Phineas Gage: The Neurosciences’ most famous patient

07/30/2020

Hello readers! Today, we bring to you the case of an erstwhile American railroad worker- Phineas Gage who was injured in an accident during the railroad construction. Why? 

Of course, if we have hit this case today, there’s definitely something very special about it. This is a hitherto unprecedented case. This case is one of the greatest medical curiosities of all time. Humans may find water on the moon but finding even the likes of this case may be next to impossible. You can get to know that by reading further.

So hold on and tighten your seat belts while we fly you through the incident’s history, medical relevance, importance, and other aspects. This case is a bit enigmatic but we’ll make sure you have a comfortable journey 🙂

Phineas Gage and the accident

Phineas Gage was an American railroad worker in Vermont. This incident dates back to 1848 when he was blasting a rock to make way for the Rutland and Burlington railroad.

When Gage was packing the explosive powder with sand, he happened to look back at his colleagues who were standing nearby. Inadvertently, the powder exploded and the tamping iron rod (an iron rod used to pack the sand over the explosive)  went through his head. The iron rod was about 1.1 m in length and 6 kg in weight. Can you think an iron rod of such massive dimensions will spare anyone’s life? It seems that it actually did. Gage went on to live for 12 years after the accident. All thanks to the doctor who treated him- Dr. John. M. Harlow (M.D.). He died of complications resulting from seizures. No autopsy was conducted after his death.

This accident was initially met with utter disbelief for it was undigestible for people to believe that a person could survive a brain trauma of such magnitude. Gage was, however, able to walk immediately after the accident. He could also communicate sensibly and was lucid through most of the period following the injury. Later on, this incident went on to play a crucial role in the discovery of behavioral syndromes resulting from frontal lobe dysfunction.

The injuries sustained and their anatomy

The tamping iron rod went through the left cheek, immediately inferior to the angle of the maxillary bone (as his mouth was open at the time of explosion) and exited through the midline of the skull anterior to the bregma. The rod went under the zygomatic arch, fracturing the temporal part of the sphenoid bone and the orbit of the left eye penetrated the masseter and temporal muscles and passed through the anterior left lobe of the cerebrum. The parietal and the frontal bones were fractured leaving a hole of about 3.5 inches in diameter.

This caused severe damage to Gage’s prefrontal cortices (left and probably right). He lost one of his teeth. His face had severe inflammation and swelling. He had extensive internal and external hemorrhage in his head which also caused hematemesis. 

A year after the accident, he developed ptosis in left eye and also lost vision in the left eye.

Treatment and observations by Dr. Harlow

Dr. Harlow shove Gage’s skull and removed the blood coagula and fragmented pieces of the neurocranium. He then dressed the wound of the face and the burns of his hands. Dr. Harlow observed that he was getting exhausted from profuse hemorrhage. In the course of treatment, he had developed pus in the frontalis muscle which was got rid of by silver nitrate. He was also given colchicum. The treatment given by Dr. Harlow was basically focussed on healing the wounds, stopping the hemorrhage, and dealing with the pus. 

It took Dr. Harlow about two months to get hold of the wounds and bleeding. But, gradually Gage’s condition improved and he began to follow his routine chores. 

All this time, Gage was delirious with lucid intervals. His general intelligence was intact but he lacked emotional sensibility and rational decision making.

Harlow wrote that the recovery of the injuries was physically complete during the four years immediately succeeding the injury.

 

Mental and Behavioral changes

Before the accident, Gage was known to be very responsible and hardworking. For the same reason, he was his colleague’s favorite. However, after the accident, the change in his mental state was so marked that his employers and colleagues considered him as “no longer Gage”.

Gage had changed so much that his employer couldn’t give him his job back. Instead of being responsible, he had become reckless. He had become obstinate and had little deference for his fellows. He had become someone with traits that contrasted the pre-accident gage. His mind had radically changed. He would make plans only to abandon them sometime later.

Conclusions and Opinions

The relationship of the frontal lobe and left and right prefrontal cortex to the personality and rational thinking of an individual became very evident after this incident. This incident has been cited many times in neurosurgery. 

The frontal lobe injury can result in changes in personality that are not demonstrable by sensory and motor exam. As mentioned earlier, though Gage recovered physically, his mental recovery was negligible. This may have been the first case to suggest the brain’s role in determining personality.

This incident paved the way for frontal lobotomies to deal with irregular behavior of certain criminals.

Frontal lobotomy was chosen as a corrective treatment for criminals, highly aggressive patients, and prisoners back then ( Dr. Rakesh Sinha, The Anatomy of Success, the science of change, page 14).

Such surgeries became popular in the 1930s but ceased a decade after.

References and Further Reads

1. The return of Phineas Gage: clues about the brain from the skull of a famous patient
2. From Phineas Gage and Monsieur Leborgne to H.M.: Revisiting Disconnection Syndromes
3. Passage of an Iron Rod Through the Head
4. Violence, mental illness, and the brain – A brief history of psychosurgery: Part 1 – From trephination to lobotomy
5. Frontal Lobe Function: Mr. Phineas Gage’s Famous Injury (Thomas C. Neylan, M.D., Section Editor)

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Authors:

Harsh Rai-NMCTH

Himanshu Jindal-GSVM Medical College