The woman in the wheelchair wearing burgundy scrubs is lovely, with full eyebrows arching over her closed eyes. Joseph Giacino, director of rehabilitation neuro­psychology at Spaulding Rehabilitation Hospital in Boston, squats beside her, looking into her face. “Hi, Kellie, it’s Dr. Giacino. How are you? Can you open your eyes?”

No response.

Two and a half months ago, during what was supposed to be a simple nasal operation for sinusitis, Kellie’s left carotid artery was accidentally sliced open, starving half her brain of blood and oxygen. Since that day, she has not spoken or clearly responded in any way. She opens her eyes, and sometimes she groans or gropes toward people nearby. Most of the time she seems to be asleep.

Is Kellie still in there? Giacino, 52, an expert in disorders of consciousness, will establish her condition more precisely with this exam. First, though, he needs Kellie to be more alert. He rubs her arm and her leg firmly, applying deep-muscle pressure, and her dark eyes pop open. She begins to breathe heavily and to shake. Giacino soothes her. “I’m just waking you up,” he says gently. “You had some bleeding in your brain, and we’re trying to help you get better.” The expression on her face is intense and hard to read. It mixes fear with annoyance, as if she has just woken from a nightmare. “Every kid has a dad and a…” he prompts. She moans, or is she trying to say “mom”? It is difficult to tell whether she is oblivious or struggling to respond. When she makes eye contact and holds it, she seems just as aware as anyone else in the room. By her fierce expression, she looks as if she is about to tell Giacino to buzz off. Yet she does not speak. That is why this exam, calibrated to distinguish between reflexes and real cognition, is so important. When Giacino hands her a toy ball, she grabs it, smoothly and naturally. It is a good sign.


Just a few years ago, a patient like Kellie would have been written off. Anyone who did not regain consciousness within a few weeks after a stroke or head injury was said to have no hope for meaningful improvement. But in the past decade, a series of increasingly spectacular experiments conducted by Giacino and Weill Cornell Medical Center neurologist Nicholas Schiff has proved that this bleak verdict is often wrong. The semiconscious brain is not a useless sack of neural goo, they have shown, and not all damaged brains are the same. Disorders of consciousness come in shades of gray, from severely impaired “vegetative states” to the perplexing “minimally conscious state” in which people slip into and out of awareness. By studying patients who emerge into consciousness after years in limbo, Schiff and Giacino have shown that the brain can sometimes fix itself even decades after damage. They have discovered apparently vegetative people whose minds can still imagine, still recognize, still respond. In turn, these profoundly disabled people have opened the door to one of the last great mysteries of science: the nature of consciousness.

Schiff, Giacino, and the handful of other scientists doing this work worldwide hope to help more brain-injured people make the leap back into consciousness. In the meantime, the implications of their work are haunting. It suggests that many of the estimated 250,000 to 300,000 or more people in this country languishing in bedrooms and nursing homes with disorders of consciousness are probably still “in there”—still have some capacity to think and to feel and might, in a limited way, be able to rejoin the world. “These are human beings who seem to have lost their humanity,” Giacino says. “The question is, is that really the case?”

The old verdict was harsh but clear-cut: Mourn your loved one, because he or she is gone. Now people like Kellie’s husband, Mark, are tormented by hope and uncertainty. Giacino’s exam establishes that Kellie is in the no-man’s-land of the minimally conscious state. Whether she will return is anyone’s guess. “The very hard part for me is looking into her deep brown eyes and not knowing what she is thinking,” Mark wrote on his website in late August. “Is she mad at me? Is she in pain? Is this process torturing her? We don’t know. These are the questions that keep me up, pretty much every night.”

In the 1970s, when intensive care dramatically improved the survival of brain-injured patients, doctors found that if the body can be kept alive, the brain usually shakes off a coma—a totally unresponsive, eyes-closed state—within two to four weeks. At that point some people simply wake up, although they may be delirious and impaired. Others graduate to an in-between zone that New York Hospital–Cornell Medical Center neurologist Fred Plum labeled the “persistent vegetative state” in 1972. At the time, among these patients, it seemed as if only “vegetative” brain functions like breathing, waking, and blinking were working. The higher functions commonly associated with consciousness seemed to be lost.

The first vegetative patient Schiff saw, the victim of a stroke, had no sign of consciousness. But when he ran into her three years later at a rehab center, he was shocked to find her awake and capable of talking to him.

The patients, doctors found, usually had widespread brain damage, but two injured areas were especially noteworthy: the thin outer rind, called the cortex, and the thalamus, a pair of walnut-size lumps in the brain’s central core, along with the neural fibers that connect these regions. The two areas are normally in constant cross talk, filtering and analyzing sensory data and making continual adjustments to attention and alertness. Lacking this chatter, someone in a vegetative state seems to be awake but not aware. They might moan and shift around, but they do not look toward a loud hand clap or pull away from a pinch. Given a feeding tube and basic medical care, someone might stay in this condition from days to decades, potentially until death.