phineas gage

Phineas P. Gage (1823 – May 21, 1860) was a railroad construction foreman, who suffered a traumatic brain injury, caused when a tamping iron accidentally passed through his skull, damaging the frontal lobes of his brain, causing the supposed inversing of his emotional, social and personal traits—leaving him in a temperamental and unsociable state.

At the time of discovery, Gage's condition led to changes in the perception of the function and compartmentalisation of the brain with regards to emotion and personality.

Gage's injury

On September 13, 1848, Phineas P Gage was working outside the small town of Cavendish, Vermont on the construction of a railroad track where he was employed as a foreman. One of his duties involved filling the hole with gunpowder, adding a fuse, and then packing in sand with the aid of a large tamping iron. Gage was momentarily distracted and forgot to pour the sand into one hole. Thus, when he went to tamp the sand down, the tamping iron sparked against the rock and ignited the gunpowder, causing the iron to be blown through Gage's head with such force that it landed almost thirty yards (27 meters) behind him.

The three foot (1 m) long tamping iron with a diameter of 1.25 inches (3.2 cm) weighing thirteen and a half pounds (6.12 kg) entered his skull below his left cheek bone and exited after passing through the anterior frontal cortex and white matter. Whether the lesion involved both frontal lobes, or was limited only to the left side, remains a matter of controversy. Remarkably, after such a traumatic accident, Gage regained consciousness within a few minutes, was able to speak, and survived a 45-minute ride back to his boarding house while sitting in a cart.

As the doctor arrived, he was reportedly conscious, and had a regular pulse of about 60 beats per minute, suggesting that he suffered only minimal blood loss. His left pupil was still reacting to direct light (and stayed that way for the following 10 days), which indicates that the left optic and oculomotor nerves were still functioning, supporting the hypothesis that the tamping iron must have passed laterally to the left optic nerve. After a seemingly complete recovery from such a serious injury, Gage was soon back at work.

While early studies by Hanna Damasio and colleagues ^[1] suggested a bilateral damage to the medial frontal lobes, a recent study by Ratiu and colleagues^[2], based on a CT scan of Gage's skull suggests that the extent of Gage's brain injury must have been more limited than previously thought.

In light of modern medical science, a bilateral damage of the frontal brain by a projectile measuring 1.25 inches in diameter and weighing thirteen pounds, appears to be incompatible with survival, since this would imply an extensive damage to vital vascular structures, such as the superior sagittal sinus. Nevertheless, Gage survived the traumatic event and reportedly developed personality changes.

Effect on Gage

According to Gage's doctor, Dr. J.M. Harlow, whereas previously he had been hard-working, responsible, and popular with the men in his charge, his personality seemed to have been radically altered after the accident. His doctor reported that ^[3]:

Some months after the accident, probably in about the middle of 1849, Phineas felt strong enough to resume work. But because his personality had changed so much, the contractors who had employed him would not give him his place again.

When he was well enough again in or around 1850, he spent about a year as a sideshow attraction and at P. T. Barnum's New York museum, putting his injury and the tamping iron which caused it, on display to anybody willing to pay for the show. He then worked as an assistant in New Hampshire and, for nearly seven years, as a coach driver in Chile. When his health started to fail in 1859, he returned to San Francisco, where he lived with his mother and, for some months before his death, was employed as a farm worker.

Significance for neuroscience

Gage's case is cited as among the first evidence suggesting that damage to the frontal lobes could alter aspects of personality and affect socially appropriate interaction. Before this time the frontal lobes were largely thought to have little role in behavior.

Neurologist Antonio Damasio has written extensively on Gage, as well as on various patients he has studied which, in his personal view, had similar brain injuries. In a theory he calls the 'somatic marker hypothesis', Damasio suggests a link between the frontal lobes, emotion and practical decision making. He sees Gage's case as playing a crucial role in the history of neuroscience, arguing that Gage's story "was the historical beginnings of the study of the biological basis of behavior".

It is occasionally suggested that Gage's case inspired the development of frontal lobotomy, a now-obsolete psychosurgical procedure that leads to a blunted emotional response and personality changes. However, historical analysis does not seem to support this claim. It seems that consideration of Gage's injury had little influence on the development of this practice.

Criticism of popular story

There is no doubt that Gage suffered the accident, and that it had a dramatic impact on his life. However, in his book An Odd Kind of Fame: Stories of Phineas Gage, Australian psychologist Malcolm Macmillan casts serious doubts on the accuracy of the account that entered both scientific and popular discourse. First, very little is known about Gage's personality and habits before the accident; second, the post-traumatic psychological changes reported while Gage was still alive were much less dramatic than later reports assert.

Within twenty four hours of the accident, a first report was (anonymously) printed in the Ludlow, Vermont Free Soil Union. Having described the accident, the paper reports that "the most singular circumstance connected with this melancholy affair is, that he was alive at two o'clock this afternoon, and in full possession of his reason, and free from pain." Gage later died, due to the damage in the frontal lobe.

Harlow mentioned very few psychological changes in his initial report of 1848. Henry Bigelow, Professor of Surgery at Harvard University, wrote in 1850 that Gage was "quite recovered in faculties of body and mind." It was Harlow's account from 1868, years after Gage's death, that introduced the now-textbook changes. Later writers began to embellish even more, adding drunkenness, braggadocio, a vainglorious tendency to show off his wound as part of Barnum's Traveling Exhibition and an utter lack of foresight — all unmentioned by Harlow.^[4][5]

Physical remains and legacy

Gage kept the rod which damaged him throughout his life as a souvenir, and it was buried with him in death. In 1867, when his skeleton was exhumed, the original rod was thus available with it. There is an inscription on the rod that reads, "[t]his is the bar that was shot through the head of Mr. Phinehas P. Gage at Cavendish, Vermont, Sept. 14, 1848. He fully recovered from the injury & deposited this bar in the Museum of the Medical College of Harvard University. Phinehas P. Gage Lebanon Grafton Cy N-H Jan 6 1850."^[6] Gage's skull, as well as the rod that pierced it, is currently part of the permanent exhibition at Harvard Medical School's Warren Anatomical Museum in Boston, Massachusetts.