The Sad Case of Phineas Gage
Santiago Ramón y Cajal’s drawing of cells in the cerebral cortex. The smaller cells with long extensions, for instance labeled “E” and “F,” are neurons, and the larger cells, for instance labeled “A,” are glial cells which support the neurons metabolically and help brain function.
The largest part of the human brain is the outer area, the cortex. In 1848, Phineas Gage suffered an injury that changed his life. Part of his cortex was destroyed. Hanna Damasio made a computer reconstruction of Gage’s skull, to find that damage was mostly to his frontal lobes. Her husband, Antonio Damasio, found that modern people with the same damage were impaired in their interactions with others. Among newer technologies of brain research is functional Magnetic Resonance Imaging (fMRI), which enables activities of brain areas to be monitored as people have different kinds of experience.
Parts and Connections in the Brain
Of all the subjects of scientific research—the subatomic structure of the universe, the evolution of plant and animal species, the biochemical processes of the body’s cells—understanding the mind seems the most challenging. Mind can be thought of as the functioning of the human brain. The figure at the opening of this chapter shows some shapes of the brain’s neurons (nerve cells) and glia, which are cells that support them. This image was drawn in 1920 by Santiago Ramón y Cajal.
In an interview for the Guardian newspaper, Suzana Herculano-Houzel said that although 100 billion had been assumed to be the number of neurons in the human brain, a recent count has shown that the number is about 86 billion.1 Herculano-Houzel and her colleagues looked hard in four brains, but just couldn’t find the other 14 billion. Even so, 86 billion are a lot: twelve times as many as the number of people in the world. Herculano-Houzel has argued that the brain can have so many neurons, more than any other primate, because neurons use a great deal of energy, and were able to become numerous by means of the invention, 1.5 million years ago, of … cooking. This allowed humans to eat foods with more calories than were available to our primate cousins.
In terms of the organization of the brain, three levels of structure are recognized. The level of smallest detail is that of the interiors and membranes of neurons, which transmit signals along their extended parts, called axons, by electrical properties of their membranes. Then, when a message is passed from one neuron to another, this happens not electrically but chemically. Small quantities of chemicals called transmitter substances are released. They cross the tiny gap, called a synapse, to affect the receiving neuron.
At the next level of brain organization are neurons themselves, and connections among them. At these connections a neuron can tend to be activated or to be inhibited, so the synaptic connections are switches of a kind. It’s thought that each human brain-neuron’s average number of connections with other neurons is about 7,000. So that makes the potential number of switches in the brain something of the order of 86 billion multiplied by 7,000. It is perhaps not surprising therefore that many scientists have made the analogy between the brain and a supercomputer. The brain uses many chemicals that affect neural activations, and they are unevenly distributed among the brain’s systems. Nearly all drugs that affect the brain—from alcohol, which has long been used to decrease anxiety, to the newest sleeping pills—work by changing the effects of particular chemicals, or groups of chemicals, on receiving neurons, that is to say they work on the connections.
At the level of anatomy that one can see without a microscope, the human brain has three main regions. The inmost region includes the brain stem and cerebellum. The brain stem is joined to the spinal cord. It receives signals from receptors and sends signals to activate muscles. It’s responsible for automatic functions such as breathing, and alertness. The cerebellum is concerned with the orchestration of movement. A middle region consists of areas that include the thalamus, thought to be a relay station for sensory signals; the amygdala, which is concerned with emotions; and the hippocampus, which has functions that include memory and understanding spatial layouts. By far the largest part of the human brain is the outer layer of the brain’s hemispheres: the cortex. At the rear of the cortex are areas concerned with vision. Above the ears are areas concerned with bodily sensation and the making of movements. At the front, above the eyes, are areas that are especially well developed in humans, the frontal lobes.
To find out how it all works may seem impossible, but there has been progress. How has it happened? Through a combination of psychology and neuroscience. An important step occurred in the middle of the nineteenth century when our understanding of neurology was given a jolt by effects of an accident that destroyed part of a person’s brain. The part was the front region of the cortex. The person was Phineas Gage.
A Railway Accident
The nineteenth century saw the coming of steam engines and trains. Rail construction was intense. Near the town of Cavendish, in Vermont, a group of men worked on a stretch of the Rutland and Burlington Railroad. The men were led by their capable and likeable foreman, Phineas Gage.
To make way for train tracks, rocky outcrops had to be cleared, and this was done by blasting them with gunpowder. A hole would be drilled in a rock and filled with gunpowder. Then a fuse would be inserted. The workers would retreat to a safe distance and an explosion would be set off. At about half past four in the afternoon of September 13, 1848, a rock had been drilled, and Gage had poured gunpowder into it. He rammed it in tight with an iron tamping rod which was three feet, seven inches long, and an inch-and-a-quarter in diameter. As he rammed in the powder, the rod must have set off a spark, because there was an explosion. The tamping rod entered Gage’s left cheek, pointed end first, and left through the top of his head. It landed a fair distance away, smeared with brain and blood.
Gage was thrown to the ground. His men, “with whom he was a great favorite,” said his limbs convulsed a bit, but a few minutes later he was able to speak. They took him by oxcart to a hotel in Cavendish, where a local doctor, John Harlow, was summoned. Harlow helped Gage to an upstairs room, laid him on a bed, dressed his wounds, and subsequently wrote up Gage’s case.
John Harlow provides us with a turning point in our understanding of ourselves.2 He came from a farming family in upstate New York, near the border with Vermont. He trained in medicine at Jefferson Medical College in Philadelphia. He was twenty-six years old in 1846, when he started his practice in Cavendish, a community of some 1,300 people. His treatment of Gage, two years later, included the draining of an abscess, and also the letting of 16 ounces of blood, as he believed this would reduce inflammation. Other than that, his treatment was conservative. He wrote: “little if anything was done to retard the progress of the case, or to interfere with the natural recuperative powers. Nature is certainly greater than art,” and, he said, on the fifty-sixth day after his accident Gage was walking the streets again.3
Gage’s injury was terrible, and in those days before antibiotics, the wound became infected. But Gage recovered. That is to say his body recovered, but something strange had happened to his mind. Whereas previously he had been even-tempered and friendly, he was now impatient and easily angered. People who knew him said he was “no longer Gage.” In his account of the case, Harlow wrote:
He is fitful, irreverent … 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.4
In the sentences that follow Harlow wrote, “he has the animal passions of a strong man,” and “[t]he equilibrium or balance, so to speak, between his intellectual faculties and his animal propensities, seems to have been destroyed.”
Although Phineas Gage had previously been the railway construction company’s “most efficient and capable foreman,” he was no longer capable of doing his former job. He kept the iron tamping rod, and he exhibited himself along with this rod at Barnum’s Circus. Later, he worked with horses for eight years in Chile, and then in 1860, with his health failing, he returned to the United States, to San Francisco where his mother and sister lived. He tried several jobs there, but found something wrong with all of them. In 1861, he died, after suffering several days of convulsions.
Figure 5. Image from John Harlow’s paper showing Phineas Gage’s skull, and the tamping iron that had passed through it. Source: Harlow, J. (1869). Recovery from the passage of an iron bar through the head. Boston: David Clapp and Son, p. 21, figure 2.
Five years later, John Harlow heard about Gage’s death, and persuaded the family to allow his body to be exhumed. Harlow read his paper to the Massachusetts Medical Society on June 3, 1868. He said that Gage’s family “waiving all claims of personal and private affection … have cheerfully placed this skull (which I now show you) in my hands, for the benefit of science.” In figure 5 you can a see a picture of Gage’s skull, with the tamping iron that passed through it.
Our knowledge of Gage comes from Harlow’s published account. Although Harlow described himself as “an obscure country physician,” this was undue self-deprecation.5 His skill helped Gage survive. His paper on the brain injury and its psychological effects came at an important moment. Word of it spread, and it became critical to our understanding of the brain’s effects on the mind, on emotions, and on personality.
If the brain is damaged, serious consequences occur. Many people will have observed sudden changes of personality that have occurred to a friend or relative who has had a stroke. Sometimes such changes come about slowly, as happens with Alzheimer’s disease. The case of Phineas Gage was distinctive in that both the brain damage and its effects were sudden and well-marked. A change occurred to the emotional structure of Gage’s way of being in himself and with others as a result of damage to a specific part of the brain.
Modern Phineas Gages
When Gage died, no autopsy was performed. It had been thought from the position of the holes in Gage’s skull that the main damage to his brain would have been in the region behind the forehead: the frontal lobes. In 1994, Gage’s fame was renewed when Hanna Damasio and colleagues made a computer reconstruction of the damage. In the same year Damasio’s husband, Antonio, wrote a best-selling book, Descartes’ Error, about the personality changes that occurred in some of his patients who had suffered damage to these same areas of the brain. He called these people “modern Phineas Gages.”
Harlow had discerned some of the changes that had occurred to the original Gage. By making comparisons with people whose brains were undamaged, Antonio Damasio was able to crystallize what had gone wrong for his modern Phineas Gages. He found that they had not lost their intelligence but that they showed two problems that were connected. They had difficulties in making everyday plans and, in conjunction with this, they suffered from disorders of their emotional lives. This was surprising. We tend to think that making plans requires mere logic: if we want to do this, we must first do this, then that, then something else. Damasio suggested that planning in everyday life is not pure logic, but is centered on the emotions.
Damasio called one of his patients Eliot, and wrote a case history. Eliot had previously been happily married and had worked professionally in a business. He had lost parts of the frontal region of his brain when a tumor had to be operated on. The operation was a success, but Eliot was no longer able to work properly. He couldn’t carry out everyday plans. He needed to be prompted to go to work, his attention was easily distracted by matters that were irrelevant to what he was supposed to be doing, and he lost sight of important goals. He would spend huge amounts of time vacillating about matters of no importance. He was fired from his position. He pursued several new business schemes. One was with a person whom his friends warned him against; it ended in failure. Eliot lost all his money and went bankrupt. His wife divorced him. He married again, someone of whom his family and friends disapproved. He divorced again.
Here is a way to imagine this. Suppose you are on the subway in a big city. A man sits next to you. Before a couple of subway stops have passed, this conversation starts:
“Are your life savings important to you?” he says.
“Of course,” you say.
“Have you got fifty thousand dollars?’
“I’m not sure.”
“I can double it for you.”
“How do you mean?”
“I’ve started a new business, on the Internet. In six months
I can turn your fifty thousand into a hundred thousand.”
“What sort of business?”
“You need not worry about that. You can trust me.”
Although it would be a nuisance to wait for the next train, many of us might say: “Sorry, this is my stop. Nice to meet you.” We would not trust someone we did not know who made such promises. We might worry that this man could suddenly become threatening. We might have an immediate intuition that we had better avoid this person.
Damasio’s Eliot, and other modern Phineas Gages, no longer had this kind of intuition. They did not know whom to trust. Damasio devised a task in which he found that people who had damage to their frontal lobes took large risks that normal people avoid. Because their emotions did not work properly, they were unable to make sensible plans.
Damasio suggests that the main explanation for this effect is that ordinarily in our interactions with others we are affected by what have come to be called conditioned emotional responses, in which, when there is a signal of danger, or when we sense that something in the world isn’t right, we become anxious and take avoiding action. This is part of our emotional guidance system. For Eliot and other modern Phineas Gages this was no longer working.
Damasio recounts how this was not the only thing that had gone wrong with Eliot. Although his intelligence and memory were good, other aspects of his emotions seemed no longer to function normally. He seemed to have no conception of the tragedy that had overtaken him. If he talked about his operation, or about losing his job, or his wife divorcing him, he would recount the events without expressing any hurt, sadness, or disappointment. When Damasio showed him pictures of burning buildings or of people injured in accidents, he had no reaction. He felt neither positively nor negatively toward them. He told Damasio that since his operation, he was no longer moved by events that previously would have caused strong emotions. It’s clear that different kinds of emotional effect can occur from brain damage. Whereas Phineas Gage had been irritable, Eliot was calm. For both, however, emotional relationships stopped working properly. An older way of thinking about this was that emotions arise in lower parts of the brain and are inhibited by higher parts such as the cortex.6 More likely to be correct is a modern view, of the kind for which Damasio is arguing. It is that emotions are to be thought of as the center of who we are and of how we relate to each other.
In describing an interaction with another patient with frontal lobe damage, Damasio recounts how he had suggested two possible dates for the patient’s next visit. Then, he writes: “For the better part of half an hour the patient enumerated reasons for and against each of the two dates.” Damasio says he found it difficult to avoid pounding on the table and telling him to stop. In the end he told the patient quietly that he should come on the second of the dates. “That’s fine,” said the patient. When those of us whose emotional systems are working properly have to make decisions of this kind we can say, “It’s all the same to me, let’s say the Tuesday.” It’s unimportant. But without properly functioning emotions, one may not know what is important and what is not.
Tim Shallice and Paul Burgess studied patients who suffered brain damage, and they have done research on how the carrying-out of plans is affected. To three such patients whose intellectual capacities were normal, they gave shopping lists and some money and asked them to go to a shopping center near their hospital, to buy the things on this list, and to find out some information. As compared with eleven people who did not have brain damage who undertook the same task, the three patients made four times more errors and two of the three got into social problems. One had a shopkeeper run after him when he took a copy of the previous day’s newspaper without paying for it. He thought that if it were yesterday’s, it was free. The other got into a heated argument with a shop assistant.
The patients we’ve discussed in this chapter are unusual. They suffered damage to discrete areas of their brains. What about changes of a far more common kind that occur to people who, perhaps toward the ends of their lives, become demented from widespread vascular damage, from Alzheimer’s disease, or from Parkinsonism?
Studies of the Brain
It’s more than a century-and-a-half since John Harlow published his paper on how the damage to the brain of Phineas Gage affected his emotions and personality. We no longer rely on effects of accidents to understand the brain’s contribution to the mind.
The anatomy of the brain at different levels has been studied, as have the effects of lesions such as that sustained by Phineas Gage. To this evidence has been added the effects of stimulating the brain electrically or with chemicals, as well as of electrical recording of nerve impulses from single neurons, and of summed neural activity in whole brain areas. Among recent methods of recording are computerized brain scans, the most popular of which is functional Magnetic Resonance Imaging (fMRI). It depends on monitoring the rate at which oxygen from the blood is absorbed into brain tissues in particular regions; it shows when neurons in these regions are active. By means of computer reconstructions, detailed images of the brain show areas that are activated during some particular task, or in certain circumstances, in contrast with those that are inactive. We discuss studies of such brain activations in chapter 11.
Studies that use neuro-imaging, and other brain-based methods, are appealing in psychology because they can seem to have more substance than the usual kinds of psychological measurement, which rely on people’s reports on their experience, or mere observations of behavior.7 Some people think, therefore, that it’s to brain science rather than to psychology that we should look to understand the mind. But imagine that you are a member of a technologically advanced alien species and have managed to acquire a consignment of one hundred mobile phones from planet Earth. You know nothing about humans. You only have these objects, and you can study them in the four ways in which researchers study the brain: anatomy, lesions, stimulation, recording. What would you be able to discover about these objects? You might find that the devices work by electricity, perhaps even that they could send and receive radio waves. But without knowing what such objects were used for in society, or what concepts of a functional kind were relevant, would not your task, perhaps, be hopeless? In an equivalent way, would not brain science be empty without psychological understandings of the mind and of how the mind makes meaning?
Descartes said, “I think therefore I am.” Damasio says he was in error, that it’s not in our ability to think, but in our emotions and our connections with other people that we are ourselves. Jaak Panksepp continued this line of thought and has written that what Descartes should have said is, “I feel therefore I am.”8 It was in their emotions and ability to make interpersonal arrangements that Phineas Gage and modern Phineas Gages had lost themselves.
We depend on friends and acquaintances being predictable to themselves and to others, on them being sensible. And despite the influence of unconscious processes, we depend on them being essentially capable of choosing their actions and interactions. What happens when damage or deterioration occurs in the brain? Are these people still the same as those we knew, the same as those on whom we once perhaps depended? Are they still themselves?
Stephanie Preston, with Hanna and Antonio Damasio, and other colleagues, used brain imaging in a study of people when they thought about stories of others.9 When participants could relate to the circumstances of another person they exhibited, in themselves, patterns of brain activation and physiological states that were equivalent to those that occurred when they imagined themselves to be in that situation. As they sought to understand the person, they experienced empathy. When they could not relate to the other person’s story, their brain activations and physiological responses decreased. These results appear to reflect differences in people’s ability to experience empathy, an emotional state. It’s to the psychology of emotions that we now turn.
