A 받은 인지신경과학 페이퍼- Balint Syndrome에 관한 픽션
It was a serene day. The sky seen through the window was movingless misty blue. Una was thinking about her friend, Dorothy, who shot herself in the head three months ago. She had survived the wound against her will and now had to undergo another obstacle. The door opened and the doctor walked in. She was short, but slim and bright dark-eyed, and seemed too young for a middle-aged woman like Una to handle a matter of life and death.
The doctor sat in front her and started to explain straightforward with sonorous voice. “We diagnosed Miss Dorothy’s symptom as Baliant’s Syndrome. It causes a cognitive problem from lesion of visual area placed in the occipital lobe. As you know, she got an open-head injury in the back part of her head. We presume the bullet didn’t harm any part of brain of vital importance, but may deprive her of conjoining representation of object and space in the right way.”
“But… How can that kind of deprivation happen? She recognized color, shape, and who I am!”
“Of course she can. Our brain is localized for its function such as motor, auditory, somatosensory area but complex ability cannot be accomplished by association of all those parts. Miss Dorothy’s primary visual cortex is intact so she still gets visual information from outside as you, but may not be able to reconstruct it as a complete representation in mind because the damaged region is including bilateral parieto-occipital junction, which charges a path for coordination. We have several case reports for this problem. A very similar case to your friend is about a patient called R.M, at the age of 54, had two stroke and been suffered from Simultanagnosia, Spatial Disorientation, Impaired Oculamotor Behavior and Optic Ataxia(Rafal, 2003).”
“From… what?”
“They are manifest evidences usually observed in Balint’s Syndrome. Simultanagnosia is described by Holmes, “the essential feature was his inability to direct attention to, and to take cognizance of, two or more objects” (Rafal, 2003, p.29) about his patient, who had a gunshot in the back of his head like Miss Dorothy. She cannot “perceive more than one object at a time”(Rafal, 2003, p.29).
Spatial Disorientaion is also one of the significant marks of it. Patients not only lose their way in space but also cannot indicate the exact place of object with any kind of expression. Do you remember her behaviors before coming here?”
Una recollected about the Saturday night of September. When she came to Dorothy’s house, she was sobbing hysterically collapsing on the floor in the kitchen. She murmured with choking voice; “I can’t reach … And don’t know how to get out…” Besides her there were broken pieces of bottles, some plastic dishes, salt and pepper in a litter. “Dorothy! Are you all right?” Una struggled to help her rise to her feet because she was still crying and mumbling, losing her mind. “Stop crying! What happened?”
“I cannot get out of here… and I can SEE those damn spices and dishes but they never gripped… several times… fell down and broken… No, I don’t know where they are… What the hell!”
“Calm down! Where were these plates?”
“I don’t know… I knew but not now… I can’t tell…”
She got out from her recollection by the doctor’s voice. “…And we observed Impaired Oculomotor Behavior from her. By the result of EOG recording, we decided she couldn’t make smooth eye movements and showed “wandering gaze”(F.Girotti et al., 1982, p.609). Eyes moved randomly and seldom matched to targets on trials.”
“…She once told me she can SEE but cannot get the object.”
“That would be Optic Ataxia. It sometimes occurs in patients with Balint’s Syndrome and they usually cannot watch and reach the object accurately until touching it. Seeing and getting is not conjoined. We assume these Optic Ataxia and Impaired Oculomotor behavior may be originated from lack of spatial representation (Rafal, 2003).”
“I don’t believe all these symptoms happened at once…”
“Actually all these symptoms are discrete, so some patients only experience Smultanagnosia without any kind of Optic Ataxia. And not all of patients who suffer from one of those signs are Balint’s Syndrome, or have lesions in the exact same area of the brain. There is also another case of deficit of visual integration about who have a unilateral lesion (Rafal, 2003).”
“How did you find all of them?”
Doctor started to explain eagerly. “To analyze patient’s behavior and the cause of symptom, we use converging methods to deal with injury or problems of the brain. There are several instrumental ways supplying each other; and MRI is one of the useful ways to scan the whole brain and find out the ruined part because we cannot open and examine the live brain directly. We can easily recognize the main problem by its well-visualized image. In this case, we could categorize the destroyed part by interpreting several images. In specific, we did find damaged area was in the watershed area and concentrated primarily on the main part of Brodmann areas 7 and 39, and possibly included some of the area 5 and 19(Rafal, 2003, p.27).
However, MRI cannot prove the relationship between distinguishes the damaged area and shown abnormal behavior even though it provides better images than those of CT. So this time we also used other methods after checking the lesion. EOG recording, that I mentioned a couple of minutes ago, helps to examine the patient’s ocular problem by certain purpose to measure abnormal eye movement like “latency of the saccade, visual search time and number of saccades required to each target”, etc (F.girotti et al, 1982, p.607). While MRI inspects the inner problem, it rather focuses on the abnormal output shown by patient.
As I explained a couple of minutes ago, symptoms are discrete. Sometimes same symptoms are shown by different diseases or lesions. To examine the output is important to complement the top-down analysis. Comparing the consequence of the recording of Miss Dorothy with MRI images and normal results, we could elicit more reliable elucidation of the patient’s condition and also interpret her state as Balint’s Syndrome. There is also one more powerful method; it is a Postmortem Examination. We can gain lots of invaluable information from a dead brain and some of facts are used to analyze this case.” Doctor shrugged. “I hope it doesn’t happen.”
Una felt a grave anger pressing her heart. How could she say that without any pity to her patient? And to me, who had been her friend for almost 27 years? She suppressed her feeling and asked in a hoarse voice.
“Then, is there any possibility to recover?”
Young woman’s face clouded over. “I hope so, but it is different person to person. The person whose brain used for postmortem examination died after three weeks. However, who had a similar case as Miss Dorothy had survived and could live by himself at last. Frankly speaking, it is hard for us to predict a patient’s prognosis.”
“How… he survived? You probably know because you doctors and psychologists inspect one poor patient everyday until he or she dies, don’t you?”
The doctor was bewildered and gazed at her for a while, but her words couldn’t make her off the balance. “If I was offensive, I’ll apologize. We are really trying to make things clear but cannot reach any conclusive causation between brain lesion and all disastrous conditions of illness. Then how could we dare to predict what will happen? What we could do is just a presumption of other associative realms that might cover the loss of function. And according to some cases, there would be still hopeful prognoses.”
Una kept silence at this time. Her description of function of MRI and EOG recording was clear enough to understand. Each method focused on different aspects- an original part of the problem and output from it– and clarified the whole picture of relationship between symptom and disease. However, the doctor still doesn’t know what should do. She may never understand who Dorothy was and what her life was. She was a great cook, a little bit sarcastic but had a hell of a sense of humor, and had never given up her dignity even in the worst situation of life. But now, so far from cooking, she cannot grip a cruet in the cupboard. She even cannot walk from bedroom to kitchen without any aid. Helplessness, Una thought, and pure chaos may dominate her vision and mind. And life would be severely different from what we used to know.
References
Rafal, R.(2003).Balint's Syndrome: A Disorder of Visual cognition. Neurological
Foundations of Cognitive Neuroscience.
Girotti. F., Milanese, C., Casazza, M., Allegranza, A., Corridori, F., &
Avanzini, G. (1982). Occulomotor disturbances in Balint's Syndrome:
Anatomoclinical findings and electrooculographic analysis in a case. Cortex,
18, 603-614.