Recovery from the passage ofan iron bar
through the head
Read before the Massachusetts Medical Society
3 June 1868
Boston: David Clapp & Son
Medical and Surgical Office, 1869
John M. Harlow M.D.
of Woburn
Mr President and Fellows of the Massachusetts Medical Society:
I have the pleasure of being able to present to you, to-day, the history and sequel
of a case of severe injury of the head, followed by recovery, which, so far as I
know, remains without a parallel in the annals of surgery. The case occurred
nearly twenty years ago, in an obscure country town (Cavendish, Vt.), was
attended and reported by an obscure country physician, and was received by the
Metropolitan doctors with several grains of caution, insomuch that many utterly
refused to believe that the man had risen, until they had thrust their fingers into
the hole of his head, and even then they required of the Country Doctor attested
statements, from clergymen and lawyers, before they could or would believe many
eminent surgeons regarding such an occurrence as a physiological
impossibility; the appearances presented by the subject being variously
explained away.
It is due to science, that a case so grave, and succeeded by such remarkable
results, should not be lost sight of; that its subsequent history, termination, and
pathological evidences, in detail, should have a permanent record. My desire to
lay before the profession the sequel of this case, has not permitted me to remain
altogether oblivious as to the whereabouts of my patient, and after tracing him in
his wanderings over the greater part of this continent, I am able to present to you
indubitable evidence that my report of the case, in the Boston Medical and
Surgical Journal, was no fiction. You will find the report in Vol. 39, No. 20,
page 389, of the Journal; also a subsequent report, with comments, by Prof.
Henry J. Bigelow, in the American Journal of Medical Sciences for July, 1850. ,
The accident occurred in Cavendish, Vt., on the line of the Rutland &
Burlington Railroad, at that time being built, on the 13th of September, 1848,
and was occasioned by the premature explosion of a blast, when this iron, known
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to blasters as a tamping iron, and which I now show you, was shot through the
face and head.
The subject of it was Phin. P. Gage, a perfectly healthy, strong and active
young man, twenty-five years of age, nervobilious temperament, five feet six
inches in height, average weight one hundred and fifty pounds, possessing an
iron will as well as an iron frame; muscular system unusually well developed
having
scarcely had a day’s illness from his childhood to the date of this injury.
Gage was foreman of a gang of men employed in excavating rock, for the road
way. The circumstances were briefly as follows :He
was engaged in charging a hold drilled in the rock, for the purpose of
blasting, sitting at the time upon a shelf of rock above the hole. His men were
engaged in the pit, a few feet behind him, loading rock upon a platform car, with
a derrick. The powder and fuse had been adjusted in the hole, and he was in the
act of ’tamping it in’, as it is called, previous to pouring in the sand. While doing
this, his attention was attracted by his men in the pit behind him. Averting his
head and looking over his right shoulder, at the same instant dropping the iron
upon the charge, it struck fire upon the rock, and the explosion followed, which
projected the iron obliquely upwards, in a line of its axis, passing completely
through his head, and high into the air, falling to the ground several rods behind
him, where it was afterwards picked up by his men, smeared with blood and
brain. The missile entered by its pointed end, the left side of the face,
immediately anterior to the angle of the lower jaw, and passing obliquely
upwards, and obliquely backwards, emerged in the median line, at the back part
of the frontal bone, near the coronal suture. The wound thus occasioned will be
demonstrated and fully described to you hereafter. The iron which thus
traversed the head, is known with blasters as a ’tamping iron’, is round and
rendered comparatively smooth by use, and is three feet seven inches in length,
one and one-fourth inches in its largest diameter, and weighs thirteen and onefourth
pounds. The end which entered first is pointed, the taper being about
twelve inches long, and the diameter of the point one-fourth of an inch.
The patient was thrown back by the explosion, and gave a few convulsive
motions of the extremities, but spoke in a few minutes. His men (with whom he
was a great favourite) took him in their arms and carried him to the road, only a
few rods distant, and put him into an ox cart, in which he rode, supported in a
sitting posture, fully three-quarters of a mile to his hotel. He got out of the cart
himself, with a little assistance from his men, and an hour afterwards (with what
I could aid him by taking hold of his left arm) walked up a long flight of stairs,
and got upon the bed in the room where he was dressed. He seemed perfectly
conscious, but was becoming exhausted from the haemorrhage, which, by this
time, was quite profuse, the blood pouring from the lacerated sinus in the top of
his head, and also finding its way into the stomach, which ejected it as often as
every fifteen or twenty minutes. He bore his sufferings with firmness, and
directed my attention to the hole in his cheek, saying ’the iron entered there and
passed through my head.’ Pulse at this time was 60, soft and regular. He
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recognized me at once, and said ’he hoped he was not much hurt.’ His person,
and the bed on which he lay, was one gore of blood. Assisted by my friend Dr.
Williams, who was first called to the patient in my absence, we proceeded to
examine and dress his wound. From the appearance of the wound in the top of
the head, the fragments of bone being lifted up, the brain protruding from the
opening and hanging in shreds upon the hair, it was evident that the opening in
the skull was occasioned by some force acting from below, upward, having very
much the shape of an inverted funnel, the edges of the scalp everted and the
frontal bone extensively fractured, leaving the irregular oblong opening in the
skull of two by three and one-half inches. The globe of the left eye was protruded
from its orbit by one-half its diameter, and the left side of the face was more
prominent than the right side. The pulsations of the brain were distinctly seen
and felt.
The scalp was shaven, the coagula removed, with three small triangular pieces
of frontal bone, and in searching to ascertain if there were foreign bodies in the
brain, I passed the index finger of the right hand into the opening its entire
length, in the direction of the wound in the cheek, which received the left index
finger in like manner, the introduction of the finger into the brain being scarcely
felt. Aside from the triangular pieces already alluded to as removed, there were
two other pieces detached from the frontal bone, the anterior being two and
one-half by two inches, and the posterior one and one-half by two inches in size,
leaving the antero-posterior diameter of the opening in the skull fully three and
one-half inches.
This examination, and the appearance of the iron which was found some rods
distant smeared with blood and brain, together with the testimony of the
workmen and of the patient himself, who was sufficiently conscious to say that
the iron ’struck his head and passed through’, was considered at the time as
sufficiently conclusive, not only of the nature of the accident, but the manner in
which it occurred.
[section omitted]
’
On the 25th (of November) he was taken, in a close carriage, a distance of thirty
miles, to Lebanon N.H., his home, where I saw him the succeeding week, and
found him going on well. He continued to improve steadily, until on Jan. 1,
1849, the opening on the top of his head was entirely closed, and the brain shut
out from view, though every pulsation could be distinctly seen and felt. Gage
passed the succeeding winter months in his own house and vicinity, improving
in flesh and strength, and in the following April returned to Cavendish, bringing
his ’iron’ with him.
He visited me at that time, and presented something like the following
appearances. General appearance good; stands quite erect, with his head inclined
slightly towards the right side; his gait in walking is steady; his movements rapid
and easily executed. The left side of his face is wider than the right side, the left
malar bone being more prominent than its fellow. There is a linear cicatrix near
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the angle of the lower jaw, an inch in length. Ptosis of the left eyelid; the globe
considerably more prominent that its fellow, but not as large as when I last saw
him. Can adduct and depress the globe, but cannot move it in other directions;
vision lost. A linear cicatrix, length two and one-half inches, from the nasal
protuberance to the anterior edge of the raised fragment of the frontal bone, is
quite unsightly. Upon the top of the head and covered with hair, is a large
unequal depression and elevation - a quadrangular fragment of bone, which was
entirely detached from the frontal, and extending low upon the forehead, being
still raised and quite prominent. Behind this is a deep depression, two inches by
one and one-half inches wide, beneath which the pulsations of the brain can be
perceived. Partial paralysis of left side of face. His physical health is good, and I
am inclined to say that he has recovered. Has no pain in head, but says it has a
queer feeling which he is not able to describe. Applied for his situation as
foreman, but is undecided whether to work or travel. His contractors, who
regarded him as the most efficient and capable foreman in their employ previous
to his injury, 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
operation, 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, though 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’.
His mother, a most excellent lady, now seventy years of age, informs me that
Phineas was accustomed to entertain his little nephews and nieces with the most
fabulous recitals of his wonderful feats and hair-breadth escapes, without any
foundation except in his fancy. He conceived a great fondness for pets and
souvenirs, especially for children, horses and dogs - only exceeded by his
attachment for his tamping iron, which was his constant companion during the
remainder of his life. He took to travelling, and visited Boston, most of the larger
New England towns, and New York, remaining awhile in the latter place at
Barnum’s, with his iron. In 1851 he engaged with Mr Jonathan Currier, of
Hanover, New Hampshire, to work in his livery stable. He remained there,
without interruption from ill health, for nearly or quite a year and a half.
In August, 1852, nearly four years after his injury, he turned his back upon
New England, never to return. He engaged with a man who was going to Chili,
in South America, to establish a line of coaches at Valparaiso. He remained in
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Chili until July, 1860, nearly eight years, in the vicinity of Valparaiso and
Santiago, occupied in caring for horses, and often driving a coach heavily laden
and drawn by six horses. In 1859 and ’60 his health began to fail, and in the
beginning of the latter year he had a long illness, the precise nature of which, I
have never been able to learn. Not recovering fully, he decided to try a change of
climate, and in June, 1860, left Valparaiso for San Francisco, where his mother
and sister resided. The former writes that ’he arrived in San Francisco on or
about July 1 st, in a feeble condition, having failed very much since he left New
Hampshire. He suffered much from seasickness on his passage out from Boston
to Chili. Had many ill turns while in Valparaiso, especially during the last year,
and suffered much from hardship and exposure.’
After leaving South America I lost all trace of him, and had well nigh
abandoned all expectation of ever hearing from him again. As good fortune
would have it, however, in July, 1866, I was able to learn the address of his
mother and very soon commenced a correspondence with her and her excellent
son-in-law, D. D. Shattuck, Esq., a leading merchant in San Francisco. From
them I learned that Gage was dead - that after he arrived in San Francisco his
health improved, and being anxious to work, he engaged with a farmer at Santa
Clara, but did not remain there long. In February, 1861, while sitting at dinner,
he fell in a fit, and soon after had two or three fits in succession. He had no
premonition of these attacks, or any subsequent ill feeling. ’Had been ploughing
the day before he had the first attack; got better in a few days, and continued to
work in various places;’ ’could not do much, changing often, and always finding
something which did not suit him in every place he tried.’ On the 18th of May,
1861, three days before his death he 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, and he expired at 10, P.M., May 21, 1861
twelve
years, six months and eight days after the date of his injury. These
convulsions were unquestionably epileptic. It is regretted that an autopsy could
not have been had, so that the precise condition of the encephalon at the time of
his death might have been known. In consideration of this important omission,
the mother and friends, waiving the claims of personal and private affection,
with a magnanimity more than praisewothy, at my request have cheerfully
placed this skull (which I now show you) in my hands, for the benefit of
science. *
I desire here to express gratefully my obligations, and those of the Profession,
to D. D. Shattuck, Esq., brother-in-law of the deceased; to Dr. Coon, Mayor of
San Francisco, and to Dr. J. D. B. Stillman, for their kind cooperation in
executing my plans for obtaining the head and tamping iron, and for their
The skull and iron have been deposited, by the writer, in the Museum of the Medical Department
of Harvard University, in Boston.
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fidelity in personally superintending the opening of the grave and forwarding
what we so much desired to see.
The missile entered, as previously stated, immediately anterior and external to
the angle of the inferior maxillary bone, proceeding obliquely upwards in the
line of its axis, passed under the junction of the superior maxillary and malar
bones, comminuting the posterior wall of the antrum, entered the base of the
skull at a point, the centre of which is one and one-fourth inches to the left of the
median line, in the junction of the lesser wing of the sphenoid with the orbitar
process of the frontal bone - comminuting and removing the entire lesser wing,
with one-half of the greater wing of the sphenoid bone - also fracturing and
carrying away a large portion of the orbitar process of the frontal bone, leaving
an opening in the base of the cranium, after the natural effects at repair by the
deposit of new bone, of one inch in its lateral, by two inches in its anteroposterior
diameters, with a line of fracture or fissure leading anteriorly through
the orbitar place of the frontal bone, the anterior fossa, and deflecting laterally,
towards the median line, divides the left frontal sinus, at the supra-orbitar
notch, and ascends the forehead along the left margin of the ridge, for the
attachment of the falx major. Inferiorly the line of separation begins at the infraorbitar
foramen and malar process of the supra-maxillary from the body of the
bone, terminating at a point upon the superior maxillary opposite the last molar
tooth. - The bones implicated in its passage were the superior maxillary, malar,
sphenoid, and frontal. The iron, as you will perceive, entered the left cerebrum
at the fissure of sylvius, possibly puncturing the cornu of the left lateral
ventricle, and in its passage and exit must have produced serious lesion of the
brain substance - the anterior and middle lobes of the cerebrum - disintegrating
and pulpifying it, drawing out a considerable quantity of it at the opening in the
top of the head, and lacerating unquestionably the upper aspect of the falx major
and the superior longitudinal sinus. As the iron emerged from the head, it
comminuted the central portion of the frontal bone, leaving an irregular oblong
opening in the bone of three and one-half inches in its antero-posterior, by two
inches in its lateral diameter. Two of these fragments, as you will see from the
specimens before you, were re-united.
Remarks
I. No attempt will be made by me to cite analogous cases, as after ransacking
the literature of surgery in quest of such, I learn that all, or nearly all, soon came
to a fatal result. Hence I conclude to leave that task to those who have more taste
for it. This case is chiefly interesting to me, as serving to show the wonderful
resources of the system in enduring the shock and in overcoming the effects of so
frightful a lesion, and as a beautiful display of the recuperative powers of nature.
It has been said, and perhaps justly, that ’the leading feature of this case is its
improbability’ (Bigelow.) This may be so, but I trust, after what has been shown
to you today, that the most skeptical among you have been convinced of its
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actual occurrence - that it was no ’Yankee invention’, as a distinguished
Professor of Surgery in a distant city was pleased to call it. Moreover, it would
seem, when we take into account all the favoring circumstances, that we may not
only regard partial recovery as possible, but exceedingly probable. These I will
name briefly.
lst. The subject was the man for the case. His physique, will, and capacity
of endurance, could scarcely be excelled.
2d. The shape of the missile - being pointed, round and comparatively
smooth, not leaving behind it prolonged concussion or compression.
3d. The point of entrance outside of the superior maxillary bone - the bolt
did little injury until it reached the floor of the cranium, when, at the same time
that it did irreparable mischief, it opened up its way of escape, as without this
opening in the base of the skull, for drainage, recovery would have been
impossible.
4th. The portion of the brain traversed, was, for several reasons, the best
fitted of any part of the cerebral substance to sustain the injury.
II. This case has been cited as one of complete recovery, it being often said
that a very considerable portion of the left cerebrum was lost, without any
impairment in the intellect. I think you have been shown that the subsequent
history and progress of the case only warrant us in saying that, physically, the
recovery was quite complete during the four years immediately succeeding the
injury, but we learn from the sequel that ultimately the patient probably
succumbed to progressive disease of the brain. Mentally the recovery certainly
was only partial, his intellectual faculties being decidedly impaired, but not
totally lost; nothing like dementia, but they were enfeebled in their manifestations,
his mental operations being perfect in kind, but not in degree or quantity. This
may perhaps be satisfactorily accounted for in the fact that while the anterior
and a part of the middle lobes of the left cerebrum must have been destroyed as
to function, its function suspended, its fellow was left intact, and conducted its
operations singly and feebly.
III. Little has been said in the foregoing account as the treatment or conduct
of this case, this being regarded as quite unnecessary. The initiatory treatment,
received from the iron, though it might not be well received in this presence, you
will permit me to say, was decidedly antiphlogistic, a very large amount of blood
having been lost. May we not infer that this prepared the system for the trying
ordeal through which it was about to pass? The recovery is attributed chiefly to
vis vitae, vis conservatrix, or, if you like it better, to the vis medicatrix naturae,
of which this case is a striking exemplification.
I desire to call your attention, in passing, to two critical periods in the progress
of the case, when what was done undoubtedly changed the tendency to a fatal
result. The first was on the fourteenth day, when the large abscess, which
probably communicated with the left lateral ventricle, was opened, followed by a
marked improvement in all the symptoms. The second was on the sixty-fourth
day, at which he was bled sixteen ounces.
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I indulge the hope, that surely but little if anything was done to retard the
progress of the case, or to interfere with the natural recuperative powers. Nature
is certainly greater than art. Some one has wisely said, that vain is learning
without wit. So we may say, vain is art without nature. For what surgeon, the
most skilful, with all the blandishments of his art, has the world ever known,
who could presume to take one of his fellows who has had so formidable a missile
hurled through his brain, with a crash, and bring him, without the aid of this vis
conservatrix, so that, on the fifty-sixth day thereafter, he would have been
walking in the streets again? I can only say, in conclusion, with good old
Ambrose Par6, I dressed him, God healed him.