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Phineas P. Gage
The first identified (2009) portrait of Gage and his "constant companion for the remainder of his life"—his inscribed tamping iron
Born	July 9, 1823 (date uncertain) Grafton County, New Hampshire
Died	May 21, 1860(1860-05-21) (aged 36) In or near San Francisco
Resting place	Warren Anatomical Museum, Boston (skull) Cypress Lawn Memorial Park, California (other remains)
Occupation(s)	Railroad construction foreman, blaster, stagecoach driver
Known for	Personality change after brain injury
Spouse	None
Children	None

Phineas P. Gage (1823–1860) was an American railroad construction foreman remembered for his improbable eleven-year survival following an accident in which a large iron rod was driven completely through his head. Much of his brain's left frontal lobe was destroyed, reportedly affecting his personality and behavior so profoundly—for a time at least—that friends saw him as "no longer Gage."

Long known as "the American Crowbar Case"—once termed "the case which more than all others is calculated to excite our wonder, impair the value of prognosis, and even to subvert our physiological doctrines"—Phineas Gage influenced nineteenth-century discussion about the mind and brain, particularly debate on cerebral localization, and was perhaps the first case to suggest that damage to specific parts of the brain might affect personality.

Gage is a fixture in the curricula of neurology, psychology and related disciplines, and is frequently mentioned in books and academic papers; he even has a minor place in popular culture. But the body of established fact about Gage and what he was like (whether before or after his accident) is neverthelesss remarkably small, which has allowed "the fitting of almost any theory to the small number of facts we have"; over the years Gage has been cited by proponents of various wholly contradictory theories of the brain. A survey of published accounts, including scientific ones, has found that they almost always severely distort Gage's behavioral changes, exaggerating the known facts when not directly contradicting them.

Two photographic portraits of Gage, and a physician's report of his physical and medical condition late in life, were announced in 2009 and 2010. This new evidence implies that Gage's most serious mental changes may have been temporary, lasting for only a limited time after his accident, so that in later life he was more functional, and socially better adjusted, than was previously assumed. A social recovery hypothesis suggests that Gage's employment as a stagecoach driver provided daily structure, allowing him to relearn lost social and personal skills.

Background

Gage was the eldest of five children born to Jesse Eaton Gage and Hannah Trussell (née Swetland, Sweatland, or Sweetland) Gage, of Grafton County, New Hampshire. Little is known about his upbringing and education, but he was almost certainly literate.

He may have gained skill with explosives on the family's farms or in nearby quarries and mines, and by the time of his accident he was a blasting foreman (possibly an independent contractor) on railway construction projects. His employers considered him (in his physician's words) "the most efficient and capable foreman in their employ ... a shrewd, smart businessman, very energetic and persistent in executing all his plans of operation", and he had even commissioned a custom-made tamping iron—an iron rod three feet seven inches long, and 11⁄4 inches (32 mm) in diameter—for use in setting charges.

Accident

On September 13, 1848 Gage (aged 25) was foreman of a work gang blasting rock while preparing the roadbed for the Rutland & Burlington Railroad outside the town of Cavendish, Vermont. Setting a blast involved boring a hole deep into a body of rock, adding blasting powder, a fuse, and sand, and then compacting this charge into the hole using the tamping iron.

Gage was doing this around 4:30 p.m. when (possibly because the sand was omitted) the tamping iron struck a spark against the rock and the powder exploded. The tamping iron rocketed out of the hole and "entered on the side of his face ... passing back of the left eye, and out at the top of the head" (according to a contemporary news report—see image).

Despite Gage being referred to in 19th century writing as "the American Crowbar Case" his tamping iron did not have the bend or claw sometimes associated with the term crowbar; rather, it was simply a cylinder, "round and rendered comparatively smooth by use":

The end which entered first is pointed; the taper being inches long ... circumstances to which the patient perhaps owes his life. The iron is unlike any other, and was made by a neighbouring blacksmith to please the fancy of its owner.

Weighing 13+1⁄4 pounds (6 kg) this "abrupt and intrusive visitor" landed some 80 feet (25 m) away, "smeared with blood and brain."

To the astonishment of his men, Gage spoke within a few minutes, walked with little assistance, and sat upright in an oxcart for the +3⁄4-mile (1.2 km) ride to his lodgings in town. Dr. Edward H. Williams arrived about thirty minutes after the accident:

When I drove up he said, "Doctor, here is business enough for you." I first noticed the wound upon the head before I alighted from my carriage, the pulsations of the brain being very distinct. The top of the head appeared somewhat like an inverted funnel ... as if some wedge-shaped body had passed from below upward. Mr. Gage, during the time I was examining this wound, was relating the manner in which he was injured to the bystanders. I did not believe Mr. Gage's statement at that time, but thought he was deceived. Mr. Gage persisted in saying that the bar went through his head .... Mr. G. got up and vomited; the effort of vomiting pressed out about half a teacupful of the brain, which fell upon the floor.

Dr. John Martyn Harlow took charge of the case about 6 p.m.:

You will excuse me for remarking here, that the picture presented was, to one unaccustomed to military surgery, truly terrific; but the patient bore his sufferings with the most heroic firmness. He recognized me at once, and said he hoped he was not much hurt. He seemed to be perfectly conscious, but was getting exhausted from the hemorrhage. Pulse 60, and regular. His person, and the bed on which he was laid, were literally one gore of blood.

Despite Harlow's skillful care, Gage's recuperation was long and difficult. Pressure on the brain left him semi-comatose from September 23 to October 3, "seldom speaking unless spoken to, and then answering only in monosyllables. The friends and attendants are in hourly expectancy of his death, and have his coffin and clothes in readiness."

But on October 7 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 ... got wet feet and a chill." He soon developed a fever, but by mid-November he was "feeling better in every respect ... walking about the house again; says he feels no pain in the head." Harlow's prognosis at this point: Gage "appears to be in a way of recovering, if he can be controlled."

Later life and travels

His mother, a most excellent lady, now seventy years age, informs me that Phineas was accustomed to entertain his little nephews and nieces with the most fabulous recitations 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 for the remainder of his life. He took to travelling ...

By November 25 Gage was strong enough to return to his parents' home in Lebanon, New Hampshire, where by late December he was "riding out, improving both mentally and physically." In April 1849 he returned to Cavendish and paid a visit to Harlow, who noted at that time loss of vision (and ptosis) of the left eye, a large scar on the forehead, and "upon the top of the head ... 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 the left side of the face." Despite all this, "his physical health is good, and I am inclined to say he has recovered. Has no pain in head, but says it has a queer feeling which he is not able to describe."

Unable to return to his railroad work, Harlow says, Gage appeared for a time at Barnum's American Museum in New York City (the curious paying to see, presumably, both Gage and the instrument which had injured him) although there is no independ­ent confirmation of this. Recently, however, evidence has surfaced supporting Harlow's statement that Gage made public appearances in "the larger New England towns". He subsequently worked in a livery stable 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 Valparaiso–​Santiago route. After his health began to fail around 1859, he left Chile for San Francisco, where he recovered under the care of his mother and sister (who had gone there from New Hampshire around the time Gage went to Chile). For the next few months he did farm work in Santa Clara.

Death and subsequent travels

In February 1860 Gage had the first in a series of increasingly severe convulsions, and he died in or near San Francisco on May 21, just under twelve years after his injury. He was buried in San Francisco's Lone Mountain Cemetery.

In 1866 Harlow, who had "lost all trace of , and had well nigh abandoned all expectation of ever hearing from him again", somehow learned that Gage had died in California and opened a correspondence with his family there. At Harlow's request they opened Gage's grave long enough to remove his skull, which was then delivered to Harlow back in New England.

About a year after the accident, Gage had allowed his tamping iron to be placed in Harvard Medical School's Warren Anatomical Museum, but he later reclaimed it, and made what he called "my iron bar" his "constant companion during the remainder of his life"; now it accompanied the skull on its journey to Harlow. After studying them for a triumphal retrospective paper on Gage (1868) Harlow redeposited the iron—this time with Gage's skull—in the Warren Museum, where they remain on display today. The iron bears this inscription:

This is the bar that was shot through the head of M Phinehas [sic] P. Gage at Cavendish, Vermont, Sept. 14, [sic] 1848. He fully recovered from the injury & deposited this bar in the Museum of the Medical College of Harvard University. Phinehas [sic] P. Gage Lebanon Grafton Cy N–H Jan 6 1850.

Much later Gage's headless remains were moved to Cypress Lawn Cemetery as part of a systematic relocation of San Francisco's dead to new burial places outside city limits.

Brain damage and mental changes

Extent of brain damage

Significant brain injury is often fatal, but Harlow called Gage "the man for the case. His physique, will, and capacity of endurance could scarcely be excelled," and as noted earlier the iron's 1/4-inch leading point may have reduced its destructiveness. Nonetheless, the amount of brain tissue destroyed must have been substantial, considering the initial trauma and the subsequent infection. Debate as to whether this was in both frontal lobes, or primarily the left, began with the earliest papers by physicians who had examined Gage. The 1994 conclusion of H. Damasio et al., that both frontal lobes were damaged, was drawn by modeling not Gage's skull but a "Gage-like" one. Ratiu et al. (2004, based on CT scans of Gage's skull, and presenting a video reconstruction of the tamping iron passing through it) confirm Harlow's conclusion, based on probing Gage's wounds with his finger, that the right hemisphere remained intact. Van Horn et al. (2012) agree that the right hemisphere was undamaged, and make detailed estimates of the locus and extent of damage to Gage's white matter. They suggest that this damage may have been more significant to Gage's mental changes than the cerebral cortex (gray matter) damage.

First-hand reports of mental changes

Gage certainly displayed some kind of change in behavior after his accident, but the nature, extent, and duration of this change are very uncertain. Little is reliably known about what Gage was like either before or after his injury, the mental changes described after his death were much more dramatic than anything reported while he was alive, and the few descriptions which seem credible do not specify the period of his post-accident life to which they are meant to apply.

In his 1848 report, as Gage was just completing his physical recovery, Harlow had only hinted at possible psychological symptoms: "The mental manifestations of the patient, I leave to a future communication. I think the case ... is exceedingly interesting to the enlightened physiologist and intellectual philosopher." And after observing Gage for several weeks in late 1849, Henry Jacob Bigelow, Professor of Surgery at Harvard, said that Gage was "quite recovered in faculties of body and mind," there being only "inconsiderable disturbance of function".

Only after Gage's death did Harlow, having obtained Gage's skull and the history of his final years, describe the mental changes found today in most presentations of the case (though usually in exaggerated or distorted form—see next section). In memorable language, Harlow now described the pre-accident Gage as hard-working, responsible, and "a great favorite" with the men in his charge, his employers having regarded him as "the most efficient and capable foreman in their employ". But these same employers, after Gage's accident, "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 operations, 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, although untrained in the schools, he possessed a well-balanced mind, and was looked upon by those who knew him as a shrewd, smart businessman, 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".

This oft-quoted description appears to draw on Harlow's own notes set down soon after the accident, but other behaviors he describes appear to draw on later communications from Gage's friends or family. It is difficult to match these various behaviors (which range widely in their implied level of functional impairment) to the particular period of Gage's life during which each described behavior was present. This complicates reconstruction of what Gage was like at various points in his post-accident life, a critical task (in light of evidence) that his behavior at the end of his life was very different from his immediate post-accident behavior as described by Harlow.

Distortion of mental changes

Psychologist Malcolm Macmillan, in his book An Odd Kind of Fame: Stories of Phineas Gage (the only book-length treatment of the case) surveys scores of accounts of Gage, both scientific and popular, showing that they almost always distort and exaggerate his behavioral changes well beyond anything described by those who had contact with Gage or even with his family. Attributes typically ascribed to the post-accident Gage which are either unsupported by, or in contradiction to, the known facts include mistreatment of wife and children (of which Gage had neither), inappropriate sexual behavior, an "utter lack of foresight", "a vainglorious tendency to show off his wound", inability or refusal to hold a job, plus drinking, bragging, lying, gambling, brawling, bullying, and thievery. Macmillan's detailed analysis shows that none of these behaviors is mentioned by anyone who had met Gage or his family.

For example, a prominent modern discussion of Gage by A. Damasio may misinterpret a passage by Harlow—"'... continued to work in various places;' could not do much, changing often, 'and always finding something that did not suit him in every place he tried'"—as implying Gage could not hold a job after his accident. In fact, Harlow's words could refer not to Gage's post-accident life in general, but only to the months just before his death, after convulsions had set in. Until then some evidence points towards Gage supporting himself, throughout his adult life, at paid work.

(Harlow himself, writing in 1868 while in contact with Gage's mother, somehow mistakes the year of Gage's death as 1861, whereas funeral records show he died in 1860—a striking illustration of the difficulty of establishing even basic fact about the case. In another example, it is often said that Gage's iron was buried with him, but there appears to be no evidence for this.)

Theoretical use and misuse

Beyond the importance of correcting the record of a much-cited case, Macmillan writes, "Phineas' story is worth remembering because it illustrates how easily a small stock of facts becomes transformed into popular and scientific myth," the paucity of evidence having allowed "the fitting of almost any theory to the small number of facts we have". Similar concerns were expressed as far back as 1877, when British neurologist David Ferrier, writing to Harvard's Henry Pickering Bowditch in an attempt "to have this case definitely settled," complained that "In investigating reports on diseases and injuries of the brain, I am constantly amazed at the inexactitude and distortion to which they are subject by men who have some pet theory to support. The facts suffer so frightfully&nbsp..."

Thus in the nineteenth-century controversy over whether or not the various mental functions are localized in specific regions of the brain, both sides managed to enlist Gage in support of their theories. For example, while Ferrier cited Gage as evidence that the brain is localized, physician Eugene Dupuy used him as proof that it is not. Phrenologists made use of Gage as well, claiming that his mental changes resulted from destruction of his "organ of Veneration" and/or the adjacent "organ of Benevolence".

It is often said that what happened to Gage played a part in the later development of various forms of psychosurgery, particularly frontal lobotomy. That would raise the question of why the unpleasant changes usually, if erroneously, attributed to Gage would inspire surgical imitation. However, according to Macmillan, careful inquiry turns up no such link:

here is no evidence that Gage's case contributed directly to psychosurgery .... As with surgery for the brain generally, what his case did show came solely from his surviving his accident: major operations could be performed on the brain without the outcome necessarily being fatal.

Social recovery

In 2008 an advertisement for a previously unknown public appearance by Gage was discovered, as well as a report of his physical and mental condition during his time in Chile, a description of what may well have been his daily work routine there as a stagecoach driver, and more recently an ad for a second public appearance. This new evidence implies that the seriously maladapted Gage described by Harlow existed for only a limited time after the accident—that Gage eventually "figured out how to live" despite his injury, and was in later life far more functional, and socially adapted, than previously thought.

Macmillan hypothesizes that this change represents a social recovery undergone by Gage over time, citing persons with similar injuries for whom "someone or something gave enough structure to their lives for them to relearn lost social and personal skills" (in Gage's case, his highly structured employment in Chile). If this is so, he points out, then along with theoretical implications it "would add to current evidence that rehabilitation can be effective even in difficult and long-standing cases"—and if Gage could achieve such improvement without medical supervision, "what are the limits for those in formal rehabilitation programs?"

Portraits

In 2009 a daguerreotype portrait of Gage was identified, the first likeness of him identified other than a life mask taken around 1850. It shows "a disfigured yet still-handsome" Gage with one eye closed and scars clearly visible, "well dressed and confident, even proud" and holding his iron, on which portions of the inscription (recited above) can be made out. (For decades the daguerreotype's owners had imagined that it showed an injured whaler with his harpoon.) Authenticity was confirmed in several ways, including photo-overlaying the inscription visible in the portrait against that on the actual tamping iron in Harvard's Warren Anatomical Museum, and matching the injuries seen in the portrait against those preserved in the life mask.

Macmillan cites the daguerreotype as consistent with the social recovery hypothesis already described. To better understand the question, he and collaborators are actively seeking additional evidence on Gage's life and behavior, and describe certain kinds of historical material (see "Phineas Gage: Unanswered questions" in External links, below) for which they hope readers will remain alert, such as letters or diaries by physicians whom their research indicates Gage may have met, or by persons in certain places Gage seems to have been.

In 2010 a second portrait of Gage was identified. This new image, copies of which are in the possession of at least two different branches of the Gage family, depicts the same subject seen in the Wilgus daguerreotype identified in 2009, according to Gage researchers consulted by the Smithsonian Institution.

See also

• Orbitofrontal cortex – an area of the brain often linked to injury-related personality change
• Eadweard Muybridge – another famous case of head injury leading to mental changes

Notes

1. Daguerreotype from the collection of Jack and Beverly Wilgus. The original, like almost all daguerreotypes, shows its subject laterally (left-right) reversed, making it appear that Gage's right eye is injured; however, there is no question (Lena & Macmillan, 2010) that all Gage's injuries, including to his eye, were on the left. Therefore, in presenting the image here a second, compensating reversal has been applied in order to show Gage as he appeared in life. See Harlow (1868), p. 340 for "constant companion".
2. ^ See Macmillan (2000) pp. 490–1 for Gage's ancestry, and pp. 11–17 for the uncertainty regarding his birth and early life. Possible birthplaces are Lebanon, Enfield, and Grafton (all in Grafton County, New Hampshire) though Harlow (1868) refers to Lebanon in particular as Gage's "native place" and as "his home" (probably that of his parents) to which he returned ten weeks after the accident.

   The vital records of neither Lebanon nor Enfield list Gage's birth. The birthdate July 9, 1823 (the only definite date given in any source) is from a comprehensive Gage genealogy, via Macmillan (2000) p. 16, and is consistent with universal agreement, among contemporary sources addressing the point, that Gage was 25 years old at the time of the accident.

   Gage's death and burial are discussed at Macmillan (2000), p. 108. Harlow (1868) is exactly one year off in the date of Gage's death, implying that certain other dates given by Harlow for events late in Gage's life—his move from Chile to San Francisco and the onset of his convulsions—must also be mistaken, presumably by the same amount; this article follows Macmillan in correcting those dates. (The age—36 years—given for Gage in undertaker's records from his death on May 21, 1860, is also consistent with the provisional July 9, 1823 birthdate.)

   There is no doubt Gage's middle initial was P (figure, Macmillan 2008, p. 839; Harlow 1848, Harlow 1868; Bigelow 1850) but there is nothing to indicate what the P stood for. See also note regarding the spelling of Gage's first name as inscribed on the tamping iron.

3. ^ Gage's iron was termed "this abrupt and intrusive visitor" in a review of Harlow (1868) appearing in the Boston Med & Surg J, March 18, 1869, 3(7)n.s.:116–117.

   A tone of bemused wonderment was common in 19th-century medical writing about Gage (as well as about victims of other unlikely-sounding brain-injury accidents—see Macmillan 2000, pp. 66–7). Noting dryly that, "The leading feature of this case is its improbability ... This is the sort of accident that happens in the pantomime at the theater, not elsewhere," Bigelow (1850, pp. 13,19) emphasized that though "at first wholly skeptical, I have been personally convinced," calling the case "unparalled in the annals of surgery". This endorsement by Bigelow, Professor of Surgery at Harvard, helped end scoffing about Gage among physicians in general—one of whom, Harlow (1868, p. 344) later recalled, had dismissed the matter as a "Yankee invention": "The case occurred nearly twenty years ago, in an obscure country town ..., 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," (see Doubting Thomas) "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."

   Indeed Jackson (1870, p. v) wrote that, "Unfortunately, and notwithstanding the evidence that Dr. H. has furnished, the case seems, generally, to those who have not seen the skull, too much for human belief." But after Gage was joined by such later cases as a miner who survived traversal of his head by a gas pipe, and a lumbermill foreman who returned to work soon after a "picket saw" cut into his forehead to a depth of several inches, the Boston Medical & Surgical Journal (1870) 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 these days." The Transactions of the Vermont Medical Society (Smith, 1886, pp. 53–54) was similarly facetious: "'The times have been,' says Macbeth [Act III], '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."

4. LeUnes, A. (1974). "Contributions to the history of psychology: 20. A review of selected aspects of texts in abnormal psychology". Psychological Reports. 35 (3): 1319–26. PMID 4614305. LeUnes' survey found Harlow (1868) to be the second most frequently cited work in twentieth-century psychology texts; see also Macmillan (2000), ch. 14, esp. pp. 307–8, 311 and 313–14. For popular culture, see Macmillan (2000), ch. 13; for example, several musical groups call themselves Phineas Gage (or some variation).
5. ^ According to Macmillan & Lena (2010, and see also Macmillan 2000, pp. 11, 89, 116) available sources which offer detailed information on Gage, and for which there is evidence (if merely the source's own claim) of contact with him or his family, were limited (until 2008) to
   • Harlow (1848, 1849 and 1868)
   • Bigelow (1850)
   • Jackson (1870) and
   • Jackson, J.B.S. (1849) Medical Cases (Vol. 4, Case 1777) Countway Library (Harvard Univ.) Mss., H MS b 72.4 (quoted at Macmillan 2000, p. 93).
   Macmillan & Lena (2010) presents previously unknown sources discovered post 2008.

   Of the primary sources, Harlow (1868) is by far the most informative, and Macmillan (2001) p. 161 and Macmillan (2000), p. 94 discuss its high general reliability. Accounts of Gage are compared to one another, and against the known facts, at Macmillan, M. "Phineas Gage's Story". Retrieved October 2, 2009. and in Macmillan 2000, esp. pp. 116–119 and chs. 13–14).

   The contrast between Gage's celebrity, and the small amount known about him, is discussed in Macmillan (2000) pp. 1–2, 11: "From my student days I had some appreciation of the importance ascribed to the case and expected there would be a reasonably extensive literature on it. This turned out not to be true. There were many mentions of him, but few papers solely or mainly about him. ... because Phineas Gage was said to be important in psychology, everyone would have been interested in him; because his survival was so remarkable, someone must have made a major study of him. Neither was the case."

6. ^ Quotations are from Ferrier (1877–9) and Macmillan (2000, p. 290). See Macmillan (2000 passim), Macmillan (2008, p. 831) and Barker (1995) for surveys and discussion of theoretical misuse of Gage. Smith (1886, p. 51) noted "the ingenuity with which advocates of various theories will explain away the evidence of their opponents"; other 19th-century exasperation was expressed by Dupuy (1877) and Jackson (1870).
7. ^ See Macmillan (2000), pp. 25–27 for the steps in setting a blast and the location and circumstances of the accident. The blast hole, about 1+3⁄4 inches (44 mm) in diameter and up to twelve feet (1.8 m) deep, might require three men working as much as a day to "drill" using hand tools. The labor invested in setting each blast, the judgment involved in selecting its location and the quantity of powder to be used, and the often explosive nature of employer-employee relations on this type of job, all underscore the significance of Harlow's statement that Gage's employers had considered him "the most efficient and capable foreman in their employ" prior to the accident.
8. ^ Boston Post, September 21, 1848, crediting an earlier report (unknown date) in the Ludlow Free Soil Union (Ludlow, Vermont). In quoting this early report (see image) here, its misstatement of the length and diameter (versus "circumference") of the tamping iron have been corrected; the words "shattering the upper jaw" have been omitted because that did not in fact happen; and has been added for clarity. See Harlow (1868), p. 342 for a description of the iron's path.
9. Harlow (1868), Fig. 2, p. 347: "Front and lateral view of the cranium, representing the direction in which the iron traversed its cavity; the present appearance of the line of fracture, and also the large anterior fragment of the frontal bone, which was entirely detached, replaced and partially re-united."
10. ^ Bigelow (1850), pp. 13–14. Harlow (1868, p. 344) listed among circumstances favoring Gage's survival "The shape of the missile—being pointed, round and comparatively smooth, not leaving behind it prolonged concussion or compression." Bigelow describes the iron's taper as seven inches long, but the correct dimension is twelve (corrected in the quotation); see Harlow (1848), p. 331 and Macmillan (2000), p. 26.
11. ^ Harlow wrote that Gage had been "a perfectly healthy, strong and active young man ... nervo-bilious 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 had scarcely a day's illness from his childhood to the date of this injury." (Nervo-bilious describes an rare combination of "excitable and active mental powers" with "energy and strength mind and body possible the endurance of great mental and physical labor.") He also emphasized the importance of the opening, created by the tamping iron, connecting Gage's cranium to his mouth, as "without this opening in the base of the skull, for drainage, recovery would have been impossible." As to his own role in Gage's survival, he merely averred, "I can only say, along with good old Ambrose Paré, I dressed him, God healed him" (Harlow 1868, pp. 330, 344, 346)—an assessment Macmillan calls far too modest (Macmillan 2000, pp. 12, 59–62, 346–7; and see Macmillan 2008, pp. 828–9; Macmillan 2001; and Barker 1995, pp. 679–80 for further discussion of Harlow's management of the case).
12. Harlow's notes (1868, p. 335) for September 24: "Failing strength ... During the three succeeding days the coma deepened; the globe of the left eye became more protuberant, with fungus pushing out rapidly from the internal canthus ... also large fungi pushing up rapidly from the wounded brain, and coming out at the top of the head". Here fungus does not mean an infecting mycosis but instead (Oxford English Dictionary) a "spongy morbid growth or excrescence, such as exuberant granulation in a wound" i.e. part of the body's own reaction to the injury (Macmillan 2000, pp. 54, 61–​2).
13. Contrary to common reports, Barnum's American Museum was not a traveling show but a stationary installation in New York City. There is no evidence Gage exhibited with a troupe or circus, or on a fairground (Macmillan & Lena 2010, pp. 3–4).
14. Commissioned by Harlow from photographer Samuel Webster Wyman (Macmillan 2000, p. 479), and here reproduced from Jackson (1870), these images were the basis of the woodcuts seen in Harlow (1868), p. 348 – see Macmillan (2000), pp. 26, 115, 479–80.
15. Harlow (1868), pp. 329–330, 342: "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. ...

    "It is to be 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 praiseworthy, 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 obligation, 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 fidelity in personally superintending the opening of the grave and forwarding what we so much desired to see."

16. Jackson (1870), p. v: "The most valuable specimen that has ever been added to the Museum, and probably every will be, was given two years ago by Dr. John M. Harlow, of Woburn ... For the professional zeal and the energy that Dr. H. showed, in getting possession of this remarkable specimen, he deserves the warmest thanks of the profession, and still more, from the College , for his donation."
17. Text of inscription from Macmillan, M. "Corrections to An Odd Kind of Fame". Retrieved October 2, 2009. The inscription's date for the accident is one day off, and Phinehas seems not to be how Gage spelled his name (figure, Macmillan 2008, p. 839); but the standardization of spelling may not have been well enough established at the time for this to be considered an error strictly speaking. See also earlier note re Gage's middle initial. The inscription was commissioned by Harvard's Dr. Bigelow in preparation for the iron's deposit in the Warren Anatomical Museum; the date following Gage's "signature" corresponds to the latter part of the period during which Gage was in Boston under Bigelow's observation.
18. ^ Ratiu et al. was the first study to account for the hairline fracture running from behind the exit region down the front of the skull, as well as fact that the hole in the base of the cranium (created as the iron passed through) seems to have a smaller diameter than does the iron itself—hypothesizing (as seen in their video reconstruction) that the skull "hinged" open as the iron entered the base of the cranium, and wss afterward pulled closed by the resilience of soft tissues once the iron had exited at the top. See Macmillan (2008), p. 830.
19. Specifically, Van Horn et al. estimated that although "extensive damage occurred to left frontal, left temporal polar, and insular cortex, the best fit rod trajectory did not result in the iron crossing the midline as has been suggested by some authors" (such as H. Damasio). "Fiber pathway damage extended beyond the left frontal cortex to regions of the left temporal, parietal, and occipital cortices as well as to basal ganglia, brain stem, and cerebellum. Inter-hemispheric connections of the frontal and limbic lobes as well as basal ganglia were also affected." (Quotations abridged to remove quantitative estimates of damage to each locus.)
20. A further consideration is potential reluctance on the part of Gage's friends and family, and of Harlow himself, to describe Gage negatively, especially while he was still alive (Macmillan 2000, pp. 106–8, 375–6). At Macmillan (2000), pp. 350–1 it is argued that an 1850 communication caling Gage "gross, profane, coarse, and vulgar" was anonymously supplied by Harlow.
21. For example, the "fitful, irreverent ... capricious and vacillating" Gage described in Harlow (1868) is somewhat at variance with Gage's stagecoach work in Chile, which required drivers "to 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 (Macmillan 2000, p. 106, citing K.A. Austin (1977). A Pictorial History of Cobb and Co.: The Coaching Age in Australia, 1854–1924. Sydney, Australia: Rigby. ISBN 0-7270-0316-X.); and see also Macmillan (2000), pp. 376–7 and Macmillan (2008), p. 839.
22. Curricular materials at one medical school (Nicholl, Jeffrey S., M.D. (2009). "Dementia Cases—Problem #1". Neurology Clerkship. New Orleans: Tulane Univ. School of Medicine. Retrieved November 1, 2009.{{cite web}}: CS1 maint: multiple names: authors list (link)) go so far as to present Gage as having been "accused of sexually molesting young children". Macmillan (2000), p. 327 refers to the complete lack of information on Gage's sexual life, and Macmillan & Lena (2010) discusses the continued absence of such data.
23. "Only Harlow writes of the exhumation and he does not say the tamping iron was recovered then. Although what he says may be slightly ambiguous, it does not warrant the contrary and undocumented account ... that Gage's tamping iron was recovered from the grave" (Macmillan & Lena 2010, p. 7, referencing Harlow 1868, p. 342).
24. " argued that psychiatric patients would benefit from having disinhibited behaviors like deliberately induced in them" (Macmillan 2000, p. 250).
25. ^ Lena & Macmillan (2010), citing also B. & J. Wilgus. The image seen here is in the possession of Tara Gage Miller of Texas; an identical image belongs to Phyllis Gage Hartley of New Jersey. (Gage had no known children—see Macmillan 2000, pp. 319,327; these are descendents of certain of his relatives—see Macmillan & Lena 2010, p. 4.) Unlike the Wilgus portrait, which is an actual daguerreotype, the Miller and Hartley images are 19th-century photographic reproductions of a common original which remains undiscovered, itself a daguerreotype or other laterally (left-right) reversing early-process photograph; a second, compensating reversal has been applied here to show Gage as he appeared in life. Gage's shirt and tie are different in the Miller-Hartley image than in the Wilgus image, though he is wearing the same waistcoat and possibly the same jacket; see Wilgus, B. & J. "A New Image of Phineas Gage". Retrieved March 10, 2010.
26. Macmillan & Aggleton (2011): "Phineas' survival and rehabilitation demonstrated a theory of recovery which has influenced the treatment of frontal lobe damage today. 'There are something like 15 or 20 cases of people who've recovered from very serious frontal brain injury, of the kind that Phineas suffered from, without any professional assistance. In every case, what's common in the reports is that someone, or something, has taken over the lives of these people and given them structure.' In modern treatment, adding structure to tasks by, for example, mentally visualising a written list, is considered a key method in coping with frontal lobe damage. 'Phineas worked as a stage-coach driver,' continues Professor Macmillan. 'The job is one that has got an external structure. You've got to be here for this part, then there's that part, then there's something else. Just as with these cases who have recovered.'"

References

1. Macmillan (2000), pp. 319,327
2. Campbell, H.F. (1851) "Injuries of the Cranium—Trepanning". Ohio Med & Surg J 4(1), pp. 20–24, crediting the Southern Med & Surg J (unknown date)
3. Barker (1995); Macmillan (2000), chs. 7–9.
4. Macmillan (2000) pp. 17,41
5. Macmillan (2000), pp. 17–18.
6. Smith (1886), p.54
7. ^ Harlow (1848), p. 331.
8. Excerpted from Williams' statement, in Bigelow (1850), pp. 15–16.
9. Excerpted from Harlow (1848), p. 390.
10. Excerpted from Harlow (1848) and Harlow (1868).
11. Harlow (1848), pp. 391–3; Bigelow (1850), pp. 17–19; Harlow (1868), pp. 334–8.
12. ^ Harlow (1868), pp. 339–342.
13. Harlow (1849); Harlow (1868), p. 338–9.
14. ^ Macmillan, M. "Phineas Gage: Unanswered questions". Retrieved October 2, 2009.
15. Macmillan (2000), pp. 119–120.
16. Harlow (1848), p. 389; Bigelow (1850), pp. 21–2; Harlow (1868), pp. 343, 345; Dupuy (1877); Ferrier (1878). See also:
    • Bramwell, B. (1888) "The Process of Compensation and some of its Bearings on Prognosis and Treatment". Br Med J 1(1425):835–840 doi:10.1136/bmj.1.1425.835
    • Cobb, S. (1940) "Review of neuropsychiatry for 1940". Arch Intern Med 66:1341–54
    • Cobb, S. (1943) Borderlands of psychiatry. Harvard Univ. Press.
    • Tyler, K.L. and Tyler, H.R. (1982) "A 'Yankee Invention': the celebrated American crowbar case". Neurology 32:A191.
17. ^ Damasio, H. and T. Grabowski, R. Frank, A.M. Galaburda, A.R. Damasio (1994). "The return of Phineas Gage: clues about the brain from the skull of a famous patient". Science. 264 (5162): 1102–5. doi:10.1126/science.8178168. PMID 8178168.{{cite journal}}: CS1 maint: multiple names: authors list (link)
18. See Macmillan (2008), pp. 829–30.
19. http://www.nejm.org/doi/full/10.1056/NEJMicm031024
20. Macmillan & Lena (2010), p. 9; Harlow (1868), pp. 332, 345; Bigelow (1850), pp. 16–17; Bigelow (1848), p. 390; Macmillan (2000), p. 86.
21. ^ Macmillan & Lena (2010) passim.
22. Harlow (1848), p. 393.
23. Macmillan (2000), pp. 90, 375.
24. Macmillan (2000), pp. 117–8 (Table 6.1); Harlow (1868), pp. 339–41,345.
25. Macmillan (2000), pp. 90–95.
26. ^ Damasio A.R. (2005). "A Modern Phineas Gage". Descartes' Error: Emotion, Reason, and the Human Brain. ISBN 0-14-303622-X. (1st ed.: 1994)
27. Damasio A.R.; Everitt, B.J.; Bishop, D. (1996). "The somatic marker hypothesis and the possible functions of the prefrontal cortex". Philos T Roy Soc B. 351 (1346): 1413–20. doi:10.1098/rstb.1996.0125. PMID 8941953.
28. Macmillan (2000), p. 107.
29. Hockenbury D.H. and S.E. Hockenbury (1997) Psychology.
30. Barker (1995); Macmillan (2000), ch. 9, esp. p. 188.
31. Ferrier (1878); Dupuy (1877).
32. Sizer, p 194.
33. For example, Carlson, N.R. (1994). Physiology of Behavior. p. 341. ISBN 0-205-07264-X. See additional discussion at Macmillan (2000), p. 246.
34. Macmillan (2000), p. 250, and see chs. 10–11 generally; see also Macmillan, M. "Phineas Gage and Frontal Lobotomies". Retrieved October 2, 2009.
35. Fleischman (2002)
36. ^ Macmillan (2008), p. 831
37. ^ Macmillan, M. "More About Phineas Gage". Retrieved October 2, 2009.
38. Twomey (2010)
39. ^ Wilgus (2009)
40. Wilgus, B. & J. "Meet Phineas Gage". Retrieved October 2, 2009.

Sources and further reading

Minor additional sources are given in the Notes and References (above).

Further reading (and viewing) for general audiences

• Fleischman, J. (2002). Phineas Gage: A Gruesome but True Story About Brain Science. ISBN 0-618-05252-6. (Intended for middle-school students)
• Lena, M.L. and M. Macmillan (2010). "Picturing Phineas Gage" (invited comment). Smithsonian. March 2010. p. 4
• Macmillan, M. The Phineas Gage Information page, School of Psychology, Deakin Univ., Victoria, Australia, including "Phineas Gage: Unanswered questions". Retrieved October 2, 2009.
• Macmillan, M. (2008). "Phineas Gage—Unravelling the myth". The Psychologist 21(9):828–831. British Psychological Society.
• Macmillan, M. (2000). An Odd Kind of Fame: Stories of Phineas Gage. MIT Press. ISBN 0-262-13363-6 (hbk, 2000) ISBN 0-262-63259-4 (pbk, 2002). Appendices reproduce Harlow (1848, 1849, and 1868), Bigelow (1850) and other key sources, some unavailable elsewhere.
  • See also Macmillan, "Corrections to An Odd Kind of Fame".
  • Review: Seamus Sweeney. "An odd kind of fame". nthposition.com.
• Macmillan, M.; Aggleton, John (March 6, 2011). "Phineas Gage: The man with a hole in his head" (Interview). Interviewed by Claudia Hammond; Dave Lee. {{cite interview}}: Unknown parameter |callsign= ignored (help); Unknown parameter |program= ignored (help)CS1 maint: multiple names: interviewers list (link)
• Ratiu et al., Video reconstruction of tamping iron passing through Gage's skull in P. Ratiu and I.F. Talos (2004). "Images in Clinical Medicine: The Tale of Phineas Gage, Digitally Remastered". New Engl J Med. 351 (23): e21 (Web only). doi:10.1056/NEJMicm031024. PMID 15575047. Technical description at P. Ratiu, I.F. Talos, S. Haker, S. Lieberman, P. Everett (2004). "The tale of Phineas Gage, digitally remastered". J Neurotrauma. 21 (5): 637–43. doi:10.1089/089771504774129964. PMID 15165371.{{cite journal}}: CS1 maint: multiple names: authors list (link)
• Twomey, S. (2010). "Finding Phineas". Smithsonian. 40 (10): 8–10 (January 2010).
• Wilgus, B. & J (2009). "Face to Face with Phineas Gage". J Hist Neurosciences. 18 (3): 340–345. doi:10.1080/09647040903018402. PMID 20183215.

For specialists

• Barker, F.G. II (1995) "Phineas among the phrenologists: the American crowbar case and nineteenth-century theories of cerebral localization." J Neurosurg 82:672–682
• Harlow, John Martyn (1868). "Recovery from the Passage of an Iron Bar through the Head." Publ Massachusetts Med Soc 2:327–347. Reproduced in Macmillan (2000).
• Macmillan, M. (1986). "A wonderful journey through skull and brains: The travels of Mr. Gage's tamping iron". Brain and Cognition. 5 (1): 67–107. doi:10.1016/0278-2626(86)90062-X. PMID 3513803.
• Macmillan, M. (2000). "Restoring Phineas Gage: A 150th retrospective". J Hist Neurosciences. 9 (1): 42–62. doi:10.1076/0964-704X(200004)9:1;1-2;FT046.
• Macmillan, M. (2001). "John Martyn Harlow: 'Obscure Country Physician'?". J Hist Neurosciences. 10 (2): 149–162 at 161. doi:10.1076/jhin.10.2.149.7254.
• Macmillan, M. and M. L. Lena (May 17, 2010). "Rehabilitating Phineas Gage". Neuropsychol Rehabil. 20: 1–18. doi:10.1080/09602011003760527. PMID 20480430.
• Van Horn, John D. (2012). "Mapping Connectivity Damage in the Case of Phineas Gage". PLoS ONE. 7 (5): e37454. doi:10.1371/journal.pone.0037454. PMID 22616011. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)CS1 maint: unflagged free DOI (link)

Other works cited

• Bigelow, Henry Jacob (1850). "Dr. Harlow's case of Recovery from the passage of an Iron Bar through the Head." Am J Med Sci 20:13–22(July 1850). Reproduced in Macmillan (2000).
• Dupuy, E. (1877) "A critical review of the prevailing theories concerning the physiology and the pathology of the brain: localisation of functions, and mode of production of symptoms." Part II. Med Times & Gaz v. II pp. 356–8.
• Ferrier, D. (1877–9) Correspondence with Henry Pickering Bowditch. Countway Library (Harvard Univ.) Mss., H MS c 5.2 (transcribed in Macmillan 2000, pp. 464–5).
• Ferrier, D. (1878) "The Goulstonian lectures of the localisation of cerebral disease." Lecture I (concluded). Br Med J 1(900):443–7
• Harlow, John Martyn (1848). "Passage of an iron rod through the head". Boston Med & Surg J 39(20):389–393. Reproduced in Neylan, T.C. (1999) "Frontal Lobe Function: Mr. Phineas Gage's Famous Injury." J Neuropsych Clin N. 11, 281–283; and in Macmillan (2000).
• Harlow, John Martyn (1849). Letter in "Medical Miscellany." Boston Med & Surg J 39:506–7. Reproduced in Macmillan (2000).
• Jackson, J.B.S. (1870) A Descriptive Catalog of the Warren Anatomical Museum Frontis. and Nos. 949–51, 3106 (Republished in Macmillan 2000, in which see also p. 107).
• Sizer, Nelson (1888). Forty years in phrenology; embracing recollections of history, anecdote, and experience. Fowler & Wells.
• Smith, William T. (1886) "Lesions of the Cerebral Hemispheres". T Vermont Med Soc for the Year 1885. pp. 46–58.

External links

• Macmillan, M. "Phineas Gage: Unanswered questions". Retrieved October 2, 2009. Lists research questions related to Gage in localities throughout the United States and Chile, for which Gage researchers request assistance from the public.
• Meet Phineas Gage—the story of how the owners of the 2009-discovered daguerreotype learned it depicted Gage.
• Phineas Gage roadside memorial, Cavendish, Vermont

Template:Persondata

• 1823 births
• 1860 deaths
• History of neuroscience
• American people in rail transportation
• American expatriates in Chile
• People from Grafton County, New Hampshire
• People from Windsor County, Vermont
• Burials in California
• People with brain injuries