Phineas Gage is one of the earliest documented cases of severe brain injury. He is the index case of an individual who suffered major personality changes after brain trauma, which makes him a legend in the annals of neurology. Gage worked as a foreman on a crew that did railroad construction and was excavating rocks to make way for the railroad track. This particular job required drilling holes deep into the boulders and filling them with dynamite. This was done with a crow bar-like tool known as a tamping iron.
On September 13th of 1848, the then 25 year old Gage and his crew were working and as Gage was preparing for an explosion compacting a bore with explosive powder using a tamping iron a spark from the tamping iron ignited the powder, causing the iron to be propelled at high speed straight through Gage’s skull. (Word press, 2006) It remains unknown whether or not Gage lost consciousness, but, remarkably, he was conscious and able to walk within minutes of the accident.
He was then transported by an oxcart about three-quarters of a mile to the boarding house where he was staying.
It was at this time he was attended to a local physician named Harlow, he cleaned Gage’s wounds by removing small fragments of bone, and replaced some of the larger skull fragments that remained attached but had been displaced by the tamping iron. He then closed the larger wound at the top of Gage’s head with adhesive straps, and covered the opening with a wet compress.
His wounds were not treated surgically, but were instead left open to drain into the dressings. (Word press, 2006) Harlow’s case report would later appear as a letter to the editor of the Boston Medical and Surgical Journal, which was met with much criticism as it was believed that nobody could have survived such an extreme injury. In a second report published by Henry J. Bigelow in 1850, a professor of surgery at Harvard University, he emphasized Gage’s lack of symptoms, and reported that Gage was quite recovered in faculties of body and mind.
Due to the disbelief with which Harlow’s report was met, for the next 20 years, Bigelow’s account came to be generally accepted by the medical community. Gage did, according to Harlow, retain “full possession of his reason “after the accident, however his wife and other’s that were close to him soon began to take notice of the dramatic changes in his personality. (Word press, 2006) In 1868 Dr. John Harlow countered Bigelow’s claims when he published his latest findings in the Bulletin of the Massachusetts Medical Society. He stated that Gage may have enjoyed full reasoning abilities but the people around him, particularly his wife noticed significant changes in his personality. Before the accident, Gage was industrious, responsible and “a great favorite” with the men.
His employers thought he was “the most efficient and capable foreman in their employ”. After the accident the employers “considered the change in his mind so marked that they could not give him his place again”. His friends even remarked that he was “no longer Gage” (Suite 101, 2009). The damage to Gage’s skull was said to have occurred in three places: a gash under the left zygomatic arch or cheekbone; second, in the orbital bone behind the eye and lastly, in the top part of his head when the iron rod went out of his skull. The third wound was the largest and it never healed. The damage to his frontal cortex had caused complete loss of social inhibition, which consequently led to unacceptable behavior (Suite 101, 2009). In effect, the tamping iron had performed a frontal lobotomy on Gage, but the exact nature of the damage incurred to his brain has been a subject of debate ever since the accident happened (Word press, 2006) In 1994, Hannah Damasio and her colleagues at the University of Iowa used neuroimaging techniques to reconstruct Gage’s skull.
The conclusion was that he incurred damage to both the left and right prefrontal cortices, but according to computer-generated three-dimensional reconstructions of a thin slice computed tomography scan of Gage’s skull, the damage to his brain was limited to the left hemisphere. The case of Phineas Gage made important contributions to early modern neurology, especially once Harlow’s report of Gage’s personality changes was published in 1868. It was able to coincide with reports from other neurologists of the effects of specific lesions on behavior. (Word press, 2009) At a time when the death throes of phrenology overlapped with the birth of modern neuropsychology, Paul Broca in 1865 described the speech center in the left hemisphere of right-handed people; that brain region, in the inferior frontal gyrus, is now known as Broca’s area. Also in the 1860’s, John Hughlings-Jackson and David Ferrier carried out physiological studies which pointed to the localization of cerebral function.
Jackson was the first to hypothesize those psychopathological conditions could be correlated to brain damage as well as confirming Broca’s findings that, in right-handed people, speech was localized to a specific area of the left temporal lobe. (Word press, 2006) In the case of Gage, Ferrier confirmed that damage to the prefrontal cortex could result in personality changes while leaving other neurological functions intact. His is actually one of the first which provided evidence that the frontal cortex is involved in personality. Today the role of the frontal cortex in social cognition and executive function is relatively well established.
Gage was unable to return to his previous job as a foreman and is said to have travelled around New England, and even to Europe, with his tamping iron trying to earn money. It was also said that he had displayed himself as a curiosity at Barnum’s Circus in New York. The story of Phineas Gage is as much folklore as it is fact. Not only the exact nature of the neurological damage Gage sustained, but also the details of his life after the accident, are disputed to this day. (Word press, 2006) Gage died in May of 1860, some 13 years after his accident from complications as a result of epileptic convulsions.
An autopsy of his brain was never conducted and up until the time of his death it was known that he worked as a coach driver in New Hampshire and Chile. When his health began to deteriorate he went to live with his mother until his death. In 1867, Gage’s body was exhumed from its burial place in San Francisco’s Lone Mountain Cemetery. His brother –in-law took the skull and the tamping iron to Dr. Harlow, who was then living in Woburn, Massachusetts and is now housed in the Warren Anatomical Museum at Harvard University School of Medicine.
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