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  Phineas Gage

  A Gruesome but True Story About Brain Science

  John Fleischman

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  PHINEAS GAGE

  A Gruesome but True Story About Brain Science

  by JOHN FLEISCHMAN

  Houghton Mifflin Company Boston

  * * *

  Copyright © 2002 by John Fleischman

  ALL RIGHTS RESERVED. For information about permission to reproduce

  selections from this book, write to Permissions, Houghton Mifflin Company,

  215 Park Avenue South, New York, New York 10003.

  www.houghtonmifflinbooks.com

  Book design by Lisa Diercks

  The text of this book is set in Janson Text.

  Library of Congress Cataloging-in-Publication Data

  Fleischman, John.

  Phineas Gage: a gruesome but true story about brain science / by John Fleischman

  p. cm.

  RNF ISBN 0-618-05252-6 PAP ISBN 0-618-49478-2

  1. Gage, Phineas—Mental health. 2. Brain damage—Patients—United States—

  Biography. 3. Brain damage—Complications. 4. Personality disorders—Etiology. I. Title.

  RC387.5 .F565 2002

  362.1'97481044'092—dc21

  [B] 2001039253

  Printed in Singapore

  TWP 20 19 18 17 16

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  As always, for Mary

  * * *

  Acknowledgments

  To Tim Clark, who gave me the time and place to begin. To my medical readers, Dr. Robert Pressberg, Dr. Barbara Skolnick, and Dr. Jeffrey Macklis, who are responsible only for correct anatomical facts, the author being responsible for all errors. To Virginia Hunt of the Countway Library of Medicine, Harvard Medical School, who was so generally helpful. To Dr. Denise Natale of the Cavendish Chamber of Commerce, who never lost patience with Phineas. To Dr. Joseph Gall and the American Society for Cell Biology for Hooke's flea and Hooke's cells. To Dr. Malcolm Macmillan of Deakin University, Australia, who knows more than anyone about Phineas Gage, and to Amy Flynn, who did not blanch at first glance.

  "Horrible Accident" in Vermont

  The most unlucky/lucky moment in the life of Phineas Gage is only a minute or two away. It's almost four-thirty in the afternoon on September 13, 1848. Phineas is the foreman of a track construction gang that is in the process of blasting a railroad right-of-way through granite bedrock near the small town of Cavendish, Vermont. Phineas is twenty-six years old, unmarried, and five feet, six inches tall, short for our time but about average for his. He is good with his hands and good with his men, "possessing an iron will as

  well as an iron frame," according to his doctor. In a moment, Phineas will have a horrible accident.

  It will kill him, but it will take another eleven years, six months, and nineteen days to do so. In the short run, Phineas will make a full recovery, or so it will seem to those who didn't know him before. Old friends and family will know the truth. Phineas will never be his old self again. His "character" will change. The ways in which he deals with others, conducts himself, and makes plans will all change. Long after the accident, his doctor will sum up his case for a medical journal. "Gage," his doctor will write, "was no longer Gage." Phineas Gage's accident will make him world famous, but fame will do him little good. Yet for many others—psychologists, medical researchers, doctors, and especially those who suffer brain injuries—Phineas Gage will become someone worth knowing.

  That's why we know so much about Phineas. It's been 150 years since his accident, yet we are still learning more about him. There's also a lot about Phineas we don't know and probably never will. The biggest question is the simplest one and the hardest to answer: Was Phineas lucky or unlucky? Once you hear his story, you can decide for yourself. But right now, Phineas is working on the railroad and his time has nearly come.

  Building a railroad in 1848 is muscle work. There are no bulldozers or power shovels to open a way through Vermont's Green Mountains for the Rutland & Burlington Railroad. Phineas's men work with picks, shovels, and rock drills. Phineas's special skill is blasting. With well-placed charges of black gunpowder, he shatters rock. To set those charges, he carries the special tool of the blasting trade, his "tamping iron." Some people confuse a tamping iron with a crowbar, but they are different tools for different jobs. A crowbar is for lifting up or prying apart something heavy. A tamping iron is for the delicate job of setting explosives. Phineas had his tamping iron made to order by a neighborhood blacksmith. It's a tapering iron rod that is three feet, seven inches long and weighs thirteen and a half pounds. It looks like an iron spear. At the base, it's fat and round, an inch and three quarters in diameter. The fat end is for tamping—packing down—loose powder. The other end comes to a sharp, narrow point and is for poking holes through the gunpowder to set the fuse. Phineas's tamping iron is very smooth to the touch, smooth from the blacksmith's forge as well as from constant use.

  His task is to blast the solid rock into pieces small enough for his crew to dig loose with hand tools and haul away in ox carts. The first step is to drill a hole in the bedrock at exactly the right angle and depth, or the explosion will be wasted. All day, Phineas must keep an eye on his drillers to make sure they stay ahead. All day, Phineas must keep an eye on his diggers to make sure they keep up. All the time between, Phineas and his assistant are working with touchy explosives.

  They follow a strict routine. His assistant "charges" each new hole by filling the bottom with coarse-grained gunpowder. Phineas uses the narrow end of his iron to carefully press the ropelike fuse down into the powder. The assistant then fills up the rest of the hole with loose sand to act as a plug. Phineas will tamp the sand tight to bottle up the explosion, channeling the blast downward into the rock to shatter it. While his assistant is pouring the sand, Phineas flips his tamping iron around from the pointy end to the round end for tamping. Black powder is ticklish stuff. When it's damp, nothing will set it off.

  This is the face of the man with a hole in his head. It's a plaster life mask of Phineas Gage made in Boston after his accident, and it shows exactly what the "recovered" Phineas looked like a year after his accident. He was twenty-seven. Notice the big scar on his forehead. To see what lies beneath the scar, compare this to the picture of his skull on [>]. Photograph by Doug Mindell; life mask courtesy of the Warren Anatomical Museum, Countway Library of Medicine, Harvard Medical School

  When it's too dry or mixed in the wrong formula, almost anything can set it off, without warning. But Phineas and his assistant have done this a thousand times—pour the powder, set the fuse, pour the sand, tamp the sand plug, shout a warning, light the fuse, and run like mad.

  But something goes wrong this time. The sand is never poured down the hole; the black powder and fuse sit exposed at the bottom. Does his assistant forget, or does Phineas forget to look? Witnesses disagree. A few yards behind Phineas, a group of his men are using a hand-cranked derrick crane to hoist a large piece of rock. Some of the men remember seeing Phineas standing over the blast hole, leaning lightly on the tamping iron. Others say Phineas was sitting on a rock ledge above the hole, holding the iron loosely between his knees.

  There is no argument about what happens next. Something or someone distracts Phineas. Does he hear his name called? Does he spot someone goofing off? Whatever the reason, Phineas turns his head to glance over his right shoulder. The fat end of his tamping iron slips down into the hole and strikes the granite. A spark flies onto the exposed blasting powder. Blam! The drill hole acts as a gun barrel. Instead of a bullet, it fires Phineas's rod straight upward. The iron shrieks through the air and comes down with a loud clang about thirty feet away.

  This is what happens. Imagine you are insid
e Phineas's head, watching in extreme slow motion: See the pointy end of the rod enter under his left cheekbone, pass behind his left eye, through the front of his brain, and out the middle of his forehead just above the hairline. It takes a fraction of a fraction of a second for the iron rod to pass from cheekbone to forehead, through and through.

  Amazingly, Phineas is still alive. The iron throws him flat on his back, but as his men come running through the gunpowder smoke, he sits up. A minute later, he speaks. Blood is pouring down his face from his forehead, but Phineas is talking about the explosion. His men insist on carrying him to an ox cart for the short ride into town. They gently lift him into the back of the cart so he can sit up with his legs out before him on the floor. An Irish workman grabs a horse and races ahead for the doctor while the ox cart ambulance rumbles slowly down the half-mile to Cavendish. Phineas's excited men crowd alongside, walking next to their injured boss. Still acting as a foreman, Phineas calls out for his time book and makes an entry as he rolls toward town.

  Something terrible has happened, yet Phineas gets down from the cart without help. He climbs the steps of the Cavendish hotel, where he has been living, and takes a seat on the porch beside his landlord, Joseph Adams. A few minutes earlier, Adams had seen the Irishman ride past shouting for Dr. Harlow, the town physician. Dr. Harlow was not to be found, so the rider was sent

  Lucky or unlucky, the sharp angle of the tamping iron made all the difference to Phineas. It entered just under his left cheekbone, passed behind his left eyeball, and continued on upward through his frontal lobes. It exited his forehead between the two hemispheres of the cortex. The iron's passage left him alive and conscious but forever changed. Illustration by Jerry Malone

  on to the next village to fetch Dr. Williams. Now Phineas takes a neighborly seat on the porch and tells his landlord what happened to him.

  That's how Dr. Edward Williams finds Phineas nearly thirty minutes after the accident. Dr. Williams pulls up in his buggy at the hotel porch, and there is Phineas, talking away. Friends, workmates, and the curious crowd around as Dr. Williams climbs down from his carriage. "Well, here's work enough for you, Doctor," Phineas says to him quite cheerfully.

  Dr. Williams examines Phineas's head. He can't believe that this man is still alive. His skull is cracked open, as if something has popped out from the inside. Accident victims are often too shaken to know what happened, so Dr. Williams turns to Phineas's workmen for the story, but Phineas insists on speaking for himself. He tells Dr. Williams that the iron went right through his head.

  Dr. Williams does not believe him. "I thought he was deceived," Dr. Williams writes in his notes. "I asked him where the bar entered, and he pointed to the wound on his cheek, which I had not before discovered. This was a slit running from the angle of the jaw forward about one and a half inch. It was very much stretched laterally, and was discolored by powder and iron rust, at least appeared so. Mr. Gage persisted in saying that the bar went through his head. An Irishman standing by said, 'Sure it was so, sir, for the bar is lying in the road below, all blood and brains.'"

  It's now an hour after the accident. The town's regular physician, Dr. John Martyn Harlow, finally arrives at the hotel. The two doctors confer, but Dr. Harlow takes over the case. Phineas is a gruesome sight. Bleeding freely from his forehead and inside his mouth, Phineas looks to Dr. Harlow like a wounded man just carried in from a battlefield. Yet Phineas is alert, uncomplaining, and still telling anyone who'll listen about the accident. Dr. Harlow wants Phineas to come in off the porch so he can treat his wound. Phineas gets up and, leaning only lightly on Dr. Harlow's arm, climbs up a long flight of stairs to his room. He lies down on his own bed so Dr. Harlow can shave his head and examine the wound more closely. What the doctor sees is terrible. Something has erupted through the top of Phineas's head, shattering the skull in its path and opening the brain to plain sight.

  Dr. Harlow does what he can. He cleans the skin around the hole, extracts the small fragments of bone, and gently presses the larger pieces of skull back in place. He looks inside Phineas's mouth. He can see the hole where the iron passed upward through the roof of his mouth. Dr. Harlow decides to leave the hole open so the wound can drain. Then Dr. Harlow "dresses" the wound, pulling the loose skin back into position and taping it in place with adhesive strips. He puts a compress bandage directly over the wound and pulls Phineas's nightcap down tightly over it. Finally he winds a roller bandage around his forehead to hold all the bandages securely. Only then does he notice Phineas's hands and forearms, which are black with powder burns. Dr. Harlow dresses the burnt skin and has Phineas put to bed with his head elevated. He gives strict orders that his patient is to remain in that position.

  Phineas should have been dead long before this. A thirteen-pound iron rod through the head should kill a person instantly. Surviving that, he should have died of shock soon after reaching Cavendish. He's lost a lot of blood, yet he remains awake and talkative. Even surviving the loss of blood, Phineas should have died of brain swelling. Any hard blow to the body causes injured tissue to swell. The brain is soft, and the skull is hard. A hard blow to the head can rattle the brain around inside like a BB in a tin can. The rattling bruises the brain, and bruised tissue swells. The brain swells, but the skull stays the same size; a swollen brain can jam itself so tightly it will cut off its own blood supply. This swelling can choke off oxygen to parts of the brain long enough to cause permanent damage. It can also cause death.

  That's a "closed brain" injury (sometimes called a concussion). The possibility of a closed brain injury is why doctors fuss if you bang your head falling off a bicycle or crashing a car or getting hit hard in the head with anything. (To prevent closed brain injuries, you should wear a helmet when bicycling, driving a race car, fighting in the infantry, playing tackle football, parachuting, exploring a cave, working on a construction site, or doing just about anything where you could strike your head hard. In Phineas's case, however, a helmet would not have helped.)

  Here Phineas has a stroke of luck. His is an "open brain" injury. The hole on top of his head gives his battered brain swelling room. The bad news is that his brain is open to infection. At first, though, he does remarkably well. The bleeding from his forehead slows and then stops within twenty-four hours. He remains cheerful and tells Dr. Harlow that he "does not care to see his friends, as he shall be at work in a few days." The morning after the accident, however, he is glad to see his mother and uncle when they arrive from New Hampshire. Two days after the accident, he takes a turn for the worse. He develops a fever and begins to have delirious spells. His wound is leaking a foul-smelling liquid, a sure sign of infection. His death seems just a matter of time now.

  More than any other organ, the brain is sealed off from the outside world and from the rest of the body. There are many layers of tissue, bone, and skin to keep it protected from the outside, but there's also a "blood-brain barrier" that keeps out many substances circulating in the blood. Oxygen and nutrients can cross the blood-brain barrier, but many dangerous substances like bacteria cannot. With his skull fractured, Phineas's exposed brain is wide open, making him an ideal candidate for a fatal infection. No one in Cavendish in 1848, no scientist in America or Europe, has the slightest notion that bacteria cause infection.

  Medical science in 1848 knows very little about bacteria, even though they were first seen through microscopes nearly two hundred years before. Today we are used to seeing the microscopic world, but when the microscope was invented in the middle of the seventeenth century, it caused a sensation. The microscope became a new kind of "high-tech" entertainment for cultured gentlemen, and in 1665 an Englishman named Robert Hooke came up with a microscopic "hit." He showed off a slide he'd made of an extremely thin slice of cork. Under the microscope lens, Hooke saw that the tissue inside a cork tree was made up of rows of tiny, boxlike structures. They reminded him of the bare rooms used by monks in a monastery. Hooke called them "cells." His cork cells, though, were empty
because they were dead and dried out. It would take two centuries to figure out that it's the living stuff inside cells that makes them the fundamental unit of life.

  While Hooke was showing off his "cells," a sharp-eyed Dutch merchant named Anton van Leeuwenhoek was making more powerful microscopes. Leeuwenhoek took a single drop of water from a rain barrel and turned his microscope on it. In that drop of water, Leeuwenhoek found a whole new planet of very, very small life forms. "Animalcules," he called them. Leeuwenhoek was the first to see single-celled microorganisms, tiny plants and tiny animals,

  In 1665, the English scientist Robert Hooke published this detailed drawing of a flea as seen through the newly invented microscope. London society clamored to see more microscope images of things too fine for the human eye. From Hooke's Micrographica; courtesy of Dr. Joseph Gall, the Carnegie Institute of Washington, Baltimore, Md.

  including bacteria. Yet Leeuwenhoek never had the faintest suspicion that some of his "animalcules" caused humans to sicken and to die.

  That's more or less the state of knowledge in 1848. Few doctors have ever used a microscope, because it is not considered a medical instrument. These microscopic animals might be marvels of nature, but no doctor suspects that they have anything to do with disease, let alone infections. Doctors in 1848 don't use the word infection, but they know its symptoms well. They call it "sepsis," and they know from bitter experience how quickly a "septic" wound can go from slight redness to gross swelling to a fatal condition called gangrene.

  The doctors of 1848 don't realize that gangrene is the end result of bacterial infection. They don't realize that floating in the air on dust particles, lurking on fingertips, or growing on the shiny steel blades of their unwashed surgical scalpels are single-celled bacteria and other microscopic life forms. On the smallest surface, there are hundreds of millions of them. They represent thousands of different species; there are tiny plants, tiny fungi, tiny viruses, and tiny animals. Among the microanimals are two particularly dangerous families of bacteria—streptococci and staphylococci ("strep" and "staph," for short). What doctors don't know in 1848, strep and staph do: that the broken head of Phineas is an ideal location to land.