Phineas Gage

Phineas P. Gage (1823 – May 21, 1860) was a railroad construction foreman who suffered a traumatic brain injury when a tamping iron accidentally passed through his skull, damaging the frontal lobes of his brain. This injury is supposed to have negatively affected his emotional, social and personal traits&mdash;leaving him in a temperamental and unsociable state, so much so that his friends said he was "no longer Gage".

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

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; however, he was getting exhausted from the hemorrhage, which was very profuse.

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 studies by Hanna Damasio and colleagues suggested a bilateral damage to the medial frontal lobes, a recent study by Ratiu and colleagues 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 the view of modern medical science, a bilateral damage of the frontal brain by a projectile measuring 1.25 inches in diameter and weighing thirteen pounds, would unlikely be compatible with survival, since this would imply an extensive damage to vital vascular structures, such as the superior sagittal sinus (however, the rod did not emerge exactly in the midline, and may have missed the sinus by passing beneath it). Nevertheless, Gage survived the traumatic event and complications by a fungal infection and over-exercise. Gage later reportedly developed personality changes.

Effect on Gage
Gage had complications from a fungal infection which left him in a "semi-comatose state" from September 23 - 3 October, "seldom speaking unless spoken to, and then only answering in monosyllables." From 4 October onwards, he began improving, and took his first step on 7 October. On 20 October, Harlow described Gage as "very childish" and stated that Gage "wishes to go home to Lebanon [New Hampshire]". When Harlow left for a week, Gage left the house every day except Sunday, and was making plans to go home to Lebanon, being "uncontrollable by his friends". He subsequently became sick with a fever, and recovered from that by 17 November, at which time he reported no pain in the head. Harlow's final remarks include the statement that "he appears to be in a way of recovering, if he can be controlled".

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:
 * Gage was fitful, irreverent, indulging at times in the grossest profanity (which was not previously his custom), manifesting but little deference for his fellows, impatient of restraint or advice when it conflicts with his desires, at times pertinaciously obstinate, yet capricious and vacillating, devising many plans of future operations, which are no sooner arranged than they are abandoned in turn for others appearing more feasible. A child in his intellectual capacity and manifestations, he has the animal passions of a strong man. Previous to his injury, although untrained in the schools, he possessed a well-balanced mind, and was looked upon by those who knew him as a shrewd, smart businessman, very energetic and persistent in executing all his plans of operation. In this regard his mind was radically changed, so decidedly that his friends and acquaintances said he was 'no longer Gage.'

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. In 1860, he began to have epileptic seizures and died a few months later.

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 was popularly supposed to have later died in some way due to the damage in the frontal lobe, but the true cause of his death so many years later remains unclear.

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, eight 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 &mdash; all unmentioned by Harlow.

Physical remains and legacy
Gage kept the rod which damaged him as a souvenir throughout his life, 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. Phineas 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. Phineas P. Gage Lebanon Grafton Cy N-H Jan 6 1850. 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

In popular culture

 * UK band Phineas Gauge located in Los Angeles sings Irish drinking songs, is named after him.

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