Phineas Gage

by John Fleischman

  A wound is an open door. A cut or break in the skin lets staph and strep bacteria colonize the warm, wet, nutrient-rich cells inside. Once these bacteria get established in the body, they reproduce wildly. The body's immune system tries to kill the invading bacteria with an array of special immune cells, while the bacteria try to protect themselves against immune cells by cranking out toxic chemicals. That's an infection. The site of this biological battle between the immune system and bacteria swells up and turns red.

  In 1848, science is still twenty years away from figuring out that infections are the work of living—that is, "biotic"—things. It will take nearly a century for science to develop the first "antibiotic," penicillin, to counter infections. In 1848, a young Frenchman named Louis Pasteur is still studying chemistry in Paris. Eventually, Pasteur will unravel the three great biological mysteries of

  Hooke called the microscopic boxes that he saw in the bark of a cork tree "cells." Compared to his flea pictures, Hooke's cells attracted little notice in 1665. Two centuries later, his "cells" turned out to be the fundamental unit of all life. From Hooke's Micrographica; courtesy of Dr. Joseph Gall, the Carnegie Institute of Washington, Baltimore, Md.

  his time—fermentation, decay, and infection. All three processes are the work of living microorganisms; Pasteur will call them "germs." Pasteur's "germ theory" will lead to a revolution in medicine. It will inspire an English surgeon named Joseph Lister to try performing surgery in sterile conditions that exclude or kill all microorganisms. Lister will scrub his hands almost raw before operating, he will boil surgical clothing and instruments, and he will set up a machine to spray carbolic acid in the operating room to kill germs in midair. Lister's first sterile operations in 1868 will cut the number of deaths from infection after surgery by 90 percent. For the first time in history, doctors will help more patients with surgery than they harm with postsurgical infections.

  None of this progress to come will do Phineas a bit of good back in 1848. Instead, Phineas is saved by good luck and good care. Dr. Harlow follows the best medical advice of his time—keep the wound clean but covered and watch for inflammation. A sign of infection is a fluid called "pus" (it's actually dead white blood cells, a sign that the body's immune system is attacking bacterial invaders) that collects in pockets to form abscesses. Fourteen days after the accident, Phineas develops a huge abscess under the skin just above his eyes. Phineas is feverish, losing his appetite, and sinking fast. Dr. Harlow lances (punctures) the abscess. He drains the pus and dresses Phineas's forehead again. The fever abates. His scalp begins to heal. Phineas is saved by his youth, his iron constitution, and Dr. Harlow's good nursing. Dr. Harlow will always be modest about his role in saving Phineas. "I dressed him," Dr. Harlow will say. "God healed him."

  The patient gains strength. Too much strength, in his doctor's opinion. Dr. Harlow is called out of town for a few days, and when he comes back he finds

  Under the microscope, streptococci bacteria have a distinctive beads-on-a-string appearance. "Strep" bacteria live on nearly everything people touch but are only dangerous if they can penetrate the body's defenses and overpower the immune system. Microphotograph by H. Morgan, Photo Researchers Inc.

  Staphylococci bacteria are the other half of the deadly duo of opportunistic bacteria. Infections by "staph" and "strep" were a leading cause of death before the discovery of antibiotic medicines. Somehow, Phineas's immune system beat off their attack. Microphotograph by Dr. Tony Brain, Photo Researchers Inc.

  Phineas out of his sickbed. His head still heavily bandaged, Phineas is roaming about Cavendish in the rain with no coat and thin shoes. He is eating unwisely, refusing nursing advice, and ignoring doctor's orders. Phineas says he wants to go home to his mother's house in Lebanon, New Hampshire, twenty miles away. He intends to walk. According to the best medical theories of his day, Dr. Harlow diagnoses an imbalance of bodily "humors." This theory, which goes back to the ancient Greeks, declares that health is maintained by a balance of four liquids, or humors, in the body—blood, phlegm, yellow

  Four hundred years ago, this was an up-to-date medical book illustration. It shows a half-man, half-woman surrounded by the signs of the zodiac and the four "humors" that for centuries doctors believed controlled health—blood, phlegm, black bile, and yellow bile. Balancing the sanguine, or blood, humor was the "reason" for bleeding the sick. Photo Researchers Inc.

  bile, and black bile. To bring them into balance, Dr. Harlow prescribes two powerful drugs—an "emetic" to make Phineas throw up and a "purgative," a powerful laxative, to evacuate his bowels. Phineas is knocked flat by the medicines and spends the next two weeks in bed, where Dr. Harlow keeps him on a "low," or bland, diet. His humors may or may not be in balance, but Phineas is resting quietly at last.

  Ten weeks after the accident, Dr. Harlow declares Phineas fully recovered from his wounds. He puts Phineas in a closed carriage and sends him home to his mother in New Hampshire. Phineas is very weak, but he can walk short distances. He can count, feed and dress himself, and sing. He can speak clearly and make sense of what he hears. Yet there is something odd about the "recovered" Phineas. Just before he leaves Cavendish, Dr. Harlow gives Phineas a little test. The doctor offers Phineas $1,000 for the pocketful of pebbles that Phineas has collected walking along the Black River near town. Dr. Harlow knows that Phineas can add and subtract, yet Phineas angrily refuses the deal. Dr. Harlow tells himself that a man who was so badly hurt is going to need time to regain his full powers.

  As soon as Phineas leaves for home, Dr. Harlow writes a short report for the Boston Medical & Surgical Journal. Most doctors ignore Dr. Harlow's article. The few who read it don't believe it. How could a man survive such an injury, let alone make a "complete recovery"? But one Boston doctor is intrigued. He writes to Harlow for information and urges the Vermont doctor to back up his case by collecting formal statements from eyewitnesses in Cavendish. The letter is from Henry J. Bigelow, professor of surgery at the Harvard Medical College.

  In the spring, Phineas is back in Cavendish, carrying his tamping iron. He never goes anywhere without it these days. Phineas has come for a final examination by Dr. Harlow and to reclaim his old job on the railroad. His left eye looks intact, but the vision has gradually faded away. Phineas has a huge scar on his forehead and a small scar under his cheekbone, but otherwise he is physically healed. Yet Dr. Harlow has private doubts about Phineas's mental state. Phineas is just not his old self.

  His old employers on the railroad quickly come to the same conclusion. The new Phineas is unreliable and, at times, downright nasty. He insults old workmates and friends. He spouts vulgar language in the presence of women. He changes his mind and his orders from minute to minute. The railroad contractors let him go. Dr. Harlow, who is keeping confidential notes on Phineas, sadly writes, "His contractors, who regarded him as the most efficient and capable foreman in their employ previous to his injury, considered the change in his mind so marked that they could not give him his place again."

  When he was an old man, Dr. Henry J. Bigelow wore a long beard and sober clothes, befitting one of Boston's senior surgeons. But when he was a young man studying medicine in Paris, Bigelow was a snappy dresser. From a daguerreotype by Leon Foucault, Paris, 1841; courtesy of Countway Library of Medicine, Harvard Medical School

  Phineas's old friends also wash their hands of him. Dr. Harlow writes: "He is fitful, irreverent, indulging at times in the grossest profanity (which was not previously his custom), manifesting but little deference for his fellows, impatient of restraint or advice when it conflicts with his desires." Phineas comes up with all sorts of new plans, the doctor writes, but they are no sooner announced than he drops them. Phineas is like a small child who says he is running away from home after lunch and then comes up with a new idea over his sandwich. Dr. Harlow writes, "A child in his intellectual capacities and manifestations, he has the animal passions of a strong man." A doctor is bound by his oath not to reveal the details of a pat
ient's condition without permission, so Dr. Harlow will keep his observations to himself for twenty years.

  Meantime, Dr. Harlow has another letter from Dr. Bigelow at Harvard, who thanks him for collecting the eyewitness statements about the accident. Would Mr. Gage consider coming to Boston at Dr. Bigelow's expense so his case could be presented at the medical school and before the Boston Society of Medical Improvement? Dr. Harlow and Dr. Bigelow make arrangements.

  What We Thought About How We Thought

  In the winter of 1850, Phineas goes to Boston so the doctors there can see for themselves. What are doctors like in 1850? They look like gentlemen, or at least they do in the oil portraits that they have painted of themselves to boost their social status. If you lined up a gallery of these doctors' portraits, you'd see a long row of wise faces, satin waistcoats, gold watch chains, and side-whiskers. By 1850, there are photographs of doctors, showing wise faces, satin waistcoats, and whiskers. Photographs of doctors at work,

  though, are rare. Photographing anyone or anything moving is difficult because the light-sensitive plates are very slow, and a single exposure can take a fall minute. Yet the year before Phineas's accident, a Boston photographer named Josiah Hawes sets up his camera in a surgical operating theater and takes a "daguerreotype" (a photograph on a metal plate) that he entitles, "Third Operation Using Ether Anesthesia at the Massachusetts General Hospital." The operating room is called the Ether Dome and still exists today.

  The picture that Hawes makes is probably the very first of doctors being doctors instead of doctors posing for portraits. In Hawes's photograph, the surgeons stand impatiently beside the operating table, ready to start work. This is truly a historic moment. Before the introduction of ether a few months before, surgeons had to employ powerful assistants to hold down patients or restrain them with leather-covered chains. Because of the discovery of ether anesthesia, the doctors in the Ether Dome can take their time operating.

  Notice two things about Hawes's picture. First, it's all men. There are no female hospital nurses, let alone female doctors. The second thing you should notice is what the doctors are wearing—nothing special. They are in street clothes—black frockcoats, shiny satin vests, and linen shirts. No one is wearing surgical scrubs. No one is wearing surgical gloves, masks, or booties. These doctors may not wash their hands until after the operation. These men know nothing about bacteria—but they think they know all about the brain.

  This is what an audience of doctors looks like when Phineas arrives in Boston in January 1850, tamping iron in hand. He is Dr. Bigelow's guest but also his prize specimen. Phineas is examined, measured, and discussed. He agrees to sit for a plaster "life" mask. Dr. Bigelow puts straws up Phineas's nose so he can

  The patient is the one in the cotton gown and wool socks, lying unconscious on the table. Knocked out by inhaling ether fumes, the patient can feel no pain in this state of "twilight sleep." When word of the discovery of anesthesia reached England, a London newspaper rejoiced, announcing, "We Have Conquered Pain Massachusetts General Hospital, Archives and Special Collections; print courtesy of Harvard University Art Museums

  breathe while the doctor pours liquid plaster over his face. Then the plaster is lifted off to make a mold. From it, Dr. Bigelow casts a three-dimensional version of Phineas's face. His eyes are shut, but the enormous scar on his forehead is clear.

  Phineas appears in person at Dr. Bigelow's lectures to convince the assembled doctors that his case is neither an exaggeration nor a fraud. Dr. Bigelow tackles that question head-on: "The leading feature of this case is its improbability," Dr. Bigelow admits. "A physician who holds in his hand a crowbar, three and a half feet long, and more than thirteen pounds in weight, will not readily believe that it has been driven with a crash through the brain of a man who is still able to walk off, talking with composure and equanimity of the hole in his head. Yet there is every reason for supposing it in this case literally true."

  The evidence is standing before them, "crowbar" in hand. Even confronted with that, there are still doctors in the audience who don't believe that the tamping iron went through Phineas's brain. Perhaps, they say, it just hit him a glancing blow on the head. Dr. Bigelow reads out accounts from Dr. Williams and Dr. Harlow. He adds other eyewitness statements from Cavendish people including Mr. Adams, the hotel owner, and some of Phineas's workmen. Dr. Bigelow unveils his plaster life mask of Phineas. The casting clearly shows scars where the iron went in and came out. Yet there are doctors who think that Phineas is a humbug, a fake from the back woods of Vermont.

  There are two other groups of doctors paying close attention to Dr. Bigelow's presentation. The two rival groups are eager to believe in Phineas's case. Their theories directly contradict each other, and yet both groups believe that Phineas's case supports their side. As it turns out, both groups are slightly right but mostly wrong. Yet their wrong theories—and Phineas himself—will steer our knowledge of the brain in the right direction.

  Everybody knows that people use their brains to think. Right? And, of course, emotions, especially love, come from the heart. Wrong? Obviously, our ideas about how the body works have changed. Three hundred years ago, everybody "knew" that anger was controlled by the spleen. Twenty-three hundred years ago, the ancient Greeks "knew" that the heart was the center of emotion and thought. Aristotle, the greatest scientist of his time, "knew" that the primary function of the brain was to cool the blood. It isn't until 1800 that an Austrian doctor named Franz Josef Gall declares that the brain is the seat of the intelligence, the emotions, and the will. Still, it takes time for new ideas to sink in. Even today, we don't talk about a lover who's been dumped as feeling "broken-brained."

  By Phineas's time, doctors know what a brain looks like, at least from the outside. They learn as students of gross (a term for "large-scale") anatomy by dissecting the cadavers of paupers, prisoners, and the unclaimed. By 1850, all doctors know the gross anatomy of the skeleton, internal organs, muscles, and, of course, the brain. They just don't know how the brain works.

  You can have a look for yourself. Imagine you could click open the top of your head and lift your brain out. It weighs about three pounds. Some compare it to half of an enormous walnut, but if you can't visualize a three-pound walnut half, think of a bicycle helmet (bicycle helmets look the way they do so they can surround the brain). Think of your brain as a big cap perched on a stalk and protected by the neck flap. The big cap is your cerebral cortex. The stalk is your brain stem, which plugs into your spinal cord. The brain stem keeps many of your automatic functions going, like your breathing and heartbeat. The neck flap covers your cerebellum, which coordinates movement. Without your cerebellum, you couldn't walk upright, touch your finger to your nose, or turn this page. Without your brain stem, you couldn't breathe. Without your cerebral cortex, you wouldn't be human.

  The cortex is where you think, remember, learn, imagine, read, speak, listen, and dream. In the cortex, you feel your emotions and you make sense of what your senses are telling you. The cortex is where you actually see what

  This is half a brain. On top and in front is the cortex. In the back and underneath are the cerebellum and the brain stem. On the bottom of the cortex is the limbic system, which coordinates memory, sensation, and emotion. In Phineas's case, the tamping iron passed through the frontal cortex, leaving the rest of his brain relatively unharmed. Illustration by Jerry Malone

  your eyes transmit, smell what your nose senses, taste what your tongue samples, touch what your nerves report, and hear what your ears pick up. None of this vital activity is visible in gross anatomy. By just holding a brain in your hands you (and the doctors of Phineas's day) can't see the thing that makes this

  Here you can see the division between the two hemispheres of the cortex. The crack between them is called the "interhemispheric fissure." The two hemispheres specialize in different mental skills, but brain functions are not as neatly divided as they appear. Phineas's tamping iron struck the left hemis
phere first but also grazed the right hemisphere on the way out. He lost something from both hemispheres. Illustration by David Macaulay

  organ work, the brain's fundamental unit, which is the brain cell, or neuron. You'll need a microscope and a lot of skill to see a single neuron, but all of these structures—the cortex, cerebellum, brain stem, and spinal cord—are made up of neurons specialized to relay and transmit tiny electrical impulses. By layering and connecting billions of neurons, you get a brain.

  But by looking at your brain in your hand, you'll notice that the cortex splits in half right down the middle. The left hemisphere and the right hemisphere are separated on top by a deep crack—the interhemispheric fissure—but joined in the middle of the brain by a thick mat of nerves—the corpus callosum. The corpus is the switchboard for signals back and forth between the two halves. In recent times, scientists have learned that the two hemispheres specialize in certain skills. Sometimes you'll hear brain researchers talk about a "right brain" or a "left brain" skill. They really mean right or left hemisphere. But you can't see any skills by looking at the outside of a brain.

  Indeed, if you're looking at your brain from the outside, you might wonder if you're holding the cortex backwards. The front of the cortex seems to be hanging in space until you realize that your face fits the space underneath. The part of the cortex above your face is the frontal lobe. The frontal lobe is the part that concerns us most regarding Phineas, but you should know the other lobes—the parietal lobe on top and the occipital lobe at the back of your head, right above your cerebellum. Wrapping around your temples on the side of your head are the temporal lobes. Each hemisphere has its own frontal, parietal, occipital, and temporal lobes. All together, the cortex is a soft mass of folded nerve tissue. It looks as if your cortex was folded up quickly and stuffed in any old way, but the truth is that every human brain is folded in exactly the