The American Crowbar Case
by Fred G. Barker, II
The following photos and captions are courtesy of Dr. Kenneth L. Tyler at the University of Colorado Health Science Center and his father Dr. H. Richard Tyler of Harvard Medical School.
In 1848, a man named Phineas Gage suffered a brain wound which has rendered him as the index case of personality change after frontal lobe injury. During work on the construction of the Rutland & Burlington Railroad, an unplanned explosion propelled a rod, about a meter long and three cm in diameter, through his head. The entrance wound was in the right cheek; the exit was in the midline near the intersection of the sagittal and coronal sutures. Against expectation, Gage survived.
Initial published reports of the accident and its treatment emphasized on Gage's survival. The mental change he suffered, from his original capable and responsible self into a man who was profane, fitful, and obstinate - in short, a man who was "no longer Gage" - makes the case noteworthy today. Although the change in Gage was noted almost immediately after the accident, for 20 years his case gained notoriety as one of incredible damage to the brain with complete mental recovery. It was not until 1868 that Gage's personal physician, John M. Harlow, reported his patient's transformation.
The reasons for this delay are briefly explored. Of the two initial reports of Gage's case, the first was published by Harlow himself. This paper hinted at Gage's mental difficulties, but the medical professional scoffed at the case as patently impossible. The second report, by Professor Henry J. Bigelow of Harvard University, was more widely accepted. This report, however, emphasized Gage's mental recovery was complete. The influence of this publication was such that the case was consistently quoted until 1868 as proof that the cerebral hemispheres had no relation to intellectual function.
In 1868, Harlow again published an account of the case, this time with full details of Gage's mental state following the accident. This account, although published in an obscure journal, quickly changed the concept of the case as reflected in contemporary American publications.
Harlow and Bigelow clearly saw the case from widely divergent viewpoints. Both physicians were young men at the time of the accident. Whereas Harlow as educated in Philadelphia by men whose interest in phrenology is well documented, Bigelow donated his own copies of phrenological works to the Harvard College Library and traveled to Paris where he studied under the most prominent antilocalizationist of his time. Bigelow's status as a newly appointed professor at Harvard, trying to follow in the footsteps of John Collins Warren (who was ardently interested in phrenology), would have been confirmed by a demonstration of the latest Parisian theories of cerebral function. Those theories predicted that Gage would be mentally intact, and Bigelow consistently presented him as such - even before he had met the patient. Bigelow's influence lasted for the next 20 years. If Harlow had not chased his patient across two continents, eventual obtaining both his exhumed skull and the rod that caused the injury, the case would have long since perished in the annals of medicine.
Harlow's version of the case, however, finally gained prominence when quoted by David Ferrier as part of the first modern theory of frontal lobe function in the 1870s.
Barker, FG: Phineas among the phrenologists: the American crowbar case and nineteenth-century theories of cerebral localization. J Neurosurg 82:672-682, 1995.
Related Web sites:
The Phineas Gage Information Page http://www.hbs.deakin.edu.au/gagepage/pgage.htm