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

Phineas P. Gage (1823–1860) was an American railroad construction foreman remembered for his improbable survival of an accident in which a large iron rod was driven completely through his head, destroying much of his brain's left frontal lobe, and for that injury's reported effects on his personality and behavior over the remaining twelve years of his life—effects so profound that (for a time at least) 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. Despite this celebrity the body of established fact about Gage and what he was like (before or after his injury) is remarkably small, which has allowed "the fitting of almost any theory to the small number of facts we have"—Gage having been cited, over the years, in support of various theories of the brain entirely inconsistent with one another. 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 mental condition late in life, were published in 2009 and 2010. This new evidence indicates that Gage's most serious mental changes may have been temporary, so that in later life he was far more functional, and socially far better adjusted, than was previously assumed. A social recovery hypothesis suggests that Gage's employment as a stagecoach driver in Chile provided daily structure allowing him to relearn lost social and personal skills.

Background

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

He may have gained skill with explosives on the family's farms or in nearby mines and quarries, and by the time of his accident he was a blasting foreman (possibly an independent contractor) on railway construction projects. His employers considered him (as town doctor John Martyn Harlow later put it) "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 (1.1m) long, and 1+1⁄4 inches (3.2 cm) in diameter—for use in setting charges.

Gage's injury

External videos
Video reconstruction of tamping iron passing through Gage's skull (Ratiu etal. 2004).

On September 13, 1848 Gage (aged 25) was directing 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 an outcropping of rock; adding blasting powder, a fuse, and sand; 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."

Despite nineteenth-century references to Gage 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+1⁄4pounds (6 kg) this "abrupt and intrusive visitor" was found some 80feet (25m) away, "smeared with blood and brain."

Gage "was thrown upon his back by the explosion, and gave a few convulsive motions of the extremities, but spoke in 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 some thirty minutes after the accident:

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.

Harlow took charge of the case around 6p.m.:

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. His person, and the bed on which he was laid, were literally one gore of blood.

Convalescence

Despite Harlow's skillful care, Gage's recuperation was long and difficult. Pressure on the brain left him semi-comatose from September23 to October3, "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 October7 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."

Subsequent life and travels

Injuries

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. 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."

New England

Harlow says that Gage, unable to return to his railroad work, 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.

Chile and California

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; he died status epilepticus in or near San Francisco on May21, just under twelve years after his injury, and was buried in San Francisco's Lone Mountain Cemetery. (Some accounts assert that Gage's iron was buried with him, but there appears to be no evidence for this.)

Skull and iron

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 initiated a correspondence with Gage's family there. At Harlow's request they opened Gage's grave long enough to remove his skull, which the family then personally delivered to Harlow back in New England.

About a year after the accident, Gage had given his tamping iron to 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 too was delivered to Harlow. After studying them for a triumphal retrospective paper on Gage, 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 (though the date it gives for the accident is one day off, and Phinehas is not the way Gage spelled his name)::

This is the bar that was shot through the head of M Phinehas P.Gage at Cavendish, Vermont, Sept.14, 1848. He fully recovered from the injury& deposited this bar in the Museum of the Medical College of Harvard University. PhinehasP. Gage Lebanon Grafton Cy N–H Jan6 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

Debate as to whether the trauma and subsequent infection had damaged both of Gage's frontal lobes, or only the left, began almost immediately after his accident. The 1994 conclusion of H.Damasio etal., that both frontal lobes were damaged, was drawn by modeling not Gage's skull but rather a "Gage-like" one. In 2004 Ratiu etal. used CT scans of Gage's actual skull to confirm Harlow's conclusion (based on probing Gage's wounds with his finger) that the right hemisphere had remained intact. Van Horn etal. (2012) agree that the right hemisphere was undamaged, and make detailed estimates of the locus and extent of damage to Gage's white matter, suggesting 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 injury, 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 the accident), 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.

Harlow's 1848 report

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, Harvard Professor of Surgery Henry Jacob Bigelow (in keeping with his anti-localizationist training) went so far as to say that Gage was "quite recovered in faculties of body and mind," there being only "inconsiderable disturbance of function".

Harlow's 1868 report

Not until 1868 did Harlow (having obtained Gage's skull, tamping iron, and late-life history) deliver the "future communication" he had promised twenty years earlier, detailing the mental changes found today in most presentations of the case (though usually in exaggerated or distorted form—see Distortion of mental changes, below). In memorable language, he 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, and 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 post-accident life during which each described behavior was present. This complicates reconstruction of how Gage's behavior changed over time, a critical task in light of evidence that his behavior at the end of his life was very different from his behavior (described by Harlow above) immediately post accident.

Social recovery

In 2008 a report was discovered calling Gage mentally unimpaired during his last years in Chile (from a physician who had known him "well" there), and since then a description of what may have been his daily work routine there as a stagecoach driver, and advertisements for two previously unknown public appearances. 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 far better adapted, than previously assumed.

Psychologist Malcolm 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, Macmillan 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 asks, if Gage could achieve such improvement without medical supervision, "what are the limits for those in formal rehabilitation programs?"

Distortion of mental changes

A moral man, Phineas Gage
Tamping powder down holes for his wage
Blew his special-made probe
Through his left frontal lobe
Now he drinks, swears, and flies in a rage.

In the only book dedicated to the case, An Odd Kind of Fame:Stories of Phineas Gage (2000), Macmillan carries out a comprehensive analysis of accounts of Gage (scientific and popular), finding that they almost always distort and exaggerate his behavioral changes well beyond anything described by anyone who had actual contact with him. In the words of Barker, "As years passed, the case took on a life of its own, accruing novel additions to Gage's story without any factual basis", and even today (writes historian Zbigniew Kotowicz) "Most commentators still rely on hearsay and accept what others have said about Gage, namely, that after the accident he became a psychopath..."

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, thievery, and acting "like an idiot". Macmillan's detailed analysis shows that none of these behaviors is mentioned by anyone who had met Gage or even his family; as Kotowicz writes, "Harlow does not report a single act that Gage should have been ashamed of."

For example, Antonio Damasio and Hanna Damasio 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 and "never returned to a fully independent existence". In fact Harlow's words refer not to Gage's post-accident life in general, but only to the months just before his death, after convulsions had set in; and until then Gage had supported himself throughout his adult life.

Theoretical use, misuse, and nonuse

Though Gage is considered the "index case for personality change due to frontal lobe damage" his scientific value is undermined by the uncertain extent of his brain damage combined with the lack of information about his behavioral changes. Instead, 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". A similar concern had been 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...

More recently Sacks refers to the "interpretations and misinterpretations, from 1848 to the present," of Gage.

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, soon after Dupuy wrote that Gage proved that the brain is not localized, Ferrier cited Gage as proof that it is. Phrenologists made use of Gage as well, contending that his mental changes resulted from destruction of his "organ of Veneration" and/or the adjacent "organ of Benevolence".

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

grotesque fabrication... the myth of Gage the psychopath... Damasio changes narrative, omits facts, and adds freely to his story... It seems that the growing commitment to the frontal lobe doctrine of emotions brought Gage to the limelight and shapes how he is described.

Or as Kihlstrom put it:

any modern commentators exaggerate the extent of Gage's personality change, perhaps engaging in a kind of retrospective reconstruction based on what we now know, or think we do, about the role of the frontal cortex in self-regulation.

Psychosurgery and lobotomy

It is frequently said that what happened to Gage played a part in the later development of various forms of psychosurgery, particularly lobotomy. Aside from the question of why the unpleasant changes usually (if hyperbolically) attributed to Gage would inspire surgical imitation, careful inquiry turns up no such link, according to Macmillan:

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.

Portraits

In 2009 a daguerreotype portrait of Gage was discovered, the first likeness of him identified other than a life mask taken by Bigelow in late 1849. 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 it showed an injured whaler with his harpoon.) Authenticity was confirmed in several ways, including photo-overlaying the inscription visible in the portraits against that on the actual tamping iron in Harvard's Warren Anatomical Museum, and matching the injuries seen in the portraits against those preserved in the life mask.

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. The 2009-identified image is 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.

The 2010-identified image 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; these are descendents of certain of his relatives—see Macmillan& Lena 2010.) 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; here again a second, compensating reversal has been applied. The shirt and tie Gage is wearing in the Miller–Hartley image are different from those seen in the Wilgus image, though he is wearing the same waistcoat in both, and possibly the same jacket.

See also

• Anatoli Bugorski—scientist through whose head a particle-accelerator proton beam accidentally passed
• Eadweard Muybridge—another early case of head injury leading to mental changes
• Prefrontal Cortex

Notes

1. ^ Macmillan (2000) discusses Gage's ancestry and what is and isn't known about 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), and is consistent with agreement, among the numerous contemporary sources addressing the point, that Gage was 25 years old at the time of the accident, as well as with Gage's age—36 years—as given in undertaker's records after his death on May 21, 1860.

   There is no doubt Gage's middle initial was P but there is nothing to indicate what the P stood for (though his paternal grandfather was also named Phineas).

   Gage's mother's maiden name is variously spelled Swetland, Sweatland, or Sweetland.

2. ^ Gage's death and (original) burial are discussed at Macmillan (2000). Harlow (1868) gives the date of Gage's death as May 21, 1861, but undertaker's records show conclusively that Gage was buried May23, 1860. That Harlow (though in contact with Gage's mother as he was writing) was mistaken by exactly one year implies that certain other dates he gives 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 (each of which carries this annotation).
3. ^ A tone of amused 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). 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) emphasized that though "at first wholly skeptical, I have been personally convinced", calling the case "unparalleled in the annals of surgery". This endorsement by Bigelow, Professor of Surgery at Harvard, helped end scoffing about Gage among medical men—one of whom, Harlow (1868) 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) 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 circular saw cut three inches (8cm) into his skull from just between the eyes to behind the top of his head (the surgeon removing from this incision "thirty-two pieces of bone, together with considerable sawdust"), the Boston Medical& Surgical Journal (1869) pretended to wonder whether the brain has any function at all: "Since the antics of iron bars, gas pipes, and the like skepticism is discomfitted, and dares not utter itself. Brains do not seem to be of much account now-a-days." The Transactions of the Vermont Medical Society (Smith 1886) 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."

   The reference to Gage's iron as an "abrupt and intrusive visitor" appears in the Boston Medical& Surgical Jouurnal's review of Harlow (1868).

4. For scientific and academic discussions see Macmillan; in particular, Macmillan found Gage cited in some 60% of introductory psychology textbooks in three university libraries. A small study found Gage to be easily the topic most frequently mentioned when, at the end of an introductory psychology course, students were asked to list "the first 10 things that come to your mind as you answer the question: What do you remember from this course?"; investigators noted that, "The Phineas Gage video re-creates the famous tamping rod piercing Gage’s skull. Students... always react emotionally to this video clip."

   For popular culture, see Macmillan (2000) and Macmillan (2008); for example, several musical groups call themselves Phineas Gage (or some variation).

5. ^ Accounts of Gage are compared to one another, and against the known facts, at Macmillan (PGIP) and in Macmillan 2000. According to Macmillan& Lena (2010, and see also Macmillan 2000) 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 with his family, were limited (until 2008) to Harlow (1848, 1849, 1868); Bigelow (1850); Jackson (1870);; Jackson (1849). Macmillan& Lena (2010) present previously unknown sources discovered post 2008.

   Macmillan (2001) and Macmillan (2000) discuss the high general reliability of Harlow (1868), and its primacy as a source.

   The contrast between Gage's celebrity, and the small amount known about him, is discussed in Macmillan (2000): "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. ^ See Macmillan (2000) and Macmillan (2008) for surveys and discussion of theoretical misuse of Gage, and Barker (1995) for, specifically, the way in which 19th-century reports of Gage were colored by various writers' doctrinal leanings:

   The educational backgrounds of Harlow and Bigelow 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 that damage to the cerebral hemispheres had no intellectual effect, and he was unwilling to consider Gage's deficit significant... The use of a single case to prove opposing views on phrenology was not uncommon.

   Smith (1886) noted "the ingenuity with which the advocates of various theories will explain away the evidence of their opponents."
7. ^ See Macmillan (2000) and Macmillan (PGIP) for the steps in setting a blast and the location and circumstances of the accident. The blast hole, about 1+3⁄4 inches (4.5cm) in diameter and up to 12 feet (4m) deep, might require three men working as much as a day to bore 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. ^ Ratiu etal. was the first study to account for the hairline fracture running from behind the exit region down the front of Gage's skull, as well as fact that the hole between the roof of the mouth and the base of the cranium (created as the iron passed through) has a diameter about half that of the iron itself—hypothesizing that the skull "hinged" open as the iron entered the base of the cranium, and was afterward pulled closed by the resilience of soft tissues once the iron had exited at the top.
9. ^ Boston Post, September 21, 1848, crediting an earlier report (unknown date) in the Ludlow Free Soil Union (Ludlow, Vermont). This early report misstates the length of the tamping iron, and confuses its circumference with its diameter. Also, despite its reference to the "shattering the upper jaw", that did not in fact happen. See Harlow (1868) for a description of the iron's path.
10. Bigelow describes the iron's taper as seven inches long, but the correct dimension is twelve (corrected in the quotation).
11. ^ Excerpted from Williams' and Harlow's statements in: Harlow (1848); Bigelow (1850); Harlow (1868).
12. ^ As to his own role in Gage's survival, Harlow merely averred, "I can only say... with good old Ambrose Paré, I dressed him, God healed him"—an assessment Macmillan (2000) calls far too modest. See Macmillan (2008), Macmillan (2001) and Barker (1995) for further discusssion of Harlow's management of the case.
13. Harlow's notes 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"—that is, part of the body's own reaction to the injury.
14. Unlike Barnum's later circus, his 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).
15. Here reproduced from Jackson (1870), these images were commissioned by Harlow from photographer Samuel Webster Wyman and were the basis for the woodcuts seen in Harlow (1868).
16. Apparently quoting Gage's mother, Harlow narrates that

    while sitting at dinner, fell in a fit, and soon after had two or three fits in succession... " 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, 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.

17. Macmillan& Lena: "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."
18. Macmillan (PGIP) gives the text of the inscription, which was commissioned by Bigelow in preparation for the iron's deposit in the Warren Anatomical Museum. The Jan 6 1850 following Gage's "signature" corresponds to the latter part of the period during which Gage was in Boston under Bigelow's observation.
19. Early authors attempting to estimate the extent of damage include: Harlow (1848); Bigelow (1850); Harlow (1868); Dupuy (1877); Ferrier (1878). See also Bramwell (1888); Tyler& Tyler (1982); Cobb (1940, 1943).
20. See Macmillan& Lena (2010); Harlow (1868); Bigelow (1850); Harlow (1848); Macmillan (2000).
21. Specifically, Van Horn etal. 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.)
22. Macmillan (2000) also discusses 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, and argues that an 1850 communication calling Gage "gross, profane, coarse, and vulgar" was anonymously supplied by Harlow.
23. 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 demanded that drivers "be reliable, resourceful, and possess great endurance. But above all, they had to have the kind of personality that enabled them to get on well with their passengers" (Macmillan 2000, citing Austin 1977)—and note Gage was hired by his employer in advance, in New England, to be part of the new coaching enterprise in Chile.
24. Fleischman (2002). See also Kotowicz (2007): "There is coherence and dignity in the way Gage dealt with his predicament. He deserves deep respect."
25. 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.'"
26. Though Macmillan (2000) refers to the complete lack of information on Gage's sexual life, and Macmillan& Lena (2010) discusses the continued absence of such information, curricular materials at one medical school go so far as to present Gage as having been "accused of sexually molesting young children".
27. For end-of-life employment difficulties see Macmillan (2000), p.107; for misinterpretation and self-support, see Macmillan& Lena (2010) passim, as well as Kotowicz (2007): "What Harlow is telling us is clear and unambiguous: Gage returns from South America to his mother to recuperate. As soon as he is fit, he goes back to work with horses, which is what he has been doing for years."
28. Kotowicz (2007), which continues, " account of Gage's last months such a grotesque fabrication that it leaves one baffled," then quotes á passage from A.Damasio (1994):

    In my mind is a picture of 1860's San Francisco as a bustling place, full of adventurous entrepreneurs engaged in mining, farming, and shipping. That is where we can find Gage's mother and sister, the latter married to a prosperous San Francisco merchant (D.D. Shattuck, Esquire), and that is where the old Phineas Gage might have belonged. But that is not where we would find him if we could travel back in time. We would probably find him drinking and brawling in a questionable district, not conversing with the captains of commerce, as astonished as anybody when the fault would slip and the earth would shake threateningly. He had joined the tableau of dispirited people who, as Nathanael West would put it decades later, and a few hundred miles to the south, "had come to California to die".

    Kotowizc comments: "This little literary flourish is pure invention... There is something callous in insinuating that Gage was some riff-raff who in his final days headed for California to drink and brawl himself to death."

    Macmillan (2000) gives detailed criticism of A.Damasio's various presentations of Gage (some of them in joint work with H.Damasio and others).

29. Kihlstrom (2010). See also Grafman:: "Although has been used to exemplify the problems that patients with ventromedial PFC [prefrontal cortex] lesions have in obeying social rules, recognizing social cues, and making appropriate social decisions, the details of this social cognitive impairment have occasionally been inferred or even embellished to suit the enthusiasm of the story teller—at least regarding Gage" (citing Macmillan 2000).
30. See for example Carlson (1994); additional examples and discussion are at Macmillan (2000).
31. " argued that psychiatric patients would benefit from having disinhibited behaviors like deliberately induced in them" (Macmillan 2000).
32. "Indeed, the recent discovery of daguerreotype portraits of Mr. Gage show a 'handsome... well dressed and confident, even proud' man in the context of 19th-century portraiture. That he was any form of vagrant following his injury is belied by these remarkable images." (Van Horn 2012, quoting Wilgus 2009)

Sources and further reading

1. ^
   ——— (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) and Bigelow (1850)
    • See also "Corrections to An Odd Kind of Fame".
2. Campbell, H.F. (1851). "Injuries of the Cranium—Trepanning". Ohio Med& Surg J. 4 (1): 20–24. (crediting the Southern Med& Surg J (unknown date).
3. ^ Barker, F.G.II (1995). "Phineas among the phrenologists: the American crowbar case and nineteenth-century theories of cerebral localization". JNeurosurg. 82: 672–682.
4. Vanderstoep, S.W.; Fagerlin, A.; Feenstra, J.S. (2000). "What Do Students Remember from Introductory Psychology?" (PDF). Teaching of Psychology. 27 (2): 89. doi:10.1207/S15328023TOP2702_02.
5. ^
   ——— (2008). "Phineas Gage—Unravelling the myth" (PDF). The Psychologist. 21 (9). British Psychological Society: 828–831.
6. ^
   Harlow, John Martyn (1848). "Passage of an Iron Rod through the Head". Boston Med& Surg J. 39 (20): 389–393. (Transcription.)
7. ^
   Harlow, John Martyn (1868). "Recovery from the Passage of an Iron Bar through the Head". Publ Massachusetts Med Soc. 2: 327–347.
8. ^
   Bigelow, Henry Jacob (July 1850). "Dr. Harlow's Case of Recovery from the Passage of an Iron Bar through the Head". Am J Med Sci. 20: 13–22. Reproduced in Macmillan (2000).
9. "Horrible Accident". Boston Post. September 21, 1848.
10. ^
    Macmillan, Malcolm B. (PGIP). "The Phineas Gage Information Page". The University of Akron. Retrieved July 22, 2013. {{cite web}}: Check date values in: |year= (help)CS1 maint: year (link) Includes:

    A. "Phineas Gage Sites in Cavendish".

    B. "Phineas Gage: Unanswered questions".

    C. "Phineas Gage's Story".

    D. "Corrections to An Odd Kind of Fame".

    E. "Phineas Gage: Psychosocial Adaptation".

    F. "Phineas Gage and Frontal Lobotomies".

11. ^ Smith, William T (1886). "Lesions of the Cerebral Hemispheres]". TVermont Med Soc for the Year 1885. pp. 46–58.
12. ^ ———. "A Descriptive Catalog of the Warren Anatomical Museum". {{cite journal}}: |chapter= ignored (help); Cite journal requires |journal= (help) Reproduced in Macmillan (2000), in which see also p.107.
13. Folsom, A.C. (1869). "Extraordinary Recovery from Extensive Saw-Wound of the Skull". Pacific Medical and Surgical Journal. pp. 550–555. {{cite news}}: Unknown parameter |month= ignored (help)
14. "Medical Intelligence. Extraordinary Recovery". Boston Medical& Surgical Journal. 3n.s. (13): 230–1. April 29, 1869.
15. ^ "Bibliographical Notice". Boston Medical& Surgical Journal. 3n.s. (7): 116–7. March 18, 1869.
16. ^
    ——— (2001). "John Martyn Harlow: Obscure Country Physician?". Journal of the History of the Neurosciences. 10 (2): 149–162. doi:10.1076/jhin.10.2.149.7254. PMID 11512426.
17. ^ ——— (1849). "Medical Miscellany (letter)". Boston Med& Surg J. 39: 506–7. Reproduced in Macmillan (2000).
18. ^
    ———; Lena, M.L. (2010). "Rehabilitating Phineas Gage". Neuropsychological Rehabilitation. 20 (5): 641–658. doi:10.1080/09602011003760527. PMID 20480430.
19. Volume 3: Lone Mountain register, 1850-1862, Halsted N.Gray – Carew& English Funeral Home Records (SFH 38), San Francisco History Center, San Francisco Public Library. p. 285.
20. ^ Damasio, H.; Grabowski, T.; Frank, R.; Galaburda, A.M.; Damasio, A.R. (1994). "The return of Phineas Gage: Clues about the brain from the skull of a famous patient". Science. 264 (5162): 1102–1105. doi:10.1126/science.8178168. PMID 8178168.
21. ^ Damasio A.R. (1994). Descartes' Error: Emotion, Reason, and the Human Brain. ISBN 0-14-303622-X. (2nd ed.:2005)
22. ^ Hockenbury, Don H.; Hockenbury, Sandra E. (2008). Psychology. p. 74. ISBN 978-1-429-20143-8.
23. Eliot, Samuel Atkins, ed. (1911). "JohnM. Harlow". Vol. 1. Massachusetts Biographical Society. {{cite book}}: |work= ignored (help); Missing or empty |title= (help)
24. ^ Dupuy, Eugene (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. PartII". Med Times& Gaz. II: 356–8.
25. ^ ——— (1878). "The Goulstonian lectures of the localisation of cerebral disease. LectureI (concluded)". Br Med J. 1 (900): 443–7.
26. Bramwell, B. (1888). BMJ. 1 (1425): 835–840. doi:10.1136/bmj.1.1425.835. PMC 2197878. PMID 20752265 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2197878. {{cite journal}}: Missing or empty |title= (help)
27. Tyler, K.L.; Tyler, H.R. (1982). "A 'Yankee Invention': the celebrated American crowbar case". Neurology. 32: A191.
28. Cobb, S (1940). "Review of neuropsychiatry for 1940". Arch Intern Med. 66: 1341–54.
29. ——— (1943). Borderlands of psychiatry. Harvard Univ. Press.
30. ^ Ratiu, P.; Talos, I.F.; Haker, S.; Lieberman, D.; Everett, P. (2004). "The Tale of Phineas Gage, Digitally Remastered". Journal of Neurotrauma. 21 (5): 637–643. doi:10.1089/089771504774129964. PMID 15165371.
31. ^ ———; Talos, I.F. (2004). "The Tale of Phineas Gage, Digitally Remastered". New England Journal of Medicine. 351 (23): e21. doi:10.1056/NEJMicm031024. PMID 15575047.
32. ^ Van Horn, J.D.; Irimia, A.; Torgerson, C.M.; Chambers, M.C.; Kikinis, R.; Toga, A.W. (2012). "Mapping Connectivity Damage in the Case of Phineas Gage". PLoS ONE. 7 (5): e37454. doi:10.1371/journal.pone.0037454. PMC 3353935. PMID 22616011.{{cite journal}}: CS1 maint: unflagged free DOI (link)
    
    

    Of historical interest

33. Jackson, J.B.S. (1849). Medical Cases. 4 (Case 1777). {{cite journal}}: Missing or empty |title= (help) Countway Library (Harvard Univ.) Mss., HMSb72.4.
34. Austin, K.A. (1977). A Pictorial History of Cobb and Co.: The Coaching Age in Australia, 1854–1924. Sydney: Rigby. ISBN 0-7270-0316-X.
35. ^ Fleischman, J. (2002). Phineas Gage: A Gruesome but True Story About Brain Science. ISBN 0-618-05252-6.
    
    

    For researchers and specialists

36. ^ Kotowicz, Z. (2007). "The strange case of Phineas Gage". History of the Human Sciences. 20 (1): 115–131. doi:10.1177/0952695106075178.
37. 
    ———; Aggleton, John (March 6, 2011). "Phineas Gage: The man with a hole in his head" (Audio 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)
    
    

    For general audiences (portraits)

38. 
    ——— (July 2009). "More About Phineas Gage, Especially After the Accident". Retrieved July 27, 2013.
39. Nicholl, Jeffrey S. (2009). "Dementia Cases—Problem#1". Neurology Clerkship. New Orleans: Tulane Univ. School of Medicine. Retrieved November 1, 2009.
40. Stuss, D.T.; Gow, C.A.; Hetherington, C.R. (1992). "'No longer Gage': Frontal lobe dysfunction and emotional changes". Journal of Consulting and Clinical Psychology. 60 (3): 349–359. doi:10.1037/0022-006X.60.3.349. PMID 1619089.
41. ^ Fuster, Joaquin M. (2008). The prefrontal cortex. Elsevier/Academic Press. p. 172. ISBN 0-12-373644-7.
42. Ferrier, David (1877–79). "Correspondence with Henry Pickering Bowditch". {{cite journal}}: Cite journal requires |journal= (help) Countway Library (Harvard Univ.) Mss., HMSc5.2. Transcribed in Macmillan (2000).
43. Sacks, Oliver (1995). An Anthropologist on Mars. pp. 59–61. ISBN 0-679-43785-1. OCLC 30810706.
44. Sizer, Nelson (1888). Forty years in phrenology; embracing recollections of history, anecdote, and experience. New York: Fowler& Wells.
45. Kihlstrom, J.F. (2010). "Social neuroscience: The footprints of Phineas Gage". Social Cognition. 28 (6): 757–782. doi:10.1521/soco.2010.28.6.757.
46. Grafman, J. (2002). "The Structured Event Complex and the Human Prefrontal Cortex". pp. 292–310. doi:10.1093/acprof:oso/9780195134971.003.0019. ISBN 978-0-195-13497-1. {{cite book}}: |work= ignored (help); Missing or empty |title= (help); Unknown parameter |editors= ignored (|editor= suggested) (help)
47. Carlson, N.R. (1994). Physiology of Behavior. p. 341. ISBN 0-205-07264-X.
48. Twomey, S. (January 2010). "Finding Phineas". Smithsonian. 40 (10): 8–10.
49. ^ Wilgus, B.&J (2009). "Face to Face with Phineas Gage". Journal of the History of the Neurosciences. 18 (3): 340–345. doi:10.1080/09647040903018402. PMID 20183215.
50. ———. "Meet Phineas Gage". Retrieved October 2, 2009.
51. ^ Lena, M.L.; Macmillan, Malcolm B. (March 2010). "Picturing Phineas Gage (invited comment)". Smithsonian. p. 4.
52. ———. "A New Image of Phineas Gage". Retrieved March 10, 2010.

External links

• Macmillan, Malcolm B. "Phineas Gage: Unanswered questions".—Lists research questions related to Gage in localities throughout the United States and Chile, for which Gage researchers request assistance from the public.
• Warren Anatomical Museum, Center for the History of Medicine, FrancisA. Countway Library of Medicine (Harvard Medical School)—Home of Gage's skull and iron.
• Meet Phineas Gage—The story of how the owners of the 2009-identified 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