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History Note Views & Reviews Dement Neuropsychol 2020 December;14(4):419-421 Dement Neuropsychol 2020 June;14(2):93-102 https://doi.org/10.1590/1980-57642020dn14-040013 http://dx.doi.org/10.1590/1980-57642020dn14-020001 Phineas Gage’s great legacy Daily functioning and dementia Gabriele Cipriani 1,2 Ricardo Vieira Teles Filho1 , Sabrina Danti3, Lucia Picchi4, Angelo Nuti1, Mario Di Fiorino2 ABSTRACT The case of Phineas Gage is an integral part of medical folklore His accident still causes astonishment and curiosity and can be considered as the case that most influenced and contributed to the nineteenth century’s neuropsychiatric ABSTRACT Dementia is characterized by a decline in memory, language, problem-solving and in other cognitive discussion on the mind-brain relationship and brain topography It was perhaps the first case to suggest the role of brain areas domains that affect a person’s ability to perform everyday activities and social functioning It is consistently agreed in determining personality and which specific parts of the brain, when affected, can induce specific mental changes In addition, thatcase cognitive impairment is an important factor approaches for developing in psychosurgery patients with dementia his contributed to the emergence of therisk scientific that functional would laterdisabilities culminate in Gage is a Functional status be conceptualized as the ability to perform self-care, self-solidified maintenance physical activity A fixed element in thecan studies of neurology, psychology, and neuroscience, having been as oneand of the greatest medical curiosities of all time, deserving its prominence person with dementia usually requires help with more complex tasks, such as managing bills and finances, or simply Keywords: Gage, behavioral symptoms, history is fundamental for elderly people to maintain independency maintainingPhineas a household Good functional performance and avoid institutionalization The purpose of this review is to describe functional changes in demented patients, O GRANDE LEGADO DE PHINEAS GAGE evaluating the variability in subgroups of dementias RESUMO O caso de Phineas Gage é parte integrante folclore médico Seu acidente aindaactivities causa espanto curiosidade, Key words: activities of daily living (ADLs), dementia, functional abilities, instrumental of dailye living (IADLs).e pode ser considerado como o caso que mais influenciou e contribuiu para a discussão neuropsiquiátrica século XIX sobre a relaỗóo mente-cộrebro e topografia cerebral Foi talvez o primeiro caso a sugerir o papel de ỏreas cerebrais na determinaỗóo da ATIVIDADES DA VIDA DIÁRIA E DEMÊNCIA personalidade e que partes especớficas cộrebro, quando afetadas, podem induzir mudanỗas mentais especớficas Além disso, RESUMO Demênciapara é caracterizada declínio na cientificas memória, que linguagem, resoluỗóo de problemas e de outrosGage domớnios seu caso contribuiu o surgimento por de abordagens culminariam posteriormente na psicocirurgia ộ um cognitivosfixoque de realizaỗóo de atividades cotidianas e atividades sociais É consensual que elemento nosafetam estudosadecapacidade neurologia, psicologia e neurociências, tendo sido solidificado como uma das grandes curiosidades médicas de todos os tempos que émerece seu destaque o comprometimento cognitivo um importante fator de risco para o desenvolvimento de incapacidades funcionais em pacientes com demência status funcional pode serhistória conceituado como a capacidade de realizar autocuidado, Palavras-chave: Phineas Gage, O sintomas comportamentais, automanutenỗóo e atividade fớsica Uma pessoa com demência geralmente requer ajuda para tarefas mais complexas, como gerenciar contas e finanỗas, ou simplesmente realizar atividades domộsticas Um bom desempenho funcional é fundamental para que os idosos mantenham a independờncia e evitem a institucionalizaỗóo O objetivo desta revisóo ộ delinear alteraỗừes funcionais em pacientes com demờncia, valorizando os subgrupos variados de demências THE ACCIDENT about kg, through his skull at high speed Palavras-chave: atividades da vida diária (AVD), demência, habilidades funcionais, atividades instrumentais da vida The bar entered his left cheek, destroyed age, a 25-year-old male, 1.70 m in height diária (AIVD) G and weighing approximately 70 kg, was employed in railroad construction at the time of the accident As the company’s most ementia constitutes a multifactorial capable employee, with a well-balanced mind is alwaysheassociated with and aprocess sense ofthat leadership, was directing cognitive decline and impaired functioning a rock-splitting workgroup while preparing As the progresses, people living with the beddisease of the Rutland & Burlington Railroad dementia experience, in addition to impaired south of Cavendish, Vermont, USA At 4:30 cognitive functions, gradual dysfunction PM on September 13, 1848, he and his group and loss of individual autonomies Besides were blasting a rock, and Gage was assigned decline in memory and/or other cognitive to put gunpowder in a deep hole inside it.1 domains, the criteria for diagnosis of demenThe moment he pressed the gunpowder tia require functional reserve and into the holeloss withofa bar, the friction caused pejoration functional An The imporsparks, andinthe powder status exploded retant quality life component from elderly sulting blastof projected the meter-long bar, people’swas perspective functional which 3.2 cm in is diameter and indepenweighed D his eye, passed through the left front of the brain, and finally completely left his head at the top of the skull on the right side dence When older show Gage was thrown onpeople his back and functional had some loss, they experience a variety ofup negative outbrief convulsions, but he woke and spoke comes, such as higher rates of use of hospital in a few minutes, walked with a little help, services, and increased and sat ininstitutionalization, an ox cart for the 1.2-km trip to risk of death The progression of healthy his quarters aging must considered a conIn to thedementia city about 30beminutes after the tinuum, both in terms of H theWilliams slow manifestaaccident, Doctor Edward arrived tion of the impairment of Gage cognitive to provide medical care hadfunctions, lost a lot as well as functional limitation Originally, of blood, and his following days4 were quite mild cognitive impairment (MCI) was condifficult The wound became infected, and sidered awas condition which someone has Phineas anemic in and remained semicominor cognitive notweeks severe He enough matose for moredecline, than two also to interferea significantly withindaily life and developed fungal infection the exposed This study was conducted at the Versilia Hospital, Neurology Unit, Lido di Camaiore (Lu), Italy This study was conducted at the Universidade Federal de Goiás, Goiânia, GO, Brazil MD,Versilia Hospital, Neurology Unit, Lido di Camaiore (Lu), Italy 2MD, Versilia Hospital, Psychiatry Unit, Lido di Camaiore (Lu), Italy 3PhD, Clinical and FacultyPsychology of Medicine,Unit, Universidade Federal de Goiás – Goiânia, Brazil PsyD, Clinical Psychology Unit, Hospital of Leghorn, Leghorn (LI), Italy Health Hospital of Pontedera, Pontedera (PI),GO, Italy Ricardo Vieira Teles Filho Avenida dos Alpes, Quadra 49, Lote 11 – Setor União – 74313760 Goiânia GO – Brazil E-mail: ricardovteles@gmail.com Gabriele Cipriani Versilia Hospital – Neurology Unit Via Aurelia, Lido di Camaiore Italy – Lido di Camaiore 55043 – Italy E-mail: cprgrl@gmail.it Disclosure: The authors report no conflicts of interest Disclosure: The authors report no conflicts of interest Funding: none Received October 25, 2019 Accepted in final form April 13, 2020 Received on May 24, 2020 Accepted in final form on September 17, 2020 Teles Filho Phineas Gage’s legacy 419 Cipriani et al Daily functioning and dementia 93 Dement Neuropsychol 2020 December;14(4):419-421 brain that needed to be surgically removed His condition slowly improved after doses of calomel and beaver oil By mid-November he was already walking around the city.2 THE CONSEQUENCES For three weeks after the accident, the wound was treated by doctors During this time, he was assisted by Dr John Harlow, who covered the head wound and then reported the case in the Boston Medical Surgery Journal In November 1849, invited by the professor of surgery at Harvard Medical School, Henry Jacob Bigelow, Harlow took Gage to Boston and introduced him to a meeting of the Boston Society for Medical Improvement (Figure 1).3 In his reports, Harlow described that the physical injury profoundly altered Gage’s personality Although his memory, cognition and strength had not been altered, his once gentle personality slowly degraded He became a man of bad and rude ways, disrespectful to colleagues, and unable to accept advice His plans for the future were abandoned, and he proceeded without thinking about the consequences.4 And here was the main point of this curious story: Gage became irritable, irreverent, rude and profane, aspects that were not part of his way of being His mind had changed radically His transformation was so great that everyone said that “Gage is no longer himself.”5 As a result of this personality change, he was fired for indiscipline and could no longer hold a steady job He became a circus attraction and even tried life in Chile, later returning to the United States However, there is something still little known about Gage: his personality changes lasted for about four years, slowly reverting later As a proof of this, he worked as a long-haul driver in Chile, a job that required considerable planning and focus skills He died on May 21, 1861, 12 years after the accident, from an epileptic seizure that was almost certainly related to his brain injury He was not submitted to an autopsy, but his mother, after exhumation of the body, donated his skull and iron rod at the request of Dr Harlow, which, in turn, sometime later donated them to Harvard University (Figure 2).1 THE LEGACY Source: Phyllis Gage Hartley/Creative Commons Figure Gage holding the iron bar that injured him 420 Phineas Gage’s legacy Teles Filho Gage’s case is considered to be one of the first examples of scientific evidence indicating that damage to the frontal lobes may alter personality, emotions and social interaction.6 Prior to this case, the frontal lobes were considered silent structures, without function and unrelated to human behavior Scottish neurologist, David Ferrier, was motivated by this fact to investigate the role of frontal lobes in brain function Ferrier removed the frontal lobes in monkeys and noted that there were no major physiological changes, but the character and behavior of the animals were altered.7 Knowledge that the frontal lobe was involved with emotions continued to be studied The surgeon Burkhardt in 1894 performed a series of surgeries in which he selectively destroyed the frontal lobes of several patients in whom he thought might control psychotic symptoms, being the modern prototype of what was later known through Egas Moniz as psychosurgery.7 Today, it is well understood that the prefrontal cortex Dement Neuropsychol 2020 December;14(4):419-421 Source: Image via J.B.S Jackson/A Descriptive Catalog of the Warren Anatomical Museum Figure Gage’s exhumed skull and the iron bar, 1870 REFERENCES Hodges J An odd kind of fame Stories of Phineas Gage J Neurol Neurosurg Psychiatry [Internet] 2001;71(1):136 [accessed on Feb 22, 2020] Available at: http://jnnp.bmj.com/content/71/1/136.4.abstract Guidotti TL Phineas Gage and His frontal lobe — the “American Crowbar Case” Arch Environ Occup Health 2012;67(4):249-50 https://doi.org/1 0.1080/19338244.2012.722469 Harlow JM Recovery from the passage of an iron bar through the head Hist Psychiatry 1993;4(14):274-81 https://doi.org/10.1177/0957154X9300401407 Steegmann AT Dr Harlow’s famous case: the “impossible” accident of Phineas P Gage Surgery [Internet] 1962;52(6):952-8 [accessed on Feb 22, 2020] Available at: https://www.surgjournal.com/article/0039-6060(62)90149-6/abstract Barker FG Phineas among the phrenologists: the American crowbar case and nineteenth-century theories of cerebral localization J Neurosurg 1995;82(4):672-82 https://doi.org/10.3171/jns.1995.82.4.0672 of the brain controls the organization of behavior, including emotions and inhibitions Folkloric as it may be, but nonetheless remarkable, the contribution of Phineas Gage’s case should not be overlooked, as it provided scientists the baseline for the promotion of studies in neuropsychiatry, and a source of inspiration for world medicine.8 In 2012, a team of neuroscientists used computed tomography of Gage’s skull with typical brain MRI scans to show how the Gage brain connection could have been affected.9 And it is not just the researchers who keep coming back to Gage Medical and psychology students still learn about Gage from their history lessons Neurosurgeons and neurologists still sometimes use Gage as a reference when evaluating certain cases.10 The final chapter of his life also offers us a thought-provoking learning about cases of massive brain damage, showing us that rehabilitation may be possible.11 Therefore, Gage — inadvertently — made a huge contribution to neurology in several areas, including the study of brain topography in behavioral disorders, the development of psychosurgery, and finally the study of brain rehabilitation Also, Gage’s case had a tremendous influence on early neuropsychiatry The specific changes observed in his behavior pointed to theories about the localization of brain function and correlated with cognitive and behavioral sequelae, thereby acquainting us with the role of the frontal cortex in higher-order actions such as reasoning, behavior and social cognition In those years, while neuropsychiatry was in its infancy, Gage’s extraordinary story served as one of the first pillars of evidence that the frontal lobe is involved in personality, which helped solidify his remarkable legacy in world medical history Macmillan M Restoring Phineas Gage: a 150th retrospective J Hist Neurosci [Internet] 2000;9(1):46-66 [accessed on Feb 22, 2020] Available at: https://www.tandfonline.com/doi/abs/10.1076/ 0964-704X%28200004%299%3A1%3B1-2%3BFT046 Macmillan M Phineas Gage’s contribution to brain surgery J Hist Neurosci 1996;5(1):56-77 https://doi.org/10.1080/09647049609525651 García-Molina A Phineas Gage and the enigma of the prefrontal cortex Neurologia 2012;27(6):370-5 https://doi.org/10.1016/j.nrl.2010.07.015 Van Horn JD, Irimia A, Torgerson CM, Chambers MC, Kikinis R, Toga AW Mapping connectivity damage in the case of Phineas Gage PLoS One 2012;7(5):e37454 https://doi.org/10.1371/journal.pone.0037454 10 Damasio H, Grabowski T, Frank R, Galaburda AM, Damasio AR The return of Phineas Gage: clues about the brain from the skull of a famous patient Science 1994;264(5162):1102-5 https://doi.org/10.1126/science.8178168 11 Haas LF Phineas Gage and the science of brain localisation J Neurol Neurosurg Psychiatry 2001;71(6):761 https://doi.org/10.1136/jnnp.71.6.761 Teles Filho Phineas Gage’s legacy 421 ... accident of Phineas P Gage Surgery [Internet] 19 62; 52( 6):9 52- 8 [accessed on Feb 22 , 20 20] Available at: https://www.surgjournal.com/article/0039-6060( 62) 90149-6/abstract Barker FG Phineas among... Restoring Phineas Gage: a 150th retrospective J Hist Neurosci [Internet] 20 00;9(1):46-66 [accessed on Feb 22 , 20 20] Available at: https://www.tandfonline.com/doi/abs/10.1076/ 0964-704X %28 200004 %29 9%3A1%3B1 -2% 3BFT046... Stories of Phineas Gage J Neurol Neurosurg Psychiatry [Internet] 20 01;71(1):136 [accessed on Feb 22 , 20 20] Available at: http://jnnp.bmj.com/content/71/1/136.4.abstract Guidotti TL Phineas Gage and