Adapted from Dirge Magazine, September 2015
What the Story of Phineas Gage Can Tell Us About Our Amazing Brains
cw: brain damage, depictions of violence
Phineas P. Gage was a good man. He enjoyed his job as the foreman of a railroad construction site in Vermont. The men working with him described him as capable, hard-working, fair, and responsible. He was well-respected and well-liked.
On September 13th in 1848, when Gage was 25 years old, he set out to work with his men at what is now the Rutland and Burlington Railroad just south of Cavendish. Gage used a tamping iron to pack gunpowder in to a hole in the rock there; the gunpowder would soon be set alight and the rock blasted to create space for new train tracks. His job required a careful and cautious touch with a lot of focus, something he was noted to be good at. He was good at his job in general; he was a model foreman.
At about 4:30pm the rod sparked against the rock, and the gunpowder detonated.
The ignition meant the hot, 43inch tamping iron exploded upwards, travelling straight towards his face. The iron entered Gage’s cheek taper-end first, and the rod passed behind his left eye and through his brain before shooting out the top of his head.
Gage lay dazed on his back for a moment. Then he stood up and thought the 19th Century equivalent of “Well, shit. I guess I’d better go see a doctor.” One of his friends found the brain-splattered tamping iron lying close by and handed it to him. Gage then travelled about a mile by foot and cart to see Doctor John Martyn Harlow. Gage waited patiently to see him until about 6pm, and reportedly told the doctor, “Here is business enough for you.” Doctor Harlow freaked the hell out at the sight of him, covered in blood and sitting there like a gravely wounded but heroic solider.
On further medical examination, it was concluded that Gage’s left frontal lobe had more or less left the building. What remained of it was bulging and pulsating through the hole in his head and when Gage (understandably) started to vomit, about half a teacups worth of white and grey matter squirted onto the floor.
Even so, Gage seemed more or less fine. He would be blind in his left eye for the rest of his life but his intellectual faculties seemed intact, and he was well enough to walk and talk. He was planning to go back to work in a few days to see his friends.
Doctor Harlow bandaged him up loosely and sent him on his way, but kept track of Gage’s progress as best he could. Gage’s physical health took a turn for the worst that persisted for most of the Autumn, but by December he seemed to be recovering nicely.
Over time, however, it became apparent that all was not well. He swore often and spectacularly, forgot arrangements, and didn’t seem to care when the hurt this caused was brought to his attention. His friends described him as ‘uncontrollable’. Dr Harlow later wrote that after the accident, Gage was ‘no longer Gage’ at all.
Picture found here.
The frontal lobes of your brain are a thing of grace and beauty. It’s the part of you that loves your friends and family; it’s the part of you that cries at a good film; and it’s the part that sees other people as distinct and separate beings to be understood and cherished (or understood and distained, depending). As the case of Phineas Gage points out, it’s also the part that makes you not a fuck-up. Take it away, and you will not be the person you once were.
After his now infamous head injury, Gage was never the same man again, and he could never go back to his old life. The extensive damage to his prefrontal cortex caused a detriment to his emotional understanding and had huge implications to his personality. It changed almost every aspect of his daily life. Without any control or comprehension of his emotions, he was no longer universally seen as a good man. People who knew him found him impatient, insensitive, lazy, irritable, and paralysed by indecision. He also often came across as capricious and reckless, sometimes seeming almost manic in behaviour. He became inseparable with the iron rod that made his fame but destroyed his old life and purportedly carried it everywhere with him, which must have made him look pretty creepy. His injuries had left him intolerable to polite society.
His alexithymia – the inability to recognise and name emotions – left him directionless and lost. He was fired from his much-loved job as a foreman due to his volatile inhibition and his terrible decision making. Doctor Harlow was reportedly astounded by his behaviour, as on the rare occasion that Gage did make a decision, it was generally detrimental to his livelihood. It was not just that Gage could not make a decision, but that every decision he did eventually make was blisteringly awful.
Gage wasn’t alone. In Damásio’s fascinating, seminal and sometimes horrifying book Descartes’ Error he tells the stories of many people with frontal lobe damage, including Elliot, who could think of many ways to make friends when moving to a new town but found it impossible to pick one, and a man who came up with many grand ideas about how to regain his earlier successful career but could never make the decision to implement any of them. Damásio, Everitt and Bishop (1996) went on to discover that research participants with damaged pre-frontal regions of the brain, especially in the ventral and medial areas, showed markedly impaired competence in decision making tasks, especially when planning and organizing. This occurred even though the ability to apply logic was preserved, as were all other intellectual abilities. Research by Bechara, Damásio, Tranel & Damásio (1997) concluded that the only converging symptom of these patients was that each participant showed profound difficulty in expressing and experiencing emotions.
In short, people with frontal lobe damage often seem to experience emotional difficulties. These emotional difficulties mean making sound life decisions is difficult, seemingly because you can’t create a representation of the imminent emotional consequences of your actions. If you struggle to interpret what’s happening in your body, your thoughts, and your imagination as emotions, but only as weird bodily symptoms, your decision-making abilities are going to be thrown into chaos.
Gage never got to go back to his family and friends after the accident. Instead his body returned to them a foul-mouthed, excitable, irrepressible man-child. The punctual, conscientious, cheerful leader never went back to his job; he was replaced by a sullen and uncommitted man who couldn’t make leading decisions and rarely turned up at all. He only survived until he was 56 and died because of seizures brought on by his wound.
But there is hope in this. If Gage could take a piece of hot metal travelling at high speed to the brain and live to tell the tale, we know the brain and body are not as fragile as we sometimes fear. Gage was a survivor, and made the enormous hole in his brain work for him; for a while he even turned it in to his job, posing next to his tamping iron at museums and lectures. He owned his trauma, he found fame and money in it, and became a legendary figure for it, finding a place in neurology and pop-psychology lore for decades to come. The old Gage died when the rod went through his head, but the new Gage lived – and, eventually, lived rather well. The brain is a master repairer and no function in the brain is truly centralised – the brain finds new neuronal pathways to do what is essential, and Gage’s bad luck with the tamping iron proved that emotional well-being is essential indeed. As time went by, Gage was reported to have mellowed substantially, and to have found a quiet and stable life driving coaches in Chile. Here, his employers once again described him as focused, reliable, and likeable. He adapted to a functional life built around routine and organisation, and he became better at social niceties as the years passed. Structure and social recovery seemed to be the key, as it is now in rehabilitation of those with frontal lobe damage. Gage rebuilt himself as a new man with a new life – and if he could do it with a hole in his brain, there’s hope for all of us.
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Katy Lees - Therapist & Author 