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> CASE 1 No Longer Phineas Gage

In 1848, a 25-year-old railroad foreman named Phineas Gage was in charge of a work crew tasked with blasting rock to lay track for the Rutland & Burlington Railroad in Vermont. As he had countless times before, Gage prepared to pack the charge into a hole in the rock, using a three-and-a-half-foot-long tamping iron. This time, however, the charge was improperly placed. As he plunged it into the hole, the rod set off a spark that detonated the charge and blew the tamping iron through Gage's left cheek and orbit, and clear through his left frontal lobe and skull, landing 80 feet away. Incredibly, some accounts tell that he never lost consciousness, spoke soon after the tragic event, and helped himself into a cart to leave the site. Dr. John Martyn Harlow became Gage's physician throughout the ordeal and for a time afterward during his recovery. He returned to his family home in New Hampshire, and after a few days in a semi-comatose state, Gage sat up and began an almost miraculous recovery. He spent several months convalescing at his family home, then returned to Vermont, where Dr. Harlow pronounced him in good health except for loss of vision in his left eye, ptosis (drooping) in his left eyelid, and a large scar and indentation in his forehead. Dr. Harlow remained Gage's physician throughout his recovery.

Over the ensuing years, Phineas Gage's personality underwent a profound change. No longer was he the quiet, competent work foreman, so he lost his job on the railroad. He performed numerous jobs afterward, including driving stagecoaches in Chile. His behavior and demeanor became increasingly erratic, prone to outburst, and inappropriate, until his friends stated that he was “no longer Gage.” He died in May 1860, 12 years after his tragic accident, but his skull and the offending tamping iron currently reside in Harvard Medical School's Warren Anatomical Museum.

Both Dr. Harlow's original observation of Gage's injury, including probing the wound by inserting his finger into the hole, and subsequent modern computed tomography (CT) reconstructions based on images from Gage's actual skull, suggest that the iron destroyed Gage's left frontal lobe, largely sparing his right hemisphere and the rest of his brain. The reconstruction infers significant damage to the prefrontal cortex and the underlying white matter tracts that likely contributed to the prolonged behavior and personality changes. Because of the incomplete understanding of his brain injury and the often contradictory reports of Gage's mental deterioration, both sides of the nineteenth-century discussion of whether function is localized in specific parts of the brain were able to cite Gage's case as supporting their hypotheses.


The brain with its central, peripheral, and autonomic components is the most complex and still least understood organ system in the human body. When it functions well, it controls bodily ...

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