Tue. Feb 25th, 2020

A metal tube went through his brain and lived to tell, but at what price?



The sky was already turning orange. The cold began to creep through the work overalls and night would soon fall. However, it was still 4:30 in the afternoon and Phineas Gage had a long job to go. His task was simple, as the foreman of the work had to drill the rock he found in its path, introduce gunpowder into the holes, cover it under pressure and set fire to the fuse. Thus, when detonated, they would clear the way for other operators to place the train tracks that would lead to Cavendish. It was a dangerous job, but luckily, Phineas was “the most capable man of service.” Nothing bad would happen while he was on duty, until, of course, it happened.

Phineas gave up for a moment, just enough time for him not to pay attention to his partner, ignoring that he had not yet covered the gunpowder of the hole. Thus, he raised the heavy metal bar and, continuing with his work, prepared to compress the powder. He inserted the bar into the hole and squeezed with all his might, however, the rock struck again. The sparks raised by the bar had made their way to gunpowder, there was no cover to prevent it. The explosion was so strong that he threw the bar through the air. When it landed, more than twenty meters from the rock, its gray surface was covered with red and strange pieces of what looked like a white jelly. They were pieces of Phineas himself.

The bar had entered his left cheek and, crossing his skull, opening an exit over his forehead. More than a meter of iron furrowing his brain, making way for its 3 centimeters thick. That September 13, 1848 Phineas was born again.

Despite the carnage, Phineas did not lose consciousness, with the help of his companions he mounted a cart of oxen that, without wasting time, approached him to Cavendish’s pension. There the doctors came, first Edward William and later John M. Harlow. Phineas was still awake and could even manage to, with British phlegm, tell William “Doctor, here is work for you.” The doctors washed the wound as they could, removing bone chips and blood clots. They could not explain how it was possible that Phineas had entered by his own foot, with the broken skull and a “bone funnel” at the top of his forehead.

Against all odds, after an infection and almost falling into a coma, Phineas recovered from the improvised intervention, though, as Harlow himself said:

The birth of a myth

Gage had changed, but so much? The truth is that at that time it began to present epileptic seizures, the lesion had altered the connections of the surrounding neurons, causing them to fire disorderly, sizzling and activating the rest of the cerebral cortex. It was an expected change, something already seen in soldiers who had received gunshot wounds. However, what their doctors related was something quite different, they talked about changes in their personality, in what they made of that man who he had been until then.

They talk about a man unable to keep his job, impulsive, aggressive, violent with his wife and children. Really hard claims that have marked the history of Phineas for decades. Thousands of neuroscience books have among their anecdotes that of that bar that transformed Phineas into an animal, an example of how the frontal cortex damaged by the metal fulfilled inhibitory, containment functions. Those things that counted the books were really heinous, things that would have made Phineas a true monster, if it were not that, the good man of Gage, had no children, no woman, not even a partner. His own mother related how, after the accident, Phineas had developed a deep love for animals and not less so, for his nephews, with whom he played daily. But then where did the most famous history of neuroscience come from? A story told to doctors, psychologists and every student of human behavior for decades began to show worrying gaps in its structure.

The little we know

Normally, the answer to these contradictions is usually found in documents of that time that corroborate or deny them. Unfortunately, there is hardly any literature on Phineas Gage beyond all posthumous publications. On the other hand, the few that do exist are vain, lacking the details that would help us reassess the situation. For example, one of the most important texts dates from 1868 and in it, his doctor summarizes the state of Phineas in barely 200 words.

After saying this, he begins to enumerate all the new defects of Phineas: Irreverent, rude, selfish, impatient, stubborn, capricious, little foresight and, as if that were not enough, he added: “show the intellect of a child”. It seems surprising that his personality could have changed so much in an instant and without altering the rest of his brain functions, but there is a trick, most of the adjectives that Harlow assigned him shared a common origin, an absolute incapacity of foresight.

Could this be true? It may be that Phineas did not become aggressive and selfish, but his personality changed more subtly, making it difficult for him to make rational decisions or take others into account. In fact, we now know that some lesions in the frontal cortex are related to the inability to decide, as was the case with Dr. P. or the EVR patient. This coincides with other testimonies, which indicate that, after the accident, Phineas was not able to keep a job again. His interests were fickle and he soon changed jobs or made mistakes for which he was fired. This is the story that is often read in many textbooks, even when they omit the myth of their animal impulses, and yet it could be that even this moderate version was not true.

An exemplary worker

Harlow insists that Phineas jumped from one job to another, possibly because of that inability to organize. He tells that he lived on charity, practically in misery, traveling as a fair monster in various circus shows. But where are the tests? There are no records or correspondence of Cage where the myriad of works attributed to him are related. In fact, the most likely statements of the good doctor were referring to the months immediately after the accident. Something that makes sense if we know that, not long after his recovery, Phineas left England to never return.

We know that, after the accident, Phineas moved to Chile, where he supposedly wanted to build a railway line. However, he ended up working as a diligence driver and taking care of the horses on a farm. A few years later he decided to reunite with his family, who now lived in California, and there he found a new job. That’s all, no circus or charity, it seems that between 1851 and his death in 1860, Phineas had only a couple of jobs.

Exhumation

However, there were still many doubts about Phineas’ injury. For doctors, it was still a matter of debate about how the bar had not affected speech, if it had supposedly crossed brain structures related to it, such as the Broca area, located precisely in the left frontal lobe. The scientific controversy motivated that in 1868 his body was exhumed, but the methods of that time were insufficient to reconstruct the real trajectory of the bar. It would take 124 years, until, in 1992, Phineas’ skull fell into the hands of the person who would solve the mystery, Dr. Hannah Damasio.

Dr. Damasio scanned the remains of Phineas with an MRI machine, digitizing every detail of its structure. Thanks to this, he was able to simulate the exact trip of the wand and, therefore, estimate what brain structures could have affected its passage. Later studies, such as Ratiu and Talos or Van Horn, further refine these estimates, roughly confirming what was proposed by Dr. Damasio. Both agreed that the injury had been fairly clean and had eluded most of the structures we consider to be of primary importance, such as the Broca area. However, the orbitofrontal cortex, the most related to the ability to make decisions (if we simplify things a lot) was in full swing of the wand, what did this mean? Can’t history tell the clear things at once?

I’m afraid not, in fact, that is one of the main problems in the history of science. We know what documents can tell us, neither more nor less. I wish we could submit Phineas to the same tests as any patient today, but since that is impossible, we will have the doubt about how the famous metal rod changed Gage forever.

There is a big difference between fables and history, and if we want to someday understand how our brain works, we will need to do without the former. Time will relegate Gage to be part of curiosity lists, and will be replaced by more current and better documented cases. Gradually Phineas will fall into oblivion, but despite that, it will remain one of the most interesting and mysterious cases in the history of our brain.

DON’T KEEP IT UP:

  • There are many cases of lesions in the frontal cortex. Not only the most popular, such as Dr. P. or the EVR patient, but unfortunately we have hundreds of histories of patients undergoing lobotomies. Subjects to whom, with therapeutic intentions, their frontal cortex was damaged.
  • There is no truthful information about the alleged aggressiveness of Phineas. On the contrary, because his relatives described him as an affectionate person, both before and after the accident.
  • We don’t know for sure if Phineas had work instability problems after recovering from the accident.

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