Phineas Gage and Cognitive Control

Learning Objectives

Where are the main cognitive control functions located in the brain?

Who was Phineas Gage and what can his unfortunate experience tell us about the
workings of the brain?

Introduction

Phineas Gage (1823 –1860) was an American railroad construction foreman who
received a traumatic brain injury that served as a natural lesioning experiment. In a
normal lesioning experiment a researcher might surgically remove part of an animal’s
(e.g., a rat’s) brain to try and infer the functioning of that part of the brain based on the
abilities that were lost after the surgery.

In the case of Phineas Gage, due to a horrific accident, a large iron rod was driven
completely through his head, destroying much of his brain's left frontal lobe. Amazingly
he lived on for 12 years afterwards (dying at the age of 37 likely due to the aftereffects
of his injury), and the changes in his behaviour that resulted from the accident gave
researchers important insights into the functionality of the frontal lobe.

The Accident

On September 13, 1848, Gage was supervising a work gang, blasting rock while
preparing the roadbed for a railroad in Vermont. After a hole was bored into a body
of rock, one of Gage's duties was to add blasting powder, a fuse, and sand,
then compact the charge into the hole using a large iron rod (a tamping iron). According
to one account Gage was distracted, just at the point where the sand should have been
put into the hole. After instructing a worker to pour sand into the hole (to prevent the
powder from exploding when it was tamped down) he turned away to talk to someone
else. A short while later, assuming that the sand had been poured in the hole as he had
requested, he started tamping down what he thought was sand, but was actually
explosive powder. The powder duly exploded, driving the tamping iron through his head
and far beyond. The iron entered on the side of his face...passing behind the left eye,
and out the top of the head, landing about 25 metres away. The accident created a
massive injury, since the tamping iron was an iron bar around 3 centimeters in diameter
and over a meter in length weighing 6 kilograms.

Later the tamping iron was picked up, wiped clean of the blood and brain tissue on it,
and presented to Phineas Gage, who carried it around with him the rest of his life.
The Immediate After-Effects of the Accident

Amazingly, Gage spoke within a few minutes of the accident, walked with little or no
assistance, and sat upright in a cart for more than a kilometer on the way back to his
lodgings. Needless to say the accident had a horrific effect, with a great amount of
bleeding and loss of brain tissue. For a detailed description of the after-effects of the
accident see the Wikipedia entry on Phineas Gage.

https://en.wikipedia.org/wiki/Phineas_Gage#Accident

Just over three weeks after the accident Gage "succeeded in raising himself up, and took
one step to his chair." One month after that he was walking up and down stairs, and
even able to go outside.

The Effects of the Accident

The injury affected Gage’s personality and behavior with the effects being so great that
his friends no longer saw him as the same person. Prior to the accident, Gage at the age
of 25 was an efficient, hard-working, and capable foreman. However, after the accident
his employer was no longer willing to employ him because of “the change in his mind”.

A physician described him as follows:

“The equilibrium or balance, so to speak, between his intellectual faculties and animal
propensities, seems to have been destroyed. He is fitful, irreverent, indulging at times in
the grossest profanity (which was not previously his custom), manifesting but little
deference for his fellows, impatient of restraint or advice when it conflicts with his
desires, at times pertinaciously obstinate, yet capricious and vacillating, devising many
plans of future operations, which are no sooner arranged than they are abandoned in
turn for others appearing more feasible. A child in his intellectual capacity and
manifestations, he has the animal passions of a strong man.”

Gage later worked in a livery stable then for some years in Chile as a long-
distance stagecoach driver on the Valparaiso–Santiago route, ultimately dying 12 years
after the accident in San Francisco.

The case of Phineas Gage had a huge impact on the medical community because it
showed that part of the brain might be linked to particular behaviours. The iron bar, by
taking a large part of tissue in the front of the brain, had transformed the behaviour and
personality of the brain, showing conclusively the mechanistic nature of the brain.

Modern Reconstruction of the Traumatic Brain Injury

170 years after the accident the case of Phineas Gage continues to fascinate
neuroscientists, including one study by Van Horn and colleagues in 2012.

https://www.ncbi.nlm.nih.gov/pubmed/22616011

Using computed tomography (CT) image data of the Gage skull in conjunction with
modern anatomical MRI and diffusion imaging data, the researchers simulated the
passage of the iron through the skull and assessed the likely extent of cortical gray
matter (GM) and white matter (WM) damage.

They found that while considerable damage was, indeed, localized to the left frontal
cortex, the impact on measures of network connectedness between directly affected
and other brain areas was profound, widespread, and a probable contributor to both
the reported acute as well as long-term behavioral changes.

Figure 1 in the paper by Van Horn et al (see the link above) shows the path that the
Tamping Iron took through Gage’s brain and skull.

● Panel A shows the skull of Phineas Gage on display at the Warren Anatomical
Museum at Harvard Medical School.
● Panel B shows the likely path of the tamping iron through the Gage skull.

● Panel C shows the path of the rod and likely white matter pathways (green)
destroyed by the iron rod as it passed through the brain.
● Panel D shows a view of the interior of the Gage skull showing the extent of fiber
pathways (based on a model subject, as explained in the paper by Van Horn et
al) intersected by the tamping iron.

What this type of reconstruction shows is that destruction of white matter connectivity
in the accident was at least as severe as the destruction of grey matter. After the
accident, there would have been a significant loss of white matter connectivity between
left frontal regions and the rest of the brain, and the surviving network of the brain
would likely have been heavily impaired and its functions compromised.

Implications for Cognitive Control

The part of the brain that was most heavily damaged was the prefrontal cortex. Gage’s
behaviour after the accident was characterized by a loss of executive functioning and
cognitive control. This led neuroscientists to formulate the frontal executive hypothesis,
which is the idea that every executive process is primarily mediated by the PFC. This
hypothesis has been very influential and has led to a lot of research that has sought to
understand the way in which different parts of the prefrontal cortex control behavior.
However, although the PFC is the main area for cognitive control, it has a number of
other important functions as will be discussed elsewhere.

Take Home

Lesions are an important way to learn about the brain. The case of Phineas Gage
persuaded researchers that the brain is in fact a machine and that specific kinds of
damage can lead to specific kinds of loss of function. The case of Phineas Gage also
showed the strong connection between the prefrontal cortex and executive functioning
and cognitive control.