Phineas Gage

Phineas P. Gage
The first identified (2009) portrait of Gage and his "constant companion for the remainder of his life"—his inscribed tamping iron
Born	July 9, 1823 (date uncertain) Grafton County, New Hampshire
Died	May 21, 1860(1860-05-21) (aged 36) In or near San Francisco
Resting place	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

Path of "this abrupt and intrusive visitor", per Harlow. Note partially detached bone flap above forehead.

Phineas P. Gage (1823–1860) was an American railroad construction foreman remembered for his improbable survival of an accident at the age of 25 in which a large iron rod was driven completely through his head, destroying much of his brain's left frontal lobe, and causing profound changes in his personality and behavior.

Gage's case was for long known as "the American Crowbar Case". It was 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". The case influenced nineteenth-century discussion about the mind and brain, particularly debate on cerebral localization, and was perhaps the first to suggest that damage to specific parts of the brain might affect personality.

Gage is a fixture in the curricula of neurology, psychology and related disciplines, and is frequently mentioned in books and academic papers; he even has a minor place in popular culture. Despite this celebrity, the body of established fact about Gage and what he was like (whether before or after his accident) is remarkably small. That lack of information has allowed "the fitting of almost any theory to the small number of facts we have". Gage has been cited, over the years, by proponents of various contradictory theories of the brain. A survey of published accounts, including scientific ones, has found that they almost always severely distort Gage's behavioral changes, exaggerating the known facts and sometimes directly contradicting them.

Unearthed between 2008–2010, three new portraits of Gage and a report on his physical and medical condition indicate that his later life was more functional and better socially adjusted than was previously known. This new evidence has led to a social recovery hypothesis under which Gage's most serious mental changes may have existed for only a limited time after the accident.

Background

Line of the Rutland & Burlington RR passing through cut in rock south of Cavendish, Vt. Gage met with his accident while setting explosives to create either this cut or a similar one nearby.

The Boston Post for Sept. 21, 1848 (understating the dimensions of Gage's tamping iron and overstating damage to the jaw).

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

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

Gage's accident

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

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

Despite 19th-century references to Gage as "the American Crowbar Case" 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 [twelve] 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 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

Gage's iron and exhumed skull (sawed to permit view of interior) photographed for Harlow in 1868

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 [Gage], 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^r 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

The brain's left frontal lobe (red), the forward portion of which was damaged by Gage's injury, according to Harlow's digital examination, as well as the digital analyses of Ratiu et al. and Van Horn et al.

(a) Gage's skull, Warren Museum; (b,c,d) Probable path of tamping iron (per Van Horn et al.) with false-color representation of cerebral fiber pathways affected.

Extent of brain damage

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

First-hand reports of mental changes

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 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." 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 only "inconsiderable disturbance of function".

It was twenty years later that Harlow, having obtained Gage's skull and the history of his final years, wrote the description of Gage's mental changes which is found today in most presentations of the case, though usually in exaggerated or distorted form. In memorable language, 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 appears to draw on Harlow's own notes set down soon after the accident, but other behaviors he describes appear to draw on later communications from Gage's friends or family. It is difficult to match these various behaviors (which range widely in their implied level of functional impairment) to the particular period of Gage's life during which each described behavior was present. This complicates reconstruction of what Gage was like at various points in his post-accident life, a critical task (in the light of evidence) that his behavior at the end of his life was very different from his immediate post-accident behavior as described by Harlow.

Distortion of mental changes

Psychologist Malcolm Macmillan, in his book An Odd Kind of Fame: Stories of Phineas Gage (the only book-length treatment of the case) surveys scores of accounts of Gage, both scientific and popular, showing that they almost always distort and exaggerate his behavioral changes well beyond anything described by those who had 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 may misinterpret a passage by Harlow—"'... continued to work in various places;' could not do much, changing often, 'and always finding something that did not suit him in every place he tried'"—as implying Gage could not hold a job after his accident. In fact, Harlow's words could refer not to Gage's post-accident life in general, but only to the months just before his death, after convulsions had set in. Until then some evidence points towards Gage supporting himself, throughout his adult life, at paid work.

(Harlow himself, writing in 1868 while in contact with Gage's mother, somehow mistakes the year of Gage's death as 1861, whereas funeral records show he 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 enlist Gage in support of their theories. For example, while Ferrier cited Gage as evidence that the brain is localized, physician Eugene Dupuy used him as proof that it is not. Phrenologists made use of Gage as well, claiming that his mental changes resulted from destruction of his "organ of Veneration" and/or the adjacent "organ of Benevolence".

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

[T]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

The second portrait of Gage to be identified (2010). "His mother ... informs me that Phineas was accustomed to entertain his little nephews and nieces with the most fabulous recitations of his wonderful feats and hair-breadth escapes, without any foundation except in his fancy. He conceived a great fondness for pets and souvenirs, especially for children, horses, and dogs—only exceeded by his attachment for his tamping iron, which was his constant companion for the remainder of his life."

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

• Eadweard Muybridge
• Orbitofrontal cortex
• Penetrating head injury

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

For specialists

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

Other works cited

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