Psychosocial Adaptation

Since writing An Odd Kind of Fame: Stories of Phineas Gage, I have given a good deal of thought to what kind of recovery Phineas Gage might have made. This page is devoted to considering that possibility. In my book, I did point out the discrepancy between the common view of his becoming an unreliable, unemployable, drunken, drifter and the facts that he was employed in the one occupation for some years after the accident, that he moved around from one job to another only in the last few months of his life, his drawing on complex cognitive and motor skills and social abilities for stage-coach driving, and his living independently. These facts pointed to some kind of adjustment to his brain injury. In a search of the literature I found several reports of similar adjustment after equally severe damage. Each pointed to the possibility of what is called ‘psycho-social adjustment’ and which I prefer to term a ‘social recovery.’

People with frontal damage as severe as Phineas’ have made similarly good psychosocial adaptations in formal programs of rehabilitation. Many have done so without their benefit. When examined, one finds that both the formal programs and the less formal ones are based on a good deal of structure being imposed on the patient’s daily activities, training the patient to use external cues to monitor what they intend doing, and re-establishing the role of the patients’ own language in controlling their behaviour.

A number of the formal programs are based on or derive from the work of Aleksandr Romanovich Luria, the Soviet neuropsychologist, in rehabilitating Red Army soldiers wounded in WWII. The foundation of Luria’s program was in his studies of the role of language in development of normal and intellectually handicapped children. His observations and experiments showed that when a child was able to add language to even a simple task like pressing or not pressing a button in response to a green or red light by saying ‘press’ or ‘not press,’ the correctness of the child’s performance increased remarkably. Adding language began with the experimenter saying ‘press’ and ‘not press,’ moved through the child saying the words out loud, and finished with the child internalising the instruction.

Re-establishing this role of internal language was the principle goal of Luria’s adult rehabilitation programs. They were begun in a highly structured environment where external cues were used to guide behaviour and, when successful, led to patients being able to maintain a degree of independence in their own lives. Formal rehabilitation programs that have been developed subsequently have also shown the need for an environment that is consistent and relevant to the patient as well as highly structured

The informal ‘treatments’ mimic these features. Thus as I have previously noted, Thomsen, Waldemar, and Thomsen (1990) described a female patient who made a good psychosocial adaptation many years after suffering severe bilateral fronto-orbital damage when she was 17. She showed typical uninhibited behaviour until, 10 years post-accident, she began living with a man who was not sexually involved with her and who drew up a simple written programme of personal and household tasks that she had to perform in exactly the same order every day. Although she remained childish, exhibited mild irritability and temper, and her memory was still impaired, two years of this routine enabled her—at 19 years post-accident—to care for herself and do housework and shopping.

My Boston colleague, Matthew L. Lena and I discovered a number of new things about Phineas Gage that are consistent with reports like that of Thomsen and his colleagues. At least they require us to change the view that for the rest of his life Phineas' behaviour continued to be impulsive and uninhibited.

What is the evidence favouring Phineas’ psycho-social adaptation? It is set put fairly fully in the two references at the bottom of this page. What follows here is a summary of the damage, its immediate consequences, and the long term outcome.

First, how was the damage caused to Phineas' brain and which parts were destroyed and damaged?

Here is the reconstruction by Peter Ratiu and Ion-Florin Talos of the passage of the tamping iron through Phineas' skull and brain.

The passage of the tamping iron: The image Peter Ratiu and Ion-Florin Talos published in the New England Journal of Medicine in 2004.

The reconstruction is based on a CT scan of Gage's real skull, not a model of it made by deforming the model of another skull. From it they believe the skull hinged open as the tamping iron passed through it and that once it was completely through, the muscles and other soft tissues of the face caused the skull to close. The damage to the brain was to the left frontal lobe.

You can read about their reconstruction and see their animated version of it in the electronic version: P. Ratiu and I-F. Talos (2004): The tale of Phineas Gage, digitally remastered. New England Journal of Medicine 351: e21-e21.

Jack Van Horn and his colleagues subsequently used the Ratiu and Talos reconstruction in an attempt to map the damage to the tracts in the white matter of Phineas’ brain that connected the various areas of his cortex. Although they seem to have come close to locating the damage, they have had to make some averaging assumptions about Phineas’ brain itself, and these may not be completely accurate. They concluded that the damage interfered with the connections in the left frontal lobe (see Reading about Gage).

Was Phineas so injured by his accident that he avoided interacting with others?

Zbigniew Kotowicz had argued that much of the antisocial behaviour ascribed to Phineas was due to his being disfigured by his accident. This laterally reversed daguerreotype shows us what people would see when they looked at him after the accident. We have no real idea of what he looked like before it.

A laterally reversed photograph of the daguerreotype made of Phineas Gage

From the collection of Jack and Beverly Wilgus

Jack and Beverly Wilgus, now of Texas, acquired this daguerreotype, of which this is a photograph, some 30 years ago but did not identify it as Phineas until 2008. They think he looks self-assured. Do you? We don't think this Phineas would hide himself from others or hide away in Chile because of his disfigurement. Do you?

How sure can we be that this image is of Phineas Gage?

Among other things, Jack and Beverly Wilgus found that the images of the writing on the real tamping iron match those on the daguerreotype and that the scars on the forehead of the daguerreotype exactly match those on an image of Phineas Gage's life mask. For these and other details, see their 2009 paper 'Face to Face with Phineas Gage' in the Journal of the History of the Neurosciences, 18:340-345. The paper is available online at libraries subscribing to the journal through InformaWorld. You can find out much more about the image at the site Jack and Beverly Wilgus set up.

Two relatives of Phineas Gage also have copies of a photograph of a similar but different daguerreotype that has been passed down through descendants of Phineas’ siblings. There is no doubt that that image is also of Phineas.

Can we reconstruct what Phineas looked like before the accident?

Reconstructing what Phineas looked like before the accident is not really possible. A blogger has posted an image that conjoins the real and undamaged right side of Phineas' face with its mirror image thinking "this helps portray Mr Gage more accurately." It is absolutely no help at all! For at least 25 years psychologists have known that the asymmetry of facial structure results in two very different 'wholes' from such conjoining. Two 'lefts' never make the same face as two 'rights' and vice versa.

Beverly Wilgus is well aware of this trap but at my insistence replaced the damaged left eye with a digitally altered mirror image of the undamaged right eye. She also removed the highlights and the scar on his forehead. The result is about the closest we can get to what the undamaged Phineas might have looked like—but his real appearance will probably always be uncertain.

Enlargement of image of head from daguerreotype on left.

Phineas with a digitally altered left eye on right.

Left image from the collection of Jack and Beverly Wilgus.

Right image prepared for this page by Beverly Wilgus

Why is it Gage? Among other things, Jack and Beverly Wilgus found that the scars on the forehead of this image exactly matched those on an image of Phineas Gage's life mask. The images of writing on the real tamping iron also match those on the daguerreotype. For these and other details, see their 2009 paper 'Face to Face with Phineas Gage' in the Journal of the History of the Neurosciences, 18:340-345. The paper is available online at libraries subscribing to the journal through InformaWorld. You can find out much more about the image at http://brightbytes.com/phineasgage

A reconstruction of what Phineas looked like before the accident? Not really. A blogger has posted an image that conjoins the real and undamaged right side of Phineas' face with its mirror image thinking "this helps portray Mr Gage more accurately." It is absolutely no help at all! For at least 25 years psychologists have known that the asymmetry of facial structure results in two very different 'wholes' from such conjoining. Two 'lefts' never make the same face as two 'rights.' Beverly Wilgus is well aware of this trap but at my insistence replaced the damaged left eye with a digitally altered mirror image of the undamaged right eye. She also removed the highlights and the scar on his forehead. The result is about the closest we can get to what the undamaged Phineas might have looked like - and his real appearance will probably always be uncertain

Barnum’s American Museum in New York as it was circa 1853 and therefore at about the time Phineas exhibited himself there. Reproduced by Courtesy of The Barnum Museum, Bridgeport, Conn.

Phineas at Barnum's American Museum, New York City

Dr. Harlow says Phineas was at Barnum's American Museum in New York and the Warren Museum possesses an 1868 letter from Dr. Bigelow confirming that fact. In advising on a related case, Bigelow threw doubt on the usefulness of such appearances: “Gage, who was a shrewd and intelligent man and quite disposed to do anything of that sort to turn an honest penny, (that style of living being also quite to his taste) tried it for a short time at New York at Barnums’, then abandoned it.” He could not have been shy if he showed himself in public during his time at Barnum’s.

Unfortunately we have no record of anyone seeing Phineas there. Nor does there seem to be a Barnum poster or an advertisement in the New York press advertising his appearance. Do you or a friend have anything documenting his appearance at Barnum's? It would have been in the 1850s.

Phineas travelled around the larger New England towns giving lectures and exhibiting himself.

Dr Gene Bont of Cavendish, Vermont found a broadside advertising a lecture-exhibition given by Phineas in Concord, New Hampshire. Matthew L. Lena of Boston, Massachusetts found an advertisement announcing Phineas' arrival in Montpelier, Vermont, in August 1852.

Above left: Undated broadside advertising a lecture-exhibition by Phineas Gage in Concord, New Hampshire.Reproduced from the Vermont Patriot and State Gazette (Montpelier, Vermont), August 12th 1852.

Above right: Digital repair of the broadside by David Williams, Knowledge Media Division, of Deakin University, Victoria, Australia and reproduced with the permission of the copyright holders, the New Hampshire Historical Society, Concord, New Hampshire.

Neither the dates the broadside was printed nor that of the lecture-exhibition are known. Because a fire destroyed the printery of McFarland and Jenks in 1851, and it did not resume production until late that year, we know the broadside was not produced earlier than that time. Phineas must have given his lecture-exhibition some time between the end of 1851 and the end of 1854, possibly some time in 1852, on an unknown 'Tuesday' in Concord, New Hampshire.

Note particularly that Phineas appeared alone, that is, not under anyone’s auspices and without any accompanying ‘freaks.’ He may have arranged the hiring of halls by himself. Note also that the claims Phineas made about his injury were supported by letters from doctors who had examined him. Presumably Phineas had asked for these testimonials himself.

In Montpelier Phineas was accompanied by a 'General' Washburn of thin stature and small height—a so-called 'dwarf skeleton.' Only loosely can this advertisement be construed as Phineas appearing in a ‘freak’ show. However, the advertisement is not for a Phineas on a fairground or as part of a circus. It is the only evidence that Phineas ever travelled in the company of what came to be called 'freaks.'

Would that someone from Concord or Montpelier who saw Phineas had left a written record describing what he did!

Was Phineas still in the USA in 1854?

Dominic Hall of the Countway library found this envelope (right) with a message written on it dated 26^th August ’54. The date conflicts with that of August 1852 given by Dr. Harlow as the time Phineas “turned his back upon New England” and left for Chile.

Envelope

Apparently written by Phineas, he requests his tamping iron to be given to the bearer, Mr. B. R. Sweatland, who was probably a relative of Phineas’ mother. Her maiden name was Hannah Trussell Swetland/Sweatland.

What abilities did Phineas need to drive a stage coach in Chile?

Phineas needed extraordinary cognitive and motor skills just to drive a Concord coach (see pages 104-106 of An Odd Kind of Fame). Matt Lena has since found an advertisement from which the other abilities Phineas needed as a driver on the Santiago-Valparaiso run can be inferred.

A Concord coach or 'diligence' on the Santiago-Valparaiso route. It is the kind Phineas is believed to have driven.

From the Abbot-Downing Collection of the New Hampshire Historical Society and reproduced by courtesy of the Society. The source of this illustration is unknown and we would like to know where it was published

The 1860 advertisement says the 13 hour, 110 mile journey from Valparaiso to Santiago started at 4am. Passengers paid $10.00 for the journey and were allowed 50 pounds of luggage. Before arriving at the starting station at 4 a.m. Phineas would have had to check (if not actually perform) the feeding, grooming and harnessing of the horses. Once there he would have had to load the luggage, collect the fares, give change, make the passengers comfortable, and keep them so for the next 13 hours. He would have driven back to Valparaiso 24 hours after arrival in Santiago.

Every day Phineas’ job structured his activities and helped him regain control over his life.

Is there evidence that Phineas’ behaviour in Chile was different from Harlow’s original description?

Matthew L. Lena discovered that Prof. J. W. Hamilton of the Starling Medical College in Columbus, Ohio, and an editor of the Ohio Medical and Surgical Journal, took part in a discussion of Phineas in 1860. He recorded that “Dr. Henry Trevitt, of Valparaiso, South America, who was present, at once replied to our remark that he knew Gage well; that he lived in Chili [sic], where he was engaged in stage driving; and that he was in the enjoyment of good health, with no impairment whatever of his mental faculties.” Matthew also established that Dr. Trevitt was in Valparaiso from mid-1858 until about mid-1859, that is, until about the time Phineas returned to live with his relatives in San Francisco.

What were Phineas' last years like?

Not long after Trevitt saw Phineas he began to suffer bad health (of an unknown kind). Eventually he left Chile and rejoined those members of his family who had moved to San Francisco, California, as part of the gold rush. Phineas gradually regained his health and became, his mother said, “anxious to work.” He moved south to Santa Clara where he worked for a farmer.

Soon after commencing work he began having occasional convulsions. He became unsettled in the periods between the seizures, now frequently becoming dissatisfied and moving from one employer to another. Three days before he died he returned from Santa Clara to his brother-in-law’s house in San Francisco. Two days later had the first of a series of severe convulsions that, over a period of some 36 hours, killed him (status epilepticus).

What can we conclude about Phineas’ psychosocial adaptation?

The combination of the new evidence and a reconsideration of the old justifies the following summary:

Phineas resumed work on the family farm within four months of the accident, and sought his old job as foreman within another four.
himself, possibly managing his appearances, advertising, and travel independently, in a context where he would have to re-learn any lost social skills.
He worked for Currier during 1851–1852, where he possibly learned stagecoach driving and developed or built on his social re-learning.
He was settled and reliable enough in his behaviour for the founder of a coach line to take him to Chile as a coach driver.
He worked in Chile for about 7 years in a highly structured occupation (possibly for just one employer) used the complex social and cognitive-motor skills required by his job, and adapted to the language and customs of a Chile that would have been a foreign land to him.
Eventually his mental faculties recovered to the point where an American doctor who knew him well in Chile saw “no impairment whatever” in them.
After recovering from illness in San Francisco, he was “anxious to work” and found farm employment in Santa Clara.
He continued to work even after his first seizure. Only from that time did he become unsettled and dissatisfied in his employment.

What happened to Phineas is consistent with Luria’s thesis, with the details of formal programs of rehabilitation for patients with brain injury, and with the response of patients, like Thomsen’s, to less formal ones.

If Phineas was “No longer Gage” for some time after the accident he finally came close enough to being Gage again.