Phineas Gage, on Second Thought

Nearly every student beginning their neurology studies is told the story of Phineas Gage, the man who had an iron rod shot through his head and survived. The story goes that he was personable before the accident, and profane and hostile afterwards. It was the first time scientists of the day learned that the brain and the mind are connected, that damage to one can affect the other. Ever since his unfortunate accident, Phineas Gage has occupied that top step on the podium of famous cases in neurology. Everybody's heard it; nobody doubts it. Today we're going to take a lesson from almost 750 past episodes of Skeptoid and view Phineas through our skeptical eye. Did the real events match the story that's told today, and was it really the milestone that every textbook makes it out to be?

The year was 1848; the place, Cavendish, Vermont. The Rutland and Burlington Railroad was running some new track and needed a patch of rock blasted away, a job done by drilling holes and filling them with blasting powder and sand. 25-year-old Phineas Gage was a hotshot foreman, known for improving the company's operations with his clever innovations. He'd even improved the design of the tamping iron he used, having recently had it custom made by a blacksmith: it was 3 feet 7 inches long (109cm) and an inch and a quarter thick (3cm), and forebodingly tapered to a rounded point at the top. Phineas was a small man but handsome and well built, looking quite a bit like a young Christopher Reeve. He was good with business matters in addition to being an efficient and productive foreman. In that role, he assumed the most dangerous job reserved for the one with the most sense: to carefully tamp the blasting powder down in the hole with the iron.

It's not clear exactly what went wrong, but the blasting powder in one hole was sparked when he struck it. The tamping iron fired upward like a shell from a cannon, its point entering Phineas's open mouth just outside his left molars (knocking just one out). It passed inside his zygomatic arch, struck the back of his left eye socket, and exited the top of his skull just behind his hairline. The maiming was instantaneous; for a moment nobody was even sure what had happened, Phineas included. The iron hovered in the air high above, turned and fell back to Earth, picked up speed, some said they heard it whistle. Phineas slowly staggered backward, and just as he collapsed, the rod speared into the ground like a javelin with a solid thunk, only 25 yards away. Those simultaneous impacts signaled the beginning of neuroscience.

Phineas never lost consciousness. He was taken by oxcart back to the hotel where he lived where he sat in a chair on the porch to await the doctor, while those who tended him were horrified by the appalling wound. When the first doctor arrived, Phineas famously deadpanned "Here's business enough for you." But it was the second doctor, John Harlow, whose role in Phineas Gage's story would make it famous.

I've no desire to be unnecessarily graphic or gross, but the messy condition of the wound is important. Dr. Harlow had to reach his fingers up through Phineas's open sinus and down through the hole in the top of his head to remove skull fragments. The whole afternoon, Phineas was gagging and retching as blood, brain matter, mucus, bone fragments, and vomit mixed freely in his mouth and sinus. Upon one retching, Dr. Harlow noted that about "half a teacupful" of brain matter was ejected through the hole from the pressure. All of this horrible unsanitary mess is important because of what happened to Phineas a few days after his wounds were closed: unsurprisingly, a fungal infection in his brain. Whatever damage the injury did to his brain, this infection may well have done even worse. The net result is that we don't know how injured his brain was; computerized reconstructions of the injury itself can at best tell only a part of the story.

For several weeks, Phineas lay in a coma and very nearly died. His infected brain swelled and Dr. Harlow performed another surgery to relieve pressure. Eventually, though, Phineas pulled through and was able to resume his life. In a nutshell, that involved showing himself off as an oddity for a while, including a stint at PT Barnum's museum in New York; working in livery stables in New Hampshire for more than a year; moving to Chile to help found a stagecoach line, then driving a six-horse stagecoach there for seven years; then finally moving to San Francisco where his parents had relocated and working as a farm laborer. Certainly as a result of his brain injury, he soon began suffering epileptic seizures, and one finally took his life at the age of 36, nearly twelve years after the accident that he never should have survived.

Generally, the frontal part of the brain handles higher functions that give us our amazing human abilities, while the back part handles the functions of keeping our bodies alive. Scientists of Phineas Gage's day knew that injuries to the back of the brain were often fatal, while injuries to the front were often survivable. So they tended to conclude that the frontal region was non-functional. The reports of Phineas's changed personality altered that perception, and truly did launch neuroscience as a field of active research. As one article in the journal Neurología put it:

Gage had, through a tragic natural experiment, provided proof of what Ferrier's studies showed: the pre-frontal cortex was not a "non-functional" brain area. A rod going through the prefrontal cortex of Phineas Gage signaled the beginning of the quest to understand the enigmas of this fascinating region of the brain.

Probably the world's leading authority on Phineas Gage is Prof. Malcolm Macmillan from the University of Melbourne School of Psychological Sciences. He literally wrote the book on Phineas, titled An Odd Kind of Fame. Macmillan finds that the facts we actually have about Phineas's injury and its effects upon him are minimal. In fact, fewer than 200 words were written describing his infamous change of personality. And not only do those descriptions contradict some of the facts of his later life, they were written from the perspective of phrenology — a now thoroughly debunked early attempt to understand the brain by studying the bumps on the skull. In an 1851 edition of the American Phrenological Journal, Dr. Harlow wrote:

We have been informed by the best authority that after the man recovered, and while recovering, he was gross, profane, coarse, and vulgar, to such a degree that his society was intolerable to decent people. Before the injury he was quiet and respectable. If we remember correctly, the iron passed through the regions of the organs of benevolence and veneration, which left these organs without influence in his character, hence his profanity, and want of respect and kindness; giving the animal propensities absolute control in the character.

In other words, it was the pseudoscience of phrenology from which we get the diagnosis that the personality traits lost to Phineas by the damage to his left prefrontal cortex were those of respect, benevolence, and reverence.

Whatever changes to Phineas Gage's personality or temperament might have followed the injury, they appear to have been short lived, judging by accounts of his later life, none of which cast him as an angry, swearing ruffian. Some evidence finds that he quite thoroughly recovered, including an account by a doctor who met him in Chile around 1858, and the very nature of the stagecoach work that he so capably performed for seven years. Macmillan described it:

He would have had to rise early each driving day, prepare himself, feed and groom the horses, harness them to the coach, and be at the departure point by 4am. There he would have had to deal politely with the passengers, load their luggage (up to 50 pounds each), and collect fares, and so on, before beginning a 13-hour journey over 100 miles of poor roads, often in times of political instability or frank revolution. All this — in a land to whose language and customs Phineas arrived an utter stranger — militates as much against permanent disinhibition as do the extremely complex sensory-motor and cognitive skills required of a coach driver.

Yet if you're a student in psychology or neurology, you probably never heard that Phineas recovered at all. In 2015, Richard Griggs at the University of Florida analyzed accounts of Phineas in 23 recently published or updated textbooks. Only four of them mention the years Phineas worked in Chile at a job requiring great physical skill and finesse. Only three of the textbooks include the reports that Phineas appeared to have recovered mentally.

It is true that the case of Phineas Gage did trigger a revolution in the science of neurology, and we should rightly remember it for that. But Macmillan argues that there's a lot more to it:

Phineas' story is worth remembering because it illustrates how easily a small stock of facts can be transformed into popular and scientific myth. I was much struck by David Ferrier's remark in an 1877 letter about Phineas to Henry Pickering Bowditch in Boston. He asked Bowditch for the facts about Phineas as they were originally reported because he was 'amazed at the inexactitude and distortion to which they are subject by men who have some pet theory to support'. And as we have seen, scientific myths about Phineas continue to be used to support particular theoretical positions.

In literature, there's something of a stereotype of a human being treated as a common lab rat by the medical sciences. The passage of time and the lack of documentation have robbed us of the chance to know anything concrete about Phineas Gage the human being, but for a few snippets of doctors' notes scribbled to meet the demands of a medical journal of the day. Phineas's skull, exhumed upon request a few years after his death, sits on display in an obscure room at Harvard — and, as if that's not enough of an indignity, it's displayed beside the very same tamping iron that blew him out of the human race and into the textbooks as an oddity. It is the symbol by which history has decided that young man should be defined. Not the ideas he had as a blossoming businessman working for the railroad, not the daydreams he painted while handling his team through the rocky passes of Chile, but a prosaic case study in cold iron and a shattered life.

Macmillan always said that over the course of his many years studying Phineas Gage he came to regard him as a friend, and only ever referred to him by his first name, Phineas. But for you and I, our lives are busy with other things so we won't ever know Phineas even to the limited degree Macmillan was able. But the two existing photographs of Phineas are widely available online. I challenge you to give yourself a little present. Find one of them, look into his one remaining eye, through that proverbial window to his soul, and imagine what he was thinking. And know that there is someone in there.

By Brian Dunning
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