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Phineas P. Gage (July 9?, 1823 – May 21, 1860) was a railroad construction foreman now remembered for his incredible survival of an accident in which a large iron rod was driven completely through his head, destroying one or both of his brain's frontal lobes, and for that injury's reported effects on his personality and behavior—effects said to be so profound 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 thinking about the brain and the localization of its functions, and was perhaps the first case suggesting that damage to specific regions of the brain might affect personality and behavior.
Gage is a fixture in the curricula of neurology, psychology and related disciplines, and is frequently mentioned in books and academic papers; he also has a minor place in popular culture. Relative to this celebrity, the body of known fact about the case is remarkably small, and this has allowed it to be cited, historically, in support of distinct theories of the brain and mind wholly contradictory to one another. A survey of published accounts has found that even modern scientific presentations are usually exaggerated and distorted in significant ways, contradicting the established facts.
A daguerreotype portrait of Gage—"handsome...well dressed and confident, even proud," and holding the tamping iron which injured him—was identified in 2009 (see right). 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 has been thought.
On September 13, 1848, 25-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. After a hole was "drilled" into a body of rock (via a laborious process which today might best be thought of as "chiseling") one of Gage's duties was to add blasting powder, a fuse, and sand, then compact ("tamp down") the charge using a large iron rod. Possibly because the sand was omitted, around 4:30 PM:
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, shattering the upper jaw, and passing back of the left eye, and out at the top of the head.
Nineteenth-century references to Gage as "the American Crowbar Case" may mislead some readers. For Americans of the time a crowbar did not have the bend or claw sometimes associated with that term today. Gage's iron was something like a javelin, "round and rendered comparatively smooth by use":
The end which entered first is pointed; the taper BBBeing [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 lb (6 kg), this "abrupt and intrusive visitor"  was said to have landed some 80 feet (25 m) away.
Amazingly, Gage spoke within a few minutes, walked with little or no assistance, and sat upright in a cart for the 3/4-mile 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. A "fungal" infection left him semi-comatose from September 23 to October 3, "seldom speaking unless spoken to, and then answering only in monosyllables." On October 7 he took his first step. On October 20 Harlow described his patient as "very childish," and while the doctor 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." 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 final prognosis at the time was that Gage "appears to be in a way of recovering, if he can be controlled." 
Subsequent life and travels
Except for loss of vision (and ptosis) of the left eye, and a large scar on the forehead, Gage's physical recovery seems to have been essentially complete by April 1849. Harlow says that Gage, unable to return to his railroad work, was for a time an attraction at P.T. Barnum's American Museum in New York City (the curious paying to see, presumably, both Gage and the instrument that 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." 
Gage later worked in a livery stable in New Hampshire, and then for some years in Chile as a coach driver. After his health began to fail around 1859, he left Chile for San Francisco, where he recovered under the care of his mother and sister (who had relocated there from New Hampshire around the time he 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 accident. He was buried in San Francisco's Lone Mountain Cemetery.
In 1866, Harlow somehow learned where Phineas had been and began a correspondence with his family, still in San Francisco. At his request they opened his patient's grave long enough to remove the skull, which was delivered to Harlow back in New England. About a year after the accident, Gage had allowed the 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" his "constant companion during the remainder of his life"; now it accompanied the skull on its journey to Harlow. After studying them for his second (1868) paper, Harlow redeposited the iron, now 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 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 mandated relocation of San Francisco's dead to new resting places outside city limits.
Brain damage and mental changes
Significant injury to the brain is often fatal, but as noted earlier the iron's 1/4-inch leading point may have reduced its destructiveness, and apparently all important blood vessels were spared. 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. A 1994 CT modelling study by Hanna Damásio and colleagues suggests bilateral damage to the medial frontal lobes, but a 2004 study by Ratiu and colleagues, based on a CT scan of the actual skull, tends to confirm Harlow's view that the damage was confined to the left frontal lobe.
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 Phineas 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 those 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, Henry Jacob Bigelow, Professor of Surgery at Harvard, wrote in 1850 that Gage was "quite recovered in faculties of body and mind."  (After noting dryly that, "The leading feature of this case is its improbability," Bigelow emphasized that although "at first wholly skeptical, I have been personally convinced," terming the case "unparalled in the annals of surgery." Bigelow's stature largely ended scoffing about Gage among physicians in general — one of whom, Harlow later wrote, had dismissed the matter as a "Yankee invention.")
It was not until his 1868 report that Harlow gave particulars of the mental changes found today (often in exaggerated or distorted form — see below) in most textbooks. In memorable language, he now 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, 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.' ||”|
It is difficult to find anything written about Gage which does not draw on this passage, particularly its existentially troubling conclusion. Yet it is unknown on just what exactly Harlow based this description, set down twenty years after his treatment of Phineas:
- He may have been working from his own notes made in the months after the accident — which would not apply to the patient's long-term outcome.
- He may have been working from his own (or Gage's acquaintances', or Gage's mother's) recollections of Gage prior to Gage's circa-1852 departure for Chile — also not applicable to the long-term outcome, nor perhaps fully trustworthy given the intervening decades.
- Or he may have been drawing on Hannah Gage's intermittent observations of her son during his nine months in California just before he died — these observations not recounted to Harlow until six or seven years later.
- The raw material for Harlow's description may even have come to him via some still-more-indirect path, such as by mother Gage recollecting for Harlow, in 1868, statements made to her by others about their observations of Phineas during his time away from her on his New England travels (between his physical recovery and his departure for Chile).
Of the handful of available primary sources on Gage, Harlow's 1868 presentation is by far the most informative, and there is no reason to doubt its general reliability. However, it is difficult to match the long list of facets he describes in Gage's behavior (which vary greatly in their implied level of functional impairment) to the period of Gage's life during which each was present, and this complicates reconstruciton of what Gage was like during those various periods.
Distortion and misuse of case
All modern authors agree that Gage displayed some kind of change in behavior after his accident, though they frequently describe these changes in terms well beyond anything given by Harlow. Psychologist Malcolm Macmillan, in his book An Odd Kind of Fame: Stories of Phineas Gage, surveys scores of accounts of the case (both scientific and popular), finding that they are varying and inconsistent, typically poorly supported by the evidence, and often in direct contradiction to it. These accounts commonly ascribe to Gage drunkenness, braggadocio," "a vainglorious tendency to show off his wound," an "utter lack of foresight," inability or refusal to hold a job, and much more — none of these mentioned by Harlow nor by anyone else claiming actual knowledge of Gage's life.
Harlow himself, writing in 1868 while in contact with Gage's mother, somehow mistakes the year of Gage's death as 1861, whereas Macmillan shows conclusively that Gage actually died in 1860 — a striking if relatively unimportant illustration of the difficulty of establishing even basic fact about the case. In another example, several sources state matter-of-factly that Gage's iron had been buried with him, but in fact Harlow's account of how he obtained the iron and the skull does not say this.
More substantively, Macmillan points out that in a passage which has been interpreted to suggest that Gage could not hold a job after his accident—Template:"'...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 triedTemplate:'"—Harlow is referring not to Gage's post-accident life in general, but only to the months between the onset of his convulsions and his death.
Beyond the obvious importance of correcting the record of a much-cited case, Macmillan claims that "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 for information in an effort "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 very unpleasant changes usually 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.
Current research and daguerreotype portrait
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 long-distance coach 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 Phineas eventually "figured out how to live" despite his injury, and was in later life far more functional, and socially far better adapted, than has been 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 then along with theoretical implications, it "would add to current evidence that rehabilitation can be effective even in difficult and long-standing cases," according to Macmillan, asking that, if Phineas could achieve such improvement without medical supervision, "what are the limits for those in formal rehabilitation programs?" 
In 2009 a daguerreotype portrait of Gage (above) was identified—the only likeness of him known other than a life mask taken around 1850 (above). It shows "a disfigured yet still-handsome" Gage with one eye closed and scars clearly visible, "well dressed and confident, even proud". He is shown holding the "iron" which had injured him, on which parts 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's subject against injuries 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 (listed here) for which they hope readers will remain alert, such as letters or diaries by physicians who their research indicates Gage may have met, or by persons in certain places Gage seems to have been. 
- REDIRECT Template:Reflist
- For general audiences:
- Macmillan, M. The Phineas Gage Information page, School of Psychology, Deakin University, Victoria, Australia, including
- Fleischman, J. (2002). Phineas Gage: A Gruesome but True Story About Brain Science. (Aimed at middle-school students)
- Macmillan, M. (2008). Phineas Gage – Unravelling the myth The Psychologist (British Psychological Society), 21(9): 828–831.
- Macmillan, M. (2000). An Odd Kind of Fame: Stories of Phineas Gage, MIT Press. (Appendices reproduce Harlow 1848 and 1868, Bigelow 1850, and other primary documents, some unavailable elsewhere.)
- Twomey, S. (2010). Finding Phineas. Smithsonian Magazine 40: 8–10 (January 2010).
- Specialized reading:
- 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
- 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).
- Damasio A.R. (2005). "A Modern Phineas Gage" Descartes' Error: Emotion, Reason, and the Human Brain. (First edition: 1994)
- Damasio H., Grabowski T., Frank R., Galaburda AM., Damasio AR (1994). The return of Phineas Gage: clues about the brain from the skull of a famous patient. Science 264 (5162): 1102–5.
- Harlow, John Martyn (1848). "Passage of an iron rod through the head". Boston Medical and Surgical Journal 39: 389–393 (Republished in Journal of Neuropsychiatry and Clinical Neuroscience 11, 281–283; and in Macmillan 2000).
- Harlow, J.M. (1849). Letter in "Medical Miscellany." Boston Medical and Surgical Journal 39: 506–7 (Republished in Macmillan 2000).
- Harlow, J.M. (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).
- 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. See also 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).
- 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.
- Macmillan, M. (2000). Restoring Phineas Gage: A 150th retrospective. Journal of the History of the Neurosciences 9 (1): 42–62.
- Macmillan, M. "Phineas Gage: Unanswered questions". URL accessed on Oct 2, 2009. Lists research questions related to Gage in localities throughout the US and Chile, for which Gage researchers request assistance from the general public.
- Meet Phineas Gage — the story of how the daguerreotype's owners realized it depicted Gage.
- Phineas Gage roadside memorial, Cavendish, Vermont
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