Phineas Gage

Phineas P. Gage
The first identified (2009) portrait of Gage, shown here with 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

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 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 causing extensive damage to his white matter tracts - and for that injury's reported effects on his personality and behavior, effects so profound—for a time, at least—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 19th-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 (head of article) 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.

Gage's accident

Track passing through cut in rock (ctr. distance—click to enlarge) south of Cavendish, Vt. Gage met with his accident while setting explosives to create either this cut or a similar one nearby.

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 instrument through his head an inch and a fourth in [diameter], and three feet and [seven] 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.

(See image above left.) 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 [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" was said to have landed some 80 feet (25 m) away, "smeared with blood and brain."

Amazingly, Gage spoke within a few minutes, walked with little or no assistance, and sat upright in a cart for the +3⁄4-mile (1.2 km) ride to his lodgings in town. The first physician to arrive 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

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

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.)

Gage later worked in a livery stable in Hanover, New Hampshire and then for some years in Chile as a long-distance stagecoach driver 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 somehow learned that Gage had died in California and opened a correspondence with Gage's 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 (according to Harlow) made what he called "my iron bar" his "constant companion during the remainder of his life"; now it accompanied the skull on the journey East. After studying them for a new paper (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 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

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 claiming actual acquaint­ance with Gage or his family.

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 Damasio et al. that there was damage to the frontal lobes on both sides was drawn by modeling not Gage's skull but a "Gage-like" one; in contrast a 2004 study by Ratiu et al. (based on CT scans of Gage's actual skull, and presenting a video reconstruction of the tamping iron passing through it) confirms Harlow's conclusion (based on probing Gage's wound with his finger) that the right hemisphere remained intact.

Primary-source presentations

Neurologist Antonio Damasio uses Gage to illustrate a hypothesized link between the frontal lobes, emotion and practical decision-making. But any theory that looks to Gage for support faces the difficulty that the nature, extent, and duration of the injury's effects on his mental state are very uncertain. In fact little is 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 even the few descriptions which seem credible do not specify the period of his post-accident life to which they are meant to apply.

In his 1848 report, as Gage was just completing his physical recovery, Harlow had only hinted at possible psychological symptoms: "The mental manifestations of the patient, I leave to a future communication. I think the case ... is exceedingly interesting to the enlightened physiologist and intellectual philosopher." And after observing Gage for several weeks in late 1849, Henry Jacob Bigelow, Professor of Surgery at Harvard, 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 not until 1868 that Harlow gave particulars of the mental changes found today (though usually in exaggerated or distorted form—see below) in most presentations of the case. In memorable language, he described the pre-accident Gage as having been 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, some months 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".

Of the handful of primary sources, Harlow's 1868 presentation is by far the most informative, and despite certain errors in dating (see below) there seems no reason to doubt its general reliability. The description above, though not published until two decades after Harlow last saw Gage, appears to draw on Harlow's own notes set down soon after the accident. But other behaviors of Gage's described by Harlow (in the same, and other, communications) 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 just after the accident—the behavior described in Harlow's famous passage above.

Distortion and misuse of case

The second portrait of Gage to be identified (2010) (Click to enlarge)

There is no question Gage displayed some kind of change in behavior after his accident, but books and articles usually describe these changes in terms well beyond anything given by Harlow or others who had contact with Gage or his family. Psychologist Malcolm Macmillan, in his book An Odd Kind of Fame: Stories of Phineas Gage (the only book-length treatment of Gage) surveys scores of accounts of the case (both scientific and popular) showing that they are varying and inconsistent, typically exaggerated far beyond the evidence, and often in direct contradiction to the evidence.

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 claiming actual acquaintance with Gage or his family.

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 if relatively unimportant illustration of the difficulty of establishing even basic facts about the case. In another example, several sources state that Gage's iron was buried with him, but there appears to be no evidence for this.

More substantively, Macmillan points out that in a passage mistakenly interpreted as implying Gage could not hold a job after his accident—" '... 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' "—Harlow is referring not to Gage's post-accident life in general, but only to the months just before his death, after convulsions had set in.

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 19th-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. 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:

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

By late 2008 an advertisement for a previously unknown public appearance by Gage had been 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 information suggests that the seriously maladapted Gage described by Harlow may have 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 (see head of article) 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 similarly, 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 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 (above) 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 as the daguerreotype identified in 2009, according to Gage researchers consulted by the Smithsonian Institution.

See also

• Penetrating head injury

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. (Aimed at middle-school students)
• Macmillan, M. The Phineas Gage Information page, School of Psychology, Deakin University, Victoria, Australia, including "Phineas Gage: Unanswered questions". Retrieved 2009-10-02.
• — (2008). "Phineas Gage—Unravelling the myth The Psychologist ([[British Psychological Society]]), 21(9):828–831" (PDF). {{cite web}}: |author= has numeric name (help); URL–wikilink conflict (help)
• — (2000). An Odd Kind of Fame: Stories of Phineas Gage. MIT Press. ISBN 0-262-13363-6. {{cite book}}: |author= has numeric name (help) (Appendices reproduce Harlow 1848, 1849, and 1868; Bigelow 1850; and other key sources, some unavailable elsewhere.)
  • Paperback edition, 2002. ISBN 0-262-63259-4.
  • See also Macmillan, Corrections to An Odd Kind of Fame.
  • Review: Seamus Sweeney. "An odd kind of fame". nthposition.com.
• 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 England Journal of Medicine. 351 (23): e21 (Web only). doi:10.1056/NEJMicm031024. PMID 15575047. Technical description at Ratiu P., I.F. Talos, S. Haker, S. Lieberman, P. Everett (2004). "The tale of Phineas Gage, digitally remastered". Journal of 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 Magazine. 40 (10): 8–10 (January 2010).
• Wilgus, B. & J.; Wilgus, B (2009). "Face to Face with Phineas Gage". J. Hist. Neurosciences. 18 (3): 340–345. doi:10.1080/09647040903018402. PMID 20183215.
• Hammond, Claudia and Lee, Dave. "Phineas Gage: The man with a hole in his head". BBC News. 6 March 2011.

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." Publications of the Massachusetts Medical Society 2:327–347 (Republished 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". Journal of the History of the Neurosciences. 9 (1): 42–62. doi:10.1076/0964-704X(200004)9:1;1-2;FT046. {{cite journal}}: |author= has numeric name (help)
• — (2001). "John Martyn Harlow: 'Obscure Country Physician'?". Journal of the History of the Neurosciences. 10 (2): 149–162 at 161. doi:10.1076/jhin.10.2.149.7254. {{cite journal}}: |author= has numeric name (help)
• Macmillan, M. and M.L. Lena (May 17, 2010). "Rehabilitating Phineas Gage". Neuropsychological Rehabilitation. 20: 1–18. doi:10.1080/09602011003760527. PMID 20480430.

Other works cited:

• Bigelow, Henry Jacob (1850). "Dr. Harlow's case of Recovery from the passage of an Iron Bar through the Head." American Journal of the Medical Sciences 20:13–22 (Republished 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. Medical Times and Gazette v.II pp. 356–8.
• 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 Medical and Surgical Journal 39:389–393 (Republished in Neylan, T.C. (1999) "Frontal Lobe Function: Mr. Phineas Gage's Famous Injury." Journal of Neuropsychiatry and Clinical Neuroscience. 11, 281–283; and in Macmillan 2000).
• — (1849). Letter in "Medical Miscellany." Boston Medical and Surgical Journal 39:506–7 (Republished in Macmillan 2000).
• Lena, M.L. and M. Macmillan (2010). "Picturing Phineas Gage". Invited comment. Smithsonian Magazine: 4. {{cite journal}}: Italic or bold markup not allowed in: |journal= (help); Unknown parameter |month= ignored (help)

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 daguerreotype portrait learned it depicted Gage.
• Phineas Gage roadside memorial, Cavendish, Vermont