Phineas Gage

BRAIN AREA: Cerebral Cortex – Frontal Lobe – Prefrontal Cortex

The remarkable case of Phineas Gage has become a classic largely because of his dramatic injury and surprising recovery. However, questions remain regarding the precise nature of Gage's injury because his brain was not examined after he died. Gage's brain injury occurred while using a tamping rod to settle an explosive charge as part of railway construction in Vermont, USA, in 1848. Gage suffered a horrific injury when the charge detonated early, firing the rod through his head, damaging his brain and skull.

Despite his injuries, he remained conscious and was able to discuss what had happened with his helpers who took him for treatment. His physician, Dr John Harlow, kept notes on Phineas' treatment and recovery, later publishing a report on the case. These contain limited but reliable information about his patient's mental condition after his injury.

It is amazing that Phineas Gage survived the accident, but little wonder he is later reported as having difficulty with planning and deficiencies in his personality and social judgement. The changes to his personality would lead physicians to consider how certain parts of the brain influence our character and the decisions we make.

Despite numerous subsequent efforts to determine the precise extent of his injury, lack of an autopsy means the most we can conclude is that the anterior part of his left frontal lobe (his left prefrontal cortex) was included in the areas affected (see Image 1). Consequently, we do not have a precise understanding of the pathology underlying Phineas Gage's mental problems. Gage's injuries also included fibre tract damage, which Van Horn et al. (2012) attempted to assess. These authors concluded that there were likely to have been connections lost between left frontal, left temporal, right frontal cortices and left limbic structures resulting in adverse effects on executive function and emotion.

Phineas Gage was relatively famous in his lifetime, exhibiting himself (with the tamping rod) at Barnum's American Museum. It is noteworthy that he travelled to South America in 1852 and was continuously employed for seven years as a stagecoach driver, caring for and controlling a team of horses on very poor roads. This indicates the strength and resilience of his cognitive ability after the injury – he was able to hold down a demanding job for a reasonable period of time and demonstrated a high degree of skill in managing the reins for six horses and accurately handling a whip, and also exercised good memory necessary for driving at night over poorly lit and frequently changing routes.

He subsequently returned to the United States, but after a series of epileptic fits he died in 1860. However, his dramatic case continued to resonate within medical science and in 1867 his body was exhumed for further studies. His skull, a cast of his head and the tamping iron are held at the Warren Anatomical Museum, an associate of the Harvard Medical School.

References & further reading

Damasio, H., Grabowski, T., Frank, R., Galaburda, A. M., & Damasio, A. R. (1994). The return of Phineas Gage: Clues about the brain from the skull of a famous patient. Science, 264(5162), 1102–1105. https://www.science.org/doi/10.1126/science.8178168

Macmillan, M. (2002). An odd kind of fame: Stories of Phineas Gage. MIT Press.

Ratiu, P., Talos, I.-F., Haker, S., Lieberman, D., & Everett, P. (2004). The tale of Phineas Gage, digitally remastered. Journal of Neurotrauma, 21, 637–643. https://doi.org/10.1371/journal.pone.0037454

Van Horn, J. D., Irimia, A., Torgerson, E. M., Chambers, M C., Kikinis, R., & Toga, A. W. (2012). Mapping connectivity damage in the case of Phineas Gage. PLoS ONE, 7(5), Article e37454. https://doi.org/10.1371/journal.pone.0037454