Frontal Lobe F u nction : Mr.Phineas Gage’s Famous Injury

1. Frontal Lobe Function: Mr.Phineas Gage’s Famous Injury 1 2 M A R C H 2 0 1 3 Presentedby by Kaan Yücel M.D., P.h.D. Thomas C. Neylan, M.D., Section Editor

2. John Martyn Harlow, M.D. November 25, 1819 - May 13, 1907 25 yearsold 29 yearsold Vermont packsandover an explosivecharge, chargeexplodedunexpectedlyandpropelled the3-foot-long Rutland& BurlingtonRailRoad

3. 13-pound rodenteredtheleftcheekandexitedthemidline of theskullanteriortothebregma, resulting in severe injuryto his leftand, in allprobability, his rightprefrontalcortex. 13 pound= 5.9 kg.

5. TheGagecase, one of themostfamousandinfluential in neuropsychiatry, played a crucial role in thediscovery of behavioralsyndromesresultingfromfrontallobedysfunction. Readers interested in detailedaccounts of thecaseanditshistoricalcontext can findexcellentreviewsbyMacMillanandBarker. MacMillanMB: A wonderfuljourneythroughskullandbrains: thetravels of Mr. Gage’stampingiron. Brain Cogn 1986; 5:67–107 4. BarkerFG: Phineasamongthephrenologists:theAmericancrow- bar caseandnineteenth-centurytheories of cerebrallocalization. J Neurosurg 1995; 82:672–682

6. Thecasereportwasinitially met withdisbeliefbecauseit wasthoughtto be impossiblefor a humantosurvive a braininjury of suchmagnitude. • Beyond theastonishingfact of Mr. Gage’ssurvivalwasthedescriptionof his abilitytowalkimmediatelyaftertheevent, communicatesensibly, andremainlucidthoughmostoftheperiodfollowingtheinjury. • Thisfactattractedtheattention of P. T. Barnum, whoemployedMr. Gagefor a shortperiodfollowing his recovery. • Dr. Henry J. Bigelow, a prominentprofessor of surgery at Harvard Medical School, examinedMr. GageafterHarlow’sreportandfailedtonotethechanges in Gage’sbehavior.

7. He proclaimedthatGage had nodemonstrablesequelaeof theinjury. Dr. BigelowandothersusedtheGagecase as a persuasiveargumentagainstthefield of phrenology,whichwastheonlyprominentdiscipline at the time thatconsideredthepossibility of localization of brainfunction. thereareseveralsugges- tions in theoriginalreportthatMr. Gage’sbehavior had changed. Dr. Harlowpromisedtoreportthementalmanifestations of theinjury in a subsequentcommunication. He did not producethisreportuntil 20 yearslater, when he described a pervasivechange in personalityandcharacter in theJournal of the Massachusetts MedicalSociety, a periodicalwithverylimitedcircula- tion. Inthisreport, Harlowdescribedthefollowing: His contractors, whoregardedhim as themostefficientandcapableforeman in theiremploypreviousto his injury, consideredthechange in his mindsomarkedthattheycould not givehim his placeagain. He is fitful, irreverent, indulging at times in thegrossestprofanity (whichwas not previously his custom), manifesting but littledeferencefor his fellows, impatient of restraintoradvicewhen it conflictswith his desires, at timespertinaciouslyobstinate, yet capriciousandvacillating, devisingmanyplans of futureoperation, whicharenosoonerarrangedthantheyareabandoned in turnforothersappearingmorefeasible. Inthisregard, his mindwasradicallychanged, sodecidedlythat his friendsandacquaintancessaid he was “nolongerGage.”

8. Dr. David Ferrier, whowas an earlychampionforthetheory of cerebrallocalization, discoveredHarlow’ssecondreportandused it as thehighlight of his famous1878 Goulstonianlectures, whichdescribedindetailthefocalmapping of thecerebralfunction. Thefrontallobeswereconsideredto be involved in higherexecutivefunction. Dr. FerriercitedtheGagecase as a primaryexampleof how frontallobeinjury can result in changes of personalitythatare not demonstrablebysensoryand motor exam. TheGagecase is nowone of themostfre- quentlycitedarticlesfromnineteenth-centurymedicalliterature. PhineasGagedied in San Francisco, apparentlyfromcomplications of seizures, yearsafter his injury. Dr. HarlowobtainedconsentfromMr. Gage’sfamilytoobtaintheskullandtampingiron, whicharenow in thecollection of theWarrenAnatomicMuseum at Harvard University.

9. Passage of an IronRod Through theHead Nov. 27, 1848 Havingbeeninterested in thereading of thecases of “Injuries of theHead,” reported in yourJournalbyProfessorShipman, of Cortlandville, N.Y., I am inducedtoofferyouthenotes of a very severe, singular, and, so far as theresult is takenintoaccount,hithertounparalleledcase,ofthatclass of injuries,which has recentlyfallenundermyowncare. Itappearsfrom his ownaccount, andthat of theby- standers, that he wasengaged in charging a hole, preparatorytoblasting. He had turned in thepowder, andwas in theact of tamping it slightlybeforepouring on thesand. He had struckthepowder, andwhileabouttostrike it again, turned his headtolookafter his men (whowereworkingwithin a fewfeet of him), whenthetampingironcame in contactwiththerock, andthepowderexploded, drivingtheironagainsttheleftside of theface, immediatelyanteriortotheangle of theinferiormaxillarybone.

10. Taking a directionupwardandbackwardtowardthemedianline, it penetratedtheinteguments, themasseterandtemporalmuscles, passedunderthezygomaticarch, and (probably) fracturingthetemporalportion of thesphenoid bone, andthefloor of theorbit of thelefteye, enteredthecranium, passingthroughtheanteriorleftlobe of thecerebrum,andmadeitsexit in themedianline, at thejunction of thecoronalandsagittalsutures, laceratingthelongitudinalsinus, fracturingtheparietalandfrontalbonesextensively, breakingupconsiderableportions of brain, andprotrudingtheglobe of thelefteyefromitssocket, bynearlyonehalfitsdiameter. Thetampingiron is round, andrenderedcomparativelysmoothbyuse.Itispointed at theendwhichenteredfirst, and is threefeet, seven inches in length, oneandonequarterinch in diameter, andweighs13 1⁄4 pounds. 1 m. 2 cm. in length 3 cm. in diameter 6 kg.

11. I am informedthatthepatientwasthrownupon his back, andgave a fewconvulsivemotions of theextremities, but spoke in a fewminutes. His men (withwhom he was a greatfavorite) tookhim in theirarmsandcarriedhimtotheroad, only a fewrodsdistant, and sat himinto an ox cart, in which he rode, sittingerect, fullthreequarters of a mile, tothe hotel of Mr. Joseph Adams, in thisvillage. He gotout of the cart himself, andwith a littleassistancewalkedup a longflight of stairs, intothehall, where he wasdressed. Beingabsent, I did not arrive at thescene of theaccidentuntilnear 6 o’clock, P.M. Youwillexcuse me forremarking here, thatthepicturepresentedwas, tooneunaccustomedtomilitarysurgery, trulyterrific; but thepatientbore his sufferingswiththemostheroicfirmness. He recognized me at once, andsaid he hoped he was not muchhurt.Heseemedto be perfectlyconscious, but wasgettingexhaustedfromthehemorrhage, whichwasveryprofusebothexternallyandinternally, thebloodfindingitswayintothestomach, whichrejected it as often as every 15 or 20 minutes. Pulse 60, andreg- ular. Hisperson, andthebedon which he waslaid,wereliterallyonegore of blood. Fromtheirappearance, thefragments of bone beingupliftedandthebrainprotruding, it wasevidentthatthefracturewasoccasionedbysomeforceactingfrombelowup- ward. portion of theanteriorsuperiorangle of eachparietal bone, and a semi-circularpiece of thefrontal bone, werefractured, leaving a circularopening of about 31⁄2 inches in diameter. Thisexamination, andtheappearance of theironwhichwasfoundsomerodsdistant, smearedwithbrain,togetherwiththetestimonyof theworkmen, and of thepatienthimself, whowasstillsufficientlyconsciousto say that “theironstruck his headandpassedthrough,” wasconsidered at the time sufficientlyconclusivetoshow not onlythenature of theaccident, but themanner in which it occurred.

12. Tellswheretheylive, theirnames, &c. Pulse65 17th, 8, A.M.—Pulse 84. Purgedfreely. Rational, andknows his friends. 11th.—Pulse 72. Intellectualfacultiesbrightening. When I askedhim how long since he wasinjured, he replied, “fourweeksthisafternoon, at 41⁄2 o’clock.” Re- latesthemanner in which it occurred, and how he cametothehouse. He keepstheday of theweekand time of day, in his mind. Says he knowsmorethanhalf of thosewhoinquireafterhim. Does not estimate size ormoneyaccurately, though he has memory as perfect as ever. He would not take $1000 for a fewpebbleswhich he tookfrom an ancientriverbedwhere he was at work. His desireto be outandtogohometoLebanon has beenuncontrollableby his friends, and he has beenmakingarrangementstothateffect. I thinkthecasepresentsonefact of greatinteresttothepracticalsurgeon, and, taken as a whole, is exceedinglyinterestingtotheenlightenedphysiologistandintellectualphilosopher .

13. Prior to the incident, Gage was described as reliable, systematic, and hard- working. Afterwards, his personality is said to have changedand he became impulsive, disorganized, and stubborn. His language was said to be colorfully profane, although he did not customarily swear before the injury. • Whether these were permanent changes or confined to the year or so after the in jury is in dispute, because Harlow depended on secondhand information for most of his follow-up, seeing Gage only once again after the first 5 months of his recovery. • Gage recovered enough in executive function to make a living for himself, first as a circus act, where he appeared holding the iron tamping rod, which he kept for the rest of his life, and then as a hand in a livery stable. • Later, he moved to Chileanddroveastagecoach,whichspeakswellofhisability to adapt behaviorally and his neurological function. • Toward theendofhislife,whichcamein1860fromaseizuredisorder undoubtedly related to the injury, he moved to California to reunite with his mother and sister.

14. Our reconstruction of Gage’s injury confirms once again Bigelow’s assessment that the “the leading feature of this case is its improbability” (Bigelow, 1850). Macmillan (2000) has shown that the record of how Phineas Gage’s character changed after the accident must be considered with caution; this circumstance, in the light of our still vague understanding of neuropsychology neither requires nor can rule out such a hypothesis. According to our results, the brain parenchyma injury appears to be much less extended than previously thought. Only the medial and lateral orbito-frontal as well as the dorsolateral prefrontal regions of the left frontal lobe were injured as a consequence of direct missile impact