DOCSLIB.ORG

A Neuropsychiatric Perspective on Traumatic Brain Injury

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
A Neuropsychiatric Perspective on Traumatic Brain Injury Volume 44, Number 7, 2007 JRRDJRRD Pages 951–962 Journal of Rehabilitation Research & Development A neuropsychiatric perspective on traumatic brain injury Warren E. Lux, MD Office of the Science Advisor, U.S. Environmental Protection Agency, Washington, DC; Center for Clinical Bioethics, Georgetown University, Washington, DC Abstract—Traumatic brain injury (TBI) due to closed mecha- medicine. In the past 25 years, however, as acute man- nisms causes strain injuries to axons that increase in number agement of both surgical and nonsurgical TBI has and severity as injury severity increases. Axons that project up improved, impaired survivors have become increasingly from the brain stem are vulnerable, even in milder concussive common. And although these survivors face many differ- injuries, and include axons that participate in key monoaminergic ent clinical issues, from epilepsy to motor problems to pathways. Although called diffuse axonal injury, the supra- endocrine disorders, the TBI sequelae that affect their tentorial injury component typically shows an anterior prepon- lives most profoundly are the chronic cognitive and derance in humans. As the injury forces increase, cerebral contusions may be superimposed on the axonal strain injuries, behavioral problems that fall squarely within the domain and these contusions show an anterior preponderance as well. of neuropsychiatry, a discipline that focuses on the rela- The chronic neuropsychiatric manifestations of TBI reflect this tionship between the brain and its role in thinking, emo- injury distribution. In the cognitive sphere, these manifesta- tions, and behavior. Indeed, the paradigmatic historical tions almost always include power function disturbances patient for many of the core issues that now define neu- marked by difficulties with cognitive processing speed, multi- ropsychiatry was a young man from 19th century Ver- tasking, and cognitive endurance. These disturbances may then mont who survived a severe TBI. be followed by disturbances in executive function and self- During the summer of 1848, a 25-year-old railroad awareness as injury severity increases. In the behavioral construction foreman named Phineas Gage was directing sphere, mood disturbances and disorders of behavioral control a blasting operation to clear a path for laying new track and regulation are particularly common. across Vermont for the Rutland & Burlington Railroad. The operation went terribly awry, with the result that a pointed iron rod 3ft. 7 in. in length, 1 1/4in. in diameter, Key words: behavior, cognition, depression, diffuse axonal and 13 1/4 lb in weight was propelled through Gage’s injury, executive function, frontal lobes, mood, neuropsychia- try, rehabilitation, self-awareness, traumatic brain injury. face and head by an errant explosion. The rod entered INTRODUCTION Abbreviations: CT = computed tomography, DAI = diffuse axonal injury, MRI = magnetic resonance imaging, TBI = trau- Seen through the lens of the acute injury and its man- matic brain injury. agement, traumatic brain injury (TBI) would appear at Address all correspondence to Warren E. Lux, MD; U.S. first glance to be far removed from the concerns of what Environmental Protection Agency, 1200 Pennsylvania Ave, could properly be called neuropsychiatry. Rather, it might NW, Mail Code 8105R, Washington, DC 20460; 202-564- seem to be more a neurosurgical disorder or perhaps par- 3746; fax: 202-564-2070. Email: [email protected] ticularly relevant to conventional neurology or sports DOI: 10.1682/JRRD.2007.01.0009 951 952 JRRD, Volume 44, Number 7, 2007 through his left cheek, continued up and through the base syndromes that develop provide a window into the brain of his skull, traversed the anterior portions of his brain, that is compellingly illuminating, if still incomplete. and exited through the frontal bone at the top of his head. Remarkably, Gage survived both the wound and the sub- sequent infection with little in the way of adverse effects PATHOPHYSIOLOGY OF TRAUMATIC BRAIN on his motor function, perception (save for the loss of his INJURY left eye), or intellect. Yet, as described in detail by Dama- sio on the basis of firsthand reports, Gage was an entirely When the head is accelerated and decelerated different person after his physical recovery than he had abruptly in space, particularly when accompanied by a been before [1]. Whereas previously he had been temper- torsional head movement, strain forces are applied to ate, efficient, and capable, after the event he demon- nerve fibers (axons) throughout the brain [3–4]. The strated aberrant social judgment, was unable to regulate resulting axonal strain injuries, collectively referred to as his behavior normally, and could no longer use his vari- diffuse axonal injury (DAI), represent the primary funda- ous physical and intellectual strengths appropriately or mental neuropathological change seen in TBI due to effectively in the real world. closed mechanisms regardless of injury severity, although However, while the relevance of Gage’s disorder to the amount of DAI increases as injury severity increases the newly emerging field of neuropsychiatry was becom- [5]. Strictly speaking, if the head moves abruptly enough, ing evident, traumatic patients of that sort were uncom- as in whiplash injuries, it need not strike or be struck by mon. Today, by contrast, TBI is one of the largest public another object for acceleration-deceleration phenomena health problems for children and young adults in the sufficient to cause an axonal strain injury within the brain United States [2]. Consequently, no modern broad-based to occur [3], and clinicians who work with TBI are famil- review of neuropsychiatry can be complete without iar with cases, usually mild, in which no head impact is addressing the problem of TBI. Yet, paradigmatic as his involved. However, blunt-force trauma produces a partic- case was, Gage’s injury differed from the most common ularly abrupt acceleration-deceleration and is, therefore, injuries of today in one important respect: it was a pene- commonly a factor in these injuries. The most severe trating injury. In penetrating injuries, of course, the injuries tend to be caused by high-speed head impacts region of the brain penetrated puts its particular stamp on against immovable objects as in falls from height and the nature of the chronic cognitive and behavioral motor vehicle accidents, in which victims either strike the sequelae that develop. Today’s injuries, by contrast, are windshield or are ejected from the vehicle [5]. predominantly closed. Gage just happened to injure an Once an axonal strain injury occurs, by whatever area of the brain that is particularly vulnerable to the mechanism, a number of consequences may ensue. First, effects of closed injury and so his is a dramatic, if fortu- axons may be torn apart completely, a phenomenon itous, exemplary case. But other vulnerabilities exist in known as axotomy. These irreversible axonal shearing closed injuries that need to be accounted for in expanding injuries may include gross ones that are immediately vis- our understanding of TBI beyond that provided by ible on neuroimaging studies. Delayed axotomy second- Gage’s injury, instructive as his case has been. A major ary to evolving pathological processes set off by the purpose of this article is the dissection of those vulnera- initial injury has also been well-demonstrated experimen- bilities and the placement of them in the context of the tally [6]. In addition, however, axons may clearly be neuropsychiatric insights derived from Phineas Gage’s case. damaged at a level that does not cause axotomy, although For several reasons then, I will focus on closed inju- the axonal injury may cause alteration of electrophysio- ries in this article. First, they represent a major public logical function [4]. That such damage may be reversible health problem, as has already been pointed out, and is consistent with clinical observations of improvement understanding them provides clinicians with an important after TBI and complete symptomatic recovery in many tool in addressing their neurocognitive and neurobehav- cases of mild TBI. Moreover, other aspects of neuronal ioral consequences. More than that, however, I believe physiology may be altered as well, theoretically either that knowledge of these injuries, their anatomic distribu- reversibly or irreversibly. Levels of chemical neurotrans- tion, their probable neurochemical consequences, and the mitters contained in axons, for example, might be vulner- relationship of their neurobiology to the neuropsychiatric able to such alteration. One such class of agents is the 953 LUX. Neuropsychiatry of TBI monoaminergic neurotransmitters, and several studies are increasingly seen, again with an anterior preponder- suggest that they are indeed affected, both acutely and ance. The undersurfaces of the frontal lobes may also be chronically [7–11]. Although the nature and distribution abraded as they slide over the rough orbital surface of the of the monoaminergic dysfunction following TBI frontal fossa. In addition, very diffuse secondary injuries remains to be more fully characterized, a number of clin- can evolve and make their effects felt throughout the ical syndromes in which these chemical neurotransmit- brain, including at sites far removed from the primary ters have been implicated are common after TBI and will injury [15]. Nonetheless, in most patients, the broad pat- be discussed here. tern determined by the
Load more

Recommended publications
  • Persistent Neurobehavioral Problems Following Mild Traumatic Brain Injury
    Archives of Clinical Neuropsychology 16 (2001) 561–570 Downloaded from https://academic.oup.com/acn/article/16/6/561/2043 by guest on 23 September 2021 Persistent neurobehavioral problems following mild traumatic brain injury Lawrence C. Hartlagea,*, Denise Durant-Wilsona, Peter C. Patcha,b aAugusta Neuropsychology Center, 4227 Evans to Locks Road, Evans, GA 30809, USA bUS Penitentiary, Atlanta, GA, USA Accepted 9 May 2000 Abstract Accumulating research documents typical rates in the range of 85% of mild traumatic brain injury (MTBI) showing prompt, complete resolution with 15% suffering from persistent neurobehavioral impairments. Studies of neurobehavioral symptoms of MTBI have not separated these two populations, resulting in either inconclusive or contradictory conclusions concerning the relationship of MTBI with residual behavioral problems. This project studied 70 MTBI patients with persistent neurobehavioral problems at two time intervals post-injury to determine whether there are consistent neurobehavioral patterns considered to be sequelae of MTBI. A matched group of 40 normal subjects provided control data. While most behavioral problems showed improvement, 21% tended to show significant behavioral impairment compared to controls at 12 or more months post-injury. Neurochemical bases of neuronal degeneration may account for some of the behavioral deterioration following MTBI. D 2001 National Academy of Neuropsychology. Published by Elsevier Science Ltd. Keywords: Persistent neurobehavioral problems; Brain; MTBI The scientific
    [Show full text]
  • Phineas Gage, Neuroscience's Most Famous Patient
    SCIENCE THE STATE OF THE UNIVERSE. MAY 6 2014 11:32 PM Phineas Gage, Neuroscience’s Most Famous Patient Each generation revises his myth. Here’s the true story. By Sam Kean 1 From a virtuous foreman to a sociopathic drifter n Sept. 13, 1848, at around 4:30 p.m., the time of day when the mind might start wandering, a O railroad foreman named Phineas Gage filled a drill hole with gunpowder and turned his head to check on his men. It was the last normal moment of his life. Other victims in the annals of medicine are almost always referred to by initials or pseudonyms. Not Gage: His is the most famous name in neuroscience. How ironic, then, that we know so little else about the man—and that much of what we think we know, especially about his life unraveling after his accident, is probably bunk. Gage's exhumed skull and tamping iron, 1870. Image via J.B.S. Jackson/A Descriptive Catalog of the Warren Anatomical Museum The Rutland and Burlington Railroad had hired Gage’s crew that fall to clear away some tough black rock near Cavendish, Vermont, and it considered Gage the best foreman around. Among other tasks, a foreman sprinkled gunpowder into blasting holes, and then tamped the powder down, gently, with an iron rod. This completed, an assistant poured in sand or clay, which got tamped down hard to confine the bang to a tiny space. Gage had specially commissioned his tamping iron from a blacksmith. Sleek like a javelin, it weighed 13¼ pounds and stretched 3 feet 7 inches long.
    [Show full text]
  • PHINEAS GAGE the Man with a Hole in His Head
    CHAPTER THREE PHINEAS GAGE The Man With a Hole in His Head Phineas Gage was the 25-year-old foreman of a construction crew preparing the path for a railroad track in the late summer of 1848. By all accounts he was reliable and friendly, both a good worker and a pleasant companion. But in an instant his life was changed through a terrible accident that would haunt him until his premature death at age 36. Gage’s accident also had ramifications for scientists who were tryingdistribute to under- stand the relationship between the brain and behavior. Although the implications of his accident were not immediately appreciated, his case became a common fixture in basic textbooks in psychology, neurology, and related fields. His caseor has also been used to demonstrate the role of the brain in determining personality. But the account of the acci- dent has also been filled with errors and exaggeration, sometimes making it difficult to separate the facts from fiction. THE ACCIDENT post, Late in the afternoon of September 13, 1848, Phineas Gage was working with his crew near Cavendish, Vermont, preparing the way for a new track bed for the Rutland and Burlington Railroad. The crew was using explosives to blast away rock. It was a slow process thatcopy, required precision in determining where to bore the holes and estimating how much explosive powder to use. Gage would place a fuse in the hole, followed by gunpowder, and then fill the rest of the hole with sand. Gage had a long iron rod, a tamping iron, which he used to pack down the sand.
    [Show full text]
  • A Hardwired Neo-Cortex – What Role for Neuroplasticity and Developmental
    Book Review Page 1 of 2 A hardwired neo-cortex – What role for BOOK TITLE: neuroplasticity and developmental processes? Beyond evolutionary psychology: How and why neuropsychological Is the neo-cortex of the brain hardwired or not? This is the central question George Ellis and Mark Solms of the modules arise University of Cape Town set out to answer in the seven chapters and 177 pages of this book. Regardless of which side of the argument one is on, there is a guarantee of a fulfilling read, with the latest information about the modern BOOK COVER: brain and its evolution. The main point of this book is that there is no language or any other instinctual system in the neo-cortex. Evolutionary psychologists claim that the mind is a product of evolution and natural selection.1,2 We have adapted successfully to our environments because the mind (specifically the neo-cortex) is modular and hardwired for specific functions, which provides us with innate knowledge from birth and equips us for survival in an environment with a ‘poverty of stimulus’. An example is that of Chomsky’s innate module for grammar which Pinker3 later argued was a ‘language instinct’ (see Rose4). We required such a mind in the context of an ‘environment of evolutionary adaptedness’ to the African savannah but would it help us survive modern life? The gene took central position from about the mid-20th century – the period of the new synthesis of Darwin’s theory (in 1859) with modern genetics – with a convergence of ideas of heredity from several sources5-8: the (‘selfish’) gene was the unit for natural selection8, the meme its cultural counterpart and gene-culture coevolution the new idea9.
    [Show full text]
  • The Return of Phineas Gage: Clues About the Brain from the Skull of a Famous Patient
    The Return of Phineas Gage: Clues About the Brain from the Skull of a Famous Patient Hanna Damaslo, Thomas Grabowski, Randall Frank, Albert M. Galaburda, Antonio R. Damasio* When the landmark patient Phineas Gage died in 1861, no autopsy was performed, but language, motor function, and perception, his skull was later recovered. The brain lesion that caused the profound personality and now Gage's case indicated something changes for which his case became famous has been presumed to have involved the left even more surprising: Perhaps there were frontal region, but questions have been raised about the involvement of other regions and structures in the human brain dedicated to about the exact placement of the lesion within the vast frontal territory. Measurements from the planning and execution of personally Gage's skull and modern neuroimaging techniques were used to reconstitute the accident and socially suitable behavior, to the aspect and determine the probable location of the lesion. The damage involved both left and right of reasoning known as rationality. prefrontal cortices in a pattern that, as confirmed by Gage's modern counterparts, causes Given the power of this insight, Har- a defect in rational decision making and the processing of emotion. low's observation should have made the scientific impact that the comparable sug- gestions based on the patients of Broca and Wernicke made (2). The suggestions, al- On 13 September 1848, Phineas P. Gage, profound change in personality were al- though surrounded by controversy, became a 25-year-old construction foreman for the ready evident during the convalescence un- the foundation for the understanding of the Rutland and Burlington Railroad in New der the care of his physician, John Harlow.
    [Show full text]
  • Causes of Mental Illness Phineas Gage (1848)
    8/26/2019 What is Mental Illness? Mental Illness: a mental, behavioral or emotional disorder that interferes in the way that we think, feel or function. • Impairments can be mild, moderate or severe. • Mental illness can affect how we handle stress, relate to others or make healthy choices. • Mental health is important at every stage of life: childhood, adolescence, the adult life span. • Mental health can change over time. • Mental health can change after a traumatic brain injury (CDC; Learn About Mental Health) How Common is Mental Illness? Causes of Mental Illness • In 2016, there were an estimated 44.7 million adults • Biological factors (genetics or a chemical imbalance) aged 18 or older with a mental illness • Chronic medical condition • This is about 1 in 5 Americans per year (cancer/brain injury and so forth) • The number (1 in 5) is the same for children • Use of alcohol or recreational drugs • The rate of diagnosis is higher for women (21%) • Early childhood trauma than men (15%) • Feeling lonely or isolated • Young adults ages 18-25 had the highest prevalence of mental illness compared to other adult groups (NIMH; Statistics: Mental Illness) Phineas Gage (1848) Neuroscience’s Most Famous Patient • Iron bar through frontal lobe: Tamping iron-43 inches long; 1.25 inches in diameter and 13 pounds • Penetrated left cheek, shot through skull and landed several dozen feet away • Responsible and well adjusted- model foreman • Negligent, irreverent, profane, unable to take responsibility • Lost his job • Died at age 36 after a series of seizures (Smithsonianmag; Phineas Gage) (Smithsonianmag; Phineas Gage) 1 8/26/2019 Depression Depression is more than ups and downs.
    [Show full text]
  • Brain-Based Rehab the Past
    Brain-Based Rehab John B. Arden, PhD Agenda • The Prefrontal Cortex • Affect Asymmetry • Neuroplasticity and Neurogenesis • The Memory Systems • Anxiety and PTSD • Hints for Forensic Neuroscience Neuropsychology The Past Attachment Transference Neurology Epigenetics Client-Centered Empathy Trust Diagnosis Alliance Psychopharm DSM V EBP-- Panic Psychotherapy Research Memory CBT EBP-- ACT, DBT EBP-- OCD Narrative GAD Psychodynamics EMDR, EFT EBP-- EBP-- Depression OCD 1 Where is the anxiety? Here is the DMN Brain-Based Therapy NEUROSCIENCE EVIDENCE-BASED PRACTICE PSYCHOLOGICAL THERAPEUTIC THEORIES ALLIANCE The BASE of BBT Brain Alliance Evidence-Based Systems Practice 2 Worth a Thousand Words Psychotherapy changes the brain Goldapple, Segal, et al. (2004). Arch. Gen. Psych., 61, 34–41. Psychotherapy and the Brain Direct, observable links between successful CBT/IPT and brain changes – Reduced amygdalar activity in treated phobics ( Straube, et al., 2006), panickers (Prasko et al., 2004), and social phobics (Furmark et.al, 2002) – Reduced frontal activity in treated depressives (Goldapple et al., 2004) – Increased ACC activation in PTSD clients (Felmingham et al., 2007) – Increased hippocampal activity in depressives (Goldapple et al., 2004) – Decreased caudate activity in OCD (Baxter, et al., 1992) Brain-Based Therapy • BBT changes how we think about the relationship and change: –Need a “Safe emergency.” –Experience creates brain biology –Brain biology effects experience (e.g. depression) 3 Mind/Brain and communication Brain-Based Therapy
    [Show full text]
  • Evolution, Cognition, Consciousness, Intelligence and Creativity
    J35 d. 73 303 SEVENTY-THIRD c>py * JAMES ARTHUR LECTURE ON THE EVOLUTION OF THE HUMAN BRAIN 2003 EVOLUTION, COGNITION, CONSCIOUSNESS, INTELLIGENCE AND CREATIVITY RODNEY COTTERILL AMERICAN MUSEUM OF NATURAL HISTORY NEW YORK : 2003 SEVENTY-THIRD JAMES ARTHUR LECTURE ON THE EVOLUTION OF THE HUMAN BRAIN 2003 SEVENTY-THIRD JAMES ARTHUR LECTURE ON THE EVOLUTION OF THE HUMAN BRAIN 2003 EVOLUTION, COGNITION, CONSCIOUSNESS, INTELLIGENCE AND CREATIVITY Rodney Cotterill Danish Technical University Wagby, Denmark AMERICAN MUSEUM OF NATURAL HISTORY NEW YORK : 2003 JAMES ARTHUR LECTURES ON THE EVOLUTION OF THE HUMAN BRAIN Frederick Tilney. The Brain in Relation to Behavior; March 15, 1932 C. Judsoil Herrick, Brains </s Instruments of Biological Values; April 6. 1933 D. M. S. Watson. The Story of Fossil Brains front fish to Matt; April 24, 1934 C. U. Ariens Kappers. Structural Principles in the Nervous System; The Devel- opment of the Forehrain in Animals anil Prehistoric Human Races; April 25. 1935 Samuel T. Orton. The Language Area of the Human Brain and Some of Its Dis- orders; May 15. 1936 R. W. Gerard. Dynamic Neural Patterns; April 15. 1937 Franz Weidenreich. The Phylogenetic Development of the Hominid Brain and Its Connection with the Transformation of the Skull; May 5, 1938 G. Kingsley Noble. The Neural Basis of Social Behavior of Vertebrates; May 1 1, 1939 John F. Fulton. A Functional Approach to the Evolution of the Primate Brain; May 2. 1940 Frank A. Beach. Central Nervous Mechanisms Involved in the Reproductive Be- havior of Vertebrates; May 8, 1941 George Pinkley. A History of the Human Brain; May 14.
    [Show full text]
  • Assessing the Elusive Cognitive Deficits Associated with Ventromedial Prefrontal Damage: a Case of a Modern-Day Phineas Gage
    Journal of the International Neuropsychological Society (2004), 10, 453–465. Copyright © 2004 INS. Published by Cambridge University Press. Printed in the USA. DOI: 10.10170S1355617704103123 CASE STUDY Assessing the elusive cognitive deficits associated with ventromedial prefrontal damage: A case of a modern-day Phineas Gage M. ALLISON CATO,1,2 DEAN C. DELIS,1 TRACY J. ABILDSKOV,3 and ERIN BIGLER3 1San Diego Veteran Affairs Healthcare System and University of California, San Diego, School of Medicine, San Diego, California 2Department of Clinical and Health Psychology and Malcom Randall VA RR&D Brain Rehabilitation Research Center, University of Florida, Gainesville, Florida 3Department of Psychology, Brigham Young University, Provo, Utah (Received April 7, 2003; Revised July 17, 2003; Accepted September 5, 2003) Abstract Cognitive deficits following ventromedial prefrontal damage (VM-PFD) have been elusive, with most studies reporting primarily emotional and behavioral changes. The present case illustrates the utility of a process approach to assessing cognitive deficits following VM-PFD. At age 26, C.D. acquired bilateral VM-PFD, more so in the left frontal region, following a penetrating head injury. Despite exemplary premorbid academic and military performances, his subsequent history suggests dramatic occupational and social changes, reminiscent of Phineas Gage. In fact, lesion analysis revealed similar structural damage to that estimated of Gage. C.D.’s scores on the vast majority of neuropsychological measures were average to superior (e.g., Verbal IQ 5 119). However, on several new process measures, particularly those that quantify error rates on multilevel executive function and memory tasks, C.D. exhibited marked impairments. From his pattern of deficits, C.D.
    [Show full text]
  • The Irish Phineas Gage: Frontal Lobe Traumatic Brain Injury
    Issue: Ir Med J; Vol 113; No. 9; P188 The Irish Phineas Gage: Frontal Lobe Traumatic Brain Injury R. Durcan1, E. Mulroy1, 2, E. Kavanagh3, T. Lynch1,4,5 1. Centre for Brain Health, Dublin Neurological Institute at the Mater Misericordiae University Hospital, Dublin, Ireland. 2. UCL Queen Square Institute of Neurology, London WC1N 3BG, UK. 3. Radiology Department, Mater Misericordiae University Hospital, Dublin, Ireland. 4. Health Affairs, University College Dublin, Ireland. 5. Ireland East Hospital Group, Ireland. Abstract Presentation We describe the clinical case of a gentleman who suffered a traumatic brain injury, following a fall on a building site. He was impaled with an iron rod through his left temple, sustaining significant injury to his frontal lobe. Diagnosis Frontal lobe traumatic brain injury with resultant behavioural change and cognitive impairment, which is discussed in detail in the manuscript and supplementary material. Treatment Emergency neurosurgical intervention, with removal of the rod and haematoma evacuation. Discussion Phineas Gage remains the archetypal example of frontal lobe dysfunction in medical education. A previously placid, mild-tempered railway foreman, Gage’s frontal brain injury irrevocably changed his personality and engendered much interest in the functions of the frontal lobes. We describe Gage’s modern-day Irish counterpart. Introduction Phineas Gage was a 25-year-old railway foreman, a “shrewd businessman with a well-balanced mind”1. In 1848, an accidental explosion caused a 3cm-wide tamping rod to be propelled upward through Gage’s facial bones and frontal skull, causing predominant left frontal lobe injuries (The Boston Crowbar Case) 2, 3. Gage recovered physically, but psychological deficits rendered him unable to resume his former position as a foreman.
    [Show full text]
  • Frontal Lobe Functions Pivotal Case: Phineas Gage What Did Change?
    Frontal Lobe Functions Fredric E. Rose, Ph.D. Winter 2006 Pivotal Case: Phineas Gage 9/13/1848 25 yo construction foreman for Rutland and Burlington RR in New England Used a tamping iron to fill holes in stones with sand over explosive powder in order to level the terrain Once forgot to put in sand… What did change? What did we learn from this? Pre-accident personality Responsible, intelligent, honest, well-liked by peers and elders, “the most efficient and capable man” according to employers Post-accident personality Disinhibited, irreverent, capricious, disrespectful of social conventions, unable to hold a job Equipotentiality v. Localization of Function Harlow (1868): some portion of the brain that was removed by the tamping rod was responsible for the restraint and well-mannered behavior that most people possess, and that Gage lost in the accident. 1 Gage Revisited (Science,1994) Damasio & Damasio Computer graphics to plot trajectory Ventromedial OFC region, sparing of Broca’s and other FL motor regions Region is responsible for decision-making regarding personal and social matters,as well as emotion processing Anatomy of the Frontal Lobes 3 prefrontal regions: Dorsolateral Orbitofrontal Mesial Frontal Lobe Circuitry Alexander, DeLong, & Strick (1986). Parallel organization of functionally segregated circuits linking basal ganglia and cortex. Annual Review of Neuroscience, 9, 357-381. Oculomotor Motor Dorsolateral Orbitofrontal Anterior Cingulate 2 Neurotransmitters Glutamate (corticostriatal, thalamocortical)
    [Show full text]
  • The Amazing Case of Phineas Gage 06/11/02 12:36
    Sabbatini, R.M.E.: The Amazing Case of Phineas Gage 06/11/02 12:36 The Amazing Case of Phineas Gage Phineas Gage was a young railroad construction supervisor in the Rutland and Burland Railroad site, in Vermont. In September 1848, while preparing a powder charge for blasting a rock, he inadvertently tamped a steel rod into the hole. The ensuing explosion projected the tamping rod, with 2.5 cm of diameter and more than one meter of lenght against his skull, at a high speed. The rod entered his head trhough his left cheek, destroyed his eye, traversed the frontal part of the brain, and left the top of the skull at the other side. Gage lost consciousness immediately and started to have convulsions. However, he recovered conscience moments later, and was taken to a local doctor, Jonh Harlow, who took care of him. Amazingly, he was talking and could walk. He lost a lot of blood, but after a bout with infection, he not only survived to the ghastly lesion, but recovered well, too. Months later, however, Gage began to have startling changes in personality in mood. He became extravagant and anti-social, a fullmouth and a liar with bad manners, and could no longer hold a job or plan his future. "Gage was no longer Gage", said his friends of him. He died in 1861, thirtheen years after the accident, penniless and epileptic, and no autopsy was performed on his brain. His former physician, John Harlow, interviewed his friends and relatives, and wrote two, reporting Gage's reconstructed medical history, one in 1948, entitled "Passage of an Iron Rod Through the Head", and another in 1868, titled "Recovery from the Passage of an Iron Rod Through the Head".
    [Show full text]