Antonio Damasio
On September 13, 1848, a twenty-five-year-old foreman was directing a team blasting rocks to open up a path for a railway line in Vermont. The task was simple. A hole was bored into the rock to a depth of around three feet. Once completed, blasting powder and a fuse were put into the hole, and pushed down with a ‘tamping iron’, some 11⁄4 inches round, three feet seven inches long, weighing just over 13 pounds. Distracted by something happening behind him, the foreman turned, and the tamping iron sparked on the rock, igniting the blasting mix. The iron shot up, went through the left-hand side of his skull, emerged out from the top, and landed 80 feet away, smeared with blood and brain matter. The man was Phineas Gage, perhaps the most famous of all those who have played a role in understanding brain function.
Despite his appalling injury, Gage survived, and was able to sit up and talk within minutes of the accident. After a few days, he became delirious, and remained in a semi-comatose state for three weeks. Eventually he began to recover and started to take some physical exercise. Three months later he was able to go out, ride a horse, and by February 1849 he was “able to do a little work about the horses and barn, feeding the cattle etc.” although his mother felt his memory was slightly impaired. He was unable to go back to working on the railways, and for a short time Gage was promoted as an ‘exhibit’ by Barnum’s American Museum in New York City. In August 1852, Gage he left for Chile to work as a long-distance stagecoach driver, ‘caring for horses, and often driving a coach heavily laden and drawn by six horses’ between Valparaíso and Santaigo. His health began to fail in mid-1859, and having returned to the USA, he died in 1860, by then living with his mother close to San Francisco.
What this brief summary has not yet included is the other side to Gage’s recovery. Physically, he survived, but the Phineas Gage immediately after the accident was a very different person from the one before. His physician (we’d call him a general practitioner today) who looked after Gage after his accident, Dr J M Harlow is the only first-hand and reliable source on Gage’s life. He published a series of papers on his patient in the Boston Medical and Surgical Journal in 1848, 1849 and 1868, (all extensively quoted in Malcolm Macmillan’s 2010 book, An Odd Kind of Fame). Harlow reports that prior to the accident Gage was hard-working, responsible, and ‘a great favorite’ with the men in his charge. His employers regarded him as “the most efficient and capable foreman in their employ”. He also noted Gage’s memory and general intelligence “seemed unimpaired after the accident, outside of the delirium exhibited in the first few days”. However, his employer “considered the change in his mind so marked that they could not give him his place again”.
To begin with, Harlow noted, Gage was fitful, irreverent, often indulging in excessive profanity (quite unlike his previous behaviour). He showed little deference for his fellows, he was impatient over any restrictions or advice when it conflicted with his desires, and at times he was obstinate. He was also capricious, to the point his friends and acquaintances said he was ‘no longer Gage’. Most popular reports about Gage after the accident stop at this point, leaving the impression he was permanently changed and had become a rather unpleasant individual. They are misleading. In 1860, J Hamilton, an American physician who had known Gage in Chile in 1858 and 1859 described him as still “engaged in stage driving [and] in the enjoyment of good health, with no impairment whatever of his mental faculties and that that Gage’s most serious mental changes had been temporary, so that the ‘fitful, irreverent … capricious and vacillating’ [behaviour by] Gage as described by Harlow immediately after the accident became, over time, far more functional and far better adapted socially”.
Gage’s stagecoach work in Chile included the requirement that the drivers were reliable and resourceful, and he had to show considerable endurance. Harlow observed drivers needed to get on well with their passengers. Each day Gage would have a 13-hour journey over some 100 miles [160 km] of poor roads. To do this he would have had to rise early in the morning, prepare himself, and groom, feed, and harness the horses; he had to be at the departure point at a specified time, load the luggage, charge the fares and get the passengers settled; and then he had to care for the passengers on the journey, unload their luggage at the destination, and look after the horses. That set of tasks established a framework that required control of any impulsive behaviour he might have demonstrated. More than that, foresight was required. Drivers had to plan for turns well in advance, and sometimes react quickly to manoeuvre around other coaches and wagons, let alone people and animals on the road, and the roads varied from some well-made to others that were dangerous and rough. In fact, Gage’s work created a structured environment rather like the rehabilitation regimens used in the treatment of World War II soldiers suffering from frontal lobe injuries.
There was no post-mortem autopsy carried out when Gage died, and Harlow only found out he had died some years later. Remarkably, he decided that his skull should be retrieved for further study. The body was exhumed, the skull removed (with Gage’s sister’s permission), and was sent to the Warren Medical Museum of the Harvard Medical School, together with the tamping iron, which was found in the coffin. To learn more about what had taken place, Dr Hanna Damasio recently photographed the skull, created a 3D virtual model, added in the tamping iron, and was able to assess the likely brain damage. That proved the injury to be almost exclusively in the prefrontal cortices of Gage’s brain, and it was damage to these that had initially compromised his ability to conduct himself as he had before, to follow what we would consider the usual conventional rules about behaviour and speech, and his ability to plan for the future, although he was able to restore at least some of that behaviour over time.
Many reports have offered evidence that damaged neural pathways can be re-established or alternative pathways constructed as the brain recovers from an injury. To the extent that Gage recovered, or at least found a set of routines to manage his life, it is a quite amazing example of that happening, and that rehabilitation can be effective even in the most traumatic cases. Although there is little else that can be said about Gage’s accident and recovery, it remains one of the more extraordinary cases in neuroscience. It has also proved to be a basis for many lurid and exaggerated accounts of what happened, with ludicrous claims that he mistreated his wife and children (he wasn’t even married); became promiscuous, gambled, lied and brawled (he did none of these things); or became a vagrant, an idiot, or a lout (none of these were true). All these colourful tales entirely missed what was the most remarkable thing of all, which was that he substantially recovered after losing part of his brain.
Phineas Gage takes up the first two chapters of Antonio Damasio’s book, Descartes’ Error. Damasio is a neuroscientist, based at the University of Southern California. His field of interest is the relationship between brain and consciousness, and his research has shown how emotions play a central role in social cognition and decision-making. For a scientist at the leading edge of exciting research, with dozens of honours and awards, he writes books that are intended to help lay readers grasp what he is discovering through his research in neuroimaging and neuroanatomy, undertaken in collaboration with his partner Hanna Damasio, another world-leading researcher, whose photographs are referred to above .
Did I say his books are aimed at lay readers? They are, but they are lay readers far smarter than I am! I have read and reread Descartes’ Error, fascinated by what he reveals, and impressed by his ability to take complex research and turn it into accessible explanations. I admit it would be even easier to understand if I were a neuroscientist, but his analysis makes sense. It makes sense at the macro-level, although he does lose me when he gets into some of the details. However, what makes it really memorable is his use of cases like that of Phineas Gage. In fact, I should explain this rather differently: it was my own fascination with Phineas Gage that led me to read Descartes’ Error.
The analysis of what happened to Gage after his accident gives Damasio the opportunity to introduce two themes in his subsequent analysis. The first is the relationship between emotions and rational activities. He believes that emotions play a critical role in high-level cognition, that emotions and their biological underpinnings are involved in decision-making (both positively and negatively, and often non-consciously). Emotions provide a framework for social cognition and Damasio has conducted experiments to show scientific validation of the linkage between feelings and the body by highlighting the connection between mind and nerve cells, describing this as the “personalized embodiment of mind”. Second, he has also proposed that emotions are part of what is called ‘homeostatic regulation’, with feelings as a ‘read-out’ of body states. Damasio regards feelings as the necessary foundation of sentience, the term he uses to refer to self-awareness and consciousness.
There are limits as to what can be done with archival evidence, and in Descartes’ Error Damasio moves on to another, rather more contemporary case. Elliot was well-regarded businessman, happily married, and his career was steadily progressing. However, quite unexpectedly, he suddenly began to experience increasingly painful headaches. Eventually, a huge tumour was successfully removed from the front region of his brain. He recovered except for two consequences. First, while he remained as mentally capable as ever, and his intellectual, analytical and strategic skills appeared unimpaired, he could easily be distracted, hopping from one task to another, moving from broad analyses to an obsessive focus on a single area of detail. The other change was that his emotional responses flattened, and he seemed to be living in the world without affect. He could observe emotional scenes, but they had no impact on his feelings: he lacked evidence of an emotional response.
Damasio’s case study of Elliot confirmed what had become central to his hypotheses. As he explains it “body and brain form an indissociable organism”. His continuing research has examined the ways in which emotions are processed in the brain, and he takes that further to argue that “feelings are just as cognitive” as any other perceptual image. As he explains, feelings “offer us the cognition of our visceral and muscoskeletal state”. The book makes its title clear. Descartes’ error was to propose a radical and unbridgeable separation between body and mind. It has had major consequences, even to the point it has encouraged the analysis of the mind as if it is behaving like a set of computer programs, as if the brain does not need to be examined through the disciplines of neurobiology and neuroanatomy.
As you are reading this, think about yourself. Do you experience in two separate ways: a body, with its aches, pains, pangs of hunger and moments of satiation, and separately, a thinking process going on independently of bodily experiences and feelings? Or are you ‘you’, indivisible, aware of a tingle in a toe at the same time as mulling over what you are reading, or, as I am right now, also dipping in and out of the music you can hear behind you? That makes for a more compelling view of consciousness than the once based on the brain as a set of clever algorithms. Damasio’s view of consciousness makes sense to me.
He also writes beautifully. At the end of the book, he comments:
“Versions of Descartes’ error obscure the roots of the human mind in a biologically complex but fragile, finite, and unique organism: they obscure the tragedy implicit in the knowledge of that fragility, finiteness, and uniqueness. And where humans fail to see the inherent tragedy of conscious existence, they feel far less called upon to do something about minimising it, and may have less respect for the value of life.”
Descartes’ Error appeared in 1994 and was followed seven years later by The Feeling of What Happens. Once again, his theme is the making of consciousness. Once again, he uses stories and incidents to illuminate what is otherwise a dense and complex argument. Indeed, the book begins with a reflection on that moment in the theatre when, with the lights down, the actor ‘steps into the light’. For Damasio this is a metaphor for what he wants to explore, that process in humans that allows a people to be aware of themselves and their surroundings. He illustrates this with another of the cases he examined, a person who had suffered from a form of epilepsy. He describes how a man sat across from him, drank some coffee, but did not engage in conversation before he got up to leave the room: he was awake, physically present but personally absent. It was, Damasio remarks, as if his sense of self and knowing had been suspended, even though he could still be aware of his environment and navigate within it. It illustrates the three topics that Damasio’s book goes on to address: “an emotion, the feeling of that emotion, and knowing we have a feeling of that emotion’.
Perhaps his analysis of another of the people he studied, David, highlights what he has concluded. David suffered from a dramatic form of amnesia, unable to learn any new fact at all, and unable to remember anything about previous interactions (even more extreme than the character Drew Barrymore plays in 50 First Dates!). Given his disability, you would imagine David is unable to learn any new skills. Repeating a task on successive days, he has to be reminded each day about the task and how to perform it but, remarkably, even though he can’t remember being asked before, he can perform it as skilfully as you or I and could still do so two years later. The knowledge was there without the conscious memory of knowing it. Is that remarkable? Not entirely. Think about driving a car. After a while, you just drive, and awareness about pressing on the accelerator, lane discipline, steering, and so many other skills drop out of conscious focus. However, if the environment or your own internal state changes unexpectedly, then you are alert and aware of what you are doing.
I can’t attempt to explain the neurophysiology that Damasio has explored in relation to this. However, his conclusion is clear. Our consciousness, our ‘knowing we have a feeling of that emotion’, is something that gives us a unique advantage in life. Unlike most organisms that learn to live in and respond to their environment, we can do more. We can create responses to situations and be aware that this is what we are doing, linking our physical bodies and out emotions into an integrated system. His work is exciting, and far more persuasive than the pedestrian ‘brain as computer’ approach many have adopted. As he sees it, Descartes’ error limits how we see ourselves and what consciousness means. For Damasio, consciousness is the feeling of knowing. The book with ends a reference to the metaphor of the stage:
“The drama of the human condition comes solely from consciousness. Of course, consciousness and its revelations allow us to create a better life for self and others, but the price we pay for that better life is high. It is not just the prices of risk and danger and pain. It is the price of knowing risk and danger and pain. Worse even: it is the price of knowing what pleasure is and knowing when it is missing and unattainable.”
Damasio offers exciting research and analysis combined with insightful writing. If the neuroscience is beyond me, the insights are not. His work is important, and I love it.
