Phineas Gage

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"Front and lateral view of the cranium, representing the direction in which the iron traversed its cavity..." [1]
Phineas P. Gage

Phineas Gage, life mask c.1850
(often mistakenly termed a death mask)
Born July 9?, 1823
Lebanon, New Hampshire
Died May 21, 1860 (aged 36)
California
Occupation Railroad construction foreman, blaster
Spouse(s) None
Children None
Parents Jesse Eaton Gage, Hannah Trussell (Swetland) Gage

Phineas P. Gage (July 9?, 1823 – May 21, 1860) was a railroad construction foreman now remembered for his incredible survival of an accident which drove a large iron rod through his head, destroying one or both of his brain's frontal lobes, and for that injury's reported effects on his personality and behavior—effects said to be so profound that friends saw him as "no longer Gage." Known as "the American crowbar case"—"the case which more than all others is calculated to excite our wonder, impair the value of prognosis, and even to subvert our physiological doctrines"[2] —Phineas Gage influenced 19th-century thinking about the brain and the localization of its functions,[3] and was perhaps the first to suggest that damage to specific regions of the brain might affect personality and behavior.

[edit] Gage's accident

On September 13, 1848, Gage was foreman of a work gang blasting rock while preparing the roadbed for the Rutland & Burlington Railroad outside the town of Cavendish, Vermont. After a hole was drilled into a body of rock, one of Gage's duties was to add gunpowder, a fuse, and sand, then tamp the charge down with a large iron rod. Possibly because the sand was omitted,[4] around 4:30 PM:

Contents
The Boston Post for September 21, 1848 (mis-stating the dimensions of Gage's tamping iron).[5]

the powder exploded, carrying an instrument through his head an inch and a fourth in [diameter], and three feet and [seven] inches in length, which he was using at the time. The iron entered on the side of his face, shattering the upper jaw, and passing back of the left eye, and out at the top of the head.[5]

Weighing 13-1/4lb (6 kg), the tamping rod was said to have landed some 80 feet (25 m) away.

Amazingly, Gage spoke within a few minutes, walked with little or no assistance, and sat upright in a cart for the 3/4-mile ride to town. The first physician to arrive was Dr. Edward H. Williams:

I first noticed the wound upon the head before I alighted from my carriage, the pulsations of the brain being very distinct. Mr. Gage, during the time I was examining this wound, was relating the manner in which he was injured to the bystanders. I did not believe Mr. Gage's statement at that time, but thought he was deceived. Mr. Gage persisted in saying that the bar went through his head....Mr. G. got up and vomited; the effort of vomiting pressed out about half a teacupful of the brain, which fell upon the floor. [6]

Dr. John Martyn Harlow took charge of the case about an hour later:

You will excuse me for remarking here, that the picture presented was, to one unaccustomed to military surgery, truly terrific; but the patient bore his sufferings with the most heroic firmness. He recognized me at once, and said he hoped he was not much hurt. He seemed to be perfectly conscious, but was getting exhausted from the hemorrhage. Pulse 60, and regular. His person, and the bed on which he was laid, were literally one gore of blood. [7]

Despite Harlow's skillful care,[8] Gage's recuperation was long and difficult. A "fungal" infection left him semi-comatose from September 23 to October 3, "seldom speaking unless spoken to, and then answering only in monosyllables." On October 7 he took his first step. On October 20 Dr. Harlow described his patient as "very childish," and while the doctor was absent for a week, Gage was "in the street every day except Sunday," his desire to return to his family in New Hampshire being "uncontrollable by his friends." He soon developed a fever, but by mid-November he was "feeling better in every respect...walking about the house again; says he feels no pain in the head." Harlow's final prognosis at the time was that Gage "appears to be in a way of recovering, if he can be controlled." [9]

[edit] Subsequent life and travels

Except for loss of vision in the left eye and some disfigurement and facial paralysis, Gage's physical recovery seems to have been essentially complete by April 1849.[10] Harlow says that Gage, unable to return to his railroad work, was for a time an attraction at P.T. Barnum's American Museum in New York City[11] (the curious paying to see, presumably, both Gage and the instrument that injured him) although there is no independent confirmation of this. Recently however, evidence has surfaced supporting Harlow's statement that Gage made public appearances in "the larger New England towns." (On Gage's job-loss and public appearances, see more below.)

Gage later worked in a livery stable in New Hampshire, and then for some years in Chile as a coach driver.[12] When his health failed in 1859, he left Chile for San Francisco, where he recovered under the care of his mother and sister (who had moved there from New Hampshire around the time Phineas went to Chile). For the next few months he did farm work in Santa Clara.

[edit] Death and subsequent travels

In February 1860, Gage had the first in a series of increasingly violent convulsions, and he died in May of that year—just under twelve years after his accident. He was buried in San Francisco's Lone Mountain Cemetery.[13]

In 1866, Dr. Harlow somehow learned where Phineas had been and opened a correspondence with his family, still in San Francisco. At his request they exhumed Phineas' body long enough to remove the skull, which was delivered to Harlow back in New England. About a year after the accident, Gage had given the tamping iron which injured him to Harvard's Dr. Bigelow (see below), but he later reclaimed it and (according to Harlow) made it his "constant companion during the remainder of his life";[12] now it accompanied the skull on its journey to Harlow.

After studying them for his second (1868) paper, Harlow placed Gage's skull, and his "iron," in the Harvard Medical School's Warren Anatomical Museum, where they remain on display today. The rod bears this somewhat error-ridden inscription:

This is the bar that was shot through the head of Mr. Phinehas [sic] P. Gage at Cavendish, Vermont, Sept. 14, [sic] 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.[14]

Much later, Phineas' headless skeleton was moved to Cypress Lawn Cemetery as part of a systematic relocation of San Francisco's dead to new resting places outside city limits.

[edit] Brain damage and mental changes

Graphic showing how the tamping iron may have damaged both[15] frontal lobes, although another study[16] suggests the damage was more limited.

Significant injury to the brain is often fatal, but in Gage's case the fact that the rod led with a 1/4-inch point may have reduced its destructiveness, and apparently all important blood vessels were spared. Nonetheless, the brain tissue destroyed must have been substantial (considering not only the initial trauma but the subsequent infection as well) though whether this was in both frontal lobes, or primarily the left, has been debated as far back as Harlow's and Bigelow's original papers.[17] A 1994 CT modelling study by Hanna Damasio and colleagues suggests bilateral damage to the medial frontal lobes,[15] but a 2004 study by Ratiu and colleagues, based on a CT scan of the actual skull,[16] tends to confirm Harlow's view that the damage was confined to the left frontal lobe.

Neurologist Antonio Damasio calls Gage's story "the historical beginnings of the study of the biological basis of behavior";[citation needed] Damasio's "somatic marker hypothesis" suggests a link between the frontal lobes, emotion and practical decision-making.[18] But any theory that looks to Gage for support faces the difficulty that the nature and extent of the injury's effects on his mental state are highly uncertain. In fact, very little is known about what Phineas was like either before or after his injury (almost none of it first-hand),[19] the mental changes described after his death were far more dramatic than anything reported while he was alive, and even those descriptions which seem credible do not tell us the period of his post-accident life to which they are meant to apply.

In his initial (1848) report, Harlow had only hinted at possible psychological symptoms: "The mental manifestations of the patient, I leave to a future communication. I think the case...is exceedingly interesting to the enlightened physiologist and intellectual philosopher." And after observing Gage for several weeks, Henry Jacob Bigelow, Professor of Surgery at Harvard, wrote in 1850 that Gage was "quite recovered in faculties of body and mind."[20] (Noting dryly that "The leading feature of this case is its improbability," Bigelow made a point of his own journey from scepticism to belief in the fact of the accident itself. His stature largely ended scoffing about Gage among physicians in general—one of whom, Harlow wrote later, had dismissed the case as a "Yankee invention.")

It was not until his 1868 report that Harlow gave particulars of the mental changes found today (often in exaggerated or distorted form—see below) in most textbooks. In memorable language, he now described the pre-accident Gage as having been hard-working, responsible, and "a great favorite" with the men in his charge, his employers having regarded him as "the most efficient and capable foreman in their employ." But these same employers, after Gage's accident, "considered the change in his mind so marked that they could not give him his place again":

The equilibrium or balance, so to speak, between his intellectual faculties and animal propensities, seems to have been destroyed. He is 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." [12]

Neuropsychology
Topics

Brain-computer interface
Traumatic brain injury
Brain regions • Clinical neuropsychology
Cognitive neuroscience • Human brain
Neuroanatomy • Neurophysiology
Phrenology • Misconceptions
Brain functions

arousal • attention
consciousness • decision making
executive functions • natural language
learning • memory
motor coordination • sensory perception
planning • problem solving • thought
People

Arthur L. Benton • David Bohm
António Damásio • Phineas Gage
Norman Geschwind • Elkhonon Goldberg
Patricia Goldman Rakic • Pasko Rakic
Donald O. Hebb • Kenneth Heilman
Edith Kaplan • Muriel Lezak
Benjamin Libet • Rodolfo Llinás
Alexander Luria • Brenda Milner
Karl H. Pribram • Oliver Sacks
Roger W. Sperry • H. M. • K. C.
Tests

Bender-Gestalt Test
Benton Visual Retention Test
Clinical Dementia Rating
Continuous Performance Task
Glasgow Coma Scale
Hayling and Brixton tests
Johari window • Lexical decision task
Mini-mental state examination
Stroop effect
Wechsler Adult Intelligence Scale
Wisconsin card sorting
Mind and Brain Portal
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It is difficult to find anything written about Gage which does not draw on this passage, particularly its existentially pregnant conclusion. And yet it is unknown on just what exactly Harlow based this description, set down twenty years after he treated Phineas:

  • He may have been working from his own notes made in the months after accident—which would not reflect the patient's long-term outcome.
  • He may have been working from his own (or Gage's acquaintances', or Gage's mother's) recollections of Gage prior to Gage's circa-1852 departure for Chile—also not reflective of the long-term outcome, nor perhaps fully trustworthy given the intervening decades.
  • Or he may have been drawing on Hannah Gage's intermittent observations of her son during his nine months in California just before he died—these observations not recounted to Harlow until eight years later.

The raw material for Harlow's description may even have come to him via some still-more-indirect path, such as by mother Gage recollecting for him, in 1868, statements made to her by others about their observations of Phineas during his time away from her on his New England travels (between his physical recovery and his departure for Chile).

The uncertainty of Harlow's sources for the changes he describes in Phineas, combined with the fact that he waited almost twenty years (between his first and second papers) to communicate those changes, constitute one of the central puzzles of the case.[21]

[edit] Distortion and misuse of case

All modern authors agree that Gage underwent some kind of change in behavior after his accident, though they frequently describe these changes in terms well beyond anything given by Harlow. Psychologist Malcolm Macmillan, in his book An Odd Kind of Fame: Stories of Phineas Gage,[22] surveys scores of accounts of Gage (both scientific and popular), finding that they are varying and inconsistent, typically poorly supported by the evidence, and often in direct contradiction to it. These accounts commonly ascribe to Gage drunkenness, "braggadocio," "a vainglorious tendency to show off his wound," an "utter lack of foresight," inability or refusal to hold a job, and much more[23] — none of these mentioned by Harlow, nor by anyone else claiming actual knowledge of Gage's life.[24]

Harlow himself, writing in 1868 while in contact with Phineas' mother, manages to give the year of Gage's death as 1861, whereas Macmillan shows conclusively[13] that Gage actually died in 1860—a striking if relatively unimportant illustration of basic data about Gage having become confused. In another example, several sources[25] state matter-of-factly that Gage's "iron" had been buried with him, but in fact Harlow's account of how he obtained the iron and the skull does not say this.[26]

More substantively for the interpretation of the case, Macmillan points out[27] that in a passage frequently cited[who?] to suggest that Gage could not hold a job after his accident — "'...continued to work in various places;' could not do much, changing often, 'and always finding something that did not suit him in every place he tried'" — Harlow is referring not to Gage's post-accident life in general, but only to the three months between the onset of his convulsions and his death.

Beyond the obvious desirability of correcting the record of a much-cited case, Macmillan claims that "Phineas' story is worth remembering because it illustrates how easily a small stock of facts becomes transformed into popular and scientific myth,"[28] the paucity of evidence having allowed "the fitting of almost any theory to the small number of facts we have."[29] A similar concern was expressed as far back as 1877, when British neurologist David Ferrier, writing to America for information in an effort "to have this case definitely settled," complained that "In investigating reports on diseases and injuries of the brain, I am constantly amazed at the inexactitude and distortion to which they are subject by men who have some pet theory to support. The facts suffer so frightfully...." [30]

Thus in the 19th-century controversy over whether or not the various mental functions are localized in specific regions of the brain, both sides found ways to cite Gage in support of their positions. Adherents of phrenology made use of Gage as well, claiming that his mental changes stemmed from destruction of his "Organ of Veneration" and/or the adjacent "Organ of Benevolence." [31]

It is often said [32] that what happened to Gage somehow inspired the development of various forms of psychosurgery, particularly frontal lobotomy. One might wonder why the unpleasant behavior attributed to Gage would invite surgical imitation, but in any event careful inquiry turns up no such link, according to Macmillan: "[T]here is no evidence that Gage's case contributed directly to psychosurgery...As with surgery for the brain generally, what his case did show came solely from his surviving his accident: major operations could be performed on the brain without the outcome necessarily being fatal."[33]

[edit] New evidence

Recently, an advertisement for a previously-unknown public appearance by Gage has been discovered, as have a report of his behavior during his time in Chile and a description of what may have been his daily work routine there as a long-distance coach driver. This new information suggests that the seriously maladapted Gage described by Harlow may have existed for only a limited number of years after the accident—that in later life Phineas may have been far more functional, and socially far better adapted, than has been thought. If this is so then (along with theoretical implications) it "would add to current evidence that rehabilitation can be effective even in difficult and long-standing cases," according to Macmillan[34]

[edit] Notes

Wikisource has original works written by or about:
  1. ^ Harlow 1868
  2. ^ Campbell, H.F. (1851) Injuries of the Cranium—Trepanning. Ohio Med. & Surg. J. 4(1):31-5 (crediting the Southern Med. & Surg. J., unknown date)
  3. ^ Barker (1995).
  4. ^ Macmillan (2000), p.27
  5. ^ a b Boston Post, September 21, 1848, crediting an earlier report (unknown date) in the Ludlow Free Soil Union (Ludlow, Vermont). The quotation in the text corrects two errors in the published report (the length and thickness of the bar; see image).
  6. ^ Excerpted from Williams' statement in Bigelow (1850).
  7. ^ Excerpted from Harlow (1848).
  8. ^ Barker (1995), pp.679-80; Macmillan (2000), pp.12,60-62; Macmillan (2008), p.828-9
  9. ^ Harlow (1848), p.393.
  10. ^ Harlow (1849).
  11. ^ Harlow (1868), p.415
  12. ^ a b c Harlow (1868), p.340.
  13. ^ a b Macmillan (2000), p.108
  14. ^ Macmillan, M. "Corrections to An Odd Kind of Fame". http://www.deakin.edu.au/hmnbs/psychology/gagepage/PgBook.php. Retrieved on March 21, 2009. 
  15. ^ a b H. Damasio (1994)
  16. ^ a b Ratiu P., Talos I.F., Haker S., Lieberman S., Everett P. (2004). "The tale of Phineas Gage, digitally remastered". Journal of Neurotrauma 21 (5): pp.637-43. 
  17. ^ Harlow (1848); Bigelow (1850); Harlow (1868). See also:
    • Dupuy, E. (1877) A critical review of the prevailing theories concerning the physiology and the pathology of the brain: localisation of functions, and mode of production of symptoms. Part II. Medical Times and Gazette v.II pp.356–8.
    • Ferrier, D. (1878) The Goulstonian lectures of the localisation of cerebral disease. Lecture I (concluded). Br. Med. J., 1(900):443–7
    • Bramwell, B. (1888) The Process of Compensation and some of its Bearings on Prognosis and Treatment Br. Med. J. 1(1425):835-840 doi: 10.1136/bmj.1.1425.835
    • Cobb, S. (1940) Review of neuropsychiatry for 1940. Arch. Internal Medicine. 66:1341-54
    • Cobb, S. (1943) Borderlands of psychiatry. Harvard University Press.
    • Tyler, K.L. and Tyler, H.R. (1982) A "Yankee Invention": the celebrated American crowbar case. Neurology 32:A191.
  18. ^ Damasio A.R. (1996). "The somatic marker hypothesis and the possible functions of the prefrontal cortex". Phil. Trans. Royal Soc. of London, Series B —Biological Sciences 351: 1413–20. 
  19. ^ Macmillan (2000), pp.1289
  20. ^ Bigelow (1850), p.14.
  21. ^ Barker (1995), p.672
  22. ^ Macmillan (2000).
  23. ^ Macmillan, M. "Phineas Gage's Story". http://www.deakin.edu.au/hmnbs/psychology/gagepage/Pgstory.php. Retrieved on 2009-03-24. 
  24. ^ Accordring to Macmillan (2008, p.830) these are Harlow (1848), Bigelow (1850), Harlow (1868), and
    • Jackson, J.B.S. (1849) Medical Cases (Vol 4, Case 1777) Countway Library (Harvard University) Mss., H MS b 72.4 (quoted at Macmillan 2000, p.93)
    • Jackson, J.B.S. (1870) A Descriptive Catalog of the Warren Anatomical Museum Nos. 949-51, 3106 (republished in Macmillan 2000).
  25. ^ e.g. H. Damasio (1994); A.R. Damasio (2005); Hockenbury D.H. and S.E. Hockenbury (1997) Psychology.
  26. ^ Harlow (1868), p.342
  27. ^ Macmillan (2000), p.107
  28. ^ Macmillan (2008), p.831
  29. ^ Macmillan (2000), p.290
  30. ^ Ferrier, D. (1877-79) Correspondence with Henry Pickering Bowditch. Countway Library (Harvard University) Mss., H MS c 5.2 (reprinted in Macmillan 2000, pp.464-5).
  31. ^ Sizer, Nelson (1888). Forty years in phrenology; embracing recollections of history, anecdote, and experience. Fowler & Wells. p. 194. http://books.google.com/books?id=xicZAAAAYAAJ&pg=PA313#PPA194. 
  32. ^ For example, Carlson, N.R. (1994). Physiology of Behavior. p. 341. ; see additonal discussion at Macmillan (2000), p.246.
  33. ^ Macmillan (2000), p.250; Macmillan, M. "Phineas Gage and Frontal Lobotomies". http://www.deakin.edu.au/hbs/GAGEPAGE/PgLobot.htm. Retrieved on 2009-03-21. 
  34. ^ Macmillan (2008), p.831

[edit] References

[edit] External links

[edit] Further reading

[edit] See also

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