Phineas among the phrenologists: the American crowbar case and nineteenth-century theories of cerebral localization

Historical Vignette

Phineas among the phrenologists: the American crowbar case and nineteenth-century theories of cerebral localization

In eighteen forty-eight, Mr. Phineas Gage suffered destruction of his left frontal lobe in a unique fashion: passage of a metal rod through his head after a freak explosion. His change in character after the accident is the index case for personality change due to frontal lobe damage. Yet, from eighteen forty-eight to eighteen sixty-eight, it was widely believed among American physicians that he was mentally intact. The case was used as evidence against phrenology, a crude precursor of modern cerebral localization theories.

The two original reports of the case by Drs. John Harlow (Gage's physician) and Henry J. Bigelow show subtle differences in attitude toward Gage's posttraumatic character change. In his eighteen forty-eight report, Harlow promised a further communication that would address Gage's "mental manifestations." Bigelow's article portrayed Gage as fully recovered. Although delayed by twenty years, Harlow's second report rapidly changed the perception of the case in the medical community, as reflected by contemporary citations.

The educational backgrounds of Harlow and Bigelow are examined to explain their differing attitudes toward the case. Harlow's interest in phrenology prepared him to accept the change in character as a significant clue to cerebral function which merited publication. Bigelow had learned that damage to the cerebral hemispheres had no intellectual effect, and he was unwilling to consider Gage's deficit significant. Although Bigelow's paradigm was initially more influential, Harlow's more closely matched emerging theories of cerebral localization. His version of the case was used by David Ferrier as the keystone in the first modern theory of frontal lobe function, and this is how the case is remembered today.

The injury suffered by Phineas Gage in eighteen forty-eight ranks as one of the most famous nonfatal brain wounds on record. While at work on the Rutland and Burlington Railroad, near Cavendish, Vermont, Gage was struck in the left cheek by a tamping iron propelled by an accidental gunpowder detonation. The rod, approximately three centimeters in diameter and over one meter long, passed entirely through his head, entering under the left zygomatic arch and exiting in the midline just anterior to the bregma. Gage was transported by wagon to Cavendish, where a young local physician, John M. Harlow, undertook his treatment. Against expectation, Gage recovered fully, or nearly so. Harlow reported the case briefly in eighteen forty-eight. The ensuing blast of skepticism from the medical profession prompted Henry J. Bigelow, a prominent Boston surgeon, to examine Gage personally. Bigelow reported his conclusions in eighteen fifty. There the case rested for two decades. Gage left New England and then the country; he resurfaced in San Francisco, where he died of an apparent seizure approximately twelve years after his injury. Harlow procured his exhumed skull in eighteen sixty-eight and republished the case with extended follow up. He now first disclosed Gage's remarkable personality change, in short, that he was "no longer Gage." Although the case was notorious for decades as an example of intact mental function despite a desperately severe cerebral injury, Gage is remembered today for the subtle change in personality that Harlow waited twenty years to report.

Some aspects of this famous case have remained largely uninvestigated to date. Why, for instance, did Drs. Harlow and Bigelow find the case so important that they chased it across two continents for twenty years? Why did Harlow wait so long to report Gage's change in personality? And how did he explain it in an age when cerebral localization was essentially unknown?

When Phineas Gage arrived at the tavern where he was to remain for the weeks of his convalescence, Dr. John M. Harlow was a relative newcomer to the Vermont medical scene. He was twenty-nine years old, just four years after his graduation from Jefferson Medical College in Philadelphia. Gage's open brain wound was almost certainly the first that had come his way. Harlow's treatment plan would be expected to rest entirely on his medical school training.

tion from Jefferson Medical College (JMC) in Philadel- phia. Gage's open brain wound was almost certainly the first that had come his way. Harlow's treatment plan would be expected to rest entirely on his medical school training.

"No medical institution has a better reputation than the Jefferson," said the Boston Medical and Surgical Journal in eighteen forty-four, as it listed the names of the graduating class. Harlow was one of just three Massachusetts men out of the one hundred fourteen graduates. His reasons for choosing Jefferson Medical College over the closer schools in Boston are unknown, but perhaps he was swayed by the reputation of the new Jefferson Medical College faculty; the famous "Faculty of forty-one." These seven worthies included J. K. Mitchell (S. Weir Mitchell's father), and Franklin Bache, the future coauthor of the first United States Dispensatory. Most relevant to Gage's case, however, would be Harlow's recollections from classes in physiology (Professor Robley Dunglison), anatomy (Professor Joseph Pancoast), and surgery (Professor Thomas D. Mütter).

Robley Dunglison was the brightest star in Jefferson's firmament. Thomas Jefferson himself had personally recruited this staggeringly prolific physiologist from his native England in eighteen twenty-five to be the sole professor in the new Medical School at the University of Virginia. After serving as Jefferson's personal physician and attending at his deathbed, Dunglison moved north in stages seeking a more kindly climate, coming to rest at Philadelphia's Jefferson Medical College in eighteen thirty-six. Here he taught physiology for over thirty years. His textbook, Human Physiology, passed through eight editions between eighteen thirty-two and eighteen fifty-six. This was just one of eleven books written by Dunglison, who also edited four journals. Dunglison's physiology lectures at Jefferson Medical College, which would have formed Harlow's main knowledge base on the functions of the brain, have vanished without trace. His physiology textbook, letters, and unsigned editorial notices in his journals provide the only evidence of his lectures' probable content. Dunglison was educated in Edinburgh during the years eighteen fifteen to eighteen sixteen, when the town was a hotbed of phrenological controversy. Phrenology, founded by Doctor Franz Joseph Gall in Vienna in the late seventeen nineties, was the first theory of brain function that assigned a cognitive function to the cerebral cortex. Gall parceled the cerebral and cerebellar cortex into twenty-seven "organs." Each was thought to control one aspect of character, such as courage, religious veneration, or love of children. The degree to which an individual expressed each trait was thought to reflect the size of the corresponding "organ," which would in turn cause a prominence, or "bump," in the overlying skull. A skilled "manipulator" could thus interpret a subject's character from his or her cranial contour.

The attention of English readers was first drawn to this "new science of the brain" by the Edinburgh Review in

Eighteen oh three point twenty-five In eighteen sixteen Dr. J. G. Spurzheim, phrenology's co-founder and future apostle to the New World, arrived in Edinburgh to promote his new doctrine in person. His advent triggered a cataclysm of debate that spread from medical circles into the town's quietest intellectual backwaters, but physicians remained the strongest advocates of phrenology during Dunglison's years in Edinburgh. In age, social and academic standing, and in his liberal political leanings, Dunglison closely resembled the typical early nineteenth-century Edinburgh phrenological convert.

Having completed his medical education, Dunglison moved to London. During his years there, articles promoting phrenology appeared in many prominent medical journals, including the Lancet, the Weekly Medico-Chirurgical and Philosophical Magazine, and the Medico-Chirurgical Review. It is thus unsurprising that Dunglison included a "head laid out according to Gall and Spurzheim's system" in a list of necessary anatomical preparations for the University of Virginia that he sent to Thomas Jefferson in eighteen twenty-five. A year later he requested that the University subscribe to the Phrenological Journal, which embodied the transactions of the Edinburgh Phrenological Society. Indeed, had he neglected phrenology, a physiology professor between eighteen twenty and eighteen forty-four would have had little to say about the higher functions of the human brain.

During the early eighteen thirties, phrenology set fire to the highest intellectual circles of America, particularly in Philadelphia and Boston. Although all varieties of American intelligentsia were intrigued, it was the physicians who were hardest bit by the phrenology bug, and they constituted a large fraction of the officers and membership of the phrenological societies which soon began to dot the landscape.

Dunglison and his colleagues on the JMC faculty kept well abreast of the controversial new theory. Of the other six faculty members, two are known to have joined Philadelphia's Central Phrenological Society (the first phrenological society in the United States), and a third translated Pierre Flourens' classic antiphrenological work, Phrenology Examined. Any discussion of the brain and its functions at JMC during this era would likely have reflected the controversy over phrenology's validity, and a JMC student seeking to read about the brain in Philadelphia's largest medical library would have had over fifty works on phrenology to choose from. These volumes comprised more than half of the library's holdings on the functions of the nervous system.

Fully sixty percent of the thirty-four pages on "Physiology of the intellectual and moral faculties" in Dunglison's Human Physiology (eighteen thirty-two edition) were devoted to a discussion of phrenological theory. These pages remained substantially unaltered through the book's many revisions, and at the date when Harlow attended JMC, phrenology was still given a respectable hearing in his professor's textbook. Regarding the phrenological explanation of the effects of cerebral injury on higher cerebral function, Dunglison wrote,

... in many of the cases of severe injury to the brain, which are on record, but one hemisphere was implicated; and accordingly, the impunity of the intellectual and moral manifestations has been ascribed to the cerebrum being a double organ; so that, although one hemisphere may have been injured; the other, containing similar organs, may have been capable of carrying on the function. ... [A case of injury to the left frontal lobe, in the area Gall thought responsible for language, is described, which was accompanied by aphasia.] ... We cannot understand why, in particular cases, such serious effects should result from severe injury done to the brain; and, in others, the comparative immunity attendant upon injury to all appearances equally grave .... The views of Gall are by no means established. They require numerous and careful experiments, which it is not easy for everyone to institute.

Phineas Gage and cerebral localization

Editorial notices and reviews in the American Medical Intelligencer, of which Dunglison was sole editor, reflect further light on his feelings toward phrenology. In his editorial comment on the first article in the first issue of his new journal, he states, "It is well known, that, according to many eminent physiologists, the seat of the organs concerned in the intellectual and moral manifestations is the periphery of the brain." In an eighteen thirty-nine review of an antiphrenological work, he wrote, "We strongly recommend its perusal to the phrenologist, as we do the standard phrenological works to those who are unbelievers. The truth or falsehood of phrenology is not to be established by angry declamation; but by calm and unprejudiced observation." In eighteen forty-one, Dunglison professed to be surprised by an antiphrenologist's accusation that he was a supporter of phrenology, and again he stated his neutral position. The eighteen forty-four edition of his A Dictionary of Medical Science explained Gall's system in detail, but expressed the opinion that the assignment of specific locations to the individual cerebral organs might be premature. As late as eighteen fifty, Dunglison's early publications were still cited as support for Gall's tenets. Overall, his attitude seems to have been one of cautious interest, rather than of partisanship either for or against phrenology's doctrines.

Of more practical import when Gage arrived on his doorstep would have been Harlow's recollection of the proper treatment of a brain wound. Such injuries, resulting from falls, horse kicks, and gunfire, were well known in pre-Civil War America. Every contemporary course of lectures on surgery described the diagnosis and treatment of head injuries, and Professor Thomas Mutter's lectures were no exception. Mütter published outlines of his lectures for his students' use, and manuscript sets of student notes from the lectures have also been preserved. For penetrating wounds of the brain, Mutter recommended replacing any sizable fragments of displaced skull, allowing dependent drainage of the wound, and not exploring the brain for retained foreign bodies. He pointed out that consciousness was frequently preserved. When the patient was initially lucid, he stated, and then developed signs of compression ("aberration of mind ... pulse slow and laboring ... can't rouse the patient"), then pus was present and must be drained. The cornerstones of his treatment plan were bleeding and vigorous antiphlogistic measures (purging and cathartics). Indeed, in eighteen forty-six, Mütter recommended nonoperative treatment with bleeding and antiphlogistics for the "vast majority" of cases in which the clinical diagnosis was epidural hemorrhage.

Less evidence exists for Professor Joseph Pancoast's lectures on anatomy, but through a happy coincidence, he performed his most celebrated operation for head injury before Harlow's medical school class during the winter between eighteen forty-three and eighteen forty-four. He described the case in his A Treatise on Operative Surgery. The patient presented with delayed cerebral symptoms from the accumulation of intracerebral pus after a head injury; Pancoast trephined to drain the pus, resulting in temporary recovery. Unfortunately, symptoms recurred and the patient died. At autopsy, reaccumulated pus was found: granulation tissue had blocked the opening in the dura. Pancoast believed that this had caused the patient's death. This operation brought Pancoast a high reputation as a cerebral surgeon. It may also have prompted him six years later to keep the wound open and draining for a month after an elective epilepsy trephination, lest the patient's seizures recur. His nonoperative treatment of head injury, like Mutter's, was designed to combat brain inflammation: purging, moderate bleeding, "but a few ounces of blood," and opiates to calm the mind. Blisters applied to the back of the neck and the extremities were also recommended, to draw off excess cerebral blood.

Harlow was well prepared, then, to grapple with Gage's staggeringly severe brain injury. In addition, he must have seen the case as a rare opportunity for physiological "experiment," as Dunglison had described, perhaps even as the cerebral equivalent of Beaumont's famous observations of digestion on Alexis Saint Martin's gastric fistula.