Phineas P. Gage was a good, steady 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 into 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. Everyone thought of him as 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 soldier.
On further medical examination, it was concluded that Gage’s left frontal lobe had more or less left the building. What was left 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 splattered 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 like the old Gage used to. 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 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, things became apparent that not all was 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.
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 disdained, depending). And as the case of Phineas Gage points out, it’s 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 and in 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 ended becoming inseparable with the iron rod that made his fame but destroyed his old life, and purportedly carried it everywhere with him. 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 often astounded by his behaviour, as on the rare occasional 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 he seemed incapable of not making blisteringly awful decisions.
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 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 Damásio et al.’s (1996) 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.
What scares me most about the case is that Gage didn’t live; Gage was gone as soon as the majority of his frontal lobe was forcibly ejected from his head and onto the dusty ground several feet away. Gage never went back to his family. 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 lived 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 into 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 wellbeing 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 more functional life built around routine and an organised life, 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.
