Phineas Gage

Phineas P. Gage
File:Phineas Gage Death Mask.jpg Phineas Gage, life mask c.1850 (often mistakenly termed a death mask)
Born	July 9?, 1823 Lebanon, New Hampshire
Died	May 21, 1860(1860-05-21) (aged 36)
Occupation(s)	Railroad construction foreman, blaster
Spouse	None
Children	None
Parent(s)	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 frontal lobes, and for that injury's reported effects on his personality and social functioning—effects said to be so profound that friends saw him as "no longer Gage." His case influenced 19th-century thinking about the brain and the localization of its functions, and was perhaps the first to suggest that damage to specific regions of the brain might affect personality and behavior.

Gage's accident and physical recovery

On September 13, 1848 Gage was foreman of a work gang blasting rock while clearing the roadbed for a new rail line 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, around 4:30 PM:

the powder exploded, carrying an instrument through his head an inch and a fourth in circumference, and three feet and eight 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.

(The report in the Boston Post for September 21, shown left, had been reprinted from the Ludlow [Vermont] Free Soil Union.) In fact, the iron was 1-1/4 inches in diameter (not "circumference") and was three feet seven inches long. Weighing 13-1/4lb (6 kg), it 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. Though physicians Edward H. Williams and John Martyn Harlow found him weak from hemorrhage, he had a regular pulse of about 60 and was alert and coherent.

Despite Harlow's skillful care, Gage's recuperation was long and difficult. A "fungal" infection left him semi-comatose from September 23rd to October 3rd, "seldom speaking unless spoken to, and then answering only in monosyllables." On October 7 he took his first step. On October 20th 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 in his contemporary (1848) case report was that Gage "appears to be in a way of recovering, if he can be controlled."

Subsequent life and travels

Illustration from Harlow's 1868 paper: "Front and lateral view of the cranium, representing the direction in which the iron traversed its cavity; the present appearance of the line of fracture, and also the large anterior fragment of the frontal bone, which was entirely detached, replaced and partially re-united."

Except for loss of vision in the left eye and some facial disfigurement and paralysis, Gage's physical recovery seems to have been essentially complete by April 1849. Harlow says that Gage, unable to return to his previous job, was for a time an attraction at P. T. Barnum's American Museum in New York City (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 implication that Gage made public appearances in "the larger New England towns" (on Gage's job-loss and public appearance, see more below).

He later worked in a livery stable in New Hampshire, and then for some years in Chile as a coach driver. 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.

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.

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' skull and the rod. About a year after the accident, Gage had given the tamping iron which injured him to Harvard's Dr. Bigelow for the medical museum, but he later reclaimed it and (according to Harlow) made it his "constant companion during the remainder of his life", thus making it available to be buried with him. At the exhumation the skull and the again-recovered rod were delivered together to Harlow back in New England. After studying them for an 1868 paper, he placed them in the Harvard Medical School's Warren Anatomical Museum, where they remain on display today. The rod bears a (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.

Much later, Phineas' headless skeleton was moved to Cypress Lawn Cemetery, south of San Francisco, as part of a general transfer of remains out of the city.

Brain damage and mental changes

Graphic by Damasio et al showing how the tamping iron may have damaged both frontal lobes. (A 2004 study by Ratiu and colleagues 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, is unclear. A 1994 study by Hanna Damasio and colleagues suggests bilateral damage to the medial frontal lobes, but a 2004 study by Ratiu and colleagues, based on a CT scan of Gage's skull, suggests more limited injury.

Neurologist Antonio Damasio calls Gage's story "the historical beginnings of the study of the biological basis of behavior"; his "somatic marker hypothesis" suggests a link between the frontal lobes, emotion and practical decision-making. 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), 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." (Noting 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 ended scepticism about the case among physicians in general—one of whom, according to Harlow, had dismissed Gage's story as a "Yankee invention.")

It was only in his second report, written after he'd obtained Phineas' skull in 1868, that Harlow introduced the now-textbook checklist of mental changes. Now he described the pre-accident Gage as having been hard-working, responsible, and "a great favorite" with the men in his charge, his employers regarding 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."

It is difficult to find anything written about Gage which does not quote this passage, or at least 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, necessarily pre-dating Gage's circa-1852 departure for Chile—so 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 the nine months between his relocation from Chile to California and his death, recounted to Harlow 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 Harlow, in 1868, statements made to her by others about Phineas' behavior during his time away from her on his New England travels (between his physical recovery and his departure for Chile).

Distortion and misuse of case

Later writers hyperbolized this difficult-to-evaluate (though undoubtedly sincere) base provided by Harlow, adding 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 — all unmentioned by Harlow. In fact, in his book An Odd Kind of Fame: Stories of Phineas Gage, psychologist Malcolm Macmillan shows that published accounts of Gage (both scientific and popular) are varying and inconsistent, typically poorly supported by the evidence, and often in direct contradiction to it.

For example Dr. Harlow, writing in 1868 while in contact with Phineas' mother, gives the year of Gage's death as 1861, whereas Macmillan has shown conclusively that Gage actually died in 1860—a striking (if relatively unimportant) illustration of basic fact about Gage having become confused. More substantively for the interpretation of the case, Macmillan points out that in a passage frequently cited 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 in fact referring only to the three months between the onset of Gage's convulsions and his death.

The paucity of the evidence has allowed, as Macmillan puts it, "the fitting of almost any theory to the small number of facts we have." 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."

It is often said that what happened to Gage somehow inspired the development of various forms of psychosurgery, particularly frontal lobotomy in the 1930s. One might wonder why the unpleasant changes attributed to Gage would inspire surgical imitation, but in any event careful inquiry turns up no such link, according to Macmillan: "There is no evidence that the changes in Gage were among the considerations that gave rise to psychosurgery....As with surgery for the brain generally, what his case did show came solely from his surviving the accident: major operations could be performed on the brain without the outcome necessarily being fatal."

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 was far more functional, and socially far better adapted, than has been thought.

External links

• Malcolm Macmillan, The Phineas Gage Information page, School of Psychology, Deakin University, Victoria, Australia
• Phineas Gage roadside memorial
• Ratiu et al.,Phineas Gage's injury digitally remastered at Google video.
• Phineas Gage Skull Replication

Further reading

• A. Damasio (2005) "A Modern Phineas Gage" in Descartes' Error: Emotion, Reason, and the Human Brain.
• J. Fleischman (2002) Phineas Gage: A Gruesome but True Story About Brain Science. ISBN 0-618-05252-6. (Aimed at middle-school students)
• Kelley DJ, Farhoud M, Meyerand ME, Nelson DL, Ramirez LF, et al. (2007) Creating Physical 3D Stereolithograph Models of Brain and Skull. PLoS ONE 2(10): e1119. doi:10.1371/journal.pone.0001119.
• M. Macmillan (1986) "A wonderful journey through skull and brains: The travels of Mr. Gage's tamping iron" Brain and Cognition 5(1): 67-107 doi:10.1016/0278-2626(86)90062-X.
• M. Macmillan (2000) "Restoring Phineas Gage: A 150th retrospective," Journal of the History of the Neurosciences, 9(1): 42-62. DOI 10.1076/0964-704X(200004)9:1;1-2;FT046.
• M. Macmillan (2002) An odd kind of fame: Stories of Phineas Gage. ISBN 0-262-63259-4. (Appendices reproduce Harlow 1848 and 1868, Bigelow 1850, and other primary documents, some unavailable elsewhere)

See also

• Traumatic brain injury
• Michael Hill
• Ahad Israfil