Front and Center

The frontal lobes of the human brain are the seat of moral consciousness.  It is here, amidst the synapses and neurotransmitters, that our moral sense resides.  How do we know this?  The short answer is by studying behavior in those individuals who have suffered traumatic injury to this area of the brain.

Take the curious case of Phineas Gage, a 19th century railroad worker who suffered a bizarre accident when a 3-foot long iron tamping bar blasted through his left cheek and exited his skull at the midline near the top of his head.  Both frontal lobes were damaged in the incident.  Remarkably, Gage was able to walk and speak immediately after the accident.  Although he continued to live an additional 12 years, his coworkers noted marked changes in his behavior.

His contractors, who regarded him as the most efficient and capable foreman in their employ previous to his injury, considered the change in his mind so marked that they could not give him his place again. He is fitful, irreverent, indulging at times in the grossest profanity (which was not previously his custom), manifesting but little deference for his fellows, impatient of restraint or advice when it conflicts with his desires, at times pertinaciously obstinate, yet capricious and vacillating, devising many plans of future operation, which are no sooner arranged than they are abandoned in turn for others appearing more feasible. In this regard, his mind was radically changed, so decidedly that his friends and acquaintances said he was “no longer Gage.”

The executive function of Phineas Gage’s prefrontal cortex had deteriorated as a result of the trauma.

Similar behavioral changes are apparent in those addicted to various substances, such as alcohol or opiates.

As dependence grows, alcoholics also lose the ability to properly regulate their behavior. This regulation is the responsibility of the prefrontal cortex, which is charged with keeping the rest of the brain apprised of the consequences of harmful actions. But mind-altering substances slowly rob the cortex of so-called synaptic plasticity, which makes it harder for neurons to communicate with one another. When this happens, alcoholics become less likely to stop drinking, since their prefrontal cortex cannot effectively warn of the dangers of bad habits.

Because the synapses in their prefrontal cortex are still damaged, they have a tough time resisting the urges created by these triggers.

According to Stefan G. Hofmann, professor of psychology at Boston University, “As we grow, the prefrontal areas of the brain develop, and we become more biologically able to control our impulses.”

Impaired executive functions, apathy, and impulsivity are hallmarks of frontal-subcortical circuit dysfunction. Personality changes from orbitofrontal damage include impulsiveness, puerility, a jocular attitude, sexual disinhibition, and complete lack of concern for others.  A lack of empathy or an inability to infer the mental state of others leads to inappropriate behavior.

An interesting sidelight here is that these sorts of behaviors—lack of empathy or an inability to infer the mental state of others—are seen in autistic individuals, who may lack a sufficient number of mirror neurons, those cells that allow us to imagine the feelings of others.

Cellular synapses might ultimately determine the moral state of the human soul.

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In another country

The young man sits quietly on the exam table with the legs of his trousers rolled up, exposing his bare feet. He dips his head in a barely perceptible bow when I enter the room. I glance at his toes; silently, they reflect the reason for today’s visit.

“How long have they been like this?” I ask, stooping down for a better look.

“One week, maybe a little longer. I thought they might get better on their own, but they got a bit worse.”

The nails of both great toes are completely blackened by underlying pools of extravasated blood. “Do they hurt?”

“A little bit,” he tells me. “I can sleep okay, but they bother me when I try to play basketball.”

I rise to my feet, regaining my footing. “We can drill a small hole through each nail to drain out the blood. You’ll feel much better when the pressure is relieved. It won’t hurt—the nail itself has no feeling, like your hair.”

“Okay,” he says.

I disappear and return shortly with a tray of medical supplies: gauze, alcohol wipes, Band-Aids, an absorbent towel. I prepare the field, clean the surface of one nail and begin to drill, twisting the tiny point of a number 11 blade into the thickened keratin. “Let me know if this bothers you,” I say.

“I’m fine,” he says.

I make conversation as I continue my work. “Where are you from?”

“China,” he tells me.

“Ah! What part?”

“Southern China,” he says. “This is my second year in the states.”

“How do you like it here?”

“I’m glad to have the opportunity to study abroad in the U.S.” he says. “The only thing I’m not accustomed to is the snow. I had never seen snow before coming to America.”

“You’re certainly getting a baptism by fire this winter,” I say, then qualify my remarks—“we’ve gotten record snows this year.”

I continue to twist the point of the blade down through the nail. “What do you plan to do after you graduate from prep school?” I ask him.

“Oh, go to college, definitely.”

“What do you want to study?”

“Probably math or science. I like the arts and music as well, but I think I would like to concentrate my studies in one of the sciences.”

“Your English is very good,” I tell him.

“Thank you. My father started to teach me English when I was two. He spent several years abroad with a company in Australia. He learned English there. I started taking formal studies in English when I turned four. Now it’s no problem for me—I get along fine.”

A bubble of dark red blood erupts onto the nail surface. I exert gentle pressure to help it along. “How does it feel now?” I ask him.

“Better,” he says.

I apply a Band-Aid and turn my attention to the other foot.

“Do you have brothers or sisters?”

“No. In China the government says you can have only one child, unless you agree to pay a lot of money for the privilege of having another one.”

I think of China’s President Hu Jintao’s visit this week to Washington. There were several days of talks on a host of issues ranging from relations with North Korea to economic problems to the recognition of the need for greater human rights in China.

So far the exchange on the diplomatic level has been cordial and mutually beneficial—but not nearly as beneficial as the myriad exchanges that my afternoon patient has been having with his schoolmates over the past two years.

“There, all done,” I say, applying the final Band-Aid. “Soak your feet in warm water several times a day over the weekend. The small holes will gradually grow out with the nail. Just keep your toenails trimmed and things should work out fine.”

He looks down at his feet. “When can I play basketball again?”

“Whenever you feel up to it,” I tell him.

“This afternoon?”

Were he born in America, I wager he would have had a Chinese Tiger mother.

The way we practice now

According to current theory, people with ADHD have a relative deficiency of dopamine, an essential neurotransmitter in the brain.  Adequate levels of dopamine are necessary to induce incentive and motivation.  Stimulant medications boost dopamine levels and enhance the ability to stay focused on task.

But in our modern psychopharmacological approach to the treatment of ADHD we have all but forgotten the environment.  more»

Precious Stone

“We are all fixing what is broken.  It is the task of a lifetime.”     —Verghese

By chance, when I was a boy searching for rocks to add to my growing collection, I found my first piece of pyrite — “fool’s gold.”  This particular nugget was big, certainly much bigger than any crystalline mineral I had previously encountered.  As I turned it over in my hand, it reflected a tarnished brassy light.

This treasure turned out to be nothing next to the tiny flakes of real gold that later, as an adolescent, I panned from the mountain streams of New Mexico.  That brilliant yellow sparkle was unmistakable.  Once you encounter the real thing, you never forget; it burns itself into your memory and you guard its image forever.

For me, now a seasoned clinician, Abraham Verghese’s 2009 novel Cutting for Stone is the real thing.

Against the backdrop of Ethiopia, a country so beautifully depicted that his descriptions can hurt, Verghese crafts the timeless narrative of two brothers, twins joined at the head by a mysterious cord identified at birth.  In an emergency caesarean section the obstetrician who will become their surrogate mother clamps and divides this tube, uncertain if it contains meninges, gray matter or aberrant blood vessels.  Thus separated at birth, the twins retain a mysterious bond between them throughout the rest of their lives.

Thomas Stone, their surgeon father, normally level-headed and dexterous in the operating theater, flounders on how to proceed with the delivery.  Because of his lack of timely intervention, the mother exsanguinates on the table.  Unable to cope with his perceived incompetence, Stone flees the hospital, the country, and, as we later learn, the continent.  He appears again in the final section of the book where he will be called upon in his brokenness to perform a surgical miracle.

Meantime, the boys are adopted and reared by Hema, the obstetrician gynecologist, and Ghosh, the internist, at Missing (a mispronunciation of “Mission”) Hospital in Addis.  Both boys are introduced to the practice of medicine at an early age.  Each pursues it in his own fashion.  Marion, the first-born, blossoms under the tutelage of Ghosh, the competent and kind clinician; while Shiva, his mother’s favorite, blazes his own unique path, pioneering and perfecting the techniques of fistula surgery that will save thousands of ill-fated young women.

Estranged from Shiva over a fiery young woman, Marion is forced to flee Ethiopia for political asylum.  The paths of the brothers will converge seven years later in America, where, in a manner of speaking, they become reunited again.

In Cutting for Stone, Verghese gives us his best, exploring how the sins of fathers are visited upon subsequent generations, the intricate relationships between broken people, the history of modern medicine from clinical practice to the art of transplantation, the interrelatedness of human existence on this planet.  The narrative is chocked full of medical aphorisms and old saws, a well-stocked larder for the practicing clinician.

Cutting for Stone was placed in my hands by a good friend who thought I might enjoy it.  He and his wife had read it over the course of their recent two-month trek through Australia and New Zealand.  I discovered a bookmark sandwiched between two pages — a dog-eared boarding pass from one of their intercontinental flights.

The read itself turned out to be a fascinating journey, one enriched by precious stone.

“Notes from a Healer” — A Personal Perspective

The toddler is being difficult. He doesn’t want to take off his shoes; he doesn’t want to get weighed. He runs down the hallway and resists his mother’s efforts to drag him back to the scale. As I rush by this scene on my way to see my next patient, I sense the frustration in our medical assistant’s demeanor. It’s the end of the morning, and she’s not happy either.  more»

My latest installment of Notes from a HealerA Personal Perspective — is now online, newly published in the Yale Journal for Humanities in Medicine.

The Yale Journal for Humanities in Medicine is an online clearinghouse for manuscripts dealing with the humanities and medicine. Interested readers can access a list of editorial board members and regular contributors here.

Expressing the Inexpressible

In his review of The Autobiography of Mark Twain, American humorist Garrison Keillor charges that Samuel Clemens’s belated musings are “a powerful argument for writers’ burning their papers.”

While Keillor is somewhat less than kind to Sam Clemens for baiting the public for a century with the promise of his last hurrah, he recognizes some gems in this massive volume (the first of three).

“What a wee little part of a person’s life are his acts and his words!” Twain writes.  “His real life is led in his head, and is known to none but himself…. The mass of him is hidden — it and its volcanic fires that toss and boil, and never rest, night nor day. These are his life, and they are not written, and cannot be written. . . . Biographies are but the clothes and buttons of the man — the biography of the man himself cannot be written.”

Keillor concludes his review with these words: “The death of the beloved daughter far beyond her father’s love and care is a disaster from which there is no recovery. Boyishness cannot prevail, nor irreverence. The story can’t be written. The man buttons up his clothes and resigns himself to the inexpressible.”

I distinctly recall my high school physics teacher brooding over how to define a problem.  “If you can’t express it in a mathematical statement,” he said, “it simply can’t be understood.”

Some things border on the inexpressible.  While it is difficult to come to grips with grief, making the attempt sometimes pays off.  Our muddled emotions stir about inside our heads.  We define them by turning them into words, fleshing them out, even if in their final form they fall short.

A friend from the other side of the globe writes that she is wrestling with two recent tragedies, one national, one personal.  “Why do these things happen?” she asks.  “I cry deep in my heart.”

Six words that express the inexpressible.

Out West

“When we saw the mountains at last, we cried—all of us. But it wasn’t getting here that mattered, it was movement and westering. The westering was as big as God, and the slow steps that made the movement piled up and piled up until the continent was crossed.” 
                               —John Steinbeck in The Red Pony

“Out west, it’s different,” the young man said. “Out west it’s big sky. Out west the air is dry and clean. And out west people talk—they just talk regular.”

He had come back east at the beginning of the month to see his family for the holidays. It was the first Christmas without his grandfather. The young man had lost his job—got laid off—and left his car at his apartment in Utah. “Go back,” his landlady had told him. “Go back east and figure things out. I’ll keep watch on your stuff here in the meantime. You come and collect it when you find yourself.”

His grandfather’s house stood empty. One of the uncles had moved away to a cottage on the lake up north. There was no one else to care for it now.

It needed some work—a new roof, maybe some structural shoring up; certainly a good cleaning. He had learned a few things about construction over the years. He knew he could do the work. It was just a question of getting the materials. Out west he had lived frugally. He wasn’t in debt, but he didn’t have a lot of money saved either.

When he drove up to the house and stepped inside, the memories hit with a rush. Slowly he walked through the rooms, surveying the home. It would take some work, but he could do it all right. The question was, should he?

“Out west I took up running,” he told me. “For a spell I trained with the Utah state marathon champion. He’s quiet, not condescending at all. He’s won a lot of marathons. He’s a great runner.”

“Have you done a marathon?”

“Not yet. I’ve done a half. Lately, I’ve been running about 25 to 30 miles a week. I’d like to do one some day. I feel so sluggish here back east. My legs are heavy; my form is off. I can’t explain it.”

“Maybe it’s the humidity.”

“I’ve thought about that. It’s dry out where I’ve been living. You can breathe easier, even though it’s 6,000 feet. I thought having trained at that elevation would be an advantage—more red blood cells, more oxygen affinity—but no, it hasn’t worked out.

“Then I thought it might be the light. Out west there’s big sky. It’s open, there’s more light. And the light is different somehow—I can’t explain it.”

“So, what will you do?”

“I’m scouting out a few jobs. I’ve got an interview this afternoon. Maybe I could coach. Maybe I could teach in a private school.” He paused. “Maybe I could swing down to Texas to look up a girl I used to date some years back.

“My parents want me to come home. My mom came out to Utah to visit me for a week. She didn’t understand what I see in the west, just didn’t understand it. They both want me to come back.”

He stopped talking and searched my silent face with his eyes.

“It’s hard to know what to do,” he finally said.