The Concussion Crisis

by Linda Carroll

  About an hour later, when Dr. John Harlow arrived at the hotel to take over the case, Gage recognized him instantly as the town’s regular physician and told him, “I hope I am not much hurt.” Anxious to begin treatment at once, Harlow offered to help Gage to his bed. Gage stood up on his own, walked inside the hotel, and climbed the flight of stairs to his room without assistance. As Gage lay on the bloodsoaked bed, Harlow removed about an inch of brain matter protruding through the fracture and several shards of bone that had been pushed up by the iron, exposing a rectangular hole in the skull more than three inches wide. Looking for loose bone fragments, Harlow passed the length of his left forefinger down through the opening in the skull and passed the length of his right forefinger up through the cheek wound until the tips of both fingers met in the brain somewhere behind Gage’s left eye. Then Harlow gently pressed the two largest bones back into place as if piecing together a jigsaw puzzle and sutured the scalp to secure them. When he checked on Gage later that night, Harlow found him surprisingly clearheaded and optimistic. When Harlow asked if Gage wanted visitors, the patient declined, saying he’d see them when he returned to work “in a day or two.” Harlow hardly shared that optimism. His prognosis wasn’t just grim—it was so hopeless that Gage would later be measured for a coffin.

  Phineas Gage’s long-term recovery from his injury would be as miraculous as his immediate survival from the iron’s explosive impact had been. Barely two months after the accident, he was well enough to endure a carriage ride home to New Hampshire. When Gage returned to Vermont for a follow-up examination five months later, Harlow found the patient’s appearance healthy, his gait steady, his movements rapid. Gage appeared almost like Harlow remembered him before the accident: strong and active with an iron will as well as an iron frame. The doctor pronounced Gage cured, his physical recovery complete.

  Gage’s psychic recovery was another matter. Remarkably, the brain injury that destroyed much of his left frontal lobe had virtually no deleterious effects on his memory, his speech, his intelligence, his learning ability. But just as remarkably, his personality had been so radically changed that his friends and acquaintances no longer recognized him. Gage, they said, was “no longer Gage.”

  It was as if his body had healed up only to be inhabited, at age twenty-five, by some alien presence. Before the accident, Gage had been quiet, respectful, temperate, rational. After it, he became fitful, impatient, irreverent, impulsive, capricious, obstinate. His language, once polite, was now so grossly profane that women were advised to stay away from him. His grasp of social conventions had vanished, leaving him suddenly unable to get along with anyone.

  Gage had returned to Vermont, his cherished tamping iron in hand, determined to go back to work building the railroad. His bosses had always regarded him as their most efficient and capable foreman, while his men had always deemed him a great favorite. But when he reapplied for work, his bosses considered him so changed that they refused to give him his job back.

  Once dependable and trustworthy, he now had no sense of responsibility. Where the old Gage had been viewed as shrewd, smart, and capable, the new Gage couldn’t follow through on anything. He had lost what scientists now call executive function: the ability to plan, to organize, to troubleshoot, to reason. Harlow had discovered this with a practical little test he had given Gage. The doctor offered to trade $1,000 for a few pebbles that Gage had picked up from the riverbed near the worksite. Though Gage’s math skills had survived the accident intact, he adamantly rejected the deal. Harlow realized then that a patient whose reasoning and decision making were thus impaired would have trouble holding down the kind of management position Gage had once held.

  No longer able to work as a construction foreman, Gage set off on a bizarre odyssey, wandering the Americas with the tamping iron as his constant—and lone—companion. He traveled around New England from town to town exhibiting himself and his iron. He became an attraction at Barnum’s American Museum in New York City, joining General Tom Thumb and the Bearded Lady of Geneva among P. T. Barnum’s collection of human oddities. Billed as “The Only Living Man with a Hole in the Top of His Head,” Gage would part his hair so skeptics could see his brain pulsating under a thin sheath of skin. A series of odd jobs followed: working in a livery stable in New Hampshire, driving a stagecoach in Chile, plowing farmland in California.

  As time went on, Gage bounced more and more often from job to job, sometimes fired because of his quarrelsome nature, other times just quitting in a huff. His behavior was becoming increasingly bizarre. His health was failing rapidly, and he began having epileptic seizures. While visiting his mother in San Francisco during the spring of 1860, he suffered a severe convulsion followed by several more seizures in quick succession. The next day, eleven and a half years after the blast that should have killed him, Phineas Gage was dead.

  His accident had made headlines in medical journals and New England newspapers, but his passing didn’t occasion so much as a death notice anywhere. Harlow would not learn of his former patient’s death for another six years. By then, of course, it was too late to autopsy the brain—but not too late to examine the skull. Harlow persuaded Gage’s mother to exhume the body. The coffin was dug up and opened to reveal a skeleton and, alongside it, the tamping iron that Gage had carried everywhere, even to his grave. The skull, marked by its unmistakable fractures, was removed from the body and delivered to Harlow along with the iron.

  On a spring day in 1868, Harlow stood in front of his colleagues at a meeting of the Massachusetts Medical Society in Boston, held aloft the skull of Phineas Gage, and revealed the inside story of its owner’s miraculous recovery and mysterious transformation. Harlow couldn’t resist chiding all the city doctors who two decades earlier had so doubted his initial report that they insisted he provide affidavits from lawyers and clergymen before they would accept what most had regarded as a physiological impossibility. It wasn’t until a year after the society’s prestigious journal published his original case history that Harlow had found an unlikely ally against the skeptics: Dr. Henry J. Bigelow of Harvard University. Bigelow himself had initially been among the chief skeptics, but he changed his mind after he extensively examined Gage and made a plaster lifemask of his head. Bigelow presented his findings to the Boston Society for Medical Improvement in 1850—his evidence including the tamping iron, the mask, and Gage himself—but the distinguished Harvard professor of surgery had little more success than the inexperienced country doctor in persuading skeptical colleagues that the case was neither a fraud nor an exaggeration.

  Only in death would Gage’s skull begin to play a role in unraveling the mysteries of the broken brain. Harlow had perceptively correlated Gage’s cognitive and behavioral changes with damage to the frontal region, making this the first case to suggest the link between the brain and complex personality characteristics. It was an idea that was ahead of its time. Doctors back then found it as controversial as it was unbelievable. Unsupported by the anatomical evidence of autopsy results, Harlow’s discovery was easy to dismiss. Many decades would elapse before further scientific consideration would be given to figuring out what brain damage the tamping iron had wrought.

  In the meantime, Phineas Gage’s skull found the kind of permanent home that he never could in life. Harlow donated the skull to Harvard’s Warren Anatomical Museum, where it would eventually become more of an attraction than Gage himself ever had been at Barnum’s American Museum. Its fame would grow with each passing discovery of brain function, until it achieved landmark status in the annals of medicine. Today the skull rests in a glass-enclosed exhibit case at Harvard, sharing shelf space with the tamping iron under the watchful gaze of the bearded Bigelow’s life-size portrait. It is the centerpiece of Harvard’s collection, the holy grail of skulls, drawing pilgrimages from some of the world’s most renowned brain researchers.

  One of them was Dr. Hanna Damasio, a neurologist who wanted to know how Gage compared to her own patients with fr
ontal lobe damage. In the early 1990s, almost a century and a half after Gage’s accident, Damasio resolved to take advantage of space age technology to retroactively study the most famous of all brain injuries. After generating a three-dimensional computer model of Gage’s skull from x-rays, photographs, and measurements, she and her colleagues projected the trajectory of the tamping iron and simulated its passage through the brain. With the top of the skull open to reveal the simulated cortex, the 3-D image plotting the iron’s path revealed something scientists had only theorized: the iron misses the brain regions controlling motor function and language, but plows right through areas responsible for planning, rational decision making, and sociability. The reconstructed brain even correlated with the scans of Damasio’s patients whose frontal lobe damage had left them with symptoms resembling those of Phineas Gage.

  II

  On April 18, 1861, Dr. Paul Broca walked into a meeting of the Anthropological Society of Paris with a glass case containing a pinkish-colored brain tucked under his arm. Broca told his fellow scientists that this was the brain of a patient named Leborgne, who had died just the day before. What was interesting about the man, Broca said, was that he had completely lost the ability to talk some twenty-one years before. Broca was convinced that this man’s brain would prove to the world that language ability was located in a tightly circumscribed area.

  In the mid-1800s, Parisian scientists were passionately arguing over the question of whether the power of speech lay in a specific region or whether a person’s ability to access words and construct conversation came from cells scattered throughout the brain. The scientific debate had gotten so heated at one point that another leading researcher, Jean Baptiste Bouillaud, offered 500 francs (a tremendous sum at the time) to the scientist who could come up with an example of language loss without damage to the frontal lobes. Broca, a physician with wide-ranging interests that included anthropology and brain science, was in the camp arguing that language ability was localized to the frontal lobes. He was sure that with the right patients, he could prove it.

  He had come across Leborgne fortuitously. Though the onetime shoe-last maker had been living for the past twenty-one years at the hospital where Broca worked, the physician didn’t meet him until Leborgne was in his declining days. Broca was excited when he heard about Leborgne. This was exactly the kind of patient he’d been looking for: someone who had started out in life perfectly normal, but who had lost the ability to talk without having lost the ability to comprehend and communicate.

  As he examined Leborgne, Broca quickly determined that the patient had normal hearing and the physical ability to speak. Equally important, the patient appeared to understand most of what was said to him. Leborgne was also very much aware of his speech disability and would often get frustrated when he could utter only the meaningless syllable “tan” in response to questions. Leborgne was, nevertheless, able to communicate with the world through gestures. “Numerical answers were his best,” Broca wrote later in a scientific paper. “He gave them by opening or closing his fingers. I asked him several times how long he had been ill, and his reply was either five or six days.” When asked how long he had been at the hospital, Leborgne held up his left hand, opened it and closed it four times, and then held up a single finger to designate twenty-one years. Even when questions were more complicated, Leborgne found ways to communicate. He had become adept at finding gestures to make his thoughts known—signaling with a small movement of his left index finger to indicate when he understood something, for example.

  Over the years, Leborgne had experienced a series of “attacks” that left his right side weak and eventually paralyzed. By the time Broca met him, Leborgne was, at age fifty-one, bedridden and dying from gangrene. Immediately after Leborgne died, Broca went to work on an autopsy of the patient’s brain. He found plenty of damaged tissue, but one area in particular—a spot toward the back of the left frontal lobe—showed a deep lesion and signs of having been injured about the time Leborgne lost his ability to speak. To Broca, this was clear proof that language abilities were localized to an isolated region of the brain. Not everyone else was convinced, however, especially since there was so much widespread damage. Broca realized he would need to find other, hopefully clearer, examples to make his case beyond a doubt.

  Broca didn’t have to wait long. Before the year was out, he found an old man named Lelong, who like Leborgne had developed problems with language in adulthood. Lelong had been healthy up to age eighty-three when he suddenly collapsed with a stroke. He recovered within a few days, except that he was having problems talking. His daughter at first thought there was something wrong with his tongue, but soon realized that it was his language ability that had suffered. He just couldn’t come up with words. Eighteen months later, Lelong fell and fractured his femur. He was brought to Broca’s hospital. When Broca met him, Lelong could utter only five words: “oui,” “non,” “toi,” “toujours,” and “Lelo.” Translated, they meant “yes,” “no,” “three” (“toi” was a mispronunciation of “trois”), “always,” and his own name mispronounced. Lelong often used those words indiscriminately, especially “toi.” When asked what he did before coming to the hospital, he answered, “Toujours,” but then gestured with his arms and hands as if he were grasping a spade, pushing it into the ground, and then digging with it. Broca asked if he had been a digger, and Lelong answered, “Oui.”

  Figure 7.2: Photographs showing the brains of Broca’s two famous patients. A is a side view of Leborgne’s brain, and B is a close-up of the lesion in that brain. C is a side view of Lelong’s brain, and D is a close-up of the lesion in that brain. (Reprinted with permission from N. F. Dronkers et al., “Paul Broca’s Historic Cases: High Resolution MR Imaging of the Brains of Leborgne and Lelong,” Brain 130:1432–41, 2007.)

  Twelve days after he arrived at the hospital, Lelong died. Broca was eager to examine Lelong’s brain, but nervous. The fact that Lelong could say a few words might mean that the damage to his brain was in a different region from Leborgne’s. When the autopsy was completed, Broca had more ammunition to make his case. Lelong not only had a lesion in the same place as Leborgne, but it was much more clearly defined. Further, there was no other brain pathology confusing the situation. Broca concluded that the differences he saw between the two patients were not explained by the site of the brain damage, but by its nature. Broca presented his findings at a meeting of the Anatomical Society and then submitted them for publication. He wrote, “I will not deny my surprise bordering on stupefaction when I found that in my second patient the lesion was rigorously occupying the same site as the first.”

  Broca preserved the two brains in alcohol and donated them to the Musée Dupuytren, where they were exhibited until the walls of the museum collapsed in 1940. For years after that, no one knew where the brains had gone. Many thought they were lost forever. But in 1962 the brains turned up in the basement of the École de Médecine in Paris, where they had been sitting on a shelf since 1940. The damage to what had become known as “Broca’s area” was clearly visible: an actual crevice in one brain and a pitted surface on the other.

  In 2007, an international team of researchers led by Nina Dronkers at the University of California–Davis got together and decided to pop the brains into an MRI machine to see if they could get more detail on exactly what had been damaged in the two patients. Broca’s research on Leborgne’s and Lelong’s brains had provided the foundations for modern neuropsychology and cognitive neuroscience since it gave credibility to the theory of localization of brain function. But studies in the late twentieth century had shown that a more extensive lesion than what Broca described would be needed to completely extinguish speech. Dronkers and her colleagues wondered just how accurate Broca had been. With the MRI scans, they constructed a computer map of the two brains and determined that only a small part of Broca’s area had been injured. Further, they found that the damaged area extended beyond what Broca could have seen without dissec
ting the brains.

  “Though the current findings provide additional anatomical information, they by no means detract from Broca’s phenomenal discovery,” the researchers concluded. “Because he elected not to slice the brains, Broca could not have known the extent of the underlying damage in his patients and the role it might play in their speech disorders.”

  III

  Henry Gustav Molaison went into the hospital for an epilepsy cure and came out with a broken memory.

  Molaison had been suffering from increasingly severe seizures since an accident when he was nine. By the time he was twenty-seven, in 1953, his seizures had become so frequent and so intense that he had to give up his job as an electric-motor repairman. Desperate to get his life back, Molaison made an appointment with a neurosurgeon at Hartford Hospital who was curing epilepsy through surgery. That appointment would completely upend his world.

  Back in the 1940s and ’50s, neurosurgeons were convinced that they could fix any brain-related illness—from depression to schizophrenia to epilepsy—with an operation. Just scoop out some faulty brain tissue and, presto, the patient would be cured with no ill effects. Lobotomies had become the rage as the cure for a host of mental disorders and even for criminal behavior. While there had been a few disastrous cases involving personality changes, neurosurgeons for the most part believed they were helping their patients by removing brain tissue.