At 4:30 p.m. on September 13, 1848, a premature blast at a railroad construction site in Cavendish, Vermont propelled a 43-inch long, 13.5-pound iron rod through the skull of Phineas Gage, a 25-year-old foreman. Before this accident, Gage was described as being of “vigorous physical organization, temperate habits, and possessed of considerable energy of character.” The 1.25-inch diameter, smooth, tamping iron entered Gage’s skull beneath the left zygomatic arch, passed through the left orbit and left frontal lobe, and exited the top of his skull “in the median line, at the juncture of the coronal and sagittal sutures.”
The rod landed yards behind Gage and was “afterwards picked up by his men, smeared with blood and brain.” Whether or not Gage sustained a brief loss of consciousness is unclear; observers noted a few impact convulsive movements of his upper extremities and that he spoke within minutes. “A great favorite” to his men, they drove Gage, sitting erect in an ox cart, for three-quarters of a mile to the Adams Hotel in Cavendish, Vermont. While sitting on the hotel porch, Gage told Dr. Edward Williams who first attended him, “Doctor, here is business enough for you.” He then walked up the stairs with the doctor.
At 6:00 p.m., about 90 minutes after the accident, Dr. Harlow took over Gage’s care and attended him for months, making careful notes about his physical condition and fluctuating mental state. Initially lucid, Gage became transiently delirious 2 days later. Harlow noted that at times Gage was childish, but his orientation to time was good, and his memory for the accident was excellent. Against all odds, Gage returned home 74 days after the accident. Harlow commented that aside from loss of vision in the left eye and partial paralysis of the left side of his face, Gage was in good physical health after recovery.
It was only in a follow-up paper 20 years later that Harlow described Gage’s behavioral changes after recovery. Gage had not been rehired as foreman because he had become disinhibited, with the “animal passions of a strong man,” “impatient of restraint or advice” and, “indulging at times in the grossest profanity (which was not previously his custom).” Having formerly been regarded as smart, efficient and capable, Gage’s friends famously stated that after the accident he was “no longer Gage.”
Gage traveled to Valparaiso, Chile in the late1850s, where he worked as a stagecoach driver. Dr. Henry Trevitt, who was well acquainted with Gage in Valparaiso, reported that Gage had no impairment of mental faculties. Gage later rejoined his family in California and worked as a farmhand at a succession of farms, “finding something that did not suit him in every place he tried.” He died in February 1860, 12½ years after his accident, apparently from status epilepticus.
After learning of Gage’s death, Dr. Harlow obtained permission from Gage’s family to have the body exhumed and Gage’s skull sent to him along with the tamping iron that had been Gage’s “constant companion” after the accident.1 The skull and tamping iron were donated by Harlow to the Museum of the Medical Department of Harvard University.
Importance of this case:
Gage is remembered as the index case of frontal lobe damage causing personality change, though the story that is told typically stops with the acute changes described by Harlow. Gage’s story teaches about behaviors associated with acute prefrontal injury as well as about the possibility of recovery from serious frontal damage in adulthood. That Gage later enjoyed some degree of functional recovery is perhaps as striking as his having survived the accident itself.
The case of Phineas Gage also added evidence for localization of mental functions. Dr. Harlow’s two reports bracketed in time Paul Broca’s report of “Tan” and the localization of language. We can assume Harlow had become aware of Broca’s work before writing his second paper about Gage. Thus, Drs. Harlow and Bigelow’s interest in Gage was part of a larger medical discussion regarding localization of mental functions.
Phineas Gage, touted as the archetypal case of prefrontal behavioral syndrome, may actually be as important for demonstrating the possibility of functional recovery after severe traumatic brain damage during adulthood. It is also interesting to note that, in contrast with Harlow’s original 1848 report that emphasized Gage’s physical recovery, Harlow’s 1868 report, published 6 years after Broca’s presentation of Leborgne, drew attention to Gage’s personality change.
Excerpted from: “Six Landmark Case Reports Essential for Neuropsychiatric Literacy”
Authors: Sheldon Benjamin, M.D., Lindsey MacGillivray, M.D., Ph.D., Barbara Schildkrout, M.D., Alexis Cohen-Oram, M.D., Margo D. Lauterbach, M.D., Leonard L. Levin, M.S. L.I.S., M.A.