Финéас Гейдж: Человек с пробитой головой.

American brain injury survivor (1823–1860)
the survivor of an iron bar through the head

Phineas P. Gage (18231860) was an American railroad construction foreman remembered for his improbable 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 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 (whether before or after his injury) is small,name=accounts reliablesources 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.

Gage was the first of five children born to Jesse Eaton Gage and Hannah Trussell (Swetland) Gage 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 "a perfectly healthy, strong and active young man, twenty five years of age, nervo bilious temperament, five feet six inches [5 feet (2 m)] in height, average weight one hundred and fifty pounds [], possessing an iron will as well as an iron frame; muscular system unusually well developedhaving had scarcely a day's illness from his childhood to the date of [his] injury". (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.

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 possible 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 his memory seemed somewhat impaired, though slightly enough that a stranger would not notice.

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. )name=firsts 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.

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 ValparaísoSantiago route. After his health began to fail in mid 1859, 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, who had relocated there from New Hampshire around the time he went to Chile. Then, "anxious to work", he found employment with a farmer in Santa Clara. In February 1860,name=death 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".

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. Only a handful of sources give direct information on what Gage was like (either before or after the accident),name=accounts reliablesources the mental changes published after his death were much more dramatic than anything reported while he was alive, 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.

In 1860, an American physician who had known Gage in Chile in 1858 and 1859 described him as still "engaged in stage driving [and] in the enjoyment of good health, with no impairment whatever of his mental faculties". Together with the fact that Gage was hired by his employer in advance, in New England, to become part of the new coaching enterprise in Chile, this implies that Gage's most serious mental changes had been temporary, so that the "fitful, irreverent  capricious and vacillating" Gage described by Harlow immediately after the accident became, over time, far more functional and far better adapted socially. Macmillan writes that this conclusion is reinforced by the responsibilities and challenges associated with stagecoach work such as that done by Gage in Chile, including the requirement that drivers "be reliable, resourceful, and possess great endurance. But above all, they had to have the kind of personality that enabled them to get on well with their passengers." A day's work for Gage meant "a 13 hour journey over 100 miles [160km] of poor roads, often in times of political instability or frank revolution. All thisin a land to whose language and customs Phineas arrived an utter strangermilitates as much against permanent disinhibition [i. e. an inability to plan and self regulate] as do the extremely complex sensory motor and cognitive skills required of a coach driver." (An American visitor wrote: "The departure of the coach was always a great event at Valparaisoa crowd of ever astonished Chilenos assembling every day to witness the phenomenon of one man driving six horses.")

In addition, Ratiu et al. noted that the hole in the base of the cranium (created as the tamping iron passed through the sphenoidal sinus into the brain) has a diameter about half that of the iron itself; combining this with the hairline fracture beginning behind the exit region and running down the front of the skull, they concluded that the skull "hinged" open as the iron entered from below, then was pulled closed by the resilience of soft tissues once the iron had exited through the top of the head. Van Horn et al. concluded that damage to Gage's white matter (of which they made detailed estimates) was as or more significant to Gage's mental changes than cerebral cortex (gray matter) damage. Thiebaut de Schotten et al. estimated white matter damage in Gage and two other case studies ("Tan" and "H. M."), concluding that these patients "suggest that social behavior, language, and memory depend on the coordinated activity of different [brain] regions rather than single areas in the frontal or temporal lobes."

"A distinguished Professor of Surgery in a distant city", Harlow continued, had even dismissed Gage as a "Yankee invention". According to the Boston Medical and Surgical Journal (1869) it was the 1850 report on Gage by BigelowHarvard's Professor of Surgery and "a majestic and figure on the medical scene of those times"that "finally succeeded in forcing [the case's] authenticity upon the credence of the as could hardly have been done by any one in whose sagacity and surgical knowledge his confrères had any less confidence". Noting that, "The leading feature of this case is its This is the sort of accident that happens in the pantomime at the theater, not elsewhere", Bigelow emphasized that though "at first wholly skeptical, I have been personally convinced". Nonetheless (Bigelow wrote just before Harlow's 1868 presentation of Gage's skull) though "the nature of [Gage's] injury and its reality are now beyond doubt  Ihave received a letter within a month [purporting] to prove that  the accident could not have happened."

As the reality of Gage's accident and survival gained credence, it became "the standard against which other injuries to the brain were judged", and it has retained that status despite competition from a growing list of other unlikely sounding brain injury accidents, including encounters with axes, bolts, low bridges, exploding firearms, a revolver shot to the nose, further tamping irons, and falling Eucalyptus branches. For example, after a miner survived traversal of his skull by a gas pipe in diameter (extracted "not without considerable difficulty and force, owing to a bend in the portion of the rod in his skull"), his physician invoked Gage as the "only case comparable with this, in the amount of brain injury, that I have seen reported". Often these comparisons carried hints of humor, competitiveness, or both. The Boston Medical and Surgical Journal, for example, alluded to Gage's astonishing survival by referring to him as "the patient whose cerebral organism had been comparatively so little disturbed by its abrupt and intrusive visitor"; and a Kentucky doctor, reporting a patient's survival of a gunshot through the nose, bragged, "If you Yankees can send a tamping bar through a fellow's brain and not kill him, I guess there are not many can shoot a bullet between a man's mouth and his brains, stopping just short of the medulla oblongata, and not touch either." Similarly, when a lumbermill foreman returned to work soon after a saw cut into his skull from just between the eyes to behind the top of his head, his surgeon (who had removed from this wound "thirty two pieces of bone, together with considerable sawdust") termed the case "second to none reported, save the famous tamping iron case of Dr. Harlow", though apologizing that "I cannot well gratify the desire of my professional brethren to possess [the patient's] skull, until he has no further use for it himself." As these and other remarkable brain injury survivals accumulated, the Boston Medical and Surgical Journal pretended to wonder whether the brain has any function at all: "Since the antics of iron bars, gas pipes, and the like skepticism is discomfitted, and dares not utter itself. Brains do not seem to be of much account now a days." The Transactions of the Vermont Medical Society was similarly facetious: The times have been,' says Macbeth , 'that when the brains were out the man would die. But now they rise again.' Quite possibly we shall soon hear that some German professor is exsecting it."

In the 19th century debate over whether the various mental functions are or are not localized in specific regions of the brain , both sides managed to enlist Gage in support of their theories. For example, after Eugene Dupuy wrote that Gage proved that the brain is not localized (characterizing him as a "striking case of destruction of the so called speech centre without consequent aphasia") Ferrier replied by using Gage (along with the woodcuts of his skull and tamping iron from Harlow's 1868 paper) to support his thesis that the brain is localized.

Throughout the 19th century, adherents of phrenology contended that Gage's mental changes (his profanity, for example) stemmed from destruction of his mental "organ of Benevolence"as phrenologists saw it, the part of the brain responsible for "goodness, benevolence, the gentle character  [and] to dispose man to conduct himself in a manner conformed to the maintenance of social order"and/or the adjacent "organ of Veneration"related to religion and God, and respect for peers and those in authority. (Phrenology held that the organs of the "grosser and more animal passions are near the base of the brain; literally the lowest and nearest the animal man [while] highest and farthest from the sensual are the moral and religions feelings, as if to be nearest heaven". Thus Veneration and Benevolence are at the apex of the skullthe region of exit of Gage's tamping iron.) Harlow wrote that Gage, during his convalescence, did not "estimate size or money accurately[,] would not take $1000 for a few pebbles" and was not particular about prices when visiting a local store; by these examples Harlow may have been implying damage to phrenology's "Organ of Comparison".

It is frequently asserted that what happened to Gage played a role in the later development of various forms of psychosurgeryparticularly lobotomyor even that Gage's accident constituted "the first lobotomy". Aside from the question of why the unpleasant changes usually (if hyperbolically) attributed to Gage would inspire surgical imitation, there is no such link, according to Macmillan:

Antonio Damasio, in support of his somatic marker hypothesis (relating decision making to emotions and their biological underpinnings), draws parallels between behaviors he ascribes to Gage and those of modern patients with damage to the orbitofrontal cortex and amygdala. But Damasio's depiction of Gage has been severely criticized, for example by Kotowicz:

As Kihlstrom put it, "[M]any modern commentators exaggerate the extent of Gage's personality change, perhaps engaging in a kind of retrospective reconstruction based on what we now know, or think we do, about the role of the frontal cortex in self regulation." Macmillan gives detailed criticism of Antonio Damasio's various presentations of Gage (some of which are joint work with Hannah Damasio and others).

Two daguerreotype portraits of Gage, identified in 2009 and 2010, are the only of him known other than a plaster head cast taken for Bigelow in late 1849 (and now in the Warren Museum along with Gage's skull and tamping iron). The first portrait shows a "disfigured yet still handsome" Gage with left eye closed and scars clearly visible, "well dressed and confident, even proud" and holding his iron, on which portions of its inscription can be made out. (For decades the portrait's owners had believed that it depicted an injured whaler with his harpoon.) The second portrait, copies of which are in the possession of two branches of the Gage family, shows Gage in a somewhat different pose, wearing the same waistcoat and possibly the same jacket, but with a different shirt and tie. Authenticity of the portraits was confirmed by overlaying the inscription on the tamping iron, as seen in the portraits, against that on the actual tamping iron, and matching the subject's injuries to those preserved in the head cast. However, about when, where, and by whom the portraits were taken nothing is known, except that they were created no earlier than January 1850 (when the inscription was added to the tamping iron), on different occasions, and are likely by different photographers. The portraits support other evidence that Gage's most serious mental changes were temporary "That [Gage] was any form of vagrant following his injury is belied by these remarkable images", wrote Van Horn et al. "Although just one picture," Kean commented in reference to the first image discovered, "it exploded the common image of Gage as a dirty, disheveled misfit. This Phineas was proud, well dressed, and disarmingly handsome."