White Coffin Case Study

Brain case study: Phineas Gage

Phineas Gage (1823–1860) was the victim of a terrible accident in 1848

His injuries helped scientists understand more about the brain and human behaviour. Holly Story gets to grips with the grisly tale and its place in the history of neuroscience.

Phineas Gage, whose story is also known as the ‘American Crowbar Case’, was an unwitting and involuntary contributor to the history of neuroscience. In 1848, when he was just 25 years old, Gage sustained a terrible injury to his brain. His miraculous survival, and the effects of the injury upon his character, made Gage a curiosity to the public and an important case study for scientists hoping to understand more about the brain.

In 1848 Gage was working as a foreman on the construction of the Rutland and Burlington Railroad in Vermont, USA. Workers often used dynamite to blast away rock and clear a path for the railway. On 13 September, Gage was using a tamping iron (a long hollow cylinder of iron weighing more than 6 kilos) to compact explosive powder into the rock ready for a blast. The iron rod hit the rock, creating a spark that ignited the explosives. The rod was propelled through Gage’s skull, entering through his left cheekbone and exiting through the top of his head. It was later found some 30 yards away from Gage, “smeared with blood and brain”.

Despite his horrific injury, within minutes Gage was sitting up in a cart, conscious and recounting what had happened. He was taken back to his lodgings, where he was attended by Dr John Harlow. The doctor cleaned and dressed his wound, replacing fragments of the skull around the exit wound and making sure there were no fragments lodged in the brain by feeling inside Gage’s head with his finger. Despite Harlow’s efforts, the wound became infected and Gage fell into a semi-comatose state. His family did not expect him to survive: they even prepared his coffin. But Gage revived and later that year was well enough to return to his parents’ home in New Hampshire.

In 1850 Henry J Bigelow, Professor of Surgery at Harvard University, reported Gage to be “quite recovered in faculties of body and mind”.

It seems that physically, Gage made a good recovery, but his injury may have had a permanent impact on his mental condition. Although accounts from the time are sometimes conflicting and often unreliable, numerous sources report that Gage’s character altered dramatically after his accident. In 1868 Harlow wrote a report on the ‘mental manifestations’ of Gage’s injuries. He described Gage as “fitful, irreverent, indulging at times in the grossest profanity… capricious and vacillating” and being “radically changed, so decidedly that his friends and acquaintances said he was ‘no longer Gage’.”

The damage to Gage’s frontal cortex caused by the iron rod seems to have resulted in a loss of social inhibitions. The role of the frontal cortex in social cognition and decision making is now well-recognised; in the 19th century, however, neurologists were only just beginning to realise these connections. Gage’s injuries provided some of the first evidence that the frontal cortex was involved in personality and behaviour.

One of the pioneering researchers in this field at the time was David Ferrier, a Scottish neurologist who performed extensive experimental research into cerebral function. In a lecture to the Royal College of Physicians in 1878, Ferrier observed that in his experiments on primates, damage to the frontal cortices seemed to have no effect on the physical abilities of the animal but brought about “a very decided alteration in the animal’s character and behavior”. He used the experience of Phineas Gage as a case study to support his claims.

The details of Gage’s life after his accident are unclear. It is known that he worked as a coach driver for several years in New Hampshire and then in Chile and that in 1859 his health deteriorated and he returned to the USA. He died in San Francisco in 1860 after suffering seizures that resulted from his injury. His brain was not examined after his death, but in 1867 his body was exhumed and his skull was sent to Dr Harlow to be studied. It now resides, along with the tamping iron, at Warren Anatomical Museum at the Harvard University School of Medicine.

Since then, scientists have made various attempts to use the skull to reconstruct Gage’s injury and establish which areas of his brain were damaged. A team led by Jack Van Horn of UCLA’s Laboratory of Neuroimaging (part of the Human Connectome Project) created a new digital model of the rod’s path. It suggested that the damage to Gage’s brain was more extensive and severe than had previously been estimated: up to 4 per cent of the cerebral cortex and about 11 per cent of the total white matter in the frontal lobe were destroyed.

The model also indicates that the accident damaged the connections between the frontal cortex to the limbic system, which are involved in the regulation of emotions. This would seem to support some of the contemporary reports of Gage’s behaviour.

In the 19th century, Gage’s survival seemed miraculous. Fascination with his plight encouraged scientific research into the brain, and the continuing research into Gage’s condition is proof that this same curiosity is still alive today.

Lead image:

A drawing of a portrait of Phineas Gage, with the tamping iron that gave him the injury that would make him one of the most famous names in brain science. The artist has added an image of his skull, showing how the tamping iron entered and exited.

Phineas Jones/Flickr CC BY NC ND

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Questions for discussion

  • Eduardo Leite had a similar accident in 2012. What happened, and how did doctors treat his injury? Search ‘Eduardo Leite news’ online to find news stories about his accident.
  • Sir David Ferrier was an important researcher in neurology, but his work was controversial. Why was this? Use the further reading links to find out.

Further reading

About this resource

This resource was first published in ‘Inside the Brain’ in January 2013 and reviewed and updated in November 2017.

Inside the Brain
Education levels:
16–19, Continuing professional development

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This is another interesting case that I started about two weeks ago.  History of problems for almost  year without much change.  Horse is not painful and trots throughout the pasture as nothing is wrong.  This is a draft or draft cross with a 6.5 in wide and 7 in long foot.  So consider the soft tissue parameters.  If we only discussed degree of rotation we would have a many veterinary clinic around the world suggest euthanasia.  However, this is Horn disease not lamellar disease (laminitis). Horn/Lamellar zone for this size of horse could easily be 20/20mm and in this case is 20/36mm in the left and 7mm of sole depth which should be closer 20mm as well.  The bacteria/fungi involved is an opportunistic bug, meaning that there must be an unhealthy hoof wall to begin with that allows this infection to proliferate.  So without addressing the mechanical aspects no drug or treatment will ever be successful.  The horn is breaking down and no longer has the ability to antagonize the pull of the deep digital flexor tendon and allows the bone and lamellae and inner portion of horn wall to be pulled away from outer horn wall.  Below is the Deep digital flexor in yellow and arrows depicting the forces applied to the coffin bone.  Similar situation with Laminitis/founder except the unhealthy attachment is at the lamellar and horn attachment versus in between the layers of horn.  This may also account for the lack of lameness commonly associated with white line disease.

So I made a very large four point rail shoe from 15 inches of 1/2 by 1in aluminum barstock.  Trimmed what little foot I had and applied a very small belly to the shoe.  I really I had more rocker in the the shoe but this is  all I could get on this day.  Plan is to monitor the defects in the hoof wall, I want to see the defect growing down with new hoof growth unaffected by fungal invasion.  If I do not get the response then a more aggressive hoof wall resection and higher mechanics (more rocker) to further unload the Deep digital flexor pull will be needed.  I would possibly add a frog support bar as well.  The Owner will be feeding biotin 100 and treating weekly with White lighting.  I will post after the next visit as well!

Hello readers, I hope this finds you well.  It has been a very dry Spring here in Oklahoma and fires are really causing troubles in many areas.  We definitely keep the firefighters in our prayers.  We had a busy weekend in the podiatry world.

On to the Case.  A very good response is noted since our last visit.  I consider a good response in a severe white line disease to be new hoof growth without fungal invasion.  The hoof defect noted in the soft tissue lateral radiograph is growing down.  The left front has 13mm  of new hoof growth with out cracks.  There is still  uneven growth rings from toe to heel but greatly improved.  Sole depth has increased but is still considered severely thin soled.  If you look at the upper portion of the barium paste you can see the new hoof wall growth that is growing down more parallel to the front/face of coffin bone/P3.  Patient has been in a small paddock and fed Biotin 100 from nanric.com daily.  I will be posting photos and radiographs from first visit and this recent visit.
first day pre shoe

first day post shoe
Before glueing 5weeks after initial visit.  Added a little more mechanics/belly/rocker to shoe.

With Superfast,  Due to poor quality walls I like to add a little extra holding power.  I drove nails but left long and create loop in end for glue to attach to
Initial visit post shoeing radiograph

Recent visit 5 weeks later, Notice the hoof wall defect growing down without fungal invasion and more parallel to front of coffin bone.  I also added a little more rocker to shoe to increase mechanics that allow further unloading of deep digital flexor tendon.  This image is after reset of shoe.
Left front day one

reset Note new growth without cracks in the upper hoof wall 
Now on the Right Front.....................................................................................................................................................
Day one
day one right front
Post Shoe day one with superfast.

Post shoe at 5wk reset.

5 week reset pre superfast.

After super fast

Day one post shoe radiograph

5 week post shoe radiograph.  Notice new growth at upper coronary band that is growing more parallel with front of coffin bone/p3

 So to restate the purpose of the use of the Rockered Rail shoe.  The Rails give us 5-7 degrees of heel elevation and the added rockering adds a self adjusting air wedge to allow further unloading of the tension in the Deep digital flexor and decreasing the pull at the inner layers of the horn wall.  The rocker action is also thought to increase the circulation of the entire foot which will enhance hoof growth and quality.  With the rocker action Digital breakover is greatly reduced.  I also added in a positive pressure frog bar to help prevent buttress/frog prolapse and spread weight distribution across the back of the hoof.

The most important aspect of why the rocker shoe is successful is it's ability to greatly reduce the action of the deep digital flexor tendon.  The deep digital tendon and it's action is the "big dog" force in the Hoof.  You must consider it's action and the forces it applys to the coffin bone and the space around it.    It pulls tension on the bone to hoof connection and a downward compression force on the solar corium below the tip of the coffin bone.  We must always first consider the action of DDF  and all other aspects of shoeing will be secondary to that.  I like this approach versus wedging alone as it can be difficult to acheive this much DDF tension release and breakover reduction with wedges.  Additionally the rocker motion greatly enhances the healing environment and speeds up recovery.  The addition of the superfast  at the quarters and over the toe adds stability  and connection of the whole hoof once again.  I do not feel it is required but does help hold the shoe longer.

Just Got off the phone with Dr. Ric Redden and things are coming together for the October lecture and demonstration.  I will have brochures ready within the next week.  October 14 will be an all day lecture and then on the 15th will be a demonstration at the 181 ranch in Bixby Oklahoma.  It will be a very informative seminar and hope you can make it.

Thanks for reading,                    Sammy L. Pittman DVM

We have been quite busy and I just haven't had the time to catch up on the blogging. We a planning a reduced price coggins clinic at Animal Health Supply on July 9th from 9-12.  If you have any questions please call 918.235.1529 or shoot us an email at innovativeequinepodiatry@hotmail.com.  Cost of coggins test will be 15 dollars and you will also receive a 10 percent off coupon for Animal health supply for that day, good for anything but dog, cat and horse food.  Hope to see you there.

I am also posting some Follow up radiographs and pictures of the White line disease case we have been following.  This case is still progressing but not as much progression as I would like to see on the right front.  We have good hoof wall growth but not as much sole depth as I would like to see.  With the onset of good green pasture and the potential for some insulin resistance in this case could have played a role in slowing of hoof growth.  We instructed to reduce the amount of pasture time and absolutely no grain products.  Both hooves are becoming much tighter and healthier.  I removed more dorsal hoof wall to allow cleaning and treatment.  The left shows significant new hoof growth without fungal invasion. noted by the measurement on the radiograph.  We reset the Rocker Rail shoe with frog plate.

Note new hoof wall growth that is nice and tight without a crack.

New growth without a crack

I am happy with the amount and quality of hoof wall growth.  I would like to see a faster sole depth recovery but it will come.  This didn't happen overnight and we probably will not fix it overnight.

Hope everyone is staying safe in this record warm weather here in the US.  For those of you not suffering from the heat, your lucky.  Well the horses don't care how warm it is they still need there hoof care!  I revisited the white line disease case this past Friday.  We have continued accelerated hoof wall growth without cracks.  The Right front which is the more upright still has signs of fungal invasion despite mechanical unloading noted by the lucent zone in the Horn component of the H/L zone.  This would likely suggest the pathogen is invading new growth.  Left front shows continued improvement in all aspects with good hoof wall growth and sole depth recovery.  Sole growth has been slow to recover but is measurably increasing at this point.  I feel that higher scale mechanics (ie more rocker or deep digital tendon release) will be required for continued success in the right front due to this being the more upright foot and is under more deep digital flexor muscle pull.  At the last visit I instructed the owner to place on a weight control program with only enough alfalfa pellets to get the 100mg biotin and vitamin and minerals in.  Significant weight loss has occurred and will help the overall success of this case as the obesity could increase insulin and decrease the amount of circulation to the lower limbs further decreasing hoof quality and quality.  A great improvement is noted in hoof structure with loss of flares and a tighter new growth coming down.
    I elected to remove more dorsal hoof wall in area's that cavities existed and pack with a mixture of pine tar and oakum versus cleaning and packing with white lighting gel.  Below are updated photos and radiographs.  Read the captions for further information regarding individual images.
Increased sole depth but lesions from fungal invasion have remained

Very first radiographs
Good improvement in sole depth and new growth without fungal invasion

right front with 1/3 of new hoof growth.

Left front with almost half of new hoof growth without cracks.

Shoes are attached with a few nails into hoof wall then 3-4 next to hoof wall and superfast adhesive is used to glue  nails to hoof wall.  A band of superfast is added across the front to attach the two sides.  This has been one of my tougher cases and I appreciate the opportunity to work on this difficult case and the commitment the Owner has made to her equine companion.  We still have several months to go but I feel we have made significant improvement.

    We have two cases in the barn right now that we have been working with and plan to post them here on the blog as soon as time will allow to put together all the images, time lines and thought processes.  One is a fractured second phalanx (short pastern) named Lila that is recovering nicely and the second is a newly acquired laminitis case that was acutely laminitic about 6 weeks ago.  We will be posting those soon so keep checking back.  I am also excited about attending Dr. Redden's In depth podiatry 201 course August 8-12 in Versailles, Ky with farrier and friend Brendan Frost.


Stay cool, but most importantly Stay Fresh,,,,in your knowledge.

 This is an update to the severe white line disease case I have been working on for the last few months.  Considerable progress has been made noted by good hoof wall growth free of fungal invasion and good sole depth recovery.  The foot has regenerated and is looking more like a foot should.  One area on the lateral (outside) toe of the right front that has not responded and has invaded the new growth.  During this visit I completely removed all horn affected and this is the only spot that I needed to remove part of the new growth.

I was able to get a couple of nails in the heel region but mostly nails are glued to the inner layers of horn wall.  Please look back at the previous months post's to see pictures and radiographs.  After the pictures I wrapped a 3" casting tape for added security but removed any glue or cast material over the Lateral toe site so the owner could clean and treat with keratex hoof hardener, but mostly keep it open to the air.

It has been a while since my last post.  I am writing this as we are driving down the road headed to visit family on Thanksgiving Day.  We had a great clinic in October with Dr. Ric Redden.  I plan to post images from the clinic. We had an interesting mild laminitis case in which we performed venograms the day of the clinic and we did follow up venograms about 2 weeks later.

The case below is one we have been working with for several months and it is coming along very well.  We had our most dramatic increase in sole depth this last cycle and we now are very close to what I would consider a normal sole depth for this size of horse.  The fungal invasion noted by defects in the hoof wall on radiographs and visual inspection is no longer present.  We reset the rocker rails with positive pressure frog bar and plan to have the next visit in conjunction with regular farrier and turn it back over for 2-3 cycles.

Please look back at previous post for comparative photos and radiographs.

We reset the rockers using nails against the hoof wall and superfast adhesive to attach nails to hoof wall.  One roll of 2 inch casting tape was then applied over that.

More to come!!  I have turned this case over to the regular farrier for maintenance and I will post the last images I have.

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