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

Phineas P. Gage (1823–1860) was an American rail­road con­struc­tion fore­man now 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, effects so profound—at least for a time—that friends saw him as "no longer Gage".

Long called "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 sug­gest­ing 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 (whether before or after his accident) 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, by proponents of various theories of the brain wholly con­tra­dic­to­ry to one another. A survey of published accounts of Gage, including scientific ones, has found that they are almost always severely distorted—exaggerating the known facts when not directly con­tra­dict­ing them.

A daguerreotype portrait of Gage—"handsome ... well dressed and confident, even proud," and holding the tamping iron which injured him—was identified in 2009. One re­search­er points to it as con­sistent with a social recovery hypothesis, under which Gage's most serious mental changes may have existed for only a limited time after the accident, so that in later life he was far more functional, and socially far better adapted, than pre­vi­ously thought. A second portrait (see below) came to light in 2010.

Attributes ascribed to Gage which are either un­sup­ported by, or in con­tra­dic­tion to, the known facts include mis­treat­ment of wife and child­ren (of which Gage had nei­ther), an "utter lack of fore­sight", "a vain­glorious tend­ency to show off his wound", inap­pro­priate sex­u­al behav­ior, ina­bil­ity or refus­al to hold a job, plus drink­ing, brag­ging, lying, gam­bling, brawl­ing, bully­ing, and thiev­ery. None of these behav­iors is men­tioned by any­one who had actu­al­ly met Gage or his fam­i­ly, and Gage sup­port­ed him­self, through­out his ad­ult life, at hon­est hard work.

Gage's accident

On September 13, 1848 twenty-five-year-old Gage was foreman of a work gang blasting rock while preparing the road­bed for the Rutland & Burlington Railroad outside the town of Cavendish, Vermont. Setting a blast involved boring a hole deep into a body of rock; add­ing blasting powder, a fuse, and sand; then compacting this charge into the hole using a tamping iron—a large iron rod. Gage was doing this around 4:30 PM when (possibly because the sand was omit­ted) the iron struck a spark against the rock and

the powder exploded, carrying an iron instrument through his head an inch and a fourth in , and three feet and inches in length, which he was using at the time. The iron entered on the side of his face ... passing back of the left eye, and out at the top of the head.

Nineteenth-century references to Gage as "the American Crowbar Case" bear clar­if­i­ca­tion. Gage's tamping iron did not have the bend or claw sometimes associated with the term crowbar; rather it was simply a cylinder, "round and rendered comparatively smooth by use":

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

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

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

I first noticed the wound upon the head before I alighted from my carriage, the pulsations of the brain being very distinct. Mr. Gage, during the time I was examining this wound, was relating the manner in which he was injured to the bystanders. I did not believe Mr. Gage's statement at that time, but thought he was deceived. Mr. Gage persisted in saying that the bar went through his head .... Mr. G. got up and vomited; the effort of vomit­ing pressed out about half a teacupful of the brain, which fell upon the floor.

Dr. John Martyn Harlow took charge of the case about an hour later:

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

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

But on October 7 Gage "succeeded in raising himself up, and took one step to his chair." One month later he was walking "up and down stairs, and about the house, into the piazza," and while Harlow was absent for a week, Gage was "in the street every day except Sunday," his desire to return to his family in New Hampshire being "uncontrollable by his friends ... got wet feet and a chill." He soon developed a fever, but by mid-November he was "feeling better in every respect ... walking about the house again; says he feels no pain in the head." Harlow's prognosis at this point: Gage "appears to be in a way of recov­er­ing, if he can be controlled."

Subsequent life and travels

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

Unable to return to his railroad work, Harlow says, Gage appeared for a time at Barnum's American Museum in New York City (the cu­ri­ous paying to see, presumably, both Gage and the instrument which had injured him) although there is no indep­end­­ent con­fir­ma­tion of this. Recently, however, evidence has surfaced supporting Harlow's state­ment that Gage made public appear­ances in "the larger New England towns". (On Gage's job-loss and public ap­pear­ances, see more below.) He later worked in a livery stable in Hanover, New Hampshire.

In August of 1852 Gage was invited to Chile to work as a long-distance stagecoach driver there, "caring for horses, and often driving a coach heavily laden and drawn by six horses" on the Valparaiso–Santiago route. After his health began to fail around 1859, he left Chile for San Francisco, where he recovered under the care of his mother and sister (who had gone there from New Hampshire around the time Gage went to Chile). For the next few months he did farm work in Santa Clara.

Death and subsequent travels

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

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

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

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

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

Brain damage and mental changes

Extent of brain damage

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

First-hand reports of mental changes

Without question Gage displayed some kind of change in behavior after his accident, but the nature, extent, and duration of this change are very uncertain. In fact comparatively little is reliably known about what Gage was like either before or after his injury (almost none of it first-hand), the mental changes described after his death were much more dramatic than anything reported while he was alive, and the very few descriptions which seem credible do not specify the period of his post-accident life to which they are meant to apply.

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

It was twenty years later that Harlow, having obtained Gage's skull and the history of his last years, described the mental changes found today in most presentations of the case (though usually in ex­ag­ger­at­ed or dis­tort­ed form—see 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 life during which each described behavior was present. This complicates recon­struc­tion of what Gage was like at various points in his post-accident life, a critical task in light of evidence (see below) that his behavior at the end of his life was very different from his behavior immediately after the accident—the behavior described above.

Distortion of mental changes

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

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

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

Theoretical use and misuse

Beyond the importance of correcting the record of a much-cited case, Mac­millan writes, "Phineas' story is worth remembering be­cause it illustrates how easily a small stock of facts becomes transformed into popular and scientific myth," the paucity of evi­dence having allowed "the fitting of almost any theory to the small number of facts we have". A similar concern was expressed as far back as 1877, when British neurologist David Ferrier, writing to America 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."

Thus in the nineteenth-century controversy over whether or not the various mental functions are localized in specific regions of the brain, both sides found ways to cite Gage in support of their theories; for example, while Ferrier (1878) cited Gage as evidence that the brain is localized, Dupuy (1877) used him as proof that it is not. Phrenologists made use of Gage as well, claiming that his mental changes resulted from destruction of his "organ of Veneration" and/or the adjacent "organ of Benevolence".

It is often said that what happened to Gage played a part in the later development of various forms of psychosurgery, par­tic­u­lar­ly frontal lobotomy. Aside from the question of why the unpleasant changes usually (if erroneously) 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.

Social recovery

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

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

Portraits

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

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

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

See also

• Penetrating head injury

Notes

1. Daguerreotype from the collection of Jack and Beverly Wilgus. The orig­i­nal, like almost all da­guerre­o­types, shows its subject laterally (left-right) reversed, making it appear that Gage's right eye is injured; how­ever, there is no question (Lena & Mac­millan, 2010) that all Gage's injuries, including to his eye, were on the left. Therefore, in presenting the image here a sec­ond, com­pen­sat­ing reversal has been applied in order to show Gage as he appeared in life. See Harlow (1868), p. 340 for "constant companion".
2. ^ Gage's parents were Jesse Eaton Gage and Hannah Trussell (née Swet­land, Sweat­land, or Sweet­land) Gage (Mac­millan 2000, pp. 490–1), but see Mac­millan (2000), pp. 11, 16 for the uncertainty regarding other circum­stances of his birth (in par­tic­u­lar, his exact birth­date) and up­bring­ing. Poss­i­ble birth­plac­es are Leb­a­non, En­field, and Graf­ton (all in Graf­ton County, N.H.) 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.

   Gage's death and burial are discussed at Mac­millan (2000), p. 108. Harlow is exactly one year off in the date of Gage's death, implying that certain other dates given by Harlow for events late in Gage's life—his move from Chile to San Francisco and the onset of his con­vul­sions—must also be mistaken, presumably by the same amount; this article follows Mac­millan in correcting those dates.

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

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

   A tone of be­mused won­der­ment was com­mon in 19th-cent­ury med­i­cal writ­ing about Gage (as well as about victims of other unlikely-sounding brain-injury accidents—see Mac­millan 2000, pp. 66–7). Noting dryly that, "The leading feature of this case is its im­prob­a­bil­ity ... This is the sort of accident that happens in the pant­o­mime at the theater, not else­where," Bigelow (1850, pp. 13,19) emphasized that though "at first wholly skeptical, I have been per­son­al­ly con­vinced," calling the case "un­par­al­led in the annals of surgery". This en­dorse­ment by Bigelow, Pro­fes­sor of Surgery at Harvard, helped end scoffing about Gage among physicians in general—one of whom, Harlow (1868, p. 344) later recalled, had dis­mis­sed the matter as a "Yankee invention": "The case occurred nearly twenty years ago, in an ob­scure country town ..., was attended and reported by an ob­scure country phys­ic­i­an, and was rec­eived by the Met­ro­pol­i­tan doctors with several grains of caution, in­so­much that many ut­ter­ly re­fus­ed to believe that the man had risen, until they had thrust their fingers into the hole of his head," (see Doubting Thomas) "and even then they required of the Country Doctor at­test­ed statements, from clergymen and lawyers, before they could or would believe—many eminent surgeons regarding such an occurrence as a phys­i­o­log­i­cal impossibility, the ap­pear­anc­es pre­sent­ed by the subject being variously explained away."

   Indeed Jackson (1870, p. v) wrote that, "Unfortunately, and not­with­stand­ing the evi­dence that Dr. H. has furnished, the case seems, generally, to those who have not seen the skull, too much for human belief." But after Gage was joined by such later cases as a miner who sur­vived traversal of his head by a gas pipe, and a lumbermill foreman who returned to work soon after a "picket saw" cut into his forehead to a depth of several inches, the Bos­ton Med­i­cal & Surg­i­cal Jour­nal (1870) pre­tend­ed to won­der whether the brain has any function at all: "Since the antics of iron bars, gas pipes, and the like skepticism is dis­com­fit­ted, and dares not utter itself. Brains do not seem to be of much account these days." The Transactions of the Vermont Medical Society (Smith, 1886, pp. 53–54) was similarly fa­ce­tious: "'The times have been,' says Macbeth [Act III], 'that when the brains were out the man would die. But now they rise again.' Quite possibly we shall soon hear that some German pro­fes­sor is ex­sect­ing it."

4. Harlow (1868), Fig. 2, p. 347: "Front and lateral view of the cranium, rep­re­sent­ing the di­rect­ion in which the iron travers­ed its cav­ity; the present appear­ance of the line of frac­ture, and also the large ant­er­i­or frag­ment of the front­al bone, which was en­tire­ly de­tach­ed, re­plac­ed and part­ial­ly re-united."
5. LeUnes, A. (1974). "Contributions to the history of psychology: 20. A re­view of selected aspects of texts in abnormal psychology". Psychological Reports. 35 (3): 1319–26. PMID 4614305. {{cite journal}}: soft hyphen character in |title= at position 54 (help) LeUnes' survey found Harlow (1868) to be the second most freq­uent­ly cited work in twentieth-century psychology texts; see also Mac­millan (2000), ch. 14, esp. pp. 307–8, 311 and 313–14. For popular culture, see Mac­millan (2000), ch. 13; for example, several musical groups call themselves Phineas Gage (or some variation).
6. ^ See Mac­millan (2000), pp. 25–27 for the steps in setting a blast and the location and circum­stances of the accident. The blast hole, about 1+1⁄2 inches (38 mm) in diameter and up to six feet (1.8 m) deep, might require two men working half a day or more to "drill" using hand tools. The labor invested in setting each blast, and the judgment involved in selecting its location and the amount of powder to be used—plus the often explosive nature of employer-employee relations on this type of job—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.
7. ^ Boston Post, September 21, 1848, crediting an earlier report (unknown date) in the Ludlow Free Soil Union (Ludlow, Vermont). In quoting this early report (see image) here, its mis­state­ment of the length and diameter (versus "circumference") of the tamping iron have been corrected; the words "shattering the upper jaw" have been omitted because that did not in fact happen; and has been added for clarity. See Harlow (1868), p. 342 for a description of the iron's path.
8. ^ Bigelow (1850), pp. 13–14. Harlow (1868, p. 344) listed among circum­stances favoring Gage's survival "The shape of the missile—being pointed, round and comparatively smooth, not leaving behind it prolonged concussion or compression." Bigelow describes the iron's taper as seven inches long, but the correct dimension is twelve (corrected in the quotation); see Harlow (1848), p. 331 and Mac­millan (2000), p. 26.
9. ^ Harlow wrote that Gage had been "a perfectly healthy, strong and active young man ... nervo-bilious temperament, five feet six inches in height, average weight one hundred and fifty pounds, possessing an iron will as well as an iron frame; muscular system unusually well developed—having had scarcely a day's illness from his childhood to the date of this injury." (Nervo-bilious describes an rare combination of "excitable and active mental powers" with "energy and strength mind and body possible the endurance of great mental and physical labor.") He also emphasized the importance of the opening, created by the tamping iron, connecting Gage's cranium to his mouth, as "without this opening in the base of the skull, for drainage, recovery would have been impossible." As to his own role in Gage's survival, he merely averred, "I can only say, along with good old Ambrose Paré, I dressed him, God healed him" (Harlow 1868, pp. 330, 344, 346)—an assessment Mac­millan calls far too modest (Mac­millan 2000, pp. 12, 59–62, 346–7; and see Mac­millan 2008, pp. 828–9; Mac­millan 2001; and Barker 1995, pp. 679–80 for further dis­cus­sion of Harlow's management of the case).
10. Harlow's notes (1868, p. 335) for September 24: "Failing strength ... During the three succeeding days the coma deepened; the globe of the left eye became more protuberant, with fungus pushing out rapidly from the internal canthus ... also large fungi pushing up rapidly from the wounded brain, and coming out at the top of the head". Here fungus does not mean an infect­ing mycosis but rather (Oxford English Dictionary) a "spongy morb­id growth or excrescence, such as exu­ber­ant gran­u­lat­ion in a wound" i.e. part of the body's own reaction to the injury (Mac­millan 2000, pp. 54, 61–2).
11. Contrary to common reports, Barnum's American Museum was not a travel­ing show but a stat­ion­ary instal­lat­ion in New York City. There is no evi­dence Gage ex­hib­it­ed with a troupe or circ­us, or on a fair­ground (Mac­millan & Lena 2010, pp. 3–4).
12. Harlow (1868): "It is due to science, that a case so grave, and succeeded by such remarkable results, should not be lost sight of; that its subsequent history, termination, and pathological evidences, in detail, should have a permanent record. My desire to lay before the profession the sequel of this case, has not permitted me to remain altogether oblivious as to the whereabouts of my patient, and after tracing him in his wanderings over the greater part of this continent, I am able to present to you indubitable evidence that my report of the case, in the Boston Medical and Surgical Journal , was no fiction."
13. Harlow (1868): "It is to be regretted that an autopsy could not have been had, so that the precise condition of the encephalon at the time of his death might have been known. In consideration of this important omission, the mother and friends, waiving the claims of personal and private affection, with a magnanimity more than praiseworthy, at my request have cheerfully placed this skull (which I now show you) in my hands, for the benefit of science."
14. Jackson (1870), p. v: "The most valuable specimen that has ever been added to the Museum, and probably every will be, was given two years ago by Dr. John M. Harlow, of Woburn ... For the professional zeal and the energy that Dr. H. showed, in getting possession of this remarkable specimen, he deserves the warmest thanks of the profession, and still more, from the College , for his donation."
15. Text of inscription from Mac­millan, M. "Corrections to An Odd Kind of Fame". Retrieved Oct 2, 2009. {{cite web}}: soft hyphen character in |last= at position 4 (help) The inscription's date for the accident is one day off, and Phinehas seems not to be how Gage spelled his name (figure, Mac­millan 2008, p. 839); but the standardization of spel­ling may not have been well enough established at the time for this to be considered an error strictly speaking. See also earlier note re Gage's middle initial. The inscription was com­mis­sioned by Harvard's Dr. Bigelow in preparation for the iron's deposit in the Warren Anatomical Museum; the date following Gage's "signature" corresponds to the latter part of the period during which Gage was in Boston under Bigelow's observation.
16. ^ Ratiu et al. was the first study to account for the hairline fracture running from behind the exit region down the front of the skull, as well as fact that the hole in the base of the cranium (created as the iron passed through) seems to have a smaller diameter than does the iron itself—hypothesizing (as seen in their video re­con­struc­tion) that the skull "hinged" open as the iron entered the base of the cranium, then later pulled closed by the resilience of soft tissues once the iron had exited at the top. See Mac­millan (2008), p. 830.
17. Com­mis­sioned by Harlow and here reproduced from Jackson (1870), these photographs were the basis of the woodcuts seen in Harlow (1868), p.348 -- see Mac­millan (2000), pp. 26, 115, 479–80.
18. Specifically, Van Horn et al. est­i­mat­ed that although "ex­ten­sive dam­age occur­red to left front­al, left tem­po­ral pol­ar, and insu­lar cortex, the best fit rod trajectory did not result in the iron crossing the midline as has been suggested by some authors" (such as H. Damasio). "Fiber pathway damage extended beyond the left frontal cortex to regions of the left temporal, parietal, and occipital cortices as well as to basal ganglia, brain stem, and cerebellum. Inter-hemispheric connections of the front­al and limbic lobes as well as bas­al ganglia were also affect­ed." (Quot­at­ions abridg­ed to re­move quant­i­tat­ive est­i­mates of damage to each locus.)
19. ^ According to Macmillan & Lena (2010, and see also Mac­millan 2000, pp. 11, 89, 116) available sources which offer detailed information on Gage, and for which there is evidence (if merely the source's own claim) of actual contact with him or his fam­i­ly, were limited (until 2008) to
    • Harlow (1848, 1849 and 1868)
    • Bigelow (1850)
    • Jackson (1870) and
    • Jackson, J.B.S. (1849) Medical Cases (Vol. 4, Case 1777) Countway Library (Harvard Univ.) Mss., H MS b 72.4 (quoted at Mac­millan 2000, p. 93).
    Mac­millan & Lena (2010) presents pre­vi­ous­ly unknown sources discovered post 2008.

    Of the primary sources, Harlow (1868) is by far the most informative, and Mac­millan (2001) p. 161 and Mac­millan (2000), p. 94 discuss its high general reliability. Accounts of Gage are compared to one another, and against the known facts, at Mac­millan, M. "Phineas Gage's Story". Retrieved Oct 2, 2009. {{cite web}}: soft hyphen character in |author= at position 4 (help) and in Mac­millan 2000, esp. pp. 116–119 and chs. 13–14).

20. A further consideration is potential reluctance on the part of Gage's friends and family, and of Harlow himself, to describe Gage negatively, especially while he was still alive (Mac­millan 2000, pp. 106–8, 375–6). At Mac­millan (2000), pp. 350–1 it is argued that an 1850 com­mun­i­cat­ion caling Gage "gross, profane, coarse, and vulgar" was anonymously supplied by Harlow.
21. For example, the "fitful, irreverent ... capricious and vacillating" Gage described in Harlow (1868) is somewhat at variance with Gage's stagecoach work in Chile, which required drivers "to be reliable, resourceful, and possess great endurance. But above all, they had to have the kind of per­son­al­ity that enabled them to get on well with their passengers (Mac­millan 2000, p. 106, citing K.A. Austin 1977. A Pictorial History of Cobb and Co.: The Coaching Age in Aus­tral­ia, 1854–1924. Sydney, Aus­tral­ia: Rigby. ISBN 0-7270-0316-X. {{cite book}}: soft hyphen character in |location= at position 12 (help); soft hyphen character in |title= at position 61 (help)CS1 maint: numeric names: authors list (link)); and see also Mac­millan (2000), pp. 376–7 and Mac­millan (2008), p. 839.
22. Curricular materials at one medical school (Nicholl, Jeffrey S., M.D. (2009). "Dementia Cases—Problem #1". Neurology Clerkship. New Orleans: Tulane Univ. School of Med­i­cine. Retrieved November 1, 2009. {{cite web}}: Check date values in: |accessdate= (help); soft hyphen character in |publisher= at position 27 (help)CS1 maint: multiple names: authors list (link)) go so far as to present Gage as having been "accused of sex­u­al­ly molesting young children". Macmillan (2000), p. 327 refers to the complete lack of in­for­ma­tion on Gage's sex­u­al life, and Mac­millan & Lena (2010) discusses the continued absence of such data.
23. "Only Harlow writes of the exhumation and he does not say the tamping iron was recovered then. Although what he says may be slightly ambiguous, it does not warrant the contrary and undoc­u­mented account ... that Gage's tamping iron was recovered from the grave" (Mac­millan & Lena 2010, p. 7, referencing Harlow 1868, p. 342).
24. Ferrier (1870–9). Smith (1886, p. 51) noted "the ingenuity with which ad­vo­cates of various theories will explain away the evidence of their opponents."
25. " argued that psychiatric patients would benefit from having disinhibited behaviors like deliberately induced in them" (Mac­millan 2000, p. 250).
26. ^ Lena & Mac­millan (2010), citing also B. & J. Wilgus. The image seen here is in the pos­ses­sion of Tara Gage Miller of Texas; an identical image belongs to Phyllis Gage Hartley of New Jersey. (Gage had no known children—see Mac­millan 2000, pp. 319,327; these are de­scend­ents of cer­tain of his rel­a­tives—see Mac­millan & Lena 2010, p. 4.) Unlike the Wilgus por­trait, which is an actual da­guerre­o­type, the Miller and Hartley images are 19th-century pho­to­graph­ic repro­duct­ions of a com­mon orig­inal which remains undiscovered, itself a da­guerre­o­type or other laterally (left-right) reversing early-process photograph; a second, com­pen­sating reversal has been applied here to show Gage as he appeared in life. Gage's shirt and tie are different in the Miller-Hartley image than in the Wilgus image, though he is wearing the same waistcoat and possibly the same jacket; see Wilgus, B. & J. "A New Image of Phineas Gage". Retrieved 2010-03-10.
27. 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.'"
28. Phineas Gage: Unanswered Questions

References

1. ^ Mac­millan & Lena (2010) passim.
2. Campbell, H.F. (1851) "Injuries of the Cranium—Trepanning". Ohio Med & Surg J 4(1):31–5, crediting the Southern Med & Surg J (unknown date)
3. Barker (1995); Mac­millan (2000), chs. 7–9.
4. ^ Macmillan (2000), p. 290; Macmillan (2008), p. 831.
5. Smith (1886), p.54
6. ^ Harlow (1848), p. 331.
7. Excerpted from Williams' statement, in Bigelow (1850), pp. 15–16.
8. Excerpted from Harlow (1848), p. 390.
9. Excerpted from Harlow (1848) and Harlow (1868).
10. Harlow (1848), pp. 391–3; Bigelow (1850), pp. 17–19; Harlow (1868), pp. 334–8.
11. Harlow (1849); Harlow (1868), p. 338–9.
12. ^ Harlow (1868), pp. 339–342.
13. ^ Mac­millan, M. "Phineas Gage: Unanswered questions". Retrieved Oct 2, 2009. {{cite web}}: soft hyphen character in |last= at position 4 (help)
14. Mac­millan (2000), pp. 119–120.
15. Harlow (1848), p. 389; Bigelow (1850), pp. 21–2; Harlow (1868), pp. 343, 345; Dupuy (1877); Ferrier (1878). See also:
    • Bramwell, B. (1888) "The Process of Compensation and some of its Bearings on Prognosis and Treatment". Br Med J 1(1425):835–840 doi:10.1136/bmj.1.1425.835
    • Cobb, S. (1940) "Review of neuropsychiatry for 1940". Arch Intern Med 66:1341–54
    • —— (1943) Borderlands of psychiatry. Harvard Univ. Press.
    • Tyler, K.L. and Tyler, H.R. (1982) "A 'Yankee Invention': the celebrated American crowbar case". Neurology 32:A191.
16. ^ Damasio, H. and T. Grabowski, R. Frank, A.M. Gal­a­burda, A.R. Damasio (1994). "The return of Phineas Gage: clues about the brain from the skull of a fam­ous pa­tient". Science. 264 (5162): 1102–5. doi:10.1126/science.8178168. PMID 8178168. {{cite journal}}: soft hyphen character in |author= at position 82 (help); soft hyphen character in |title= at position 74 (help)CS1 maint: multiple names: authors list (link)
17. See Mac­millan (2008), pp. 829–30.
18. Mac­millan & Lena (2010), p. 9; Harlow (1868), pp. 332, 345; Bigelow (1850), pp. 16–17; Bigelow (1848), p. 390; Mac­millan (2000), p. 86.
19. Harlow (1848), p. 393.
20. Macmillan (2000), pp. 90, 375.
21. Macmillan (2000), pp. 117–8 (Table 6.1); Harlow (1868), pp. 339–41,345.
22. Macmillan (2000), pp. 90–95.
23. ^ Damasio A.R. (2005). "A Modern Phineas Gage". Descartes' Error: Emotion, Reason, and the Human Brain. ISBN 0-14-303622-X. (1st ed.: 1994)
24. Damasio A.R.; Everitt, B. J.; Bishop, D. (1996). "The somatic marker hypothesis and the pos­si­ble functions of the prefrontal cortex". Philos T Roy Soc B. 351 (1346): 1413–20. doi:10.1098/rstb.1996.0125. PMID 8941953. {{cite journal}}: soft hyphen character in |title= at position 42 (help)
25. Macmillan (2000), p. 107.
26. Hockenbury D.H. and S.E. Hockenbury (1997) Psychology.
27. Barker (1995); Macmillan (2000), ch. 9, esp. p. 188.
28. Sizer, Nelson (1888). Forty years in phrenology; embracing recollections of history, anecdote, and experience. Fowler & Wells. p. 194.
29. For example, Carlson, N.R. (1994). Physiology of Behavior. p. 341. ISBN 0-205-07264-X. See additional dis­cus­sion at Mac­millan (2000), p. 246.
30. Mac­millan (2000), p. 250, and see chs. 10–11 generally; see also Mac­millan, M. "Phineas Gage and Frontal Lobotomies". Retrieved Oct 2, 2009. {{cite web}}: soft hyphen character in |author= at position 4 (help)
31. Fleischman (2002)
32. ^ Macmillan (2008), p. 831
33. ^ Mac­millan, M. "More About Phineas Gage". Retrieved Oct 2, 2009. {{cite web}}: soft hyphen character in |last= at position 4 (help)
34. Twomey (2010)
35. ^ Wilgus (2009)
36. Wilgus, B. & J. "Meet Phineas Gage". Retrieved Oct 2, 2009.

Sources and further reading

Further reading (and viewing) for general audiences

• Fleischman, J. (2002). Phineas Gage: A Gruesome but True Story About Brain Science. ISBN 0-618-05252-6. (Intended for middle-school students)
• Lena, M.L. and M. Macmillan (2010). "Picturing Phineas Gage" (invited comment). Smithsonian. March, 2010. p. 4
• Macmillan, M. The Phineas Gage Information page, School of Psychology, Deakin Univ., Victoria, Australia, including "Phineas Gage: Unanswered questions". Retrieved 2009-10-02.
• —— (2008). "Phineas Gage—Unravelling the myth". The Psychologist 21(9):828–831. British Psychological Society.
• —— (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). {{cite book}}: |author= has numeric name (help) Appendices reproduce Harlow (1848, 1849, and 1868), Bigelow (1850) and other key sources, some unavailable elsewhere.
  • See also Macmillan, "Corrections to An Odd Kind of Fame".
  • Review: Seamus Sweeney. "An odd kind of fame". nthposition.com.
• ——; Aggleton, John (March 6, 2011). "Phineas Gage: The man with a hole in his head" (Interview). Interviewed by Claudia Hammond; Dave Lee. {{cite interview}}: |last= has numeric name (help); Unknown parameter |callsign= ignored (help); Unknown parameter |program= ignored (help)CS1 maint: multiple names: interviewers list (link)
• Ratiu et al., Video recon­struc­tion of tamping iron passing through Gage's skull in P. Ratiu and I.F. Talos (2004). "Images in Clinical Medicine: The Tale of Phineas Gage, Digitally Remas­tered". New Engl J Med. 351 (23): e21 (Web only). doi:10.1056/NEJMicm031024. PMID 15575047. {{cite journal}}: soft hyphen character in |title= at position 71 (help) Technical description at P. Ratiu, I.F. Talos, S. Haker, S. Lieberman, P. Everett (2004). "The tale of Phineas Gage, digitally remas­ter­ed". J Neuro­traum. 21 (5): 637–43. doi:10.1089/089771504774129964. PMID 15165371. {{cite journal}}: soft hyphen character in |journal= at position 38 (help); soft hyphen character in |title= at position 42 (help)CS1 maint: multiple names: authors list (link)
• Twomey, S. (2010). "Finding Phineas". Smithsonian. 40 (10): 8–10 (January 2010).
• Wilgus, B. & J (2009). "Face to Face with Phineas Gage". J Hist Neur­o­sci­enc­es. 18 (3): 340–345. doi:10.1080/09647040903018402. PMID 20183215. {{cite journal}}: soft hyphen character in |journal= at position 17 (help)

For specialists

• Barker, F.G. II (1995) "Phineas among the phrenologists: the American crow­bar case and nineteenth-century theories of cerebral localization." J Neur­o­surg 82:672–682
• Harlow, John Martyn (1868). "Recovery from the Passage of an Iron Bar through the Head." Publ Massachusetts Med Soc 2:327–347. Reproduced in Mac­millan (2000).
• Macmillan, M. (1986). "A wonderful journey through skull and brains: The travels of Mr. Gage's tamping iron". Brain and Cognition. 5 (1): 67–107. doi:10.1016/0278-2626(86)90062-X. PMID 3513803.
• —— (2000). "Restoring Phineas Gage: A 150th retrospective". J Hist Neur­o­sci­enc­es. 9 (1): 42–62. doi:10.1076/0964-704X(200004)9:1;1-2;FT046. {{cite journal}}: |author= has numeric name (help); soft hyphen character in |journal= at position 63 (help)
• —— (2001). "John Martyn Harlow: 'Obscure Country Physician'?". J Hist Neur­o­sci­enc­es. 10 (2): 149–162 at 161. doi:10.1076/jhin.10.2.149.7254. {{cite journal}}: |author= has numeric name (help); soft hyphen character in |journal= at position 63 (help)
• —— and M.L. Lena (May 17, 2010). "Rehabilitating Phineas Gage". Neuropsychol Rehabil. 20: 1–18. doi:10.1080/09602011003760527. PMID 20480430.
• Van Horn, John D. (2012). "Map­ping Con­nect­iv­ity Damage in the Case of Phineas Gage". PLoS ONE. 7 (5): e37454. doi:10.1371/journal.pone.0037454. PMID 22616011. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help); soft hyphen character in |title= at position 4 (help)CS1 maint: unflagged free DOI (link)

Other works cited

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

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

External links

• Mac­millan, M. "Phineas Gage: Unanswered questions". Retrieved Oct 2, 2009. {{cite web}}: soft hyphen character in |last= at position 4 (help) Lists re­search questions related to Gage in localities throughout the United States and Chile, for which Gage re­search­ers request assistance from the public.
• Meet Phineas Gage—the story of how the owners of the 2009-discovered da­guerre­o­type learned it depicted Gage.
• Phineas Gage roadside memorial, Cavendish, Vermont

Template:Persondata

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