D n v a s r o .

D r s c n n r e s ' En n o R

59

rock;the sand is essential,for without its protection the explosion would be directedaway from the rock. The shape of the iron and the way it is played arealso important. Gage,who has had an iron manufactured to his specifiis a virtuoso of this thing. cations, Now for what is going to happen. It is four-thirry on this hor afterr.roon. Gagehas just put powder and fuse in a hole and rold the man who is helpinghim to cover it with sand. Someonecalls from behind, and Gage looks away,over his right shoulder, for only an instant. Distracted, and before his man has poured the sand in, Gage begins tamping the powder directlywith the iron bar.In no rime he strikesfire in the rock, and the charge blows upward in his face. The explosion is so brural that the entire gang freezeson their feet. lt bang is unusual, takes a few secondsto piecetogetherwhat is going on. TI're and the rock is intact. Also unusual is the whisrling sound, as of a rocket hurled at the sky.But this is more than fireworks.It is assaultand battery. the left cheek,piercesthe baseofthe skull, traverses The iron entersGage's front of his brain, and exits at high speedthrough the top of the head.The rod has landed more than a hundred feet away,coveredin blood and brains. PhineasGage has been thrown to the ground. He is stunned, in the afternoon glow, silent but awake.So are we all, helplessspectators. "Horrible Accident" will be the predictableheadline in the Boston Daily Courier and Daily lournnl of Septemberzo, a week later. "Wonderful of September Accident"wilf be the strangeheadlinein the Vermont.Mercury "Passage headline zz,. of an Iron Rod Through the Head" will be the accurate with Medical and Surgical in shgfi6.sfo,r Jounnl. From the matter-ofl-factness which they tell the story, one would think the writers were familiar with EdgarAllan Poe'saccountsof the bizarre and the horrific. Ancl perhaps they were,although this is not likely; Poe'-s gothic tales are not yet popular, and the Poehimselfwill die the next year,unknown and impecunious.Perhaps air. horribleis just in tl.re Noting how surprisedpeoplewere that Gagewas not killed instantly, that "immediatelyafter the explosion the Boston medicalarticledocurnents the patientwas thrown upon his back"; that shortly thereafterlre exhibited "a few convulsivemotions of th e extrernities,"and "spokein a few tninrttes"; th at "his rnen (with whom he was a great favourite) took him in theit arms and carriedhim to the road, only a few rods distant (a rod is equivalentto 5',r. ox cart, in which he rode, sitting erect, yards,or t6't, feer),and sat him into ar-r

From Descartes' Error: Emotion, Reason, and the Human Brain

Arrtortio R. Dctnnsio

PhineasP Gage
lr is rhe sunrner of rB4B. We are in New Ingland. IrhineasIr.Gage,fwentyfivc yearsold, construction foreman,is about to go lrom riches ro rags.A cen turya nd a half lat c r lr is downf allwill s t ill be quitcmeaningful. Gageworks fbr the Rutland & Burlingron Railroad and is in chargeof a largegroup of men, x "sanf " as it is called, whose job it is to lay down the new tracks for tlre railroad',s expansion acrossVermont. Over the pasr two rvee ks the men haveworked tlreir way srowlytoward the town of cavendish; they are now ar a bank of rhe Black River. The assignmentis anything but easy lhe terrain is rneven in everydirectionand is filled witl-rhard, stratifierl rock' Rathert^an twist a'd turn the tracks around everyescarpmenr, tl-restrategy is to blasr rhe stone now and then to make way fo. ,trright". ^ ancl more levcl path. Gage oversees all rhesetasks and is equal ro them in everyway'IIe is five-foor-six and arr-rletic, and his movementsare swift and plecise'I le looks like a young caeney, Jimmy a yankeeDoodredandy dancine his tap shoesover tie.s and tracks,movin6lwirhvigor and grace. Ir-r tl-re eyes of his bosses, however, Gageis more rhan just anorherable body.T'heysay he is "rhe mosr efficient and capable,, man in their emr;lov. 'l-hisis a good thing, because the job takesas much p'ysical prowess k..,., ", concenrrarion, especially when it comesto preparine the detonations. Several step's have to lre {sll6nt",1, in orderly fashior-r. First,a hole must be driiled in the rock' Afrer it is filled about halfivayrvith exprosive'owder,a frse musr be irrserted,and r'e porvcler covcredwith santl..fher_r the sand must be "tarnpsdi'r," or pourded wirh a careftrr of strokesfrom an iron rocl. -sequence |inally, the fusemtrsrbe lit- Iialr goesweil, tlre powder.r.r,iil exprotre into the 58

6o

69uP-JHE CHAPTER

BRAIN

Dlvesto

. D ssca n r e s' En n o n

6t

a full three quartersof a mile, to the hotel of Mr. JosephAdams"; and that from his men.'' Gage "got out of the cart himsi:lf,with a little assistance Let me introduce Mr. Adams. He is the iustice of the peace for Cavendish and the owner of the town's hotel and tavern. He is taller than He apGage,twice as round, and as solicitous as his Falstaff shapesuggests' one Harlow Dr. John proachesGage,and immediately has someonecall for of the town physicians.While they wait, I imagine, he says,"Come, come, troubles Mr. Gage,what have we got here?" and, why not, "My, -y,what we've seen."He shakeshis head in disbelief and leadsGageto the shadypart of the hotel porch, which has been described as a "piazza'" That makesit sound grand and spaciousand open, and perhaps it is grand and spacious, but it is not open; it is iust a porch' And there perhapsMr. Adams is now giving PhineasGage lemonade,or maybe cold cider. An hour has passedsince the explosion.The sun is declining and the heat is more bearable.A younger colleague of Dr. Harlows, Dr' Edward "He at Williams, is arriving. Yearslater Dr. Williams will describethe scene: that time was sitting in a chair uPon the piazza of Mr. Adams' hotel, in Cavendish.When I drove up, he said, 'Doctor, here is business enough for you.' I first noticed the wound uPon the head before I alighted from my carriage, the pulsations of the brain being very distinct; thete was also an apwhich, before I examined the head,I could not account for: the top pearance of the head appearedsomewhat like an inverted funnel; this was owing, I discovered,ro rhe bone being fractured about the opening for a distanceo[ about two inches in every direction. I oughr to have mentiofled above that the opening through the skull and integuments was nor far from one and a half inch in diameter; the edgesof this opening were everted,and the whole wound appearedas if some wedge-shapedbody had passedfrom below upward. Mr. Gage,during the time I was examining this wound' was relating rhe manner in which he was injured to the bystanders;he talked so rationally and was so willing to answer questions, that I directed my inquiries to to the men who were with him at the time of the accident, him in preference and who were standing about at this time. Mr. G. then relatedto me someof as he has since done; and I can safelysay that neither at the circumsrances, that time nor on any subsequentoccasion,saveonce, did I consider him to be other than perfectly farional. The one time to which I allude was about a fortnight after the accident,and rhen he persistedin calling me John Kirwin; yet he answeredall my questions correctly."

when one considersthe shape The survivalis madeall the more amazing Bigelow' a surgery professor at Harvard' and weight of the iron bar' Henry thus traversedthe skull weighs thirteen describesthe iron so: "The iron which a seveninches in length' and one and and a quarter pounds' It is three feet entered first is pointed; the taPer qo".,". in.h", in diameter'The end which of the point one quarter of an inch; beingsevenincheslong, and the diameter owes his iife' The iron is unlike circumstancesto which the patient perhaps blacksmith to please the fancy of any other, and was made by " "tighbot"itg and its proper tools' the owner." Gageis seriousabout his trade a wound to the head' being able Surviving the explosionwith so large totalkandwalkandremaincoherentimmediatelyafterward-thisisallsursurviving the inevitable infection prising.But iust as surprisingwill be Gage's Gages physician,John Harlow' is well that is about to rake over hil *orr.rd. havethe help of antibiotics' but of the role of disinfection' He does not aware will clean the wound vigorously and using what chemicalsare availablehe position so that drainage ,.g,rl"rh and placethe patient in a semi-recumbent high fevers and at least one abwill be narural and easy' Gage will develop with his scalpel'In the end' Gage's which Harlowwill p'o-ptly "tot'e scess, the odds against him' assisted' youth and strong consti;tionwill overcome "I dressedhim' God healedhim'" asHarlowwiil put it, by divine intervention: in less than two months' Yet Phineas Gagewill be pronounced cured with the extraordinary turn this astonishing outcome pales in comparison Gages disposition' his likes and that Gage'spersonaliryis about to undergo' all to change' Gage'sbody may be dislikes,his dreams and aspirations are animating it ' aliveand well,but there is a new spirit

GageWas No Longer Gage

Dr' Harlow we can glean today from the account Justwhat exactlyhaPPened with an text' trustworthy a It is preparedNventy years after the accident' husense interpretation' It makes abundanceof facts and a minimum of we can piece together not iust Gage manly and neurologically,and from it been a schoolteacherbefore he enbut his doctor as well' John Harlow had and was only a few years tered JeffersonMedical College in Philadelphia' of Gage' The casebecamehis lifeinto his medical careerwhen h" took care it made Harlow want to be a scholar' consuminglntelest' and I suspect that

6z
A P TE R FOU R ..-Tnr B nnrn

h is B o s ro n;;Jfi
must have b""n

;ff::'f#::;l:"

h.ave been in hisprans when hesetup hisrnedicar

D e v e s r o . D e sce n r r s, En n o R

A. vr

j'il,; ;'il ;:;ff o' *i'rh t'i" ;;;"';, ::' ;n l',:: T:"' ;.;i plans of futureoperation devising manv
*o"tt anirnar passions o,u "* ;:ffiiH::i:ff:il; The foul language "r..ntt""t*'t women were aclvised was so debased 1:t-1":'"
"",

rtre.grossesr wasnot previously profaniry which hi" c.,rtoir.manifesting ;,",;"-,-^'; but little d"f".".,." t;il;; lows,imparien. *";:'::tm' ";

n ow,, ri tru i,,.*"." i.ll"ir;: J,*T ",, f ff 1:il|:lfiHT:

";;;;-'vacillating'

his inrel"0""u' berwee' "' olootn",'""i:n'o ;:'to became apparenr as,oo

lflililT*1i,t::1y ":;*:::1

T",ll :::;T;ffi ilffiT*; *:1il ril*; iii; il ;"' :' """:q'*

",.

nor paralyzed of

:;T *d:tlit, #:i,:::::,ff :: :: ii**ffi: j,;il

limb ,^":,:^-;_\rd8e could touch,hear, and see, and was

dirtur.,",;,a,,;^;::1,

. reportin ';:"ff ffi:Ti:,,'l l*..,,,,, :, of hisg,n. rne shrning hours

career, and he

n*' hiswou j,T"]']ji"'.I;ijj nds and th etampin g,," : "r :r:::::1 ion, and
was new and somewl

As Harlow nores, he was good ar ,.always findrng somerhing which did nor suit him." Then camehis careeras a circus Gagewas featured at Barnum's Museum ir "rrr^.rio.r.

injuries like Gage's, as well Then far more rl

,torector,s o.n*,".," l,l"-'.:f,f,T*:il,T';":,*Jj;:;:J::ffi

as in autistic individuals.)

polnr, orr, Gage,s srrong attachment ,ffi;:: i::iTil[::il;

doned. . . . A chird,n t.,,,,'*l]'n "";"

*:" ro tonger ent a man was Gage."so differhe rhat hi.spmhl^,,^-^,-*:' ro tet him go shonty rtrrned ro work, after he re_ for ** ;::::"j"j:,r"1 tn nts mind so tney corrldnor markecl give him his oir." thar l;;""tt "-^,^ 'The problem ical was abiliry The unraveling

r.rncd to work, fo.h"y,.on,ri.l"a ffi ;.;"j,:'il,r;,'#::r;iili:J: I

*". ;,"H.iil' "' "uri,, ',
con

nize,he ,'.n rn., ;t U:fui::"::*,i ".;J::ffiil "._

,lt

was the chanse ;r, hl.

inexecu ri n gar' r;""r" ;:T;;,t:r ;i"'ff;:"'of:his *lil,'* :m;:: job and titne,
he o

;Tfiff:::T:ffij; wa, r o o r. e.r ., r;; ;;;;;" :;'r':H_i: :"ljt

new personaliry rra.its conrrasred urrtras[ed sharpl sh y with w i th rhe the ,.remperare "temperate tt'"'sr ortl;'t".* "^ - "_.'^. fiitn't havepossessed before ,;lt , , . Trr"r" h a b its"
a n d ,to n sid e r "f_ r l.

ff::i*j::il'$[ffir;il'T:rffi"ff$;*f*T: ]

rhar

nor ,"J;;;;;-

Nolonser man, able Gage to workasa forerook jobs nll"l"j::"1i*o tarms' rle would "" work at blefly, only,"
;;;r;'.."rse priciousfir or "..0,"." ".'""*". be ler go because ofpoor discipline.

who, as Nathanael w"rt--ould pur it decades ,"r"., ro the sourh, "had corne "til;l*il::::fi:ij: to California to die.,,

commerce, as astonishedas anybodywhen the fault would slip and rhe earth would shake threateningly. He had joined the rabl

that isnotwhere we wourd find him irwe ."",'jH:T":il,,T*.r# ,r', and brawling in, qu".rionrble disrrict, ,.ro..o.ru".Jl;:ffj-,::fi*:?

In my mind is a picure "i"rffi,l:rtff[:"""' of rB6os San Francisco as a bustling place,full of advenrurous enrrepreneurs engaged in mining, fhrming, and shipping. That is where we can find Gage'smorher ,iri"., the latter married ro a prosperousSan Francisco ".,d merchant (D. D. Shamuck, Esquire), and thar is where the old phineas Ge

remunerarive jobthat hehad once herd. The ."0

;::Trif";,T,: expatriatelife exceprrhat in rg59 his health was dererioraring. In r860' Gagererurned to rhe united sraresro live with his morher and sister, who had since moved to San Francisco. Ar first he was employed on a farm in santa Clara,bur he did not l"";.;; ;cr, he moved around "r"r often, occasionally finding work as a laborer in rh". n.ya."^. It is clear thar he was nor an independentperson and rhat he could not

sragecoach driver in santiago and Valparais" ;il';,"lT

O"OOi., Four years after the accidenr, there was an reft for south America. He worked on horse ,o'n".

jHH::::li # :TJ.: wi rh er "" ll'J'l::; eph a n t,u,,, ",. i imagine him in such f;:* Fellinian company, misery

man, the felrowwith

endocrine u".i.ry inalil; ::j[,T.JL:Tj

t"-"..1",." :": ii:-."":

onnarure,s cru er rhe ry. :1',.0 woman on earth, the tallesr

for gold. thearricar coup. Gage

The rneagerdocurnenrs availablesuggesrrhar Gage developed epilep_ tic fits (seizures)'The end came on xr^y zrl reet,after an i'ness that lasted litrle more than a day' Gage had a major .on*rrion which made him lose

64 cHAprER F9SR--THE BRATN consciousness. A series ofsubsequent convu.lsions, one coming soon on rhe heelsof another,followed. He neverregai.r.d .o.rr.io,r.ness. I believehe was the vicrim of stat's epirepticus, a condition in which convursions become nearly continuous and usher in death. He was rhirry-eight years ord. There was no death notice in the San Francisconewspapers. D n u n s r o . D e scn n r r s' En n o n b5

The alterations in Gage'spersonalitywere not subtle. He could not and the choiceshe madewere not simply neutral' They makegood choices, were not the reservedor slight decisions of someonewhose mind is diminished and who is afraid to act, but were instead actively disadvantageous.Gage worked hard at his downfall. One might venture that either his valuesystemwas now different, or, if it was still the same,there was no exNo evidence way in which the old valuescould influence his decisions. brain with patients of ists to tell us which is rrue, yer my investigation convincesme rhat neither explanation Gage'.s damagesimilar to Phir-reas Some part of the circumstances. in those happens captureswhat really value system remains and can be utilized in abstractterms, but it is unWhen rhe Phineas Gages of this world connecredto real-life sitr.rations. needto operatein realiry,the decision-makingprocessis minimally influencedby old knowledge. Another important aspectof Gages story is the discrepanry between the degeneratedcharacterand the intactness of the several instruments of perception,memory language,intelligence.In this rype of one or more Perdiscrepanry,known in neuropsychology as dissociation, formanceswithin a generalprofile of operarions are ar odds with the rest. In mind-attention, casethe impaired characterwas dissociatedfrom the otherwise intact Gage's cognition and behavior.In orher patients, with lesions elsewherein the brain, languagemay be the impaired aspect,while characterand all other cognitive aspeds remain intact; language is then the "dissociated" abiliry. srudyof patientssimilar to Gagehas confirmed that his specific subsequent dissociation profile occursconsistently. It must have been hard to believethat the characterchange would not resolveitself, and at first even Dr. Harlow resistedadmitting that the change sincethe most dramaticelementsin This is understandable, was permanent. story were his very survival, and then his survival without a defect Gage'.s that would more easilymeet the eye: paralysis,for example, or a speech desocial emphasizingGagesnewly developed fect,or memory loss.Somehow, shortcomings smackedof ingraritude to both providence and medicine. By r868, however,Dr. tlarlow was ready to acknowledgethe full extent of his patient'spersonalirychange. survivalwas duly noted, but with the caution reservedfor freakGage's oI his behavioralchangeswas largelylost. The significance ish phenomena. There were good reasonsfor this neglect. Everr in rhe small world of brain

Whyphineas

Gage?

ro u n d a tio n""..0, :l ;lj;"jfi : TJ,:;r,fi ",,, I1,, ;jT;:.:,i::::':ridenceo[concern abour his future,
no sign oflbrethought.

in rerms of sociar convention and appearsto have been erhicarin r'risdealings. After rhe accidenr,he no ronger showed respect for social convention; ethics were violatecl;rhe decisions he made did not t ak e inr o ac c ount his t

fo,rh"qu"liryof hi, and anra*ed rh. "d.,*;::";.T;Hl:*::1 leagues'te was wet-o.k, adapred

the abiriry to anticipare the futr-rreand plan accordingly wirhin a .on-,pto social environmenr; the senseofresponsibilityrowarcl rhe selfand o,h".r, and rhe abiliry ro orches_ trare one'.s survival deliberately, ar the command of one,sfree will. The most striking aspectof this unplea-sant srory is the discrepancy be_ rweenrhe normar personariry stmcnrre that preceded the accidentand rhe nefarious personaliryrraits that surfacedrhereafter-and remained for the rest of Gage'slife. Gage had once known all he needed to know about making choicesconduciveto his betterment. He had a senseofpersonar and sociarresponsibiliry refleced in rhe way he had securedaclvz

cr (iage'.s exa rn pleincl ica tecl rh", ; n g i n rhe ;il;:t::i."HT:il "o- "rh icallywith unique human properties, among them

ve n ri o na n de rh ica r.;t *: ;:,.:,":T ;: il:il:,ll.ffi neither

basic intellecr nor language seemed

why is this sad story worrh tering? what is the possibre significanceof such a bizarre tale?The answer is while odrer casesof neurorogical -simple. damage that occurred ar about the same time revearedthar the brain was the foundarion for language, perceprion,and motor funcion, and generallypro_ vided more conclusive details, Gage,sstory hinted ar an amazing fact: somehow' there were sysrems in the human brain dedicated more to reasoning than to anything erse, and in particurar to the personal and sociar dimensionsof reasonir

i :::m;

D a u e s t o . D e sca a r e s' En n o n

o/

:;."." at rherime, Nvo camps *... r"r,""::;,. ;r:;il;

chologicalfunctions such as languageor memory could never be rracedto a particularregion of the brain. If one had to accept,reluctantly,that the brain did produce the mind, it did so as a whole and not as a collection of parts with specialfunctions. The other camp held that, on rhe contrary rhe brain did have specializedparts and those parts generatedsepararemind functions' The rifr between the rwo camps was not merely indicative of rhe inlancy of brain research; the argument endured for another cenrury and, to a certain exrent, is still with us roday. Whatever scientific debate Phineas Gages story elicired,it focusedon the issue of localizing language and movement in the brain. The debate neverturned ro the connection between impaired socialconduct and frontal lobedamage. I am remindedhereof a sayingof WarrenMcCulloch's: "When I poinr, look where I point, nor at my finger." (Mcculloch, a legendaryneurophysiologisr and a pioneer in the field that would becomecornputational neuroscience, was also a poet and a prophet. This sayingwas usually part of a prophecy.) Few looked to where Gaqe was unwittingly pointing. It is of course difficult to imagine anybody in Gages day with the knowledge and the courageto look in rhe proper direction. It was acceptable that the brain sectorswhose damagewould have causedGage'shearcto stop pumping and his lungs to stop breathing had nor been touched by the iron rod. It was also acceptablethat the brain sectors which control wakefulnesswere far from the iron'.s courseand were thus spared.It was evenacceptable rhat the in jury did not render Gage unconscious for a long period. (The event anricipared what is currenr knowledge from srudies oF head in juries:The sryleof the injury is a critical variable.A severeblow ro the l.read, evenif no bone is broken and no weapon penerratesrhe brain, can causea mafor disruption of wakefulness for a long time; the forces unleashed by the blow disorganizebrain function profoundly. A penetrating iniury in which the forces are concentrated on a narrow and sreadypath, rather than dissipateand accelerate rhe brain against the skull, may causedysfunction only where brain tissueis actually destroyed,and thus spare brain function elsewhere.)But to understand Gage'-s behavioralchangewould have meant believingthat'ormal social conduc required a particular correspor.rding brain region, and this conceptwas far more unthinkable than its equivalenrfor movement,the senses, or even language.

A I-andmark bY Hindsight
caused by a circumThereis no quesrion that Gage'spersonaliry changewas site' But that explanationwould not be aPlesionin a specific brair-r scribed after the accident, and it becamevaguely acceptable parent until two decades John Harlow included' only in this century.For a long time, most everybody' for severalreasons'the was' that "the Portion of the brain traversed, believed the iniury": in best fitted of any part of the cerebral substance to sustain and was thus exother words, a part of the brain that did nothing much himself reHarlow as But nothing could be further from the truth' pendable. "was only partial' his alized.He wrote in 1868 that Gage'smental recovery lost; nothing intellecrualfaculriesbeing decidedly impaired, but not totally his mental like dementia, but they were enfeebled in their manifestations, quantity"' The uninoperationsbeing perfect in kind, but not in degreeor convention' besocial tentional messagein Gage'scasewas that observing survival and having ethically,and making decisions advantageousto one's rhe integriry of speprogressrequire knowledgeof rules and strategiesand was that it lacked the evThe problem with this message cific brain systems. Instead the mesidencerequired to make it understandable and definitive' "enigma" of frontal lobe becamea mystery and came down to us as the sage function. Gage posed more questions than he gaveanswers' that it was To begin with, all we knew about Gage'sbrain lesion was is probaChicago in the frontal lobe.That is a bit like sayingthat probably helpful' Granted bly in the United States-'accurate but not very specific or exactly was it where lobe' that the damagewas likely to involve the frontal w i t h i n t h a tr e g i o n ? l 'h e l e ftl o b e ? Th e r i g h t? Bo th ? So m e w h e r e e l se to o ? As have helped us you will see in the next chapter, new imaging technologies comeup with the answer to this puzzle' T l . r e n th e r e w a sth e n a tu r e o fGa g e 'sch a r a cte r d e fe ct.H o w d i d th e a b The prirnary cause'sure enough' was a hole in the head' normalirydevelop? in any'uvhere but that iust tells why the defect arose, not how' Might a hole by what plausithe frontal lobe have rhe same result?Whatever the answer' If there ale personaliry? ble meanscan destrttction of a brain region change

68

cHAPTER FouR-THE

BRArN

Dlunsto

. D e sca n r r s' En n o n

6g

specific regions in the frontal lobe, what are they made ol and how do they operate in an intact brain?Are they some kind of "center" for social behavior? Are they modules selectedin evolution, filled with problem-solving algorithms ready to tell us how to reason and make decisions?How do these modules, if that is what they are, interact with the environment during development to permit normal reasoningand decision making?Or are there in fact no such modules? What were the mechanismsbehind Gage'sfailure at decision making? It might be that the knowledge required to reason through a problem was destroyed or rendered inaccessible, so that he no longer could decide appropriately. It is possible also that the requisite knowledge remained intact and accessiblebut the strategies for reasoning were compromised. If this was the case, which reasoningstepswere missing?More to the point, which steps are there for those who are allegedlynormal? And if we are fortunate enough to glean the nature of some of these steps, whar are their neural underpinnings? Intriguing as all thesequestionsare,they may not be as important as those which surround Gage'sstatus as a human being. May he be describedas having freewill? Did he havea senseof right and wrong, or was he the victim of his new brain design, such that his decisions were imposed upon him and inevitable?Was he responsible for his acts?If we rule that he was not, does this tell us something about responsibiliryin more general terms? There are many Gages around us, people whose fall from socialgraceis disturbingly similar.Somehavebrain damageconsequent to brain tumors, or head injury, or other neurologicaldisease. Yet some have had no overt neurological diseaseand they still behavelike Gage, for reasons having to do with their brains or with the sociery into which they were born. We need to understand the nature of these human beings whose actions can be destructive to themselvesand to others, if we are to solve humanely the problems they pose. Neither incarceration nor the death penalry among the responses that society currently offers for those individuals-contribute to our understandingor solvethe problem. In fact, we should take the question further and inquire about our own responsibiliry when we "normal" individuals slip into the irrationaliry that marked Phineas Gage'sgreat fall. Gage lost something uniquely human, the abiliry to plan his future as a social being. How awarewas he of rhis loss?Might he be describedas self-

soul and I are?Is it fair ro say rhar his consciousin the samesensetharyou Descartes his soul?And if so' what would was diminished, or that he had lost of Gage and had he had the knowledge have thought had he known about pineal Gage's he have inquired about neurobiology we now have?Would sland?