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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 brain injury
Spouse	None
Children	None

Phineas P. Gage (1823 – May 21, 1860) was an American railroad construction foreman remembered for his improbable survival of a rock blasting 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 (see neuroscience), 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 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 contradictory to one another. Historically, published accounts (including scientific ones) have almost always severely distorted and exaggerated Gage's behavioral changes, frequently contradicting the known facts.

A report of Gage's physical and mental condition shortly before his death implies that Gage's most serious mental changes were temporary, so that in later life he was far more functional, and socially far better adapted, than in the years immediately after his accident. 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 his family's farms or in nearby mines and quarries, and by the time of his accident he was a blasting foreman on railway construction projects.

Town doctor John Martyn Harlow described Gage as "a perfectly healthy, strong and active young man, twenty-five years of age, 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." His employers considered him "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 (1.1 m) long and 1+1⁄4 inches (3.2 cm) in diameter—for use in setting charges.

Gage's accident

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

On September 13, 1848, Gage 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 iron "struck fire" against the rock and the powder exploded. Rocketing out of the hole, the iron "entered on the side of 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 a pointed cylinder something like a javelin, "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" was found some 80 feet (25 m) 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 about 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 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. His person, and the bed on which he was laid, were literally one gore of blood.

Treatment and convalescence

With Williams' assistance Harlow shaved the scalp around the region of the tamping iron's exit, then removed coagulated blood, small bone fragments, and an ounce of protruding brain. After probing for foreign bodies and replacing two large detached pieces of bone, Harlow closed the wound with adhesive cloth strips, leaving it partially open for drainage; the entrance wound in the cheek was bandaged only loosely, for the same reason. A wet compress was applied, then a nightcap, then further bandaging to secure these dressings. Harlow also dressed Gage's hands and forearms (which along with his face had been "deeply burned") and ordered that his head remain elevated. Late that evening Harlow noted: "Mind clear. Says he 'does not care to see his friends, as he shall be at work in a few days.'"

Gage's convalescence was long and difficult. He was semi-comatose beginning September 23, "seldom speaking unless spoken to, and then answering only in monosyllables." The next day Harlow noted, "Failing strength ... coma deepened; the globe of the left eye became more protuberant, with pushing out rapidly from the internal canthus from the wounded brain, and coming out at the top of the head."

By September 27, "The friends and attendants are in hourly expectancy of his death, and have his coffin and clothes in readiness." Galvanized by this pessimism Harlow "cut off the sprouting out from the top of the brain and filling the opening, and made free application of caustic to them. With a scalpel I laid open the integuments, between the and immediately there were discharged eight ounces of ill-conditioned pus, with blood, and excessively fetid." ("Gage was lucky to encounter Dr. Harlow when he did," wrote Barker. "Few doctors in 1848 would have had the experience with cerebral abscess with which Harlow left [Jefferson Medical College] and which probably saved Gage's life.")

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."

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 (not the later Barnum's circus—there is no evidence Gage ever exhibited with a troupe or circus) though there is no confirmation of this. But advertisements for two public appearances by Gage, which he may have arranged and promoted himself, support Harlow's statement that Gage made public appearances in "most of the larger New England towns". (Years later Bigelow wrote that Gage had been "a shrewd and intelligent man and quite disposed to do anything of that sort to turn an honest penny", but had given up such efforts because " sort of thing has not much interest for the general public".)

Gage subsequently worked for the owner of a livery and coach service 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 relocated 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 May 21, just under twelve years after his injury, and was buried in San Francisco's Lone Mountain Cemetery. (Though some accounts assert that Gage's iron was buried with him, there is 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 wrote to 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 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 the following 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. Phinehas 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

The 1994 conclusion of H. Damasio et al., that both of Gage's frontal lobes (right as well as left) had been damaged, was drawn by modeling not Gage's skull but rather a "Gage-like" one. Using CT scans of Gage's actual skull, Ratiu et al. (2004) and Van Horn et al. (2012) rejected that conclusion, agreeing with Harlow's opinion (based on probing Gage's wounds with his finger) that only the left frontal lobe had been damaged.

In addition, Ratiu et al. pointed out 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; combining this with the hairline fracture running from behind the exit region down the front of the skull, they concluded that the skull "hinged" open as the iron entered the cranium, then (once the iron had exited at the top) were pulled closed by the resilience of soft tissues.

Van Horn et al. concluded that damage to Gage's white matter (of which they made detailed estimates) may have been more significant to Gage's mental changes than cerebral cortex (gray matter) damage.

Firsthand 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 have been difficult to establish.

Early observations (1849–1851)

Harlow 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 is from Harlow's notes set down soon after the accident, but Harlow—perhaps hesitant to describe his patient negatively while he was still alive—left them unpublished until 1868 (after Gage had died and his family had forwarded "what we so much desired to see", as Harlow termed Gage's skull and iron).

In the interim, Harlow's 1848 report (published just as Gage was emerging from his convalescence) only hinted at 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.

But after Harvard Professor of Surgery Henry Jacob Bigelow (who had brought Gage to Boston for observation in late 1849) termed Gage "quite recovered in faculties of body and mind", with only "inconsiderable disturbance of function", a rejoinder in the American Phrenological Journal—

That there was no difference in his mental manifestations after the recovery is not true ... The man was gross, profane, coarse, and vulgar, to such a degree that his society was intolerable to decent people.

—was apparently based on information anonymously supplied by Harlow.

Barker explains these contradictory evaluations (only six months apart) by differences in Bigelow's and Harlow's educational backgrounds:

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.

Later observations (1852–1858)

In 1860, an American physician returned from Chile, reporting that he had known Gage well and "that he is in the enjoyment of good health, with no impairment whatever of his mental faculties." Together with the fact that Gage was hired by his employer in advance, in New England, to be part of the new coaching enterprise in Chile, this implies that Gage's most serious mental changes were temporary, so that the "fitful, irreverent ... capricious and vacillating" Gage described by Harlow (who last saw Gage less than a year after the accident) later became more functional and better adapted socially.

This conclusion is reinforced by the general requirement 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"; and by the fact that the sensory-motor and cognitive skills required for driving a six-horse team, as Harlow reports Gage did, were so unusual that "the departure of the coach was always a great event at Valparaiso—a crowd of ever-astonished Chilenos assembling every day to witness the phenomenon of one man driving six horses."

Social recovery

Psychologist Malcolm Macmillan hypothesizes that this change in Gage over time represents a social recovery by Gage over time, citing people 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:

Phineas' survival and rehabilitation demonstrated a theory of recovery which has influenced the treatment of frontal lobe damage today. 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 job as a stage-coach driver provided that external structure to aid in his recovery.

Macmillan writes that if Gage made such a recovery—if he eventually "figured out how to live" (as Fleischman put it) despite his injury—then 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?" As Kean put it, "If even Phineas Gage bounced back—that's a powerful message of hope."

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.

—Anonymous

Distortion of mental changes

Macmillan's survey of accounts of Gage (scientific and popular) suggested that they distorted and exaggerated his behavioral changes; 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 ..." Kotowicz writes, "Harlow does not report a single act that Gage should have been ashamed of."

For example, H. Damasio et al. and A. 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 (as previously mentioned) until then Gage had always supported himself.

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 and 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 Oliver 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".

In a more recent example A. 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 A. Damasio's depiction of Gage has been criticized by Kotowicz as "grotesque fabrication ... the myth of Gage the psychopath ... 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, there is no such link, according to Macmillan:

There is simply no evidence that any of these operations were deliberately designed to produce the kinds of changes in Gage that were caused by his accident, nor that knowledge of Gage's fate formed part of the rationale for them‍... hat 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

Two daguerreotype portraits of Gage, discovered in 2009 and 2010, are the only known likenesses of him other than a life mask taken for Bigelow in late 1849. The first 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 its inscription can be made out. (For decades the portrait's owners had imagined it showed an injured whaler with his harpoon.)

The second, found in the possession of two different branches of the Gage family, shows Gage in a somewhat different pose, wearing a different shirt and different tie, but the same waistcoat and possibly the same jacket. The portraits' authenticity was confirmed in several ways (including photo-overlaying the inscriptions seen in the portraits against that on the actual tamping iron, and matching the subject's injuries against those preserved in the life mask) but about when and where they were taken nothing is known, except that they were likely taken by different photographers.

The portraits lend support to the social recovery hypothesis already described. "Although just one picture," Kean wrote in reference to the first image, "it exploded the common image of Gage as a dirty, disheveled misfit. This Phineas was proud, well-dressed, and disarmingly handsome."

Analysis of sources

Harlow (1868) gives the date of Gage's death as May 21, 1861, but undertaker's records show that Gage was buried on May 23, 1860. Macmillan alters certain other dates for events late in Gage's life, his move from Chile to San Francisco and the onset of his convulsions, to account for this discrepancy.

Notes

^ 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, 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; these are descendents of certain of his relatives.) Unlike the Wilgus portrait, which is itself a daguerreotype, the Miller and Hartley images are 19th-century photographic reproductions of a common original which remains undiscovered, itself a daguerreotype or other laterally reversing early-process photograph; here again a second, compensating reversal has been applied.
^ Macmillan (2000) discusses Gage's ancestry and what is and isn't known about his birth and early life. His parents were married April 27, 1823.
The birthdate July 9, 1823 (the only definite date given in any source) is from a comprehensive Gage genealogy via Macmillan (2000), which notes that while the genealogy gives no source for it, it is consistent with agreement, among contemporary sources addressing the point, that Gage was 25 years old on the date of his accident, as well as with Gage's age—36 years—as given in undertaker's records after his death on May 21, 1860.
Possible homes in childhood and youth are Lebanon or nearby East Lebanon, Enfield, and/or Grafton (all in Grafton County, New Hampshire), though Harlow refers to Lebanon in particular as Gage's "native place" and "his home" (probably that of his parents), to which he returned ten weeks after his accident.
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 a Phineas and brother Dexter's middle name was Pritchard). Gage's mother's first and middle names are variously given as Hannah or Hanna and Trussell, Trusel, or Trussel; her maiden name is variously spelled Swetland, Sweatland, or Sweetland.
^ 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—including encounters with axes, bolts, bridges, exploding firearms, a revolver shot to the nose,and "even falling gum tree branches"). 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", and this endorsement by the Professor of Surgery at Harvard "finally succeeded in forcing authenticity upon the credence of the profession ... as could hardly have been done by any one in whose sagacity and surgical knowledge his confrères had any less confidence".
Indeed, Harlow later recalled, "a distinguished Professor of Surgery in a distant city" had dismissed Gage 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, 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.
Even as late as 1870, Jackson was able to write 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 (8 cm) 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 Journal's review of Harlow (1868).
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), Macmillan (2008), and Hodges; for example, several musical groups call themselves Phineas Gage (or some variation).
^ See Macmillan (2000) and Macmillan (PGIP) for the steps in setting a blast and the location and circumstances of the accident.
Harlow's reference to Gage's "temperament" reflects his interest in phrenology, which termed nervo-bilious a subject possessing a rare combination of "excitable and active mental powers" with "energy and strength mind and body possible the endurance of great mental and physical labor"(Macmillan 2000), " great power with great activity, and, although it seldom gives great brilliancy, it produces that kind of talent which will stand the test, and shine in proportion as it is brought into requisition" (Fowler 1838).
^ The Boston Post credits an earlier report (of unknown date) in the Ludlow (Vermont) Free Soil Union, which appears to have been the first printed report of Gage's accident anywhere; although reprinted by several New England papers, it is itself no longer extant. This report confuses the iron's circumference with its diameter, and despite the reference to the "shattering the upper jaw", that did not in fact happen.
^ Excerpted from Williams' and Harlow's statements in: Harlow (1848); Bigelow (1850); Harlow (1868).
Before the advent of antisepsis, wrote surgeon Frederick Treves,
Practically all major wounds suppurated . Pus was the most common subject of converse, because it was the most prominent feature in the surgeon's work. It was classified according to degrees of vileness.
But pus was considered desirable if of the right kind. "If a patient was lucky ... a thick cream-colored odorless fluid would appear within five or six days"; such "laudable" pus was considered "a sure sign that the wound would heal" because it meant "Nature has put up a bold fight against the invader". "On the other hand, if the pus gradually became watery, blood tinged and foul smelling, it was designated 'sanious' and the wound condition was considered unfavorable". (It later came to be understood that "laudable" pus generally stemmed from an invasion of relatively benign staphylococci, while what Harlow's contemporaries called "ill-conditioned" pus usually signaled that the more dangerous streptococcus was present.)
Barker writes that " from falls, horse kicks, and gunfire, were well known in pre-Civil War America every contemporary course of lectures on surgery described the diagnosis and treatment" of such injuries. But to Gage's benefit, surgeon Joseph Pancoast had performed "his most celebrated operation for head injury before Harlow's medical school class, [trephining] to drain the pus, resulting in temporary recovery. Unfortunately, symptoms recurred and the patient died. At autopsy, reaccumulated pus was found: granulation tissue had blocked the opening in the dura." By keeping the exit wound open and elevating Gage's head to encourage drainage from the cranium through the hole in the roof of the mouth, Harlow "had not repeated Professor Pancoast's mistake." Noting that Harlow had been a "relatively inexperienced local physician ... graduated four and a half years earlier", Macmillan's discussion of Harlow's "skillful and imaginative adaptation of traditional methods" additionally mentions the decision (in diverence from the teachings of one of his medical school instructors) to forego an exhaustive search for bone fragments, thus avoiding risk of hemorrhage and further brain injury; and treatment of the granulation tissue with caustic silver nitrate, thereby avoiding the risks of two more-usual treatments: excision (which risked hemorrhage) and forcing the tissue into the wound (which risked compressing the brain). As to his own role in Gage's survival, Harlow merely averred, "I can only say ... with good old Ambrose Parè, I dressed him, God healed him" —an assessment Macmillan (2000) calls far too modest. See Macmillan (2000), Macmillan (2008), and Barker (1995) for further discussion of Harlow's management of the case.
Bigelow gives a more detailed and technical description of Gage's post-recovery appearance.
^ Gage's death and (original) burial are discussed at Macmillan (2000); see also Macmillan's "Corrections to An Odd Kind of Fame" regarding Gage's date of death. Harlow gives the date of Gage's death as May 21, 1861, but undertaker's records show that Gage was buried on May 23, 1860. That Harlow 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).
Here reproduced from Jackson's Descriptive Catalog of the Warren Anatomical Museum, these images were commissioned by Harlow from photographer Samuel Webster Wyman and were the basis for the woodcuts seen in Harlow (1868).
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 May 18, 1860 he left Santa Clara and went home to his mother. At 5 A.M. on May 20, 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."
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."
Jackson (1870): "The most valuable specimen that has ever been added to the Museum, and probably ever will be, was given two years ago by Dr. John M. Harlow ... 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."
The inscription 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 period during which Gage was in Boston under Bigelow's observation.
See Macmillan (2000) and Macmillan (2008) for surveys and discussion of theoretical misuse of Gage. Smith (1886) noted "the ingenuity with which the advocates of various theories will explain away the evidence of their opponents."
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."
Kotowicz 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).
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).
See for example Carlson (1994); additional examples and discussion are at Macmillan (2000).
Van Horn (2012): "That was any form of vagrant following his injury is belied by these remarkable images."

Sources and further reading

^
Macmillan, Malcolm B. (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).
• See also "Corrections to An Odd Kind of Fame".
Campbell, H. F. (1851). "Injuries of the Cranium—Trepanning". Ohio Med & Surg J. 4 (1): 20–24.{{cite journal}}: CS1 maint: multiple names: authors list (link) (crediting the Southern Med & Surg J (unknown date).
^ Barker, F. G. II (1995). "Phineas among the phrenologists: the American crowbar case and nineteenth-century theories of cerebral localization". J Neurosurg. 82 (4): 672–682. doi:10.3171/jns.1995.82.4.0672. PMID 7897537.{{cite journal}}: CS1 maint: multiple names: authors list (link)
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.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^ Hodges, John (2001). "Book review: An Odd Kind of Fame: Stories of Phineas Gage". Journal of Neurology, Neurosurgery, and Psychiatry. 71 (1). doi:10.1136/jnnp.71.1.136c.
^
Macmillan, Malcolm B. (2008). "Phineas Gage—Unravelling the myth" (PDF). The Psychologist. 21 (9). British Psychological Society: 828–831.
McRae, Mike (2011). Tribal Science: Brains, Beliefs and Bad Ideas. University of Queensland Press. pp. 9–11. ISBN 0702247340.
^
Harlow, John Martyn (1848). "Passage of an Iron Rod Through the Head" (PDF). Boston Med & Surg J. 39 (20): 389–393. (Transcription.)
"Incredible, But True Every Word". National Eagle. Claremont, New Hampshire. March 29, 1849. p. 2. Transcribed in Macmillan (2000), pp. 40–41
^
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.
^
Harlow, John Martyn (1868). "Recovery from the Passage of an Iron Bar through the Head". {{cite journal}}: Cite journal requires |journal= (help) (Transcription.) Originally published in Publ Massachusetts Med Soc. 2: 327–347. {{cite journal}}: Missing or empty |title= (help)
Fowler, O. S. (1838). Synopsis of phrenology: and the phrenological developments: together with the character and talents of ________ as given by ________: with references to those pages of "Phrenology proved, illustrated and applied," in which will be found a full and correct delineation of the intellectual and moral character and manifestations of the above-named individual. New York: Fowler & Wells. p. 6.{{cite book}}: CS1 maint: multiple names: authors list (link)
^ Ratiu, P.; 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.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^
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".
^ Smith, William T. (1886). "Lesions of the Cerebral Hemispheres". T Vermont Med Soc for the Year 1885. pp. 46–58.
^ Kean, Sam (May 6, 2014), "Phineas Gage, Neuroscience's Most Famous Patient", Slate
Sutton, W. L. (1850). "A Centre Shot". Boston Medical & Surgical Journal. 3: 151–152.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^ "Bibliographical Notice". Boston Medical & Surgical Journal. 3&thinsp, n.s. (7): 116–117. March 18, 1869.
^ Jackson, J. B. S. "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.
Jewett, M. (1868). "Extraordinary Recovery after Severe Injury to the Head". Western Journal of Medicine. 43: 241.
Folsom, A. C. (May 1869). "Extraordinary Recovery from Extensive Saw-Wound of the Skull". Pacific Medical and Surgical Journal. pp. 550–555.{{cite news}}: CS1 maint: multiple names: authors list (link)
"Medical Intelligence. Extraordinary Recovery". Boston Medical & Surgical Journal. 3&thinsp, n.s. (13): 230–231. April 29, 1869.
"Horrible Accident". Boston Post. September 21, 1848.
^ Nuland, Sherwin B. (2011). Doctors: The Biography of Medicine. Knopf Doubleday. ISBN 978-0-307-80789-2.
Van Hoosen, Bertha (Autumn 1947). "A Woman's Medical Training in the Eighties". Quarterly Review of the Michigan Alumnus: A Journal of University Perspectives. University of Michigan Libraries: 77–81. UOM:39015006945235.
Scott, William (1922). An indexed system of veterinary treatment. Chicago: Eger. p. 603.
^ Schneider, Albert (1920). Pharmaceutical bacteriology (2nd ed.). P. Blakiston. p. 247.
Williams, Charles J. B. (1848). Principles of Medicine: Comprising General Pathology and Therapeutics, and a Brief General View of Etiology, Nosology, Semeiology, Diagnosis, and Prognosis: With Additions and Notes by Meredith Clymer. Churchill. p. 306.
^ Twomey, S. (January 2010). "Finding Phineas". Smithsonian. 40 (10): 8–10.
Harlow, John Martyn (1849). "Medical Miscellany (letter)". Boston Med & Surg J. 39: 507. Reproduced in Macmillan (2000).
^
Macmillan, Malcolm B.; Lena, M. L. (2010). "Rehabilitating Phineas Gage". Neuropsychological Rehabilitation. 20 (5): 641–658. doi:10.1080/09602011003760527. PMID 20480430.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^ "Dr. Warren's Possessions". Harvard Magazine. 89: 28ff. 1986.
^ 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.
^ 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.{{cite journal}}: CS1 maint: multiple names: authors list (link)
^ Damasio, A. R. (1994). Descartes' Error: Emotion, Reason, and the Human Brain. ISBN 0-14-303622-X.{{cite book}}: CS1 maint: multiple names: authors list (link) (2nd ed.:2005)
^ Hockenbury, Don H.; Hockenbury, Sandra E. (2008). Psychology. p. 74. ISBN 978-1-429-20143-8.
"The Phineas Gage Case". Warren Museum. Retrieved 2013-01-10.
^ 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: multiple names: authors list (link) CS1 maint: unflagged free DOI (link)
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.{{cite journal}}: CS1 maint: multiple names: authors list (link)
Eliot, Samuel Atkins, ed. (1911). "John M. Harlow". Vol. 1. Massachusetts Biographical Society. {{cite book}}: |work= ignored (help); Missing or empty |title= (help)
^ Kotowicz, Z. (2007). "The strange case of Phineas Gage". History of the Human Sciences. 20 (1): 115–131. doi:10.1177/0952695106075178.
"A most remarkable case". American Phrenological Journal. 13: 89. 1851.
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.{{cite book}}: CS1 maint: multiple names: authors list (link)
Merwin, Mrs. George B. (1863). Three Years in Chili. New York: Follett, Foster and Company.
Macmillan, Malcolm B.; 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)
Fleischman, J. (2002). Phineas Gage: A Gruesome but True Story About Brain Science. ISBN 0-618-05252-6.
^
Macmillan, Malcolm B. (July 2009). "More About Phineas Gage, Especially After the Accident". Retrieved July 27, 2013.
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. {{cite journal}}: line feed character in |title= at position 51 (help)CS1 maint: multiple names: authors list (link)
^ Fuster, Joaquin M. (2008). The prefrontal cortex. Elsevier/Academic Press. p. 172. ISBN 0-12-373644-7.
Ferrier, David (1877–1879). "Correspondence with Henry Pickering Bowditch". {{cite journal}}: Cite journal requires |journal= (help) Countway Library (Harvard Univ.) Mss., HMSc5.2. Transcribed in Macmillan (2000).
Sacks, Oliver (1995). An Anthropologist on Mars. pp. 59–61. ISBN 0-679-43785-1. OCLC 30810706.
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. Part II". Med Times & Gaz. II: 356–358.
Ferrier, David (1878). "The Goulstonian lectures of the localisation of cerebral disease. Lecture I (concluded)". Br Med J. 1 (900): 443–447.
Sizer, Nelson (1888). Forty years in phrenology; embracing recollections of history, anecdote, and experience. New York: Fowler & Wells.
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.{{cite journal}}: CS1 maint: multiple names: authors list (link)
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)
Carlson, N. R. (1994). Physiology of Behavior. p. 341. ISBN 0-205-07264-X.{{cite book}}: CS1 maint: multiple names: authors list (link)
Lena, M. L.; Macmillan, Malcolm B. (March 2010). "Picturing Phineas Gage (Invited comment)". Smithsonian. p. 4.{{cite news}}: CS1 maint: multiple names: authors list (link)
^ 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.
^ Wilgus, B. & J. (July–September 2009). "Phineas Gage – Hiding in Plain Sight". The Daguerreian Society Newsletter. 21 (3): 6–9.
^ Wilgus, B. & J. "Meet Phineas Gage". Retrieved October 2, 2009.{{cite web}}: CS1 maint: multiple names: authors list (link)
Wilgus, B. & J. "A New Image of Phineas Gage". Retrieved March 10, 2010.{{cite web}}: CS1 maint: multiple names: authors list (link)

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External links

Warren Anatomical Museum, Center for the History of Medicine, Francis A. 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

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