Phineas Gage
Phineas Gage, the most famous case of prefrontal damage and resulting behavior changes, first revealed a connection between impaired rationality and specific brain damage.
September 13, 1848 at 4:30 pm, a 25-year old construction foreman of a blasting crew is working for the Rutland and Burlington Company as it made its way through central Vermont near the town of Cavendish. Phineas Gage is in charge of a “gang” whose job is to lay down the new track for the railroad’s expansion across Vermont. They are now at the bank of the Black River and their task is to blast the outcrop of considerably large boulders that lie in the way of the planned track bed. Removing the outcrop of rock will enable a straighter and more level path for the railroad bed.
The blasting process is an orderly and meticulous. First, the hole must be drilled in the rock. About hallway through the rock, it is filled with explosive powder, a fuse is inserted, and the powder is covered in sand. Then the sand must be “tampered in ” or pounded in with a careful sequence of strokes from a tamping iron. Phineas uses a 3 foot 7 inches, 13 1/4 pound iron rod to tamp gunpowder and sand into a hole in the rock. Finally, the fuse is lit. The sand is essential, for without its protection the explosion would be directed away from the rock.
On this hot afternoon, something went horribly wrong. Phineas had just put powder and a fuse in a hole and told the man who is helping him to cover it with sand. Someone calls from behind, and Phineas looks away, over his right shoulder, for only an instant. Distracted, and before the man has poured the sand in, Phineas begins tamping the powder directly with the tamping iron. Instantaneously, the rod striking the stone causing a spark, and the charge blows upward in his face. The resulting explosion sent the rod flying up and through his left cheek, pierces the base of the skull, transverses the front of his brain, and exits through the top of his head.
The explosion freezes the entire gang and takes a few seconds to piece together what is going on. The bang and the whistling sounds are unusual, and the rock is intact. The rod has landed more than 80 feet away covered in blood and brains.
So what happens to Phineas? To the amazement of everyone, he was not killed. Phineas has been thrown to the ground, is stunned and silent, but awake. In fact, when everyone came running to see what the problem was, Phineas could talk to them. He was clearly dazed and confused but he was conscious and could articulate what just happened.
The Boston medical article documents that Phineas “immediately after the explosion the patient was thrown upon his back”: that shortly thereafter he exhibited “a few convulsive motions of the extremities,” and spoke in a few minutes.” The article goes on to write that “his men took him in their arms and carried him to the road, only a few rods distant, and sat him into an ox cart, in which he rode, sitting erect, a full quarter of a mile, to the hotel of Mr. Joseph Adams.” At the hotel Phineas “got out of the cart himself, with a little assistance from his men.”
“Horrible Accident” in the Boston Daily Courier and Daily Journal on September 20, 1948, a week after the accident
Adams, the justice of the peace for Cavendish and the owner of the town’s hotel and tavern, immediately has someone call for Dr. John Harlow, one of the town’s physicians. An hour pasts before Dr. Edwards Williams, a younger colleague of Dr. Hallow, arrives.
Years later Dr. Williams describes the scene: “He at the time was sitting in a chair upon the piazza of Mr. Adams’ hotel, in Cavendish. When I drove up, he said, ‘Doctor, here is the business for you.’ I first notice the wound upon the head before I alighted from my carriage, the pulsations of the brain being very distinct; there was also an appearance which, before I examined the head, I could not account for: the top of the head appeared somewhat like an inverted funnel; this was owning, I discovered, to the bone being fractured about the opening for a distant of about two inches in every direction.
Mr. Gage, during the time I was examining the wound, was relating the manner in which he was injured to the bystanders; he talked so rationally and was so willing to answer questions, that I directed my inquires to him in reference to the men who were with him at the time of the accident, and who were standing about at the this time. Mr. Gage then related to me some of the circumstances, as he has since done; and I can safety say that neither at that time nor on any subsequent occasion, save once, did I consider him to be other than perfectly rational.”
The doctor said he didn’t believe him until Phineas started to feel nausea and bent over to vomit. The pressure of vomiting pushed out about a teacup full of Phineas gage’s brain onto the floor. The consistency of the brain is like Jell-O and lacks internal structure.
Phineas’ treatment lasted about 3 months, and when he had recovered sufficiently, he moved back to his parent’s farm in Lebanon, New Hampshire.
The damage to Phineas’ brain seems to have been largely contained to his left prefrontal cortex, an area that is linked closely with personality. While he retained full possession of his reasoning abilities, his wife and others soon began to notice dramatic changes in his personality. It was not until Phineas tried to resume his duties with the railroad did the role of the pre frontal cortex become fully obvious.
Gage was no longer Gage.
When he went back to the railroad at the end of 1849, his employer said, “Gage was no longer Gage.” Instead of the incredible mature, well-liked, respectful employee, Phineas was extremely aggressive, belligerent, vulgar individual who had no respect for authority, and couldn’t plan or keep to a given plan. He couldn’t do any goal directed activities and lacked some basic executive function skills.
Due to these factors, Phineas was unable to return to his job as a foreman, and over the next several years worked a variety of jobs, including stints as an attraction at the Barnum’s American Museum in New York City and on the lecture circuit at major cities in New England. Four years after the accident, Phineas left for South America and at sometime was a long-distant stagecoach driver in Chile on the Santiago and Valparaiso route. To say the least, he had an eventful life.
In 1860, Phineas returned to the United States to live with his mother and sister, who had since moved to San Francisco. Upon entering the U. S., Phineas’ health had started to deteriorate and he died May 21, 1860 at age 36 just under 12 after his accident, after an illness that lasted little more than a day.
What does the story of Phineas Gage teach us?
Why is this sad tale worth telling? What is the possible significance of such a bizarre story? The story is important for various reasons. Obviously, the story illustrates the importance of the pre frontal cortex role in decision-making capacity, impulsivity, ability to obey normal social conventions, aggression, anger or hostility, inability to tolerate frustrations, and excessive emotionalism.
But what was more important was what Phineas could still do. He did lack the overall maturity that he had before the accident, but it was as if he couldn’t function anymore. In the 19th century, simply making it from New Hampshire to New York City requires a lot of complex thinking.
Also, you could not be a stagecoach driver in Chile without a little executive function capacity. Consider the demands of stagecoach driving. Phineas routine imposes a repetitive and fairly rigid daily structure and a description of the daily tasks of a driver on the very route Phineas may have driven. Phineas had little choice over his tasks: he had to rise early in the morning, prepare himself, and groom, feed, and harness the horses; he had to be at the departure point at a specified time, load the luggage, charge the fares and get the passengers settled; and then had to care for the passengers on the journey, unload their luggage at the destination, and look after the horses. Phineas demonstrated amazing executive functioning skills considering a tamping iron had entered his brain under his left eye and exited through the top of his skulls just a few years prior.
What does Phineas Gage’s story tell us about the brain as a whole? The most important point is it is incredibly difficult to talk about the brain and its inconceivable complexity. Many people have assumed a one-to-one mapping in the brain associating one exact brain area to a certain function. As Phineas’ story proves, this is not a valid assumption.
To explain the complexity of the human brain, Todd Rose, Harvard University Graduate School of Education, uses an analogy that can be made to starting a car without a spark plug. The spark plug is part of broad structure of the engine structure that contributes to the starting of the car. The spark plug is necessary to starting a car but is not sufficient by itself. Likewise, the pre frontal cortex, just like other brain areas, plays a vital role in several high level functions, but alone it is not sufficient to give rise to complex functions.
Antonio Damasio writes that, “Gage’s example indicated that something in the brain was concerned specifically with unique human properties.” In Descartes’ Error, Damasio concludes that Phineas’ story “hinted at an amazing facts. Somehow, there were systems in the human brain more to reasoning than to anything else, and in particular to the personal and social dimensions of reasoning.”
Not only from a human-interest focus but also from a neurobiological functioning aspect, Phineas’ story is a story worth telling.