The Tale of the Dueling Neurosurgeons: The History of the Human Brain as Revealed by True Stories of Trauma, Madness, and Recovery

by Sam Kean

  Like everyone else, Harlow didn’t believe Gage at first. Surely, the rod didn’t pass through your skull? But after receiving assurance that it had, Harlow watched Gage lumber upstairs to his hotel room and lie down on the bed—which pretty much ruined the linens, since his upper body was one big bloody mess. As for what happened next, readers with queasy stomachs should skip to the next paragraph. (I’m not kidding.) Harlow shaved Gage’s scalp and peeled off the dried blood and gelatinous brains. He then extracted skull fragments from the wound by sticking his fingers in from both ends, Chinese-finger-trap-style. Throughout all this, Gage was retching every twenty minutes, mostly because blood and greasy bits of brain kept slipping down the back of his throat and gagging him. The violence of the heaving also caused “half a teacupful” of brain to ooze out the exit wound on top. Incredibly, even after tasting his own brains, Gage never got ruffled. He remained conscious and rational throughout. The only false note was Gage’s boast that he’d be back blasting rocks within two days.

  The bleeding stopped around 11 p.m. Gage’s left eyeball was still protruding a good half inch, and his head and arms remained heavily bandaged (he had flash burns up to his elbows). Harlow nevertheless allowed visitors the next morning, and Gage recognized his mother and uncle, a good sign. He remained stable over the next few days thanks to Harlow’s diligent care, which included fresh dressings and cold compresses. But just when Harlow grew hopeful that Gage would survive, his condition deteriorated. His face puffed up, his brain swelled, and the wound, no doubt due to something beneath Harlow’s fingernails, developed a mushrooming fungal infection. Worse, as his brain continued swelling, Gage started raving, demanding that someone find his pants so he could go outside. He soon lapsed into a coma, and at one point a local cabinetmaker measured him for a coffin.

  Gage would indeed have died—of intracranial pressure, like Henri II three centuries before—if Harlow hadn’t performed emergency surgery and punctured the tissue inside his nose to drain the wound of pus and blood. Things were touch and go for a few weeks afterward, and Gage did lose sight in his left eye. (The lid remained sewn shut the rest of his life.) But he eventually stabilized and returned home to Lebanon, New Hampshire, in late November. In his case notes Harlow downplayed his role here and even quoted Ambroise Paré: “I dressed him, God healed him.” In reality it was Harlow’s dedicated care and his bravery in performing an emergency operation—something Paré had refused to do with Henri—that saved Phineas Gage.

  Or did it? Harlow kept Gage alive, but Gage’s friends and family swore that the man who came home to Lebanon was not the same man who’d left Lebanon months before. True, most things were the same. He suffered some memory lapses (probably inevitable), but otherwise his basic mental faculties remained intact. It was his personality that had changed, and not for the better. Although resolute in his plans before the accident, this Gage was capricious, almost ADD, and no sooner made a plan than dropped it for another scheme. Although deferential to people’s wishes before, this Gage chafed at any restraint on his desires. Although a canny businessman before, this Gage lacked money sense: Harlow once tested Gage by offering him $1,000 for some random pebbles that Gage had picked out of a riverbed; Gage refused. And although a courteous and reverent man before, this Gage was foul-mouthed. (To be fair, you’d probably swear, too, if an iron rod had rocketed through your skull.) Harlow summed up Gage’s personality changes by saying, “The equilibrium or balance… between his intellectual faculties and his animal propensities seems to have been destroyed.” More pithily, friends said that Gage “was no longer Gage.”

  Daguerreotype of Phineas Gage. (Collection of Jack and Beverly Wilgus)

  Despite his stellar work record, railroad managers refused to reinstate Gage as foreman. So he began working odd jobs on farms, and even exhibited himself and his tamping iron—his constant companion now—for spare cash in P. T. Barnum’s museum in New York, staring back at the audience with his one good eye. (For an extra dime skeptics could part his hair and gape at the one-inch-by-two-inch soft spot in his skull, beneath which his brain still pulsated.) After leaving Barnum’s employ he indulged a newfound love of horses and became a stablehand and coach driver in New Hampshire. He also felt drawn to children, and on visits home would spin wild—and wholly untrue—yarns for his nieces and nephews about his supposed adventures. Whether this was a simple love of tall tales or, consistent with his frontal lobe damage, a sign of confabulation, no one knows.

  Ironically, Gage’s own life story soon became something of a tall tale. Not immediately: Gage lived a mostly anonymous life after his accident. But in the decades after his death, rumors began to circulate about him—some of them plausible, some of them pretty warped, all of them probably false. One claimed that Gage developed a drinking problem and started scrapping and brawling in taverns. Another claimed that he turned into a scam artist: he supposedly sold the exclusive, posthumous rights to his skull to a certain medical school, then sold the same rights to another school, and another, and another, skipping town and pocketing the cash each time. One source even had Gage living for a dozen years with the tamping iron still impaled in his noggin.

  More important for neuroscience, there’s a dearth of hard detail about the personality changes he experienced. We simply don’t know how Gage spent most of his postaccident life, nor what his behavior was really like. Harlow’s case reports do make it clear that Gage changed somehow; but Harlow focuses more on his blue language and irrational attachment to pebbles than on the things neuroscientists would investigate today, like Gage’s foresight, emotional capacity, or ability to complete a sequence of steps. As a result of all this, Gage’s life has become as much legend as fact, and the most tantalizing questions about him—how did his mind work now? did he see himself differently? did he recover any lost skills?—remain unanswered.

  Nevertheless, all is not lost. If we’re careful, there are some recent cases in neuroscience that can at least get at those questions. There are “modern Phineas Gages” who can help us glimpse how, when the iron rod finished remodeling Gage’s brain, his mind might have changed in response.

  Of all the incredible details about Gage’s accident, perhaps the most incredible is his claim that he never lost consciousness. Still, in light of modern research, the claim makes some sense.

  Neuroscientists of yesteryear scoured every last cranny inside the brain for the seat of human consciousness. Modern neuroscientists search for something different. As one put it, “Consciousness isn’t a thing in a place; it’s a process in a population.”

  * That is, consciousness isn’t localized: it emerges only when multiple parts of the brain hum in harmony.

  Some of these parts provide basic infrastructural support. A web of neurons in the brainstem called the reticular formation controls sleeping and waking cycles, and acts like the power switch for consciousness. If it suffers damage, basic bodily processes like breathing and digestion continue, but the brain can’t “boot up” its higher faculties. Lesser injuries, like concussions, can also send ripples through the brain that disrupt the reticular formation and cause blackouts. Gage’s injury, by contrast, was focal: however gruesome, the damage was confined to a small tunnel of tissue, without a devastating shock wave of trauma. As a result, his reticular formation escaped unscathed, and his consciousness might never have experienced any hiccups.

  Drawing comparing the size of Gage’s skull and tamping iron. (National Library of Medicine)

  However important for supporting consciousness, though, the reticular formation and related structures don’t actually stir consciousness to life. That responsibility falls more to the thalamus and prefrontal parietal network.

  The thalamus, at the core of the brain, brokers information. It receives information from all over the brain, analyzes it, then relays it around—patching different parts of the brain together like an old-time telephone operator. And for whatever reason, damage to the thalamic relay centers can obliterate
consciousness, leading to what’s called a vegetative state. Unlike coma victims, vegetables remain awake, but they cannot focus on anything or engage in any higher thinking. Their minds drift listlessly from moment to moment, leaves in an indifferent wind. You can also become a vegetable if you suffer damage to the prefrontal parietal network, which (truth in advertising) consists of a patch of frontal cortex, a patch of parietal cortex, and the connections between them. These two patches almost always light up in tandem when we pay close attention to something, an important aspect of consciousness. In sum, the thalamus and prefrontal parietal network don’t ignite consciousness all by themselves, but they do keep the fire stoked.

  Another prerequisite for consciousness is short-term memory, since consciousness requires you to keep track of things from minute to minute. Most amnesiacs, like H.M. and K.C., do have a working short-term memory and a normal moment-to-moment consciousness. But there are people out there with even more severe amnesia, like English musician Clive Wearing, whose consciousness functions differently.

  Wearing made a name for himself in the 1970s as a classical musician and conductor; his concerts of Renaissance music—which re-created everything from the costumes the musicians wore to the meals they ate before performances—have been described as “the next best thing to going back in time.” He also arranged the score for a BBC radio broadcast celebrating Charles and Diana’s wedding in 1981. Clive himself got hitched two years later, but in March 1985, at age forty-six, he came down with a prolonged “flu” and headache; doctors diagnosed meningitis, which had been going around London that week. He became lethargic and irritable, and at one point wandered outside, got lost, hailed a cab, and couldn’t remember his address. The driver dumped him at a local police station, where his wife eventually found him. He suffered on for six more days before finally being dragged to the hospital. Doctors there diagnosed our old friend the herpes virus, and he began suffering seizures and lapsing into and out of consciousness.

  Wearing pulled through and remains alive today. But he suffered heavy limbic-system damage and woke up with no episodic (personal) memory whatsoever. Many semantic memories disappeared, too: he couldn’t define common words like “tree,” “eyelid,” or (fittingly) “amnesia”; he couldn’t remember who penned Romeo and Juliet; and he once ate a whole lemon, rind and all, because he didn’t recognize what it was. Most devastating of all—and unlike virtually every other known amnesiac—Wearing also lost his short-term working memory. When he turned his head, people’s shirts seemed to change color; when he blinked, the cards in his solitaire game rearranged themselves. Especially at first, his memories lasted no longer than his sensory perceptions did.

  As a result, Wearing lost all sense of continuity between past and present: as far as he knew, no other day had ever existed. And however strange it sounds, he interpreted this break with the past as evidence that he’d just “woken up.” That is, he started claiming, incessantly, every few minutes, with the zeal of an evangelist, that he’d just become conscious for the very first time. To be clear: Wearing wasn’t actually blacking out or anything; anyone watching him would have seen that he remained awake moment to moment. But in his own mind, based on the little evidence available to him, he could only conclude that the past few seconds were his first-ever moments of consciousness. This ecstatic rebirth reoccurred dozens of time every day.

  This obsession with consciousness comes through most clearly in his diaries. He started keeping a diary in 1985, to provide an anchor for his past—proof he even had a past. Instead, Wearing filled whole pages with entries like:

  8:31 AM: Now I am really, completely awake.

  9:06 AM: Now I am perfectly, overwhelmingly awake.

  9:34 AM: Now I am superlatively, actually awake.

  And so on. Every few minutes, the rapture of having just become conscious would overwhelm him and compel him to record the moment. (A few times, when he couldn’t find the diary right away, he grabbed a pen and recorded his epiphany on the walls or furniture.) But because he’d only just woken up—just now—the old entries were clearly false. Hence, he struck them out.

  Wearing has dozens of diaries littered with such entries, each one denying, with incredible adverbial dexterity, that he’d ever been awake before. And as you might suspect, Occam’s razor cannot kill this delusion: he can even recognize his handwriting in the struck-out passages, but any suggestion that he therefore probably wrote them can send him into a rage. Old videos of him playing the piano do the same. He once again recognizes himself in them, but denies he was actually conscious at the time. When asked the obvious follow-up question—what, then, was going on in your head during those videos?—he might erupt, How the hell should I know? I’ve only just woken up.

  So why does Wearing lose consciousness over and over, while Gage never lost it at all? Again, we know the rough answer with regard to Gage: the skinny tamping iron must have skirted all the regions that help produce consciousness, or it would have been lights out. And lest you dismiss the claim that Gage stayed awake as nineteenth-century credulity, there are modern reports of people getting impaled with metal rods or shafts and remaining cognizant,

  * too. Gage was nothing special here.

  Wearing’s case is tougher to understand. His consciousness circuits certainly work to some extent, since he can recognize that he’s conscious at any one moment. But part of being conscious is maintaining that awareness over time, and whatever structures in the brain support that function seem to be draining every few seconds, like a battery that can’t hold a charge. So while Wearing never quite sinks into a vegetative state, he never quite emerges into full, sustained consciousness, either. This might make sense if Wearing’s thalamus, prefrontal parietal network, or reticular formation had suffered damage, but they actually look okay on brain scans. So scientists are reduced to guessing. Perhaps some region that connects those structures together suffered damage. Perhaps those structures suffered damage that brain scans can’t pick up. (Wearing does confabulate, a sign of frontal lobe impairment, and some neuroscientists have pegged his endless babbling and “incontinent punning” as another frontal lobe disorder, Witzelsucht, literally, the joking disease.) Perhaps the damage to individual structures matters less than the overall, brain-wide extent of his damage. Or perhaps Wearing’s troubles can be traced to something we don’t yet understand, something that plays an unsuspected role in consciousness. Nor do we understand why other amnesiacs escaped his fate. H.M. and others do sense the present constantly slipping away from them, seeping into indistinctness, and it unnerves them. But unlike Wearing, they don’t deny that their pasts exist. Only Wearing loses the continuity and continually “pops awake.”

  In the end, Gage and Wearing sit on a spectrum, the tenacity of Gage’s consciousness on one end, the fragility of Wearing’s on the other. You certainly couldn’t call Gage lucky, but his focal damage at least spared his consciousness. Wearing, meanwhile, enjoys neither the gift of full mental awareness nor the release of permanent oblivion. Instead, his own brain torments him with an almost mythological malice. Like Sisyphus’s boulder, as soon as he gets a purchase on his consciousness, it slips away. Like Prometheus’s liver, it grows back every few seconds, only to be torn out again.

  *

  The comment by his loved ones that Gage “was no longer Gage” after the accident brings up another point worth unpacking. To friends and family, Gage had changed, clearly. But how did Gage himself understand these changes? Was his sense of self transformed or diminished? Sadly, Gage didn’t record his thoughts on this (or any) subject. But again, we can infer some things about his sense of self from other cases of brain damage.

  The annals of neuroscience contain some pretty distorted views of the self. Victims of Cotard syndrome are convinced they’re corpses. Other deluded folk swear they have three arms or legs. H.M. never matured beyond age seventeen in his own mind. (When handed a mirror, he would stare nonplussed at his wrinkles and gray hair and deadpan,
“I’m not a boy.”) Other amnesiacs forget things you wouldn’t think possible, even basic biological functions. Aleksandr Luria, the Russian neuroscientist who studied the memory freak Shereshevsky, wrote another “neurological novel” about a soldier named Zazetsky, who took a bullet to the parietal lobe while fighting off Nazis near Belarus in 1943. The parietal lobe helps monitor bodily sensations, and when his parietal lobe got shredded, Zazetsky forgot how to go to the bathroom. He would feel a bulge in his sphincters and know something was up, but couldn’t recall what to do next.

  Still, even the most desperate amnesiacs never forget themselves—never forget, deep down, who they are. For instance, most amnesiacs can describe their own personalities: they know they’re generous or impatient or whatever, even if they can’t recall a single time they displayed that trait. They can also tap into their core selves by drawing on different types of memory. Clive Wearing can still sight-read music and play the piano, since those skills draw on his procedural (unconscious) memories. And for whatever reason, being a musician is so deeply rooted within him that those procedural memories can resurrect something of his old, lost self: as soon as he strikes the first chord, the momentum of the phrases keeps him intact, dragging him along and providing a coherence and unity he otherwise lacks. It’s as if he slipped through a wormhole into an alternative dimension where his brain circuits never suffered damage. After the final note, of course, he’s ejected from that world. And the bewilderment and disappointment of finding himself lost again often causes a swell of emotion so intense that his body begins to convulse. But for the entire étude or rondo, Clive is Clive again.