Phineas P. Gage (18231860) was an American railroad construction foreman remembered for his improbable survival of an accident in which a large tamping iron rod was driven completely through his head, destroying much of his brain's left frontal lobe, and for that injury's reported effects on his personality and behavior over the remaining 12 years of his lifeeffects sufficiently profound that friends saw him (for a time at least) as "no longer Gage".
Long known as the "American Crowbar Case"once termed "the case which more than all others is to excite our wonder, impair the value of prognosis, and even to subvert our doctrines"Phineas Gage influenced 19th-century discussion about the mind and brain, debate on cerebral , and was perhaps the first case to suggest the brain's role in , and that damage to specific parts of the brain might induce specific mental changes.
Gage is a fixture in the curricula of neurology, psychology, and neuroscience, one of "the great medical curiosities of all time" and "a living part of the medical folklore" frequently mentioned in books and scientific papers; he even has a minor place in popular culture. Despite this celebrity, the body of established fact about Gage and what he was like, both before and after his injury, is small, which has allowed "the fitting of almost any theory [desired] to the small number of facts we have"Gage acting as a "Rorschach inkblot" in which proponents of various conflicting theories of the brain all saw support for their views. Historically, published accounts of Gage, including scientific ones, have almost always severely exaggerated and distorted his behavioral changes, frequently contradicting the known facts.
A report of Gage's physical and mental condition shortly before his death implies that his most serious mental changes were temporary, so that in later life he was far more functional, and socially far better adapted, than in the years immediately following his accident. A social recovery hypothesis suggests that his work as a stagecoach driver in Chile fostered this recovery by providing daily structure that allowed him to regain lost social and personal skills.
Life Background
Gage was the first of five children born to Jesse Eaton Gage and Hannah Trussell Gage ( Swetland) of Grafton County, New Hampshire. Little is known about his upbringing and education beyond that he was literate.
Physician John Martyn Harlow, who knew Gage before his accident, described him as
(In the pseudoscience of phrenology, which was then just ending its vogue, nervo-bilious denoted an unusual combination of "excitable and active mental powers" with "energy and strength [of] mind and body [making] possible the endurance of great mental and physical labor".)
Gage may have first worked with explosives on farms as a youth, or in nearby mines and quarries. In July 1848 he was employed on construction of the Hudson River Railroad near Cortlandt Town, New York, and by September he was a blasting foreman (possibly an independent contractor) on railway construction projects. His employers' "most efficient and capable foreman ... a shrewd, smart business man, very energetic and persistent in executing all his plans of operation", he had even commissioned a custom-made tamping irona large iron rodfor use in setting explosive charges.
Accident
On September 13, 1848, Gage was for the south of the village of . Setting a blast entailed boring a hole deep into an of rock; adding and a fuse; then using the tamping iron to pack ("tamp") sand, clay, or other inert material into the hole above the powder in order to contain the blast's energy and direct it into surrounding rock.
As Gage was doing this around 4:30 p.m., his attention was attracted by his men working behind him. Looking over his right shoulder, and bringing his head into line with the blast hole and tamping iron, Gage opened his mouth to speak; at that same instant the tamping iron sparked against the rock and (possibly because the sand had been omitted) the powder exploded. Rocketed from the hole, the tamping iron in diameter, long, and weighing entered the left side of Gage's face in an upward direction, just forward of the angle of the lower jaw. Continuing upward outside the upper jaw and possibly fracturing the cheekbone, it passed behind the left eye, through the left side of the brain, then completely out the top of the skull through the frontal bone.
Despite 19th-century references to Gage as the "American Crowbar Case", his tamping iron did not have the bend or claw with the term crowbar; rather, it was simply a pointed cylinder something like a javelin, round and fairly smooth:
The tamping iron landed point-first some away, "smeared with blood and brain".
Gage was thrown onto his back and gave some brief convulsions of the arms and legs, but spoke within a few minutes, walked with little assistance, and sat upright in an oxcart for the ride to his lodgings in town. (A possibly apocryphal contemporary newspaper report claimed that Gage, while en route, made an entry in his time-bookthe record of his crew's hours and wages.) About 30 minutes after the accident, physician Edward H. Williams found Gage sitting in a chair outside the hotel and was greeted with "one of the great understatements of medical history":
Harlow took charge of the case around 6 p.m.:
Gage was also swallowing blood, which he regurgitated every 15 or 20 minutes.
Treatment and convalescence
With Williams' assistance Harlow shaved the scalp around the region of the tamping iron's exit, then removed coagulated blood, small bone fragments, and "an ounce or more" of protruding brain. After probing for foreign bodies and replacing two large detached pieces of bone, Harlow closed the wound with adhesive straps, leaving it partially open for drainage; the entrance wound in the cheek was bandaged only loosely, for the same reason. A wet compress was applied, then a nightcap, then further bandaging to secure these dressings. Harlow also dressed Gage's hands and forearms (which along with his face had been deeply burned) and ordered that Gage's head be kept elevated.
Late that evening Harlow noted, "Mind clear. Constant agitation of his legs, being alternately retracted and extended... Says he 'does not care to see his friends, as he shall be at work in a few days.
Despite his own optimism, Gage's convalescence was long, difficult, and uneven. Though recognizing his mother and unclesummoned from Lebanon, New Hampshire, 30 miles (50km) away on the morning after the accident, on the second day he "lost control of his mind, and became decidedly delirious". By the fourth day, he was again "rational ... knows his friends", and after a week's further improvement Harlow entertained, for the first time, the thought "that it was for Gage to recover ... This improvement, however, was of short duration."
Beginning 12 days after the accident, Gage was semi-comatose, "seldom speaking unless spoken to, and then answering only in monosyllables", and on the 13th day Harlow noted, "Failing strength ... coma deepened; the globe of the left eye became more protuberant, with ["fungus"deteriorated, infected tissue] pushing out rapidly from the internal canthus [as well as] from the wounded brain, and coming out at the top of the head." By the 14th day, "the exhalations from the mouth and head [are] horribly fetid. Comatose, but will answer in monosyllables if aroused. Will not take nourishment unless strongly urged. The friends and attendants are in hourly expectancy of his death, and have his coffin and clothes in readiness. One of the attendants implored me not to do anything more for him, as it would only prolong his sufferingsthat if I would only keep away and let him alone, he would die."
Galvanized to action, Harlow "cut off the fungi which were sprouting out from the top of the brain and filling the opening, and made free application of caustic [i.e. crystalline silver nitrate] to them. With a scalpel I laid open the and immediately there were discharged eight ounces [250 ml] of ill-conditioned pus, with blood, and excessively fetid." ("Gage was lucky to encounter Dr. Harlow when he did", writes Barker. "Few doctors in 1848 would have had the experience with cerebral abscess with which Harlow left and which probably saved Gage's life." See § Factors favoring Gage's survival, below.)
On the 24th day, Gage "succeeded in raising himself up, and took one step to his chair". One month later, he was walking "up and down stairs, and about the house, into the piazza", and while Harlow was absent for a week Gage was "in the street every day except Sunday", his desire to return to his family in New Hampshire being "uncontrollable by his friends ... he went without an overcoat and with thin boots; got wet feet and a chill". He soon developed a fever, but by mid-November was "feeling better in every respect [and] walking about the house again". Harlow's prognosis at this point: Gage "appears to be in a way of recovering, if he can be controlled".
By November 25 (10 weeks after his injury), Gage was strong enough to return to his parents' home in Lebanon, New Hampshire, traveling there in a "close carriage" (an enclosed conveyance of the kind used for transporting the insane). Though "quite feeble and thin ... weak and childish" on arriving, by late December he was "riding out, improving both mentally and physically", and by the following February he was "able to do a little work about the horses and barn, feeding the cattle etc. [and] as the time for ploughing came [i.e. about May or June] he was able to do half a day's work after that and bore it well". In August his mother told an inquiring physician that Gage's memory seemed somewhat impaired, though slightly enough that a stranger would not notice.
Injuries
In April 1849, Gage returned to Cavendish and visited Harlow, who noted at that time loss of vision, and ptosis, of the left eye, a large scar on the forehead (from Harlow's draining of the abscess) and
Gage's rearmost left upper molar, adjacent to the point of entry through the cheek, was also lost. Though a year later some weakness remained, Harlow wrote that "physically, the recovery was quite complete during the four years immediately succeeding the injury".
New England and New York (18491852)
In November 1849 Henry Jacob Bigelow, the Professor of Surgery at Harvard Medical School, brought Gage to Boston for several weeks and, after satisfying himself that the tamping iron had actually passed through Gage's head, presented him to a meeting of the Boston Society for Medical Improvement and (possibly) to the medical school class.
Unable to reclaim his railroad job Gage was for a time "a kind of living museum exhibit" at Barnum's American Museum in New York City. (This was not the later Barnum's circus; there is no evidence Gage ever exhibited with a troupe or circus, or on a fairground.) Advertisements have also been found for public appearances by Gagewhich he may have arranged and promoted himselfin New Hampshire and Vermont, supporting Harlow's statement that Gage made public appearances in "most of the larger New England towns". (Years later Bigelow wrote that Gage had been "a shrewd and intelligent man and quite disposed to do anything of that sort to turn an honest penny", but gave up such efforts because "[that] sort of thing has not much interest for the general public".) For about 18 months, he worked for the owner of a stable and coach service in Hanover, New Hampshire.
Chile and California (18521860)