Phineas Gage Retrospective

A Wonderful Journey through Skull and Brains:The Travels of Mr. Gage’s

Tamping Iron

1

di M. B. MacmillanMonash University, Clayton, Victoria, Australia

Biographical Notes/1• September 9, 1823: Phineas gage borns in

Lebanon, New Hampshire, son of Jesse E. Gage e Hannah Sweatland, first of 5 children.

• Grows up and attends school in Lebanon

• May 1847: He’s hired by Rutland and Burlington Railroad, attaining foreman role

• September 13, 1848, 4.30 p.m.: the crowbar starts traveling...

• November 25, 1848: Goes back to Lebanon after recovering from injuries

Biographical Notes/2

•August 1852: He goes in Chile, working as a coachdriver

•1849-50: He’s working as a freak at Barnum’s Museumin N.Y.C.

•July 1860: Returns back, very ill, in USA

•February 1860: He has his first seizures

Biographical Notes/3• May 20, 5 a.m.: He has a very severe sezure

• Phineas dies after a day and a night having convulsions...

“10 p.m., May 21, 1861 - twelve years six months and eight days after the date of his injury”

(Harlow, 1868)

The Tamping Iron...

1,09 m

3,1 cm6,3 mm

6 Kg

the bar had been “made to please the fancy of the owner”

(Bigelow, 1850)

30 cm

...and his ownerGage was1,68 m talland weighed 68 Kg.

Therefore, he was half again as tall as his tamping iron, and

about 11⅓ times as heavy, although it was

some 5¼ times longer than the height

of his head.

Tamping an explosive chargePhineas Gage’s workplaceMr. Phineas P. GageFirst newspaper report of Gage’s accident

Gage, Harlow said, was possessed of “a well-balanced mind”, and was looked upon by those

who knew him as a shrewd, smart business man, very energetic and persistent in executing

all his plans of operation

(Harlow, 1868)

[he was] regarded by his superiors as “the most efficient and capable in their employ”

(Harlow, 1868)

Version #1Gage dropped the tamping iron

while distracted by his men,with his head turned towards them

The iron hit the rock,struck a spark,

ignited the chargeand immediately

reversed itsinitial direction

(Harlow, 1848, 1868)

Version #2

Powder and fuse were in, and Gage was waiting for an assistant to pour the sand in the hole.

While waiting, Gage turned his head away, and after some seconds he dropped the iron, as he

supposed sand was in.

However, no sand had been added, and when the bar struck the rock, the charge exploded,

driving the bar upwards.

Gage’s posture

Gage was “sitting [...] on a shelf of rock above the

hole”

(Harlow, 1868)

“Mr. Gage was [...] standing above the hole, leaning forward, with his face

slightly averted”

(Bigelow, 1850)

If one grasps a rod in Gage’s posture, trying left and right hand, it becomes evident that Gage must have been right-handed and probably,

therefore, left-hemisphere dominant for speech

da “Ratiu P and Talos I-F. The Tale of Phineas Gage, Digitally Remastered. N Engl J Med 2004;351(23):e21”

da “Ratiu P and Talos I-F. The Tale of Phineas Gage, Digitally Remastered. N Engl J Med 2004;351(23):e21”

The first travel of the Tamping Iron

da “Ratiu P and Talos I-F. The Tale of Phineas Gage, Digitally Remastered. N Engl J Med 2004;351(23):e21”

The first travel

the integuments, the masseter and temporal muscles, passed under the zygomatic arch, and (probably)

fracturing the temporal portion of the spenoid bone, and the floor of the orbit of the left eye, entered the

cranium, passing through the anterior left lobe of the cerebrum, and made its exit in the median 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 one half of its diameter.

(Harlow, 1848)

Interesting locationsThe iron [...] entered the left cerebrum at the fissure of Sylvius, possibly puncturing the cornu of the left lateral ventricle, and in its passage and exit must have produced serious lesions of the brain substance - the anterior and middle left

lobes of the cerebrum - disintegrating and pulpifying it, drawing out a considerable quantity of it at the opening in the top of the head, and lacerating unquestionably the upper aspect of

the falx major and the superior longitudinal sinus(Harlow, 1868)

Unknown damagesNo postmortem studies were carried out immediately after Gage’s death, and they

would not have been very revealing, even had they been carried out, when his body was

exhumed some 5 or 6 years later.[There was] no certainty about the damage

it had done on the way.

The blacksmith’s shopAfter emerging from the top of Gage’s head, the tamping iron continued high into the air, landing behind Gage, about 30m, from its launching place

(Harlow, 1848, 1868; Bigelow, 1850; Vermont Mercury, 22/9/1848)

Gage himself was “thrown upon his back and gave a few convulsive movements of the

extremities but spoke in a few minutes”(Harlow, 1848)

He then rode, unassisted, in the cart to his lodgings at Mr. Joseph Adam’s tavern, making

an entry in his time-book in the way.

“Doctor, here is businessenough for you”

Williams, in Bigelow, 1850 et al.

The skull

Gage’s RecoveryGage returned to Lebanon, New Hampshire,

on 25 November 1848.Gage had “gone back to resume his post of

labor and peril on the road”(Claremont National Eagle)

Bigelow thoughtsThe leading feature of this case is its improbability. A physician who holds in his hand a crowbar, one meter, and more than six kilograms in weight, will not readily believe that it has been driven with a crash through the brain of a man who is still able

to walk off, talking with composure and equanimity of the hole in his head.

This is the sort of accident that happens in the pantomime at the theatre, but not elsewhere. Yet there is every reason for supposing it in this case

literally true.(Bigelow, 1850)

Harlow’s treatment of GageLiberal doses of calomel, rhubarb and caster oil

Four circumstances worked in Gage’s Favor:•His physique, will and endurance;•the pointed shape and

smoothness of the missile reduced damage by concussion and compression;•the entrance through the base of the skull created a natural drainage point for the wound;•the portion of the brain traversed, was, for several reasons, the best fitted of any [...] to sustain the injury.

“Several reasons”

It has been frequently demonstrated, that a great part of the cerebrum may be taken away without destroying the animal, or even depriving it of its faculties; whereas the cerebellum will scarcely admit the smallest injury, without being followed by mortal symptoms.

(Pott, 1808, p. 148 &n.)

The treatment•Gage was in a semirecumbent position;•bone fragments got removed from inside the skull;•several pieces from the skull were reunited and applied with dressings;•the wound was kept clean and disinfected very often;•purging and blood letting “favourably influenced the outcome”.

These views were very in advance of his time!

A similar case...

Noyes’ case (1882) of Lewis Avery

In September 1881, Avery’s musket exploded in his face. The breech pin had been driven through the skull above the right eye,

lodging in the right frontal lobe, destroying the tissue

around it.

Gage as a standardThe case of Joel Lenn

The case of the mill worker[His head] had been cut open by a circular saw, 3 mm thick, spinning at 2000 rpm. The cut extended 1.3 cm above the nose for a distance of about 23 cm to the “occipital

protuberance” and was about 7,6 cm deep. 6 weeks later, he fully recovered.

Joel had had a blasting barrel shot through his head, through the right frontal and left temporal lobes,

lacerating the longitudinal sinus.Eight months later, Lenn was physically as well as ever.

(Jewett, 1868)

The aftermath Gage

His desire to be out and to go home in Lebanon has been uncontrollable by his friends, and he has been making arrangements to that effect. Yesterday [14

November, 1848] he walked half a mile and purchased some small articles at the store. The atmosphere was

cold and damp, the ground wet, and he went without an overcoat, and with thin boots. He got wet feet and a chill.

(Harlow, 1848)

His contractors, who regarded him as the most efficient and capable foreman in their employ previous to his

injury, considered the change in his mind so marked that they could not give him his place again.

(Harlow, 1868)

He is fitful, irreverent, indulging at times in the grossest profanity, manifesting but little deference for his fellows,

impatient of restraint or advice, obstinate, capricious, vacillating.His equilibrium between his intellectual faculties and his animal

propensities seems to have been destroyed.(Harlow, 1868)

He was “no longer Gage”

The localization debatethe long received opinion among mankind, learned as well as illiterate, that the slightest injury of the brain was followed, in all cases by death.

(Wharton, 1818)

Many cases are recorded in which large portions of the cerebrum have been lost without any immediate or subsequent derangement of the

mental and corporeal functions.(“The exploding gun case”, Tyrrell, Rogers, 1825)

Injuries of the head affecting the brain on are difficult to distinguish, doubtful in their character, treacherous in their

course, and for the most part fatal in their result.(Guthrie, 1842, p. 1)

It is a popular notion, and even some of the profession are involved in it, that injuries to the brain, more especially where any portion of

its substance has been lost, necessarily involve loss of life.(in Fitch, 1852)

“every part of the brain is not equally concerned in the execution of its functions”

The phrenologists debateDr. Franz Joseph Gall insisted that:•the external surface of the brain had a regular structure;•the convolutions were not randomly arranged.

He was the first to:•differentiate the gray and the white matter;•dissect the brain from below upward.

And finally, he was the most important contributor to the doctrine that the brain was the organ of the mind, in both intellectual and affective respects.

DeductionsGall showed that the faculty responsible for word-memory was located in the frontal lobes, more particularly in that

part which rested on the posterior roof of the orbit.He is credited with “the first complete description of aphasia

due to a wound of the brain”(Head, 1926, pp. 9-11)

Flourens concluded that the effect of ablation depended upon the amount of cortical tissue removed and not upon its location. He was wrong, basing his experiments on birds.

Magendie discovered that the dorsal roots of spinal nerves “seemed to be particularly destined for sensibility while the ventral roots seemed to be

especially concerned with movement”(Magendie, 1822)

The big turningMagendie couldn’t relate abstract functions

(hemisphere) with sensory-motor functions (“lower down in the nervous system”)

In the next decade, Marshall Hall discovered the spinal reflex, stating that “the motor nerves were distinct from sensation and voluntary or instinctive motion”

(Hall, 1832)

He studied the by-him-called “cerebral system”, that controlled respiration, swallowing, retention and expulsion of feces and urine, and ejaculation of semen.

He stated that “all these functions are strictly psychical. They imply consciousness.”

The brain as a pianistThe fibres of all the motor, cerebral and spinal nerves may be imagined as spread out in the

medulla oblongata, and exposed to the influence of the will like the keys of a piano-forte. The will

acts only on this part of the nervous system, but the influence is communicated along the

fibres by their action.(Müller, 1842, p. 934)

the Associationism theory:so close to how the brain works.

The right ideaFerrier maps motor centers in

over 30 animals, including monkey, and refers it to human brain.

He notes that ablating frontal lobes in monkeys make them apathetic,

without the faculty of attentive and intelligent observation

(Ferrier, 1876, pp. 231-232)

The idea the frontal lobes have an inhibitory function begins being accepted

by Ferrier...

The “cordo-cephalic” progression goes on.

In 1940s, Moniz starts lobotomizing patients.

Localizing the speechBouillaud first distinguished between losses due to

distruction of “the organ for the memory of words” and those due to the “alteration of the nervous principle

which presides over the movements of speech”(Bouillaud, 1825)

Offers a 500 francs prize for anyone who could produce a case with severe frontal lobe lesion without loss of speech

Auburtin confirms it, without the money prize

Broca joins the debate. The second case he presents, aphasia connected

to a circumscribed lesion of the second and third frontal

convolutions, clinches the matter.

Gage was first counted against Broca

localization of speech, then dr. Hammond

(1871) noted that the third frontal convolution

[...] escaped all injury.

Damasio H, Grabowski TJ, Frank RJ, Galaburda AM, Damasio AR, "The Return of Phineas Gage: Clues About the Brain from the Skull of a Famous Patient," Science, Vol 264, 20 May 1994.

Gage and phrenology

It’s more than likely than young Dr. Harlow was influenced by phrenology.

Fowler and Wells lectures in New England...

According to phrenologists, the tamping iron had gone in “[...] the neighborhood of Benevolence and

the front part of Veneration.”(Sizer, 1882, pp. 193-194)

Does the slightly downcast expression discernible on

Gage’s life mask foreshadow his disappointment with the status finally granted to him?

ReferencesPer i contributi non specificati:

M. B. Macmillan, A Wonderful Journey through Skull and Brains: The Travels of Mr. Gage’s Tamping Iron, Brain and

Cognition 5, 67-107 (1986)