The extraordinary life of Phineas Gage
In the 1940s and 1950s, more than 40,000 “lobotomies” were performed in the USA alone. Doctors essentially disconnected the bit of your brain behind your forehead, the “prefrontal cortex”, in misguided attempts to treat a range of illnesses, but mainly schizophrenia. A dark chapter in medical history, prefrontal lobotomies probably did more harm than good. Tragically, a great deal of the pain inflicted upon vulnerable, and sometimes even non-consenting patients, could have been avoided had doctors just studied the extraordinary case of Phineas Gage.
Phineas Gage survived an accidental self-inflicted lobotomy in 1848
In 1848, Phineas Gage gave himself a prefrontal lobotomy by accident. Inadvertent prefrontal lobotomies arise from grave misfortune, but are survived by sheer luck. Phineas was the foreman of a railway line construction crew and was responsible for clearing large rocks that obstructed the planned railway tracks. He drilled holes into the rocks and filled them with explosives. They pushed the explosives down into the holes using “tamping irons”: metal rods approximately 1 meter long and 3 cm in diameter. Although dangerous, tamping the explosives down was a routine procedure. On September 13th 1848 however, Phineas became distracted. Somehow, he accidentally detonated the explosives and succeeded in propelling the 13 pound iron tamping rod straight through his skull.
Remarkably, not only did Phineas survive having bits of his brain blasted almost 20 feet behind him, he also regained consciousness within a few minutes of the accident. His colleges drove him to a nearby inn, in an oxcart, where he was attended by Dr John Martyn Harlow. Despite a torn scalp and a fractured skull, Harlow notes that Phineas was lucid and able to talk rationally with him. He also noted that the iron passed directly through Phineas’ frontal lobes, or - as we would now call it - his prefrontal cortex. This has been confirmed by modern doctors who examined his skull and the original tamping iron. Despite the severe trauma and an ensuing infection, Phineas was allowed to return home to New Hampshire 10 weeks later. He would go on to live another 11 years.
The changes in Phineas Gage's behaviour give insight into the role of the prefrontal cortex
His recovery was truly astonishing for the time and is still extremely intellectually informative. He could walk and move as he did before the accident. His memory and intellect seemed unchanged. However he was not the same man. He went from a well-liked, friendly, and respected individual to a “fitful, irreverent, and grossly profane” person. Also “impatient and obstinate, yet capricious and vacillating”, he was “unable to settle on any of the plans he devised for future action.” Harlow considered Phineas to have become “a child intellectually” but with “the animal passions of a strong man.” His family and friends, merely said he was “no longer Gage.” The new Phineas, erratic and unpredictable, would never regain his foreman’s job. Indeed he struggled to hold down any job. By 1850 he earned his living as a circus exhibit - carrying around the tamping iron.
Phineas’ behaviour changed so dramatically because the prefrontal cortex is an extremely important and complex brain region. When summarising the prefrontal cortex, Dr Steven Wise, a neuroscientist, links it to a plethora of processes. These include “attention to objects, places, actions and intentions”, “problem solving strategies”, “processing events across time”, “decision making and goal selection”, “reward expectation, the valuation and revaluation of actions and stimuli” and “response inhibition” (preventing responses an individual performs automatically). To summarise, the prefrontal cortex does a lot. It’s unsurprising then that Phineas changed so drastically. What is remarkable is that, until really recently, the prefrontal cortex was considered the “silent cortex” because electrical stimulation produced no discernable results. This is a great example of a logical fallacy - just because we couldn’t measure what the prefrontal cortex was doing, didn’t mean it wasn’t doing anything.
The rise of the lobotomy
A lack of understanding of the importance of the prefrontal cortex does not account for the glut of lobotomies performed in the mid 1900s. Whilst some earlier experiments were performed, the story of the prefrontal lobotomy really starts with Carlyle Jacobsen.
In the 1930s, Jacobsen damaged the prefrontal cortices of some non-human primates. He found that they became deficient at tasks where they had to remember things for more than a few seconds. As an aside, he noted that one of the chimps, Becky, became calmer after the surgery, as if she had joined a “happiness cult”. This observation was just that - an observation. He didn’t see this behaviour in any of the other animals, and the side effect of calm behaviour was never analysed with the same scientific rigour that the memory effects were. This is quite reasonable, Jacobson was performing the experiments to look at the role of the prefrontal cortex in memory, not mood.
But at a scientific meeting in 1935, Jacobsen mentioned his observations about Becky when presenting the results of his memory data. Egas Moniz, Portuguese psychiatrist, became extremely excited about Becky, wondering if such a surgery (it wasn’t called a prefrontal lobotomy back then) might help mentally-disturbed patients. Jacobsen was skeptical and refused to collaborate.
This didn’t deter Moniz; he teamed up with a neurosurgeon and they soon began performing prefrontal lobotomies on patients suffering from a diverse spectrum of mental disorders. These lobotomies were performed “blind” - that is to say that the exact route of the lobotomy could not be determined in advance. Each surgery was different. In addition, they performed the surgeries on a broad range of patients, who varied not only in their mental illness, but in a range of variables scientists should try to control for when studying humans, such as age, race and gender. Combined these two things - inconsistent surgeries and a diverse patient group - would have made it very difficult to accurately assess the effectiveness of prefrontal lobotomies, had Moniz even bothered to do it.
A dark chapter in medical history
It seems that Moniz became so enamoured of his own work that he failed to perform rigorous analysis of the patients post surgery. Nor, does it seem, did the rest of the medical community, at least initially. In 1949 he was awarded the Nobel Prize in Physiology or Medicine. What Moniz did was not science and it’s truly staggering that he managed to self promote his way into one of the world’s most prestigious awards. Moniz and his followers performed more than 40,000 lobotomies in the USA and 10,000 in the UK (far more per capita) on, at best, anecdotal evidence.
Observing that some of the patients treated seemed calmer after a lobotomy is step one of the scientific method. Step two would be testing to see if this holds true for the majority if not all of the patients treated, ideally at several different time points after the surgery. It’s step two that Moniz failed to do. It wasn’t just Moniz who failed to perform sufficient postoperative analysis: American physician Walter Freeman, co-developer of the “ice-pick lobotomy” that could be performed by people without medical training, personally performed about 3,500 lobotomies and also failed to put his results under sufficient scrutiny. The UK’s equivalent to Walter Freeman, Sir Wylie McKissock, is believed to have performed around 3,000 lobotomies. He got so efficient at it, he could do one in about 5 minutes.
Some of McKissocks patients were eventually followed up by psychiatrist Dr John Pippard. He found a roughly even split between those that benefited, those that didn’t and those that were unaffected. The detrimental side effects were severe and included unresponsiveness, lack of motivation, decreased attention span, inappropriate or blunted emotions and the loss of behavioral inhibitions. All of these are behaviours displayed by Phineas Gage. If prefrontal lobotomies were unsuccessful two thirds of the time, either because the surgery had no effect or because it had horrific side effects, why then did doctors and physicists persist in doing them for so long?
The fall of the lobotomy
A cynic might tell you that the reason the psychiatric community finally transitioned away from lobotomies was not the mounting evidence of their ineffectiveness, but money. Indeed, the reason so many were performed in the first place is financial. Until the mid 20th century, mental illness had no real effective treatment. With the exception of surgery, treatment for mentally ill individuals in the early 1900s would look little different from treatment prescribed in the notorious Bedlam Hospital in 19th Century London: long term hospitalization, confinement, straight-jackets and isolation in padded cells. The cost of this would have been immense. In 1937, there were 450,000 patients in 477 asyla in the USA. Housing and treating them is estimated to have exceeded 24 billion of today’s Dollars.
If you bought into the pseudoscience, lobotomies offered a way to reduce the financial burden of the mentally ill. Practitioners were promised that lobotomies would calm patients so that they could leave the hospital and, perhaps, even rejoin society. Desperation for a solution might have made them susceptible to assurances, which seem staggering to have been believed in, retrospectively. This doesn’t absolve them of what they did - it takes a certain kind of arrogance to “treat” patients, some as young as 12, in such a manner; to decide that they are better off living a life disengaged with their surroundings (i.e. calmer) than their current one. Particularly when the decisions made running the asyla easier and cheaper.
The popularity of lobotomies fell as they rose, on the back of coins. In 1952, clinical trials showed that a drug called chlorpromazine could be used to treat a wide range of psychotic disorders. It was reversible, easy to administer and actually fulfilled the promise that most patients could return home. Together these three attributes saved a lot of money. Within a few years chlorpromazine was being given to millions of patients.
The legacy of prefrontal lobotomies and Phineas Gage
Nowadays prefrontal lobotomies are performed only rarely, mainly to remove tumours. These patients have been studied extensively. Performing normally on many tasks, they tend to make bad decisions in both real life and in the lab. In simulated gambling situations, patients with damage to their prefrontal cortices are unable to pass up short term rewards even if this sets them back in the long term.
Modern patients, with injuries to their prefrontal cortices, are supported: their friends and family are briefed to be prepared for the changes that will occur after their surgeries. The altered behaviours should not come as such a shock. Phineas Gage had no such support. It must have been truly disconcerting for his friends and family to interact with such an altered man. We will never know what Phineas felt about his accident, but it may not be much. Modern research about patients with damaged profrontal cortices suggests that they generally have trouble generating emotions. Whether he was happy about it or not, Phineas Gage lived a truly extraordinary life and it’s a great tragedy that his traumatic injury did not influence the lobotomy trend.