The Best American Science and Nature Writing 2015

by Rebecca Skloot

  Dr. Henry Bigelow brought Gage to Harvard Medical School for a formal evaluation in 1849. Although Bigelow treated Gage like a curiosity—he once presented Gage at a meeting along with a stalagmite “remarkable for its singular resemblance to a petrified penis”—the visit resulted in the only other detailed, firsthand account of Gage and his accident besides Harlow’s. Surprisingly, Bigelow’s report pronounced Gage “quite recovered in his faculties of body and mind.” However, as was common in neurological exams then, Bigelow probably only tested Gage for sensory and motor deficits. And because Gage could still walk, talk, see, and hear, Bigelow concluded that his brain must be fine.

  Bigelow’s assessment meshed well with the medical consensus at the time, which held that the frontal lobes didn’t do much—in part because people could suffer grave injuries to them and walk away. Scientists now know that parts of the frontal lobes contribute to nearly every activity inside the brain. The forefront of the lobes, called the prefrontal area, plays an especially important role in impulse control and planning.

  But even today scientists have only a vague idea of how the prefrontal lobes exercise that control. And victims of prefrontal injuries can still pass most neurological exams with flying colors. Pretty much anything you can measure in the lab—memory, language, motor skills, reasoning, intelligence—seems intact in these people. It’s only outside the lab that problems emerge. In particular personalities might change, and people with prefrontal damage often betray a lack of ambition, foresight, empathy, and other ineffable traits. These aren’t the kind of deficits a stranger would notice in a short conversation. But family and friends are acutely aware that something is off.

  Frustratingly, Harlow limited his discussion of Gage’s mental status to a few hundred words, but he does make it clear that Gage changed—somehow. Although resolute before the accident, Harlow says Gage was now capricious, and no sooner made a plan than dropped it for another scheme. Although deferential to people’s wishes before, Gage now chafed at any restraint on his desires. Although a “smart, shrewd businessman” before, Gage now lacked money sense. And although courteous and reverent before, Gage was now “fitful [and] irreverent, indulging at times in the grossest profanity.” Harlow summed up Gage’s personality changes by saying, “The equilibrium . . . between his intellectual faculties and his animal propensities seems to have been destroyed.” More pithily, friends said that Gage “was no longer Gage.”

  As a result of this change, the railroad refused to reinstate Gage as foreman. He began traveling around New England instead, displaying himself and his tamping iron for money. This included a stint in P. T. Barnum’s museum in New York—not Barnum’s traveling circus, as some sources claim. For an extra dime skeptical viewers could “part Gage’s hair and see his brain . . . pulsating” beneath his scalp. Gage finally found steady work driving a horse coach in New Hampshire.

  Beyond that sketch of his activities, there’s no record of what Gage did in the months after the accident—and we know even less about what his conduct was like. Harlow’s case report fails to include any sort of timeline explaining when Gage’s psychological symptoms emerged and whether any of them got better or worse over time. Even the specific details of Gage’s behavior seem, on a closer reading, ambiguous, even cryptic. For instance, Harlow mentions Gage’s sudden “animal propensities” and, later, “animal passions.” Sounds impressive, but what does that mean? An excessive appetite, strong sexual urges, howling at the moon? Harlow says that Gage cursed “at times,” but how often is that? And was this a saucy “hell” or “damn” here and there or something more dastardly? Harlow notes that Gage started telling his nieces and nephews wild stories about his supposed adventures. Was he confabulating here, a symptom of frontal lobe damage, or simply indulging a love of tall tales? Even the conclusion that Gage “was no longer Gage” could mean almost anything.

  Indeed, it has come to mean almost anything. One reason it’s hard to diagnose frontal lobe damage is that people vary quite a bit in their baseline behavior: some of us are rude, crude, cruel, flighty, or whatever naturally. To judge whether a person changed after an accident, you have to have known him beforehand. Unfortunately, no one who knew Gage intimately left any sort of statement. And with so few hard facts to constrain people’s imaginations in later years, rumors began to swirl about Gage’s life, until a wholly new Phineas emerged.

  Macmillan summarizes this caricature of Gage as “an unstable, impatient, foul-mouthed, work-shy drunken wastrel, who drifted around circuses and fairgrounds, unable to look after himself and dying penniless.” Sometimes his new traits contradicted one another: some sources describe Gage as sexually apathetic, others as promiscuous; some as hot-tempered, others as emotionally void, as if lobotomized. And some anecdotes seem like outright fabrications. In one, Gage sold the exclusive, posthumous rights to his skeleton to a certain medical school—then sold the same rights to another school, and another, skipping town and pocketing the cash each time. In another tale, a real howler, Gage lived for 20 years with the iron rod still impaled in his skull.

  More uncomfortably, some scientists have questioned Gage’s humanity. Descartes’ Error, a popular book from 1994, trotted out many familiar tropes: that women couldn’t stand to be in Gage’s presence, that he started “drinking and brawling in questionable places,” that he was a braggart and a liar and a sociopath. The neuroscientist author then got metaphysical. He speculated that Gage’s free will had been compromised, and raised the possibility that “his soul was diminished, or that he had lost his soul.”

  People butcher history all the time, of course, for various reasons. But something distinct seems to have happened with Gage. Macmillan calls it “scientific license.” “When you look at the stories told about Phineas,” he says, “you get the impression that [scientists] are indulging in something like poetic license—to make the story more vivid, to make it fit in with their preconceptions.” Science historian Douglas Allchin has noted the power of preconceptions as well: “While the stories [in science] are all about history—events that happened,” Allchin writes, “they sometimes drift into stories of what ‘should’ have happened.”

  With Gage, what scientists think “should” have happened is colored by their knowledge of modern patients. Prefrontal lobe damage is associated with a subsequent slightly higher rate of criminal and antisocial behavior. Even if people don’t sink that low, many do change in unnerving ways: they urinate in public now, blow stop signs, mock people’s deformities to their faces, or abandon a baby to watch television. It’s probably inevitable, Macmillan says, that such powerful anecdotes influence how scientists view Gage in retrospect: “They do see a patient and say, ‘Ah, he’s like what Phineas Gage was supposed to be like.’” To be clear, Harlow never reports anything criminal or blatantly unhinged about Gage’s conduct. But if you’re an expert on brain damage, scientific license might tempt you to read between the lines and extrapolate from “gross profanity” and “animal passions” to seedier behavior.

  If repeated often enough, such stories acquire an air of truthiness. “And once you have a myth of any kind, scientific or otherwise,” Macmillan says, “it’s damn near impossible to get it destroyed.” Macmillan especially bemoans “the degree of rigor mortis in textbooks,” which reach a large, impressionable audience and repeat the same anecdotes about Gage in edition after edition. “Textbook writers are a lazy lot,” he says.

  Historians have also noticed, not surprisingly, that myths have more staying power when they’re good stories—and Gage’s is truly sensational. Once upon a time, a man with a funny name really did survive having an iron rod explode through his skull. It’s tragic, macabre, bewildering—and even comes with the imprimatur of a science lesson. In contrast to other scientific fables, Gage’s has an intriguing twist as well. Most other scientific myths depart from reality by inflating the heroes (usually scientists) into godlike creatures, wholly pure and wholly virtuous. Gage, meanwhile, gets dem
onized. He’s Lucifer, fallen. Gage’s myth has proved so tenacious in part because it’s fascinating to watch someone break bad.

  3. The Journey of the Tamping Iron

  With the development of new scanning and computer technologies, a new chapter in Gage studies has opened in the past quarter century. Unfortunately, no one preserved Gage’s brain when he died, so scientists are left examining the few remaining relics from his life instead, especially his skull and tamping iron, which are on display at the Warren Anatomical Museum at Harvard Medical School.

  In six years as museum curator, Dominic Hall has become an expert on Gageanalia. He often shows the skull and tamping iron to student groups, and he finds that people don’t mind hearing even graphic details about Gage’s injury. “There’s just something about him,” Hall says.

  Gage’s skull and tamping iron are basically the only reason the Warren Museum still exists, says Hall, although calling it a “museum” seems generous. It’s really just two rows of eight-foot-tall wooden cabinets; one sits on either side of an atrium on the fifth floor of Harvard’s medical library. Surrounding the Gage artifacts are head sculptures with phrenology labels, a life mask of Samuel Taylor Coleridge, and stillborn Siamese twins, among other curios.

  The left eye socket of Gage’s skull, near the entry wound, looks jagged. The exit wound on top consists of two irregular holes with a patch of bone stuck between them, like a flattened wad of white gum. The tamping iron rests one shelf below the skull. Hall describes the rod as heavy, but struggles beyond that. “It’s not like a baseball bat or shovel,” he says, “because the weight is distributed throughout.” He finally just says, “It feels real.” The tip of the iron looks blunted, like a slightly used crayon, and the shaft contains an inscription, in white calligraphic script, explaining Gage’s case. Phineas is misspelled twice.

  The skull’s obvious entry and exit wounds have tempted several scientists to digitally recreate the journey of the tamping iron. They hope to determine what parts of the brain were destroyed, which might make Gage’s deficits clearer. The sophisticated computer modeling helps scientists study normal brain function as well, but there’s something undeniably splashy about recreating the most famous accident in medical history.

  The best-known recreation of the accident was done by the husband-and-wife team of Antonio and Hanna Damasio, neuroscientists now at the University of Southern California. Antonio Damasio developed a famous theory of how emotions work, especially how they supplement and enhance our reasoning skills. To do so, he drew on a number of his own patients with frontal-lobe deficits. But he also drew on Gage. (Damasio, the author of Descartes’ Error, is the scientist who described Gage as a vagrant sociopath.) The Damasios modeled Gage’s accident in part to search for evidence that he suffered damage to both his left and right hemispheres, which would make any personality changes more drastic. They found what they were looking for, and the study graced the cover of Science in 1994.

  The Damasios still stand behind their paper. But two later studies, which took advantage of higher-horsepower computers to create more accurate models of Gage’s skull, have since questioned their results. In 2004 a team led by Peter Ratiu, who was then teaching neuroanatomy at Harvard and now works as an emergency doctor in Bucharest, Romania, concluded that the rod could not have crossed over the midline and damaged Gage’s right hemisphere. What’s more, Ratiu determined that, based on the angle of entry and lack of a broken jawbone, Gage must have had his mouth open and been speaking at the moment of impact. Ratiu’s renderings of this moment—with the iron rod piercing a gaping mouth—have an unnerving quality, reminiscent of Francis Bacon’s paintings of screaming popes.

  In 2012 neuroimaging expert Jack Van Horn led another study on Gage’s skull. In contrast to Macmillan, Van Horn refers to Phineas as “Mr. Gage.” He first delved into the case while living in New Hampshire, near the old Gage farmstead on Potato Road. Van Horn now works at USC in the same department as the Damasios.

  Van Horn’s study sifted through millions of possible trajectories for the iron rod, he says, and ruled out all but a few “that didn’t break his jaw, didn’t blow his head off, and didn’t do a bunch of other things.” (For comparison, the Damasio study scrutinized a half-dozen trajectories.) Overall, Van Horn’s work supported Ratiu’s: the rod, he argues, never crossed over to the right hemisphere.

  Van Horn did introduce a new wrinkle, however. He studies brain connectivity, the emerging awareness that while neurons are important to brain function, the connections between neurons are equally vital. Specifically, the patches of neurons that compute things in the brain (gray matter) reach their full potential only when networked together, via axon cables (white matter), to other centers of neural computation. And while Gage suffered damage to 4 percent of his gray matter, Van Horn concluded, 11 percent of his white matter suffered damage, including cables that led into both hemispheres. Overall, the injury “was much more profound than even we thought,” he says.

  How that damage affected Mr. Gage’s behavior, though, is tough to predict. Van Horn has read Macmillan’s work closely, and he says it scared him away from undue speculation. “I didn’t want to piss [Macmillan] off,” he jokes. Van Horn nevertheless did compare the destruction of Gage’s white matter to the damage wrought by neurodegenerative diseases like Alzheimer’s. Gage might even have displayed classic symptoms of Alzheimer’s, he argues, such as moodiness and an inability to complete tasks. John Harlow’s original case report did state that Gage’s changes were “nothing like dementia,” Van Horn acknowledges. But Harlow examined Gage shortly after his accident, Van Horn says, not months or years later, when such symptoms might have emerged.

  Despite different interpretations, Damasio, Ratiu, and Van Horn all agree about one thing: their models are basically sophisticated guesswork. Clearly the tamping iron destroyed some brain tissue. But the flying bone shrapnel and the fungal infection would have destroyed still more tissue—and that destruction is impossible to quantify. Perhaps even more important, both the position of the brain within the skull and the location of various structures within the brain itself actually vary a lot from person to person—brains differ as much as faces do. When cataloguing brain destruction, then, millimeters matter. And no one knows which exact millimeters of tissue got destroyed in Gage.

  That ignorance hasn’t slowed down the speculation. Phineas Gage is reborn every generation, but as a different man: each generation reinterprets his symptoms and deficits anew. In the mid-1800s, for example, phrenologists explained Gage’s profanity by noting that his “organ of veneration” had been blown to bits. Nowadays scientists cite Gage in support of theories about multiple intelligences, emotional intelligence, the social nature of the self, brain plasticity, brain connectivity—every modern neuro-obsession. Even Macmillan, after studying the end of Gage’s life, has edged beyond merely debunking other people’s stories and started presenting his own theory about Phineas Gage’s redemption.

  4. “I Knew There Was a Contradiction There”

  Incredibly, after working 18 months in the horse stable in New Hampshire, Gage struck out for South America in 1852. He was seasick the whole voyage. He’d been recruited by an entrepreneur hoping to take advantage of a gold rush in Chile, and once ashore Gage resumed driving coaches, this time along the rugged, mountainous trails between Valparaiso and Santiago. You wonder how many passengers would have climbed aboard had they known about their one-eyed driver’s little accident, but he did the job for seven years.

  Poor health forced Gage to quit Chile, and in 1859 he caught a steamer to San Francisco, near where his family had moved. After a few months of rest, he found work as a farm laborer and seemed to be doing better, until a punishing day of plowing in early 1860 wiped him out. He had a seizure the next night over dinner. More followed, and after one particularly intense fit he died, on May 21, age 36, having survived his accident by almost a dozen years. His family buried him two days later, possibly with his b
eloved tamping iron.

  Gage’s story might have ended there—an obscure small-town tragedy, little more—if not for Dr. Harlow. He had lost track of Gage years before, but he learned the address of Gage’s family in 1866 (through some unspecified “good fortune”) and wrote to California for news. After milking the family for details, Harlow prevailed upon Gage’s sister, Phebe, to open the grave and salvage Gage’s skull in 1867. The exhumation sounded like quite a to-do, with Phebe, her husband, their family doctor, the city mortician, and even San Francisco’s mayor, one Dr. Coon, all present to peek inside the coffin. Gage’s family then hand-delivered the skull and tamping iron to Harlow in New York a few months later. At this point Harlow finally wrote up a full case report, which included virtually everything we know about Gage’s mental status and sojourn to South America.

  Most accounts of Gage’s life omit all mention of Chile. Even Macmillan didn’t know what to make of it for decades. But in the past few years he has become convinced that Chile holds the key to understanding Gage.

  The epiphany came while, of all things, watching Queen Elizabeth’s husband, Prince Philip, race coaches on television one night. Philip, an old-fashioned sportsman, drives horse coaches similar to the ones Gage did, and the intricacy of the rein-work and difficulty of the maneuvering struck Macmillan as significant. The driver controls each of his horses’ reins with a different finger, for example, so even rounding a bend takes incredible dexterity. (Imagine driving a car while steering each wheel independently.) Moreover, the trails Gage drove were crowded, forcing him to make quick stops and dodges, and because he probably drove at night sometimes, he would have had to memorize their twists and drop-offs, plus watch for bandits. He also presumably cared for the horses and collected fares. Not to mention that he likely picked up a soupçon of Español in Chile. “To have someone with impulsive behavior, uncontrolled behavior, carrying out the highly skilled task of stagecoach driving,” Macmillan says, “I knew there was a contradiction there.”