Blood and Guts (30 page)

A modern operation for the treatment of Parkinson's
disease. The fearsome looking clamp is to hold the patient's
head in place so that surgeons can place implants precisely
in the affected area of the brain.

Vermont, 13 September 1848

The navvies said that Phineas Gage was the best foreman they'd ever
had. The twenty-five-year-old was fair and honest, a good worker and
a fine leader. He was employed on the Rutland & Burlington
Railroad. The promoters of the railroad hoped it would soon make
them rich: winding through the wooded hills of New England, it
would link Vermont to the cities of the east coast, bringing trade
and creating new markets for the state's agricultural and mineral
wealth. It was a fine enterprise indeed, and one well suited to an
industrious and practical worker such as Gage.

Gage's work gang had been toiling since early morning near the
town of Cavendish. They were building the roadbed – clearing and
levelling the land in preparation for the rails. The plans called for a
deep cutting, which had to be blasted through the granite hillside.
When it was finished, rock would dwarf the trains as they rounded
the sharp bend in the track. It would be a proud moment, thought
Gage, when the first steam engine – wheels pounding, head lamp
blazing – rolled along the track into town. For that to happen there
was still much work to do. Gage would make sure it was done, on
time and to the highest standards.

As foreman, Gage was highly skilled in the use of explosives, but
it was a tricky and dangerous job. First his men would drill a hole in
the rock – using a manual drill on solid granite was not an easy task.
Gage made sure that the hole was carefully positioned so that the
natural fractures in the rock could be used to maximize the effects
of the explosion. Next he lowered a measured amount of gunpowder
into the shaft and inserted a fuse. He tamped the powder gently
with his tamping iron before adding a layer of sand. The sand
helped confine the explosion to a small space, focusing the charge
into the rock rather than back up through the hole, which was
simply a waste of good gunpowder. Finally, Gage tamped the sand
good and hard, lit the fuse and stood well back. It was a job he did
every day.

Gage was so practised with explosives that he even had his own
custom-made tamping iron. The three foot seven inch-long iron bar
was an inch and a quarter in diameter. The bar was round, flat at
one end – the end he used to pack the explosives and sand – and
tapered to a point at the other. It was more than a crowbar; it was
styled almost like a javelin. A fine iron bar for an iron-willed man.
An unfortunate description given what was about to occur.

It was half past four. They were nearing the end of another hard
day and Gage could not wait to get back to the inn where he was
staying. Most of his men were looking forward to an evening drink,
but Gage rarely touched alcohol himself. They were loading lumps
of rock on to a flat car as Gage prepared to blast another section
from the hillside.

He lowers the string of the fuse into the hole and pours in the
gunpowder. He begins to tap the powder gently with his iron.
Distracted by the work going on behind him, he leans forward over
the hole. Perhaps he forgets that the sand hasn't yet been poured,
or perhaps he slips. But when he tamps the iron again, it goes in too
hard and catches on the granite. It ignites a spark.

The gunpowder explodes.

The iron rod shoots out of the hole like a bullet from a gun. It
goes straight through Gage's cheek, passes through the floor of his
left eye into the front of his brain and tears out of the top of his
head. His skull is splayed apart as the iron continues its journey
upwards, eventually returning to earth some eighty feet away,
smeared with blood and bits of brain. Some of Gage's brain is later
found splattered across the rocks where the rod landed.
^*

^*
The men who found the iron reported that it was 'covered with blood and brains'. They
washed it in a nearby brook, but it still had a 'greasy' appearance and was 'greasy to the touch'.

Gage was knocked on to his back by the force of the explosion.
His men ran across to find him twitching on the ground. A few
moments later he spoke. Then, to everyone's astonishment, he got
up and started to walk towards the road. He was helped on to an
ox cart and driven the three-quarters of a mile into the centre of
town. When he arrived at the tavern of Joseph Adams, where he
was lodging, he walked with only a little assistance and sat in a chair
on the veranda. He chatted with some of the men who gathered
around and answered questions about his injury. Gage had rarely
missed a day's work in his life and said he was keen to get back to
the railroad.

When Dr Edward Williams arrived at around five o'clock he
could not believe what he seeing. It made no sense – how could this
man possibly be alive? Gage remained perfectly lucid, insisting that
the bar did indeed pass right through his head. One of the labourers
corroborated the story: 'Sure it was so, sir, for the bar is lying in
the road below, all blood and brains.'

Despite the burn marks on Gage's cheek, the copious amounts
of blood dribbling down the poor man's face and the fragments of
bone sticking from his head, Williams was still unable to accept what
had happened. It wasn't until Gage started vomiting a large quantity
of blood and, as Williams noted, 'about half a teacupful of the brain,
which fell upon the floor' that the doctor finally came round to the
idea that Gage had survived the firing of an inch and a quarter-wide
tamping iron through his head.

Williams was completely flummoxed by the case, and seemed
reluctant to administer any treatment. So an hour later, when Dr
John Harlow arrived, Gage was still sitting on the veranda answering
questions and recounting his dramatic tale; also occasionally vomiting
blood, bone and lumps of brain that had dropped through the
hole from the top of his head into his mouth. Harlow was impressed
with how Gage 'bore his sufferings with the most heroic firmness'.
Despite becoming increasingly exhausted from the massive loss of
blood, Gage recognized the doctor at once and needed little assistance
to make his way up the stairs to his room.

Harlow was much more practical although, unsurprisingly,
somewhat taken aback by the mess. 'His person and the bed on
which he was laid were literally one gore of blood,' he recalled.
However, this didn't stop the doctor passing his fingers completely
through the hole. 'I passed in the index finger its whole length, without
the least resistance, in the direction of the wound in the cheek,
which received the other finger in like manner,' he later reported.

Together the doctors cleaned and dressed Gage's wounds. They
shaved his scalp and removed a few bits of bone and a stray piece of
brain that was 'hung by a pedicle', as well as bandaging the burns on
his hands and arms. Harlow pressed the jigsaw of bones on the top
of Gage's skull back into position as best he could and left the man
propped up in bed, where his bandages gradually became saturated
with blood. A couple of the men volunteered to watch over him.

When Harlow returned at seven the next morning, Gage was
still conscious. He had even managed to snatch some sleep during
the night. Harlow didn't expect him to live for much longer, and the
undertaker was called so that Gage could be measured for his coffin.
It seemed the prudent thing to do. As the undertaker took his measurements,
Gage's mother arrived to say her last goodbyes.

By 15 September Gage's condition had indeed deteriorated. He
was passing in and out of consciousness, he was delirious and incoherent.
On the 16th Harlow replaced the dressings but described 'a
fetid sero-purulent discharge, with particles of brain intermingled'.
That couldn't be good.

Harlow continued to visit his patient every day, and by the 22nd
it seemed that the stubborn (and iron-willed) Gage was finally ready
to die. He was hardly sleeping at all; he threw his arms and legs
about as if he was trying to get out of bed. His body was hot, his
wounds fetid. He even told the doctor, 'I shall not live long so.'

One month later Gage was walking up and down the stairs, even
into the street. His wounds were healing rapidly and he was eating
well. His bowels were described as 'regular' and he had even
stopped vomiting globules of brain. By the end of November all the
pain had subsided and Gage told the doctor that he was 'feeling
better in every respect'. He could walk, talk and eat. There was only
one problem: Gage was no longer Gage.

He described it as a 'queer feeling'. Others said the man had
completely changed. The accident had radically transformed his
personality. The railroad foreman who had once been described
as sober, patient and industrious was now vulgar, impatient and
impulsive. Gage was rude, they said, and could suddenly break forth
into vile profanity. When he reapplied for his position as foreman
his employers said the change in his mind was so marked that they
refused to take him on. He was described as childlike in his attitude,
but 'with the animal passions of a strong man'.

Gage's accident went beyond mere medical curiosity. When the
iron bar tore away part of his brain it revealed the inner workings of
the mind. It demonstrated that the brain is not some homogeneous
grey pudding, but is made up of different parts doing different
things. This is a concept known as localization, and would become
vitally important for our understanding of the brain and for the first
tentative advances in brain surgery.

Most of our personality, our sense of 'self', is contained behind
the forehead, in the frontal lobes of the brain. These were the parts
that were blasted away by Gage's tamping iron – the parts sprayed
on to the rock or those that he later vomited across the floor. The
frontal lobes are where we think and plan things. When the rod
ripped through Gage's brain it tore away his personality and made
him more impulsive. A century later surgeons would employ smaller
rods to do much the same thing.

Gage never did return to the railroad. With his tamping iron as
his constant companion, he travelled across New England. He eventually
ended up in New York, where for a while it is said he became
a sideshow in the famous Barnum's American Museum. For a few
cents, punters could see a living man with a hole in his head.
Although anyone expecting to see something truly gruesome would
have been sorely disappointed. They could see (and perhaps if they
were lucky, touch) the tamping iron, but the hole was now healed
and there was little to show for Gage's trauma. Instead visitors could
listen to Gage as he used another skull to regale his dramatic story.

In December 1848 Harlow's account of the case was printed in
the
Boston Medical and Surgical Journal
. It was greeted with scepticism
by the medical establishment, most of whom believed Gage's survival
to be completely impossible. Surely Harlow must be mistaken? What
would a rural doctor like Harlow know about the anatomy of the
brain anyway? However, by 1849 Gage's case had attracted the attention
of the new professor of surgery at Harvard Medical School,
Henry Jacob Bigelow, who compiled a detailed account of the accident
and paraded Gage (and his tamping iron) in front of surgical
colleagues, suggesting that this was 'the most remarkable history of
injury to the brain which has been recorded'. Thanks to Bigelow,
Gage's accident would become a medical sensation and one of the
most curious incidents in the whole history of surgery.

In the first days after the explosion it had been reported in the
local paper as merely a 'Horrible Accident'. Workers died all the
time on the railroad; it was hardly big news. But now, as more and
more newspapers heard about the case, Gage's fame spread. He
could have made a comfortable living on the medical freak show
circuit – travelling around the USA from circus to surgical symposium
(they often amounted to the same thing). He would be the
nineteenth-century equivalent of a daytime chat show guest.

However, Gage's new impulsive nature took him in a different
direction. The new Gage discovered that he enjoyed working with
animals and went to work at a livery stable. For a while he cared for
horses and drove a stagecoach in Chile. But with his health failing,
he returned to the United States in 1859, finding employment on a
farm in California. Then, in 1860, the accident that should have
killed him finally did.

In February 1860, while ploughing a field, he suffered an
epileptic fit. During these final few months of his life he started to
suffer more and more fits and convulsions. Doctors did the only
thing they knew how – which was to bleed him – but the treatment
seemed to have little effect. Phineas Gage finally died in May 1860,
twelve years after a three foot seven inch-long iron rod passed
through his brain.

Although Harlow's treatment of Gage was exemplary, it is one
thing to piece back together a fractured skull or even care for major
head injuries such as those sustained by Gage, but it is quite another
to open up the head and poke around in the brain – to have a crack
at brain surgery. As far as most surgeons were concerned, any
attempt to go further than repairing a head injury was to be avoided
at all costs. Anaesthetics, advances in anatomy and, later, Joseph
Lister's antiseptic operating techniques (see Chapter 1) might have
transformed nineteenth-century medicine, but the brain was still a
mystery, locked away in the sealed casket of the skull. Few surgeons
were prepared to open this casket, and those who did usually came
quickly to regret it. The only exception to the unwritten 'no operating
on the brain' rule was the ancient practice of trepanning.

Trepanning is arguably the world's oldest surgical practice –
although amputation is likely to run it a close second. It involves
drilling a hole, from half an inch to two inches across, into the skull.
The patient would have had their hair and skin scraped away before
the prehistoric equivalent of a surgeon started to bore into their
head with a sharpened stone or, later, a crude metal drill.