficult to
make sound comparisons between left and right excisions. But, nevertheless,
neurologists reported an amazing capacity for recovery of language after the
removal of the left cortex. Thus the study of hemispherectomized subjects
became an important issue in the debate on hemispheric equipotentiality and
language acquisition.
The concept of “hemidecorticate syntax” was introduced. In a study of
ten children subjected to left or right hemispherectomy because of infantile
hemiplegia, Maureen Dennis (1980) discovered that left and right hemi-
spheres “perform different encoding and decoding operations on a syntacti-
cally complex sentence in order to identify its meaning”. In particular, left
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978-0-521-03111-0 - Half a Brain is Enough: The Story of Nico
Antonio M. Battro
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h al f a b rain is e nough
hemispherectomized children were inferior to their right counterparts in
both “ease and speed of syntactic discrimination, despite their similar verbal
and non verbal intelligence.” The results of Dennis and Kohn (1975) on nine
cases of infantile hemiplegia who underwent left or right hemidecortication
show that some syntactic skills, such as the comprehension of passive nega-
tive sentences of the kind “the truck was not hit by the car,” were inferior in
the left hemidercorticates compared to the right hemidecorticates. For
example, Dennis and Whitaker (1976) have shown that one left hemidecorti-
cated and two right children who underwent surgery prior to the age of five
months, confirmed this linguistic asymmetry as “an organizational, analyti-
cal, syntactic problem, rather than a difficulty with the conceptual or seman-
tic aspects of language.” In research on written language acquisition after
hemispherectomy Dennis (1981) has analyzed how the isolated hemisphere
learns to read, write and spell in different ways. We shall discuss this most
important topic later and also some new opportunities for using computers
to enhance writing skills in the “atypical” brain – as Dennis called it – of a
right hemispherectomized child. There were scarcely any computers at
school twenty years ago and at that time the radical change which can be
affected at the cortical level by computer word processing was unimaginable!
Research on speech and language in hemispherectomized children and
young adults still continues to dominate the interest of neuroscientists. The
work of R. E. Stark and associates (1995, 1997) provides a good example of
the “left to right” transfer of language processes in left hemispherectomized
subjects, but there are few studies about the inverse transfer of cognitive pro-
cesses from the right to the left hemisphere. Perhaps the best analysis of the
cognitive consequences of hemispherectomy is to be found in the review by
Faraneh Vargha-Khadem and Charles E. Polkey (1992). The authors are
aware of the lack of cross control of several variables in most studies (and
they analyze fifty-one recent papers), such as age of initial disorder, age of
hemidecortication, time elapsed since surgery, and psychological testing,
left- or right-handedness before surgery, etc. They conclude that for those
subjects with a left hemispherectomy
a) the isolated right hemisphere has a basic visual and auditory lexicon
consisting of concrete and high-frequency words; b) the isolated right
hemisphere can recognize, comprehend, and produce words from this
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Antonio M. Battro
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t he he art is i n th e br a i n
9
lexicon through both speech and writing; c) in contrast with these
domains of ability, the isolated right hemisphere has difficulty compre-
hending abstract, low-frequency and low-imagery words, manipulat-
ing subtleties of grammatical structure, and analyzing words
according to their phonetic features. (p. 144)
Nothing particularly relevant is said of the right hemispherectomized sub-
jects except that, “contrary to expectations, no gross deficits on many visual
tasks sensitive to right hemisphere function, such as spatial orientation, visu-
ospatial construction and face perception” were found (p. 146). Only one
case of prosopagnosia – a cognitive deficit in human face recognition – was
reported by Sergent and Villemure (1989) in a thirty-three-year-old patient
who had undergone a right hemispherectomy at the age of thirteen following
seizure onset at the age of five.
It is interesting to note that there are no reports of serious language
impairment in right half-brained children or adults. This makes sense if we
accept that language has a left brain location in most right-handers but we
also know that there is a significant percentage (70 per cent) of the popula-
tion of left-handers that may have a bilateral cortical representation of lan-
guage as reported by Satz (1979). Unfortunately, we lack statistics on the
number of left-handers among the right hemispherectomized population to
make a comparison. The question of the different cognitive outcomes of
right and left hemispherectomy is still a matter of discussion. Our study is
about a right-handed boy with a high linguistic performance, but in scientific
literature the focus continues to be the loss of the left brain, not of the right
one, as in our case study.
The core of the debate was again correctly identified by Corballis (1983):
at one extreme we have the notion of two hemispheres as fundamen-
tally the same and as interchangeable, but each programmed differen-
tially by different rates of growth on the two sides. At the other
extreme, we have the idea of the hemispheres as fundamentally differ-
ent, each predestined to develop its own specialized functions. The one
extreme emphasizes symmetry, continuity between humans and other
species, and plasticity of function; the other stresses asymmetry, dis-
continuity, and rigid predetermination. Perhaps by keeping these
extremes in mind, we shall be able in the future to arrive at a correct
compromise. (p. 110)
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Antonio M. Battro
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h al f a b rain is e nough
I think we are closer now to reaching a new synthesis. The decisive factor
might be the introduction of non-invasive dynamic brain image technologies,
such as positron emission tomography (PET) and functional nuclear mag-
netic resonance images (fMRI). The impact of the new imaging techniques as
a research and clinical tool is enormous. A good introduction to the non-
invasive technologies is the splendid book Images of Mind by Michael I.
Posner and Marchus E. Raichle (1994) and publications by Bigler (1996),
Damasio (1995), and Salamon (et al., 1990). It is important to note that the
first dynamic brain images performed by Pawlick (et al., 1990) on patients
who had undergone hemispherectomies because of uncontrollable epilepsy
show a remarkable involvement of association areas in both motor and
speech activation. This new frontier of knowledge should be explored, but
before proceeding any further, a careful and explicitly ethical approach is
needed in case a conflict occurs between the interests of the patient and the
advancement of science. The beginning of a promising new field of research
often implies new moral dilemmas.
We may now return to our main question. How can half a brain sustain a
full mind? And this in turn leads us to the brain/mind controversy – a very dif-
ficult epistemological problem that should be solved some day. New labora-
tories and research departments are being dedicated to the neurocognitive
sciences and in several countries new journals contribute to the advancement
of the field. We will rapidly globalize the findings through the Internet, where
some leading scientists are now sharing interactive brain models on the Web.
The number of scientists, publications, meetings, and grants in the neurocog-
nitive sciences is rapidly increasing and I am convinced that only collabora-
tive work on an international scale will succeed.4
Let us start with the most basic knowledge about the evolution of the nervous
system. Evolutionary theories tell us that the mind and the brain evolve
together, and as Harry Jerison (1979) affirms, “the size of the brain, its
weight or volume is an extraordinarily useful measure in neurobiology.” But
the problem is that nobody can explain why Homo sapiens sapiens have such
a huge brain if it can be shown that, following surgery, half of this brain
suffices! The once famous, encephalization quotient (EQ), and the ubiqui-
tous intellectual quotient (IQ) are, in my opinion, two mismeasures of the
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