Phineas Gage: case study of traumatic brain injury

Phineas Gage

The strange but (somewhat) illuminating case of Phineas Gage

This paper will examine the details of the (somewhat) illuminating case of Phineas Gage: the specifics of the Gage case itself, and also how it has been interpreted by brain surgeons, psychologists, and historians. It will examine if the case itself is still relevant, and more importantly the implications of how the case was read by Gage's contemporaries.

The strange story of Phineas Gage is one of the earliest recorded accounts of how changes in brain anatomy, as the result of traumatic damage could affect an individual's cognitive functioning, including his or her personality. Gage was the foreman of a railway construction gang in Vermont, who suffered a horrific injury when an accidental explosion of a charge blew his tamping iron directly through his head (Macmillan, 2000, Phineas Gage's story). Miraculously, Gage survived the incident, but after he had physically recuperated from the accident his fellow railroad workers said he had changed, and was "No longer Gage," that is not himself. Before "he had been their most capable and efficient foreman, one with a well-balanced mind, and who was looked on as a shrewd smart business man. He was now fitful, irreverent, and grossly profane, showing little deference for his fellows. He was also impatient and obstinate, yet capricious and vacillating, unable to settle on any of the plans he devised for future action (Macmillan, 2000, Phineas Gage's story).

Accounts vary as to Gage's personality change before and after the accident. Some say he wandered aimlessly, never able to hold down a job, although he may have worked at a coach house or in South America, or exhibited himself at freak shows. Others emphasize his sexual activity or drunkenness. The one thing that does seem clear is that Gage had changed in such a way so as to make him more impulsive, and less able to screen out desires to engage in impulsive and antisocial behavior. This was a profound challenge to Victorian notions about the ability of the will to enforce morality, and an argument for the anatomical base of character.

Gage's skull has been reconstructed through computer neuroimaging, but controversy remains as to the exact nature of the damage done to his brain, given the likely trajectory of the tamping iron. Some believe only the left hemisphere had been affected while others allege there must be some right-sided damage., still others place it less frontally, despite the fact that Gage had no motor impairment or aphasia. Also, because Gage sustained an infection from his wound, it is hard to know the exact amount of damage, based only upon the skull (Macmillan, 2006, Damage). Hannah Damasio's 1994 neuroimaging study most recently concluded that Gage incurred damage to both the left and right prefrontal cortices. But according to computer-generated three-dimensional reconstructions of a thin slice computed tomography scan of Gage's skull performed by another university, the damage to Gage's brain was limited to the left hemisphere (the incredible case of Phineas Gage, 2006, Neurophilosophy)

The idea that changes in personality was linked to brain damage, and therefore personality was a product of the brain is perhaps the most significant development of the Gage case. Because of the notoriety of the Gage, the 19th century American neurologist, M. Allan Starr, used the Gage case as evidence that a tumor, injury or other damage a specific part of the brain such as the frontal lobe could be related to particular symptoms. According to Starr, Gage had suffered no sensory impairment and had no physical symptoms. "Starr advocated using Gage's alleged personality change as a way of diagnosing frontal tumors" (Macmillan, 1996, Phineas Gage and brain surgery).

Eventually, as modern neuroscience progressed, "it soon became clear that in only about half the cases of frontal tumor were there any 'mental symptoms' and only in a minority of those did the symptoms resemble Gage's...At about the same time, in the early 1920's, Walter Dandy, the American brain surgeon, developed a more radical method of removing tumors. He had found that about 60% of brain tumors could not be removed because they were not sufficiently differentiated from the tissue around them. Dandy's new method removed the lobe containing the tissue" (Macmillan, 1996, Phineas Gage and brain surgery). Thus the influence of the Gage case continued. The ability of Gage to survive "may have reinforced the belief that large areas of the brain could be removed with relative impunity. It seemed that the brain could be operated on without causing death or major impairment of psychological functions" (Macmillan, 1996, Phineas Gage and brain surgery). While advocates of psychosurgery into the 20th century did not always cite the Gage case, it had an undeniable subtle, influence upon acceptance of the practice.