The Curious Case of Phineas Gage

The place is Cavendish, Vermont. The site, Rutland and Burlington Rail Road. It is 13th of September, 1848. A series of events are about to unfold that would alter the understanding of brain function forever. Phineas P. Gage, a 25 yr old railroad construction foreman has a job to do. He's tamping the charge with an iron rod. Tamping involve packing a gunpowder charge in a small space and pointing it where needed. The gunpowder is added, tamped, then sand is added. Gage had tamped the charge with the iron and was about to tamp it a second time. The time, 4:30PM. He looked over to check his fellow workers if they were safe, and the tamping iron accidentally came into contact with the rock and the powder exploded. This drove the tamping iron three feet, seven inches in length, one and one quarter inch in diameter, and weighing 13
pounds, against the left side of his face entering through the chin, going upwards and backwards, behind the left eye, through his left frontal lobe and above out of the skull. The tamping iron was picked up a distance behind Gage covered with blood and brains. It is said that Gage was thrown back on the ground with slight convulsions of his arms and legs. Here's the amazing part. A few minutes after this horrendous accident, Gage gets up and starts talking,was put on an ox cart to proceed to his boarding house and get checked by the local physician!!That local physician was Dr.John Martyn Harlow. With Dr.Edward H Willaims, he removed the smaller bone fragments, left the larger ones intact and covered the hole in the head with wet compresses and adhesive strap. The wound was left open to drain into the dressings. This all very incredible as evident from Dr.Harlow's letter to the boston post. An excerpt is as under:
"......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, which was very profuse both externally and internally, the blood finding its way into the stomach, which rejected it as often as every 15 or 20 minutes. Pulse 60, and regular. His person, and the bed on which he was laid, were literally one gore of blood. Assisted by my friend, Dr. Williams, of Proctorsville, who was first called to the patient, we proceeded to dress the wounds......"

A few days after this, Gage's brain got infected with a fungus resulting in him being comatose from September 23rd to October 3rd 1848. He got feverish in November but at the end of november, except for the loss of vision in the left eye, some disfigurement and slight facial paralysis, Gage's physical recovery was thought to be complete!!! We are talking within 3 months of a major brain injury here!

Dr.Harlow's description of the injuries is as follows:
"[The tamping iron] entered the cranium, passing through the anterior left lobe of the cerebrum, and made its exit in the medial line, at the junction of the coronal and sagittal sutures, lacerating the longitudinal sinus, fracturing the parietal and frontal bones extensively, breaking up considerable portions of the brain, and protruding the globe of the left eye from its socket, by nearly half its diameter. "

BEHAVIOURAL CHANGES; "NOT GAGE ANYMORE":

Gage's brain tissue had extensive damage to the left and quite possibly the right frontal lobe owing to the original injury followed subsequently by the fungal infection. According to Dr.Harlow in 1848:
"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."
Dr.Henry Jacob Bigelow, Professor of Surgery at Harvard University, after observing Phineas Gage for several weeks in 1850 concluded that Gage was "quite recovered in faculties of body and mind." He at first was skeptic, then became a believer after the lack of evidence and ended up scoffing at the case with other physicians - one of whom, according to Harlow, labelled the case as a "Yankee invention"!

20 years later, in 1868, Dr.Harlow detailed the mental manifestations (albeit exaggerated according to some sources) in a report published in the Bulletin of the Massachusetts Medical Society as:

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 was this account of Gage's mental changes a good 20 years later that made this case historic.
The opposition to Harlow's report in 1848 was in part due to the popularity of phrenology in that era. Phrenology is a now-defunct field of study in which a person's personality traits were determined by measuring and feeling the bumps and fissures on their skull! It was invented by the German physician Franz Joseph Gall around 1800. According to Gall, the brain is an organ of the mind. He described 27 different "brain organs" of which the brain is made. These 27 organs, spread all over the brain, determined a person's personality. The bumps and fissures, when measured give an idea of the size of the part of the brain (the organ) which is larger which would mean the patient has an increasing tendency to carry out the "organ's function". In summary, the personality of a person was spread out over the entire brain.
Gage's case changed all that. An injury to the frontal lobe leading to personality change with rest of physical senses intact was a big hit to the "anti-localization" group of neuroscientists. It was the first time there was evidence of localization of personality in a specific area of the brain! This led to the overlapping of death of phrenology with the birth of modern neuroscience. Significant discoveries were being made. In 1865, Paul Broca (1824-1880) described the speech centre in the left cerebral hemisphere of right-handed people in the inferior frontal gyrus,now aptly known as Broca’s area. Also in the 1860s, John Hughlings-Jackson (1835-1911) and David Ferrier carried out (1843-1928) physiological studies which pointed to the localization of cerebral function.
Ferrier, an early supporter of localization of brain function, used Gage’s case as the highlight of his famous Goulstonian lecture in 1878, leading him to the conclusion that:

There are certain regions in the cortex to which definite functions can be assigned; and that the phenomena of cortical lesions will vary according to their seat and also to their character…removal or destruction…of the antero-frontal lobes is not followed by any definite physiological results…And yet, notwithstanding this apparent absence of physiological symptoms, I could perceive a very decided alteration in the animal’s character and behaviour, while it is difficult to state in precise terms the nature of the change…while not actually deprived of intelligence, they had lost, to all appearance, the faculty of the attentive and intelligent observation [Regarding the trajectory of the tamping iron through Gage's brain]…the absence of paralysis in this case is quite in harmony with the results of experimental physiology.

Thus, the tragedy of Phenias Gage, followed by the mental irregularities replicated by Ferrier in monkeys paved the way to a new era in neuroscience and eradicated the phrenological beliefs. Thanks to Dr.Harlow's persistence and the 1868 report, there has been an explosion of research work in the prefrontal cortex and it is now known that it is, among other things, responsible for social "control" (the ability to suppress urges that, if not suppressed, could lead to socially-unacceptable outcomes). Now, we know that the changes in Gage's personality were consistent with the findings of today.
CONCLUSION:
Although, a lot about Gage's life before and after the accident is in dispute, it is known that, he died in San Francisco on 20th May, 1860,after 13 years since the accident from epileptic convlsions leading to complications. He was 36 years old. An autopsy on Gage’s brain was not conducted. Little did Phenias Gage know that on September the 13th, 1848, events would unfold making him the index case for behavioral changes following injury to the frontal cortex, and the spark leading to an explosion in neurophysical research giving birth to modern neuroscience!


A 3-D representation of the trajectory of the rod
and damage to Gage's skull and brain:

















The Skull and Rod as on display:




REFERENCES:
Wikipedia: http://en.wikipedia.org/wiki/Phineas_Gage#Brain_damage_and_mental_changes
http://en.wikisource.org/wiki/Passage_of_an_iron_rod_through_the_head

BMJ: "No longer Gage": An iron bar through the head
http://www.bmj.com/cgi/content/extract/317/7174/1673/a

Neurophilosophy: The interesting case of Phineas Gage
http://neurophilosophy.wordpress.com/2006/12/04/the-incredible-case-of-phineas-gage/

Harlow's letter: http://en.wikisource.org/wiki/Passage_of_an_iron_rod_through_the_head