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A Holey Brain: How a 19th Century Mishap Sheds Light on ADHD

September 13, 1848, began as a regular day for Phineas Gage, a railroad worker in Vermont. That day, his group was blasting rock as they were preparing the roadbed for railroad tracks. The procedure was to first bore a hole in the rock. Then gunpowder, sand, and a fuse were inserted into the hole. Finally, the mixture was compressed by inserting an iron rod, called a “tamping iron,” into the hole. When the fuse was ignited, the subsequent explosion would blast the rock away.

Phineas’s Accident

That day, Phineas disastrously forgot to put sand into the hole, significantly raising the risk of a premature explosion of the gunpowder. Sure enough, when Phineas banged down the gunpowder with the tamping iron, a spark ignited the gunpowder, and the iron rod flew out of the hole as fast as a rocket. The iron went through Phineas’ jaw, passed behind his left eye and then exited through the top of his skull.

In the 19th century, a projectile flying through the brain carried a rather grim prognosis. Amazingly, however, Phineas did not lose consciousness and within minutes was able to carry a regular conversation. He was entrusted to the care of Dr. John Harlow, whose medical treatment was limited to the cleaning and the draining of the wound to avoid infection (this being close to a century before the advent of antibiotics). Within a few months, Phineas recovered and was mostly back to normal, despite the hole in his skull. Although Phineas had what we would call today a TBI (traumatic brain injury), he did not suffer from memory loss and did not have any speech or motor impairments.

At this point, this remarkable story takes a dramatic turn. You see, Phineas after the accident did not resemble Phineas from before the accident. His behavior had dramatically changed. Until the accident, he was an efficient and responsible person who always spoke kindly. After the accident he became unreliable, impatient, and extremely impulsive. His social skills suffered tremendously, as he would often speak irreverently and seemed to have little respect for his peers. Furthermore, he would devise plans for himself but constantly abandon them for new plans, which made it impossible for him to follow through on anything he started.

Phineas’s Symptoms and ADHD

Do Phineas’ symptoms sound familiar? They happen to be eerily similar to the symptoms of ADHD – attention deficit hyperactivity disorder. This might not be readily apparent, since most people’s understanding of ADHD is based on how the disorder appears in childhood. In adulthood, the presentation of the symptoms is much more subtle. Let us first understand how ADHD presents in children and adults, and then we will compare it to Phineas’ symptoms.

The three primary categories of symptoms in ADHD are inattention, hyperactivity, and impulsivity.

  • Inattention: Children with inattention may have difficulty paying attention during class and seem to not be listening when spoken to. Adults with inattention may forget to pay bills, miss appointments, or fail to return phone calls. They also might not be sufficiently focused when driving a car. Furthermore, they have poor listening skills.
  • Hyperactivity: Children with hyperactivity may be constantly running, climbing, squirming in their seat, or “bouncing off the walls.” Adults with hyperactivity may often feel restless and feel uncomfortable remaining seated. They can be constantly tense or edgy.
  • Impulsivity: Children with impulsivity may blurt out answers in class and act disrespectfully towards authority figures. Adults with impulsivity may interrupt conversations or talk without thinking (which can result in saying very insulting comments to friends and loved ones). They also take risks that other mature adults know to avoid.

Based on this list of symptoms, it does seem that, after the accident, Phineas had a presentation that was similar to ADHD. He had great difficulty staying on task and was extremely unreliable. He was edgy and impatient. He was also extremely impulsive, saying whatever came to his mind without thinking about the social ramifications.

The Neurology of ADHD

The obvious and glaring question is how does a hole in the brain give someone symptoms of ADHD? The answer lies in the neurological basis of ADHD. Brain scans have shown that in individuals with ADHD there is a significant delay in the development of the frontal lobe of the brain and, more specifically, the prefrontal cortex. This area of the brain is right behind the forehead. Jewish men would recognize this area as being directly under the tefilin shel rosh. This part of the brain does not control the basic systems of our senses, memories, or emotions. But it does control our ability to synthesize all of the output from the other parts of our brain, allowing us to make decisions about our behaviors and actions. In other words, the prefrontal cortex is the executive of our brain. It takes all of the information provided by the other parts of the brain and comes up with a plan on how to act based on all of that information. It also helps us remain focused on our tasks. The term that describes the role of the prefrontal cortex is therefore “executive function.”

Since people with ADHD have a prefrontal cortex that has a developmental lag, their decision making and behavior regulation is impaired. All of the symptoms of ADHD can be attributed to the fact that the executive in the brain is “out to lunch” and decisions are therefore not being made about what is the appropriate behavior at the present time and what kinds of activities would be most beneficial for the person.

In some individuals, their brain development will eventually catch up, which is why many children with ADHD will not have the disorder in adulthood. But for many individuals, the prefrontal cortex will not catch up, which leaves them impaired even in adulthood.

In conclusion, individual with ADHD can be extremely intelligent and talented in many areas. Their issue lies in the part of the brain that allows them to “bring it all together.”

Phineas’ Brain

The question now is what part of Phineas’ brain was damaged? How can we know today what happened to Phineas’ brain back in 1848? Incredibly, 19th century scientists were aware that the study of the case of Phineas Gage would help the promotion of brain science, and his skull was donated to science by his family and is presently on display in the Warren Medical Museum of Harvard Medical Science. (Do I hear a Chol Hamoed outing in the making?) Many modern scientists have concluded, based on studying the hole in Phineas’ skull, that the iron rod went right through the prefrontal cortex. Essentially, Phineas acquired ADHD-like symptoms by getting a hole in the part of his brain that controls executive function!

In truth, the jury is still out about Phineas Gage. There is much controversy in the scientific community surrounding the facts of Phineas’ injury and the nature of his behavior after his miraculous recovery. Nevertheless, modern day scientists do believe that ADHD has a neurological basis.

What we can definitely learn from the story of Phineas Gage is that we should never cease to be amazed at the wonderful organ called the brain. From the impairment that occurs when someone’s brain is damaged or underdeveloped, we can better appreciate our incredible brains. How can three pounds of spongy gray tissue grant us our manifold physical and intellectual abilities? It must be Hashem!