Phineas P. Gage (1823–1860) was an American railroad construction foreman remembered for his improbable[B1] survival of an accident in which a large 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 life—effects 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 calculated to excite our wonder, impair the value of prognosis, and even to subvert our physiological doctrines" —Phineas Gage influenced 19th-century discussion about the mind and brain, particularly debate on cerebral localization,[M][B] and was perhaps the first case to suggest the brain's role in determining personality, 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,[M7] one of "the great medical curiosities of all time"[M8] and "a living part of the medical folklore" [R] frequently mentioned in books and scientific papers;[M] he even has a minor place in popular culture. Despite this celebrity, the body of established fact about Gage and what he was like (whether before or after his injury) is small, which has allowed "the fitting of almost any theory [desired] to the small number of facts we have" [M]—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 (née Swetland) of Grafton County, New Hampshire. Little is known about his upbringing and education beyond that he was literate.[M][M10]
Physician John Martyn Harlow, who knew Gage before his accident, described him as
a perfectly healthy, strong and active young man, twenty-five years of age, nervo-bilious temperament, five feet six inches [168 cm] in height, average weight one hundred and fifty pounds [68 kg], possessing an iron will as well as an iron frame; muscular system unusually well developed—having had scarcely a day's illness from his childhood to the date of [his] injury.[H]
(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".)[M]
Gage may have first worked with explosives on farms as a youth, or in nearby mines and quarries.[M] In July 1848 he was employed on construction of the Hudson River Railroad near Cortlandt Town, New York,[M10] and by September he was a blasting foreman (possibly an independent contractor) on railway construction projects.[M] His employers' "most efficient and capable foreman ... a shrewd, smart business man, very energetic and persistent in executing all his plans of operation",[H] he had even commissioned a custom-made tamping iron—a large iron rod—for use in setting explosive charges.[B1][M]
Accident
On September 13, 1848, Gage was directing a work gang blasting rock while preparing the roadbed for the Rutland & Burlington Railroad south of the village of Cavendish, Vermont. Setting a blast entailed boring a hole deep into an outcrop of rock; adding blasting powder 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 inadvertently 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—1+1⁄4 inches (3.2 cm) in diameter, three feet seven inches (1.1 m) long, and weighing 13+1⁄4 pounds (6.0 kg)—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.[B1][H][M]
Despite 19th-century references to Gage as the "American Crowbar Case", his tamping iron did not have the bend or claw sometimes associated with the term crowbar; rather, it was simply a pointed cylinder something like a javelin,[K] round and fairly smooth:[H]
The end which entered [Gage's cheek] first is pointed; the taper being [eleven inches (28 cm) long, ending in a 1⁄4-inch (0.5 cm) point] [V]... circumstances to which the patient perhaps owes his life. The iron is unlike any other, and was made by a neighbouring blacksmith to please the fancy of the owner.[B1]
The tamping iron landed point-first some 80 feet (25 m) away,[M] "smeared with blood and brain".[H]
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 3⁄4-mile (1.2 km) ride to his lodgings in town.[H]
(A possibly apocryphal contemporary newspaper report claimed that Gage, while en route, made an entry in his time-book—the record of his crew's hours and wages.)[L1]
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":[M5]
When I drove up he said, "Doctor, here is business enough for you." I first noticed the wound upon the head before I alighted from my carriage, the pulsations of the brain being very distinct. The top of the head appeared somewhat like an inverted funnel, as if some wedge-shaped body had passed from below upward. Mr. Gage, during the time I was examining this wound, was relating the manner in which he was injured to the bystanders. I did not believe Mr. Gage's statement at that time, but thought he was deceived. Mr. Gage persisted in saying that the bar went through his head. Mr. G. got up and vomited; the effort of vomiting pressed out about half a teacupful of the brain [through the exit hole at the top of the skull], which fell upon the floor.
Harlow took charge of the case around 6 p.m.:
You will excuse me for remarking here, that the picture presented was, to one unaccustomed to military surgery, truly terrific; but the patient bore his sufferings with the most heroic firmness. He recognized me at once, and said he hoped he was not much hurt. He seemed to be perfectly conscious, but was getting exhausted from the hemorrhage. His person, and the bed on which he was laid, were literally one gore of blood.
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;[M] 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 uncle—summoned from Lebanon, New Hampshire, 30 miles (50 km) away—[H][M] 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 possible for Gage to recover ... This improvement, however, was of short duration."
Beginning 12 days after the accident,[M] 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][M] 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 sufferings—that 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][M][H1] to them. With a scalpel I laid open the [frontalis muscle, from the exit wound down to the top of the nose][H1] 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 [Jefferson Medical College] and which probably saved Gage's life." [B] 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).[H][M] Though "quite feeble and thin ... weak and childish"[M] on arriving, by late December he was "riding out, improving both mentally and physically",[H2] 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)[H1] and
upon the top of the head ... a quadrangular fragment of bone ... raised and quite prominent. Behind this is a deep depression, two inches by one and one-half inches [5 by 4 cm] wide, beneath which the pulsations of the brain can be perceived. Partial paralysis of the left side of the face. His physical health is good, and I am inclined to say he has recovered. Has no pain in head, but says it has a queer feeling which he is not able to describe.[H]
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,[M] Harlow wrote that "physically, the recovery was quite complete during the four years immediately succeeding the injury".[H]
New England and New York (1849–1852)
In November 1849 Henry Jacob Bigelow, the Professor of Surgery at Harvard Medical School,[M1] 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.[B1][M]
Unable to reclaim his railroad job (see § Early observations (1849–1852)) 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 Gage—which he may have arranged and promoted himself—in New Hampshire and Vermont,[M10] supporting Harlow's statement that Gage made public appearances in "most of the larger New England towns".[H][M1] (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".)[B2][M10]
For about 18 months, he worked for the owner of a stable and coach service in Hanover, New Hampshire.[H][M]
Chile and California (1852–1860)
In August 1852, Gage was invited to Chile to work as a long-distance stagecoach driver there, "caring for horses, and often driving a coach heavily laden and drawn by six horses" on the Valparaíso–Santiago route.[M][H] After his health began to fail in mid-1859,[H] he left Chile for San Francisco, arriving (in his mother's words) "in a feeble condition, having failed very much since he left New Hampshire ... Had many ill turns while in Valparaiso, especially during the last year, and suffered much from hardship and exposure." In San Francisco he recovered under the care of his mother and sister,[H] who had relocated there from New Hampshire around the time he went to Chile.[M] Then, "anxious to work", he found employment with a farmer in Santa Clara.[H]
In February 1860, Gage began to have epileptic seizures. He lost his job, and (wrote Harlow) as the seizures increased in frequency and severity he "continued to work in various places [though he] could not do much".[M][H]
Death and exhumation
On May 18, 1860, Gage "left Santa Clara and went home to his mother. At 5 o'clock, A.M., on the 20th, he had a severe convulsion. The family physician was called in, and bled him. The convulsions were repeated frequently during the succeeding day and night," [H] and he died in status epilepticus,[M2] in or near San Francisco,
late on May 21, 1860. He was buried in San Francisco's Lone Mountain Cemetery.
In 1866, Harlow (who had "lost all trace of [Gage], and had well nigh abandoned all expectation of ever hearing from him again") somehow learned that Gage had died in California, and made contact with his family there. At Harlow's request the family had Gage's skull exhumed, then personally delivered it to Harlow,[M][H][M10] who was by then a prominent physician, businessman, and civic leader in Woburn, Massachusetts.[M][M7]
About a year after the accident, Gage had given his tamping iron to Harvard Medical School's Warren Anatomical Museum, but he later reclaimed it[B1][M] and made what he called "my iron bar" [M10][G1] his "constant companion during the remainder of his life";
now it too was delivered by Gage's family to Harlow.[M10] (Though some accounts assert that Gage's iron had been buried with him, there is no evidence for this.)[M10][L1] After studying them for a triumphal[L1] 1868 retrospective paper on Gage,[H] Harlow redeposited the iron—this time with Gage's skull—in the Warren Museum, where they remain on display today.
The tamping iron bears the following inscription, commissioned by Bigelow in conjunction with the iron's original deposit in the Museum (though the date given for the accident is one day off):
This is the bar that was shot through the head of Mr Phinehas [sic] P. Gage at Cavendish Vermont Sept 14, [sic] 1848. He fully recovered from the injury & deposited this bar in the Museum of the Medical College of Harvard University. • Phinehas P. Gage • Lebanon Grafton Cy N–H • Jan 6 1850
The date Jan 6 1850 falls within the period during which Gage was in Boston under Bigelow's observation.[B1][H][M]
In 1940 Gage's headless remains were moved to Cypress Lawn Memorial Park as part of a mandated relocation of San Francisco's cemeteries to outside city limits (see San Francisco cemetery relocations).[M]
Mental changes and brain damage
Gage may have been the first case to suggest the brain's role in determining personality and that damage to specific parts of the brain might induce specific personality changes, but the nature, extent, and duration of these changes have been difficult to establish.[M][M10] Only a handful of sources give direct information on what Gage was like (either before or after the accident), the mental changes published after his death were much more dramatic than anything reported while he was alive,[M] and few sources are explicit about the periods of Gage's life to which their various descriptions of him (which vary widely in their implied level of functional impairment) are meant to apply.[M10]
Early observations (1849–1852)
Harlow ("virtually our only source of information" on Gage, according to psychologist Malcolm Macmillan)[M] described the pre-accident Gage as hard-working, responsible, and "a great favorite" with the men in his charge, his employers having regarded him as "the most efficient and capable foreman in their employ"; he also took pains to note that Gage's memory and general intelligence seemed unimpaired after the accident, outside of the delirium exhibited in the first few days.[M] Nonetheless these same employers, after Gage's accident, "considered the change in his mind so marked that they could not give him his place again":
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. Previous to his injury, although untrained in the schools, he possessed a well-balanced mind, and was looked upon by those who knew him as a shrewd, smart business man, very energetic and persistent in executing all his plans of operation. In this regard his mind was radically changed, so decidedly that his friends and acquaintances said he was "no longer Gage."[H]