Phineas Gage’s story

Gage’s story suggests that the ventromedial prefrontal cortex plays an important role in practical reasoning.

So what exactly happened to Phineas Gage?

Barring the invention of a time machine, we’ll never know for sure. Gage died in 1861, and his brain is no longer around for us to examine. But his skull has been preserved by Harvard Medical School, and we can study it for clues.

With the help of advanced computer simulation technology, researchers have been able to retrace the trajectory of the rod that flew through Gage’s head. Based on their research, we can say that it probably destroyed a part of the brain called the ventromedial prefrontal cortex (VPC), while leaving most other areas intact.

For further evidence in favor of this hypothesis, we need to find a modern-day Phineas Gage to study – someone with similar brain damage and symptoms. Enter Elliot – the pseudonym the author has given to one of his patients.

Elliot was a happy and successful businessman, husband, and father in his 30s, until one day, like Gage, he suffered brain damage to his VPC. In Elliot’s case, the cause of the damage was different: a brain tumor. But the results were similar.

Inside the author’s laboratory, Elliot’s brain seemed fully functional. Tests showed that Elliot was perfectly normal or above average in a wide range of areas, including visual perception, memory, language, arithmetic, facial recognition, abstract moral reasoning, and general intelligence.

But out in the real world, something was obviously wrong with his practical reasoning skills. He was no longer able to make good decisions for himself. At work, he struggled to prioritize his tasks and manage his time. If he had to sort some documents, for example, he‘d get obsessed with reading one of them or devising a new organization system. He would then spend the rest of the day on one of these side quests, totally forgetting about the main task at hand or how much time it warranted.

Of course, all of us fall prey to this tendency occasionally, but Elliot couldn’t help himself – and it happened almost constantly. As a result, like Gage, he was fired from his job. He then got caught up in a series of ill-advised and ill-fated money-making schemes, which his friends tried to warn him against. From there, his life fell apart. He ended up unemployed, bankrupt, and divorced – another victim of damage to the VPC.