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The Return of Phineas Gage: Clues About the Brain from the Skull of a Famous Patient

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The Return of Phineas Gage: Clues About the Brain from the Skull of a Famous Patient The Return of Phineas Gage: Clues About the Brain from the Skull of a Famous Patient Hanna Damaslo, Thomas Grabowski, Randall Frank, Albert M. Galaburda, Antonio R. Damasio* When the landmark patient Phineas Gage died in 1861, no autopsy was performed, but language, motor function, and perception, his skull was later recovered. The brain lesion that caused the profound personality and now Gage's case indicated something changes for which his case became famous has been presumed to have involved the left even more surprising: Perhaps there were frontal region, but questions have been raised about the involvement of other regions and structures in the human brain dedicated to about the exact placement of the lesion within the vast frontal territory. Measurements from the planning and execution of personally Gage's skull and modern neuroimaging techniques were used to reconstitute the accident and socially suitable behavior, to the aspect and determine the probable location of the lesion. The damage involved both left and right of reasoning known as rationality. prefrontal cortices in a pattern that, as confirmed by Gage's modern counterparts, causes Given the power of this insight, Har- a defect in rational decision making and the processing of emotion. low's observation should have made the scientific impact that the comparable sug- gestions based on the patients of Broca and Wernicke made (2). The suggestions, al- On 13 September 1848, Phineas P. Gage, profound change in personality were al- though surrounded by controversy, became a 25-year-old construction foreman for the ready evident during the convalescence un- the foundation for the understanding of the Rutland and Burlington Railroad in New der the care of his physician, John Harlow. neural basis of language and were pursued England, became a victim of a bizarre acci- But as the months passed it became appar- actively, while Harlow's report on Gage did dent. In order to lay new rail tracks across ent that the transformation was not only not inspire a search for the neural basis of Vermont, it was necessary to level the radical but difficult to comprehend. In some reasoning, decision-making, or social be- on April 14, 2014 uneven terrain by controlled blasting. respects, Gage was fully recovered. He re- havior. One factor likely to have contrib- Among other tasks, Gage was in charge of mained as able-bodied and appeared to be uted to the indifferent reception accorded the detonations, which involved drilling as intelligent as before the accident; he had Harlow's work was that the intellectual holes in the stone, partially filling the holes no impairment of movement or speech; atmosphere of the time made it somewhat with explosive powder, covering the powder new learning was intact, and neither mem- with sand, and using a fuse and a tamping ory nor intelligence in the conventional iron to trigger an explosion into the rock. sense had been affected. On the other A On the fateful day, a momentary distraction hand, he had become irreverent and capri- let Gage begin tamping directly over the cious. His respect for the social conventions www.sciencemag.org powder before his assistant had had a chance by which he once abided had vanished. His to cover it with sand. The result was a abundant profanity offended those around powerful explosion away from the rock and him. Perhaps most troubling, he had taken toward Gage. The fine-pointed, 3-cm-thick, leave of his sense of responsibility. He could 109-cm-long tamping iron was hurled, rock- not be trusted to honor his commitments. et-like, through his face, skull, brain, and His employers had deemed him "the most then into the sky. Gage was momentarily efficient and capable" man in their "em- stunned but regained full consciousness im- ploy" but now had to dismiss him. In the Downloaded from mediately thereafter. He was able to talk and words of his physician, "the equilibrium or even walk with the help of his men. The balance, so to speak, between his intellec- iron landed many yards away (1). tual faculty and animal propensities" had Phineas Gage not only survived the been destroyed. In the words of his friends momentous injury, in itself enough to earn and acquaintances, "Gage was no longer him a place in the annals of medicine, but Gage" (1). Gage began a new life of wan- he survived as a different man, and therein dering that ended a dozen years later, in lies the greater significance of this case. San Francisco, under the custody of his Gage had been a responsible, intelligent, family. Gage never returned to a fully in- and socially well-adapted individual, a fa- dependent existence, never again held a job vorite with peers and elders. He had made comparable to the one he once had. His progress and showed promise. The signs of a accident had made headlines but his death went unnoticed. No autopsy was obtained. H. Damasio and A. R. Damasio are in the Department Twenty years after the accident, John of Neurology, University of Iowa Hospitals & Clinics, Iowa City, IA 52242, and the Salk Institute for Biolog- Harlow, unaided by the tools of experimen- ical Research, San Diego, CA 92186-5800, USA. T. tal neuropsychology available today, per- Grabowski and R. Frank are in the Department of ceptively correlated Gage's cognitive and Neurology, University of Iowa Hospitals & Clinics, Iowa City, IA 52242, USA. A. M. Galaburda is in the Depart- behavioral changes with a presumed area of ment of Neurology, Harvard Medical School, Beth focal damage in the frontal region (1). Israel Hospital, Boston, MA 02215, USA. Other cases of neurological damage were Fig. 1. Photographs of (A) several views of the *To whom correspondence should be addressed. then revealing the brain's foundation for skull of Phineas Gage and (B) the skull x-ray. 1102 SCIENCE * VOL. 264 * 20 MAY 1994 more acceptable that there was a neural eas Gage was once again the protagonist of mensional reconstruction of a standard hu- basis for processes such as movement or a grim event. As a result, the skull and the man skull (7) so that its dimensions matched even language rather than for moral reason- tamping iron, alongside which Gage had those of Phineas Gage's skull. We also con- ing and social behavior (3). But the prin- been buried, have been part of the Warren structed Talairach's stereotactic space for cipal explanation must rest with the sub- Anatomical Medical Museum at Harvard both this skull and Phineas Gage's real skull stance of Harlow's report. Broca and Wer- University. (8). On the basis of the skull photographs, nicke had autopsy results, Harlow did not. As new cases of frontal damage were the dimensions of the entry and exit holes Unsupported by anatomical evidence, Har- described in this century, some ofwhich did were scaled and mapped into the deformed low's observation was the more easily dis- resemble that of Gage, and as the enigmas standard skull. Based on measurements of missed. Because the exact position of the of frontal lobe function continued to resist the iron rod and on the recorded descrip- lesion was not known, some critics could elucidation, Gage gradually acquired land- tions of the accident, we determined the claim that the damage actually involved mark status. Our own interest in the case range of likely trajectories of the rod. Final- Broca's so-called language "center," and grew out of the idea that Gage exemplified ly, we simulated those trajectories in three- perhaps would also have involved the near- a particular type of cognitive and behavior- dimensional space using Brainvox (9). We by "motor centers." And because the pa- al defect caused by damage to ventral and modeled the rod's trajectory as a straight line tient showed neither paralysis nor aphasia, medial sectors of prefrontal cortex, rather connecting the center of the entry hole at some critics reached the conclusion that than to the left dorsolateral sector as im- orbital level to the center of the exit hole. there were no specialized regions at all (4). plicit in the traditional view. It then oc- This line was then carried downward to the The British physiologist David Ferrier was a curred to us that some of the image process- level of the mandibular ramus. The skull rare dissenting voice. He thoughtfully ven- ing techniques now used to investigate anatomy allowed us to consider entry points tured, in 1878, that the lesion spared both Gage's counterparts could be used to test within a 1.5-cm radius of this point (20 motor and language centers, that it had this idea by going back in time, reconsti- points in all) (Fig. 2). damaged the left prefrontal cortex, and that tuting the accident, and determining the Possible exit points were determined as such damage probably explained Gage's be- probable placement of his lesion. The fol- follows: We decided to constrain the exit havioral defects, which he aptly described lowing is the result of our neuroanthropo- point to be at least 1.5 cm (half the diam- as a "mental degradation" (5). logical effort. eter of the rod) from the lateral and poste- Harlow only learned of Gage's death We began by having one of us (A.M.G.) rior margins of the area of bone loss (Fig. 3) about 5 years after its occurrence. He pro- photograph Gage's skull inside and out and because there were no disruptions of the ceeded to ask Gage's family to have the obtain a skull x-ray (Fig.
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