Phineas Gage

Cavendish, Vermont, 20 years after Gage's accident: (a) Region of the accident site; (t) Gage's lodgings, to which he was taken after his injury; (h) Harlow's home and surgery.[note 3]

Gage was the first of five children born to Jesse Eaton Gage and Hannah Trussell (Swetland) Gage of Grafton County, New Hampshire.[note 1] Little is known about his upbringing and education beyond that he was literate.​​^{[M]:17,41,90[M10]:643}

Physician John Martyn Harlow, who knew Gage before his accident, described him as "a perfectly healthy, strong and active young man, twenty-five years of age, nervo-bilious temperament, five feet six inches [1.68 m] in height, average weight one hundred and fifty pounds [68 kg], 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 [his] injury".^[H]:4 (In the pseudoscience of phrenology, which was then just ending its vogue,[12] nervo-bilious denoted an unusual combination of "excitable and active mental powers" with "energy and strength [of] mind and body [making] possible the endurance of great mental and physical labor".)​​^[M]:346-7[13]^:6

Gage may have first worked with explosives on farms as a youth, or in nearby mines and quarries.^[M]:17-8 He is known to have worked on construction of the Hudson River Railroad near Cortlandt Town, New York,[14]^[M10]:643 and by the time of his accident he was a blasting foreman (possibly an independent contractor) on railway construction projects.^{[M]:18-22,32n9} His employers' "most efficient and capable foreman ... a shrewd, smart business man, very energetic and persistent in executing all his plans of operation",^[H]:13-4 he had even commissioned a custom-made tamping iron‍—‌a large iron rod‍—‌for use in setting explosive charges.​​^[B1]:5[M]:25

Line of the Rutland & Burlington Railroad passing through "cut" in rock south of Cavendish. Gage met with his accident while setting ex­plo­sives to create either this cut or a similar one nearby.[note 3]

Explosive charge ready for fuse to be lit. tamping (sand or clay) directs blast into surrounding rock.

On September 13, 1848, Gage was direct­ing a work gang blast­ing rock while pre­par­ing the road­bed for the Rut­land & Bur­ling­ton Rail­road south of the village of Cav­en­dish, Ver­mont. Setting a blast entailed boring a hole deep into an out­crop of rock; adding blast­ing pow­der and a fuse; then using the tamping iron to pack ("tamp") sand, clay, or other inert material into the hole above the powder in order to contain the blast's energy and direct it into surrounding rock.[note 3]

The "cone of un­cer­tain­ty" for the path taken by the tamping iron. Gage's mouth was open at the moment of the ex­plo­sion, and the front and back of his skull tem­po­rarily "hinged" apart as the iron entered from below, then were pulled back to­geth­er by the re­sil­ience of soft tissues once the iron had exited through the top of Gage's head.[15]

Panel from Bring Me the Head of Phineas Gage, a portrayal of Gage in popular culture[16]

As Gage was doing this around 4:30 p.m., his attention was attracted by his men working behind him. Looking over his right shoulder, and inad­vert­ent­ly bringing his head into line with the blast hole, Gage opened his mouth to speak; in that same instant the tamping iron sparked against the rock and (possibly because the sand had been omitted) the powder exploded. Rocketed from the hole, the tamping iron‍—‌1 ¹⁄₄ inches (32 mm) in diameter, three feet seven inches (1.1 m) long, and weighing 13 ¹⁄₄ pounds (6.0 kg)‍—‌entered the left side of Gage's face in an upward direction, just forward of the angle of the lower jaw. Continuing upward outside the upper jaw and possibly fracturing the cheekbone, it passed behind the left eye, through the left side of the brain, then completely out the top of the skull through the frontal bone.​​^{[B1]:13-4[H]:5}​​^[M]:25-9​​[15]​​[17]

Despite 19th-century references to Gage as the "American Crowbar Case",[note 4] his tamping iron did not have the bend or claw some­times asso­ci­at­ed with the term crowbar; rather, it was simply a pointed cylinder something like a javelin,^[K] round and fairly smooth:^[H]:5

The end which entered [Gage's cheek] first is pointed; the taper being [eleven inches (280 mm) long, ending in a ¹⁄₄-inch (6.4 mm) point] ^[V]:17... 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 the owner.^[B1]:14

The tamping iron landed point-first some 80 feet (25 m) away,^[M]:29[17][7] "smeared with blood and brain".^[H]:5

Gage was thrown onto his back and gave some brief convulsions of the arms and legs, but 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.^[H]:5 About 30 minutes after the accident physician Edward H. Williams, finding Gage sitting in a chair outside the hotel, was greeted with "one of the great understatements of medical history":​​^[M5]:244

When I drove up he said, "Doctor, here is business enough for you." I first noticed the wound upon the head before I alighted from my carriage, the pulsations of the brain being very distinct. The top of the head appeared somewhat like an inverted funnel, as if some wedge-shaped body had passed from below upward. Mr. Gage, during the time I was examining this wound, was relating the manner in which he was injured to the bystanders. I did not believe Mr. Gage's statement at that time, but thought he was deceived. Mr. Gage persisted in saying that the bar went through his head. Mr. G. got up and vomited; the effort of vomiting pressed out about half a teacupful of the brain [through the exit hole at the top of the skull], which fell upon the floor.[19]

Harlow took charge of the case around 6 p.m.:

You will excuse me for remarking here, that the picture presented was, to one unaccustomed to military surgery, truly terrific; but the patient bore his sufferings with the most heroic firmness. He recognized me at once, and said he hoped he was not much hurt. He seemed to be perfectly conscious, but was getting exhausted from the hemorrhage. His person, and the bed on which he was laid, were literally one gore of blood.[19]

A nightcap used as a bandage

With Williams' assistance[note 5] Harlow shaved the scalp around the region of the tamping iron's exit, then removed coagulated blood, small bone fragments, and "an ounce or more" of protruding brain. After probing for foreign bodies and replacing two large detached pieces of bone, Harlow closed the wound with adhesive straps, leaving it partially open for drainage;^[M]:60-1 the entrance wound in the cheek was bandaged only loosely, for the same reason. A wet compress was applied, then a nightcap, then further bandaging to secure these dressings. Harlow also dressed Gage's hands and forearms (which along with his face had been "deeply burned") and ordered that Gage's head be kept elevated.

Late that evening Harlow noted: "Mind clear. Constant agitation of his legs, being alternately retracted and extended ... Says he 'does not care to see his friends, as he shall be at work in a few days.'" [19]

The first known report of Gage's ac­ci­dent, under­stat­ing the size of his tamp­ing iron (by confusing its diam­e­ter with its cir­cum­fer­ence) and over­stat­ing damage to his jaw.​​[21]^[M]:12[22] "His fame is of the kind that is, and in his case literally so, thrust upon other­wise ordinary people", writes Malcolm Macmillan.^[M]:11

Despite his own optimism, Gage's convalescence was long, difficult, and uneven. Though recognizing his mother and uncle—summoned from Lebanon, New Hampshire, 30 miles (50 km) away‍—‌^[H]:12[M]:30 on the morning after the accident, on the second day, he "lost control of his mind, and became decidedly delirious". By the fourth day, he was again "rational ... knows his friends", and after a week's further improvement Harlow entertained, for the first time, the thought "that it was possible for Gage to recover ... This improvement, however, was of short duration." [19]

The entry damage to Gage's left cheek, and the raised bone fragment in the exit area above his forehead, are visible in this plaster cast taken in late 1849.​​[note 6]

"Disfigured yet still hand­some".^[T] Note ptosis of the left eye and scar on forehead.

Beginning 12 days after the accident,^[M]:53 Gage was semi-comatose, "seldom speaking unless spoken to, and then answering only in monosyllables", and on the 13th day Harlow noted, "Failing strength ... coma deepened; the globe of the left eye became more protuberant, with ["fungus"‍—‌deteriorated, infected tissue]^[M]:61,283 pushing out rapidly from the internal canthus [as well as] from the wounded brain, and coming out at the top of the head." By the 14th day, "The exhalations from the mouth and head [are] horribly fetid. Comatose, but will answer in monosyllables if aroused. Will not take nourishment unless strongly urged. The friends and attendants are in hourly expectancy of his death, and have his coffin and clothes in readiness." [19]

Galvanized to action, Harlow "cut off the fungi which were sprouting out from the top of the brain and filling the opening, and made free application of caustic [i.e. crystalline silver nitrate]^{[M]:54[H1]:392} to them. With a scalpel I laid open the [frontalis muscle, from the exit wound down to the top of the nose]^[H1]:392 and immediately there were discharged eight ounces [250 ml] of ill-conditioned pus, with blood, and excessively fetid." [19] ("Gage was lucky to encounter Dr. Harlow when he did", writes Barker. "Few doctors in 1848 would have had the experience with cerebral abscess with which Harlow left [Jefferson Medical College] and which probably saved Gage's life." ^[B]:679-80 See § Factors favoring Gage's survival, below.)

On the 24th day, 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 ... he went without an overcoat and with thin boots; got wet feet and a chill". He soon developed a fever, but by mid-November he was "feeling better in every respect [and] walking about the house again". Harlow's prognosis at this point: Gage "appears to be in a way of recovering, if he can be controlled".[19]

By November 25 (10 weeks after his injury), Gage was strong enough to return to his parents' home in Lebanon, New Hampshire, traveling there in a "close carriage" (an enclosed conveyance of the kind used for transporting the insane).^[H]:12[M]:92 Though "quite feeble and thin ... weak and childish"[23]^[M]:93 on arriving, by late December he was "riding out, improving both mentally and physically",^[H2] and by February 1849 he was "able to do a little work about the horses and barn, feeding the cattle etc. [and] as the time for ploughing came [i.e. about May or June] he was able to do half a day's work after that and bore it well". In August his mother told an inquiring physician that his memory seemed somewhat impaired, though slightly enough that a stranger would not notice.[note 7]

In April 1849, Gage returned to Cavendish and visited Harlow, who noted at that time loss of vision, and ptosis, of the left eye,[note 8] a large scar on the forehead (from Harlow's draining of the abscess)^[H1]:392 and

upon the top of the head ... a quadrangular fragment of bone ... raised and quite prominent. Behind this is a deep depression, two inches by one and one-half inches [51 by 38 mm] wide, beneath which the pulsations of the brain can be perceived. Partial paralysis of the left side of the face. His physical health is good, and I am inclined to say he has recovered. Has no pain in head, but says it has a queer feeling which he is not able to describe.^[H]:12-3

Gage's rearmost left upper molar, adjacent to the point of entry through the cheek, was also lost.[note 9] Though a year later some weakness remained,^[M]:93[24] Harlow wrote that "physically, the recovery was quite complete during the four years immediately succeeding the injury".^[H]:19

Bigelow presented Gage to the elite Boston Society for Medical Im­prove­ment in 1849. In this 1853 Society portrait Oliver Wendell Holmes is seated second from left.

For a time Gage was "a kind of living museum exhibit" at Barnum's American Museum in New York City.

"Admittance ​12 ¹⁄₂ cents" (equiv­a­lent to about $4 in 2019).[25] Gage briefly resumed exhib­it­ing just before going to Chile, possibly to help finance that move; this adver­tise­ment appeared August 1852 in Montpelier, Vermont.​​^[L1]:175

In November 1849, Henry Jacob Bigelow, the Professor of Surgery at Harvard Medical School,^[M1]:828 brought Gage to Boston for several weeks and, after satisfying himself that the tamping iron had actually passed through Gage's head, presented him to a meeting of the Boston Society for Medical Improvement and (possibly) to the medical school class.​​^{[B1]:20[M]:43,95}[26][note 10]

Unable to reclaim his railroad job (see § Early observations (1849–1852)) Gage was for a time "a kind of living museum exhibit" [29] at Barnum's American Museum in New York City. (This was not the later Barnum's circus; there is no evidence Gage ever exhibited with a troupe or circus, or on a fairground.)[30][note 10] Advertisements have also been found for public appearances by Gage‍—‌which he may have arranged and promoted himself‍—‌in New Hampshire and Vermont,^[M10]:643-4 supporting Harlow's statement that Gage made public appearances in "most of the larger New England towns".^{[H]:14[M1]:829} (Years later Bigelow wrote that Gage had been "a shrewd and intelligent man and quite disposed to do anything of that sort to turn an honest penny", but gave up such efforts because "[that] sort of thing has not much interest for the general public".)​​^[B2]​​[31]^:28​​^[M10]:643-4 For about 18 months, he worked for the owner of a stable and coach service in Hanover, New Hampshire.​​^{[H]:14[M]:101}

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 Valparaíso–Santiago route.^{[M]:103-4[H]:14} After his health began to fail in mid-1859,​​^[H]:14-5[note 11] he left Chile for San Francisco, arriving (in his mother's words) "in a feeble condition, having failed very much since he left New Hampshire ... Had many ill turns while in Valparaiso, especially during the last year, and suffered much from hardship and exposure." In San Francisco he recovered under the care of his mother and sister,^[H]:15 who had relocated there from New Hampshire around the time he went to Chile.^[M]:103-4 Then, "anxious to work", he found employment with a farmer in Santa Clara.^[H]:15

In February 1860,[note 11] Gage began to have epileptic seizures. He lost his job, and (wrote Harlow) as the seizures increased in frequency and severity he "continued to work in various places [though he] could not do much".​​^[M]:14[H]:16

New Hampshire Statesman, July 21, 1860​​[33]

On May 18, 1860 Gage "left Santa Clara and went home to his mother. At 5 o'clock, A.M., on the 20th, he had a severe con­vul­sion. The family physician was called in, and bled him. The con­vul­sions were repeated frequently during the suc­ceed­ing day and night," ^[H]:15 and he died in status epi­lep­ti­cus,^[M2]:E in or near San Francisco,[note 12] late on May 21, 1860. He was buried in San Francisco's Lone Mountain Cemetery.​​[note 11]

"[T]he 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 in my hands, for the benefit of science." Gage's skull (sawn to show inte­rior) and iron, photo­graphed for Harlow in 1868.​​[34]

Gage's brother-in-law (a San Fran­cis­co city offi­cial) and his fam­i­ly per­son­al­ly de­liv­ered Gage's skull and iron to Harlow.​​^[M10]:646[35]

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 made contact with his family there. At Harlow's request the family had Gage's skull exhumed, then personally delivered it to Harlow,​​^{[M]:108-11[H]:15-6[M10]:646} who was by then a prominent physician, busi­ness­man, and civic leader in Woburn, Massachusetts.​​^{[M]:351-64[M7]}

About a year after the accident, Gage had given his tamping iron to Harvard Medical School's Warren Anatomical Museum, but he later reclaimed it​​^[B1]:22n[36]^[M]:46-7 and made what he called "my iron bar" ^{[M10]:644[G1]} his "constant companion during the remainder of his life";[note 13] now it too was delivered by Gage's family to Harlow.^[M10]:646 (Though some accounts assert that Gage's iron had been buried with him, there is no evidence for this.)​​^{[M10]:647[L1]:177} After studying them for a triumphal^[L1]:178 1868 retrospective paper on Gage^[H]:3 Harlow redeposited the iron‍—‌this time with the skull‍—‌in the Warren Museum, where they remain on display today.[37]

The tamping iron bears the following inscription, commissioned by Bigelow in conjunction with the iron's original deposit in the Museum[36] (though the date given for the accident is one day off):

This is the bar that was shot through the head of Mr 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[38]

The date Jan 6 1850 falls within the period during which Gage was in Boston under Bigelow's observation.​​^{[B1]:20[H]:4n[M]:43}

In 1940 Gage's headless remains were moved to Cypress Lawn Memorial Park as part of a mandated relocation of San Francisco's cemeteries to outside city limits (see San Francisco cemetery relocations).​​^[M]:119-20[39]

Excerpt from record book, Lone Mountain Cemetery, San Francisco, reflecting the May 23, 1860 interment of Phineas B.^[sic] Gage by undertakers N. Gray & Co.[note 11] (Position pointer over writing for transcription; click for full page.)

Harlow ("virtually our only source of information" on Gage, according to psychologist Malcolm Macmillan)^[M]:333[note 2] 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"; he also took pains to note that Gage's memory and general intelligence seemed unimpaired after the accident, outside of the delirium exhibited in the first few days.^[M]:30,91 Nonetheless 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 business man, 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."^[H]:13-4

This description ("now routinely quoted", says Kotowicz)^[K2]:125 is from Harlow's observations set down soon after the accident,​​^{[M]:90,375[M10]:646-9} but Harlow‍—‌perhaps hesitant to describe his patient negatively while he was still alive^[M]:375-6‍—‌delayed publishing it until 1868, after Gage had died and his family had supplied "what we so much desired to see" (as Harlow termed Gage's skull).^[H]:16

In the interim, Harlow's 1848 report, published just as Gage was emerging from his convalescence, merely hinted at psychological symptoms:^[M]:169

The mental manifestations of the patient, I reserve to a future communication. I think the case ... is exceedingly interesting to the enlightened physiologist and intellectual philosopher.^[H1]:393

"Before the in­jury he was quiet and re­spect­ful." 1851 report, ap­par­ently based on infor­ma­tion from Harlow, coun­ter­ing Bigelow's claim that Gage was mentally unchanged.

But after Bigelow termed Gage "quite recovered in faculties of body and mind" with only "inconsiderable disturbance of function",^[B1]:13-4 a rejoinder in the American Phrenological Journal‍—‌

That there was no difference in his mental manifestations after the recovery [is] not true ... he was gross, profane, coarse, and vulgar, to such a degree that his society was intolerable to decent people.[45]

‍—‌was apparently based on information anonymously supplied by Harlow.^[M]:350-1 Pointing out that Bigelow's extensive verbatim quotations from Harlow's 1848 papers omitted Harlow's promise to follow up with details of Gage's "mental manifestations", Barker explains Bigelow's and Harlow's contradictory evaluations (less than a year apart) by differences in their educational backgrounds, in particular their attitudes toward cerebral localization (the idea that different regions of the brain are specialized for different functions) and phrenology (the nineteenth-century pseudoscience that held that talents and personality can be inferred from the shape of a person's skull):

Harlow's interest in phrenology prepared him to accept the change in [Gage's] character as a significant clue to cerebral function which merited publication. Bigelow had [been taught] that damage to the cerebral hemispheres had no intellectual effect, and he was unwilling to consider Gage's deficit significant ... The use of a single case [including Gage's] to prove opposing views on phrenology was not uncommon.^{[B]:672,676,678,680}

A reluctance to ascribe a biological basis to "higher mental functions" (functions‍—‌such as language, personality, and moral judgment‍—‌beyond the merely sensory and motor) may have been a further reason Bigelow discounted the behavioral changes in Gage which Harlow had noted.​​^{[M]:169-70[M1]:838} (See Mind–body dualism.)

"Please deliver my iron bar to the bearer". While in Chile, Gage had his relative B. R. Sweetland retrieve the tamping iron from Harvard's Warren Anatomical Museum.[note 13]

In 1860, an American physician who had known Gage in Chile in 1858 and 1859 described him as still "engaged in stage driving [and] in the enjoyment of good health, with no impairment whatever of his mental faculties".​​[46]^[M10]:648 Together with the fact that Gage was hired by his employer in advance, in New England, to become part of the new coaching enterprise in Chile,​​^{[H]:15[M10]:655} this implies that Gage's most serious mental changes had been temporary, so that the "fitful, irreverent ... capricious and vacillating" Gage described by Harlow immediately after the accident became, over time, far more functional and socially far better adapted.​​^{[M1]:831[M10]:642,655}

Macmillan writes that this conclusion is reinforced by the responsibilities and challenges associated with stagecoach work such as that done by Gage in Chile, including the requirement that drivers "be reliable, resourceful, and possess great endurance. But above all, they had to have the kind of personality that enabled them to get on well with their passengers." ​​[47]^{:127-32[M]:104-6[M10]:644-5} A day's work for Gage meant "a 13-hour journey over 100 miles [160 km] of poor roads, often in times of political instability or frank revolution. All this‍—‌in a land to whose language and customs Phineas arrived an utter stranger‍—‌militates as much against permanent disinhibition [i.e. an inability to plan and self-regulate] as do the extremely complex sensory-motor and cognitive skills required of a coach driver." ​​^{[M10]:645[M1]:831}[48] (An American visitor wrote: "The departure of the coach was always a great event at Valparaiso‍—‌a crowd of ever-astonished Chilenos assembling every day to witness the phenomenon of one man driving six horses.")[49]^:73

A Concord coach, likely the type driven by Gage in Chile[50]

Macmillan writes that this contrast‍—‌between Gage's early, versus later, post-accident behavior‍—‌reflects his "[gradual change] from the commonly portrayed impulsive and uninhibited person into one who made a reasonable 'social recovery'",[51] 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":^[M1]:831

Phineas' survival and rehabilitation demonstrated a theory of recovery which has influ­enced the treat­ment of frontal lobe damage today. In modern treat­ment, adding struc­ture to tasks by, for example, mentally vis­u­al­is­ing a written list, is con­sid­ered a key method in coping with frontal lobe damage.^[M4]

According to contemporary accounts by visitors to Chile,​​[49][48]^{[M1]:831[M10]:645} Gage would have had to

rise early in the morning, prepare himself, and groom, feed, and harness the horses; he had to be at the departure point at a specified time, load the luggage, charge the fares and get the passengers settled; and then had to care for the passengers on the journey, unload their luggage at the destination, and look after the horses. The tasks formed a structure that required control of any impulsiveness he may have had.^[M9]

En route (Macmillan continues):

much foresight was required. Drivers had to plan for turns well in advance, and sometimes react quickly to manoeuvre around other coaches, wagons, and birlochos travelling at various speeds ... Adaptation had also to be made to the physical condition of the route: although some sections were well-made, others were dangerously steep and very rough.

Thus Gage's stagecoach work‍—‌"a highly structured environment in which clear sequences of tasks were required [but within which] contingencies requiring foresight and planning arose daily"‍—‌resembles rehabilitation regimens first developed by Soviet neuropsychologist Alexander Luria for the reestablishment of self-regulation in World War II soldiers suffering frontal lobe injuries.​​^{[M10]:645,651-2,655[L2]}

A neurological basis for such recoveries may be found in emerging evidence "that damaged [neural] tracts may re-establish their original connections or build alternative pathways as the brain recovers" from injury.[51] Macmillan adds that if Gage made such a recovery‍—‌if he eventually "figured out how to live" (as Fleischman put it)^[F]:75 despite his injury‍—‌then it "would add to current evidence that rehabilitation can be effective even in difficult and long-standing cases";^[M1]:831 and if Gage could achieve such improvement without medical supervision, "what are the limits for those in formal rehabilitation programs?" ^[M9] As author Sam Kean put it, "If even Phineas Gage bounced back‍—‌that's a powerful message of hope." ^[K]

Macmillan's analysis of scientific and popular accounts of Gage found that they almost always distort and exaggerate his behavioral changes well beyond anything described by anyone who had direct contact with him,[note 2] concluding that the known facts are "inconsistent with the common view of Gage as a boastful, brawling, foul-mouthed, dishonest useless drifter, unable to hold down a job, who died penniless in an institution". [52] In the words of Barker, "As years passed, the case took on a life of its own, accruing novel additions to Gage's story without any factual basis".^[B]:678 Even today (writes Zbigniew Kotowicz) "Most commentators still rely on hearsay and accept what others have said about Gage, namely, that after the accident he became a psychopath";^[K2]:125 Grafman has written that "the details of [Gage's] social cognitive impairment have occasionally been inferred or even embellished to suit the enthusiasm of the story teller";^[G]:295 and Goldenberg calls Gage "a (nearly) blank sheet upon which authors can write stories which illustrate their theories and entertain the public". [53]

For example, Harlow's statement that Gage "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" ^[H]:15 refers only to Gage's final months, after convulsions had set in.^{[M]:107[M10]:646} But it has been misinterpreted[54] as meaning that Gage never held a regular job after his accident,[55][56][57] "was prone to quit in a capricious fit or be let go because of poor discipline",[58]^:8-9 "never returned to a fully independent existence",[59]^:1102 "spent the rest of his life living miserably off the charity of others and traveling around the country as a sideshow freak",[57] and ("dependent on his family" [60] or "in the custody of his parents")[61] died "in careless dissipation".[62] In fact, after his initial post-recovery months spent traveling and exhibiting, Gage supported himself‍—‌at a total of just two different jobs‍—‌from early 1851 until just before his death in 1860.​​^{[M10]:654-5[D]:77}

Other behaviors ascribed, by various authors, to the post-accident Gage that are either unsupported by, or in contradiction to, the known facts include the following:

None of these behaviors are mentioned by anyone who had met Gage or even his family,[note 2] and as Kotowicz put it, "Harlow does not report a single act that Gage should have been ashamed of." ^[K2]:122-3 Gage is "a great story for illustrating the need to go back to original sources", writes Macmillan,[83] most authors having been "content to summarize or paraphrase accounts that are already seriously in error". ^[M]:315

Nonetheless (write Daffner and Searl) "the telling of [Gage's] story has increased interest in understanding the enigmatic role that the frontal lobes play in behavior and personality",[84] and Ratiu has said that in teaching about the frontal lobes, an anecdote about Gage is like an "ace [up] your sleeve. It's just like whenever you talk about the French Revolution you talk about the guillotine, because it's so cool." ^[K] Benderly suggests that instructors use the Gage case to illustrate the importance of critical thinking.[83]

The left frontal lobe (red), with Ratiu et al.'s estimate of the tamping iron's path^[R1]

External video
Video re­con­struc­tion of tamp­ing iron pass­ing through Gage's skull (Ratiu et al.)[R1] (registration required)

Debate about whether the trauma and sub­se­quent infection had damaged both of Gage's frontal lobes (left and right), or only the left, began almost immedi­ate­ly after his accident.​​[note 14] The 1994 con­clu­sion of Hanna Damasio et al., that the tamping iron did physical damage to both lobes, was drawn not from Gage's skull but from a cadaver skull dig­i­tal­ly deformed to match the dimen­sions of Gage's​​^[M1]:829-30​​[59]^:1103-4‍—‌and made a priori assumptions about the location of Gage's internal injuries and the exit wound which in some cases contradict Harlow's observations.[91]^[M]:77-82 Using CT scans of Gage's actual skull, Ratiu et al.^[R]:638 and Van Horn et al.^[V]:4-5,22 both rejected that conclusion, agreeing with Harlow's belief‍—‌based on probing Gage's wounds with his fingers‍—‌that only the left frontal lobe had been damaged.​​[92][note 15]

False-color representations of cerebral fiber pathways affected, per Van Horn et al.^[V]:3

In addition, Ratiu et al. noted that the hole in the base of the cranium (created as the tamping iron passed through the sphenoidal sinus into the brain) has a diameter about half that of the iron itself; combining this with the hairline fracture beginning behind the exit region and running down the front of the skull, they concluded that the skull "hinged" open as the iron entered from below, then was pulled closed by the resilience of soft tissues once the iron had exited through the top of the head.​​^{[R]:640[M1]:830}

Van Horn et al. concluded that damage to Gage's white matter (of which they made detailed estimates) was as or more significant to Gage's mental changes than cerebral cortex (gray matter) damage.^[V]:abstr Thiebaut de Schotten et al. estimated white-matter damage in Gage and two other case studies ("Tan" and "H.M."), concluding that these patients "suggest that social behavior, language, and memory depend on the coordinated activity of different [brain] regions rather than single areas in the frontal or temporal lobes."^[T1]:12

Boston Herald, 1907

Barker notes that Harlow's original 1848 report of Gage's sur­viv­al and recov­ery "was widely dis­be­lieved, for obvious reasons" ^[B]:676 and Harlow, recall­ing this early skep­ti­cism in his 1868 ret­ro­spec­tive, invoked the Biblical story of Doubting Thomas:^[L1]:178

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 [in] his head, and even then they required of the Country Doctor attested state­ments, from clergy­men and lawyers, before they could or would believe‍—‌many eminent surgeons regarding such an occur­rence as a phys­i­o­log­i­cal impos­si­bil­i­ty, the appear­ances pre­sented by the subject being var­i­ous­ly explained away.

"A distinguished Professor of Surgery in a distant city", Harlow continued, had even dismissed Gage as a "Yankee invention".^[H]:3,18

According to the Boston Medical and Surgical Journal (1869) it was the 1850 report on Gage by Bigelow‍—‌Harvard's Professor of Surgery and "a majestic and author­i­ta­tive figure on the medical scene of those times" [27]‍—‌that "finally succeeded in forcing [the case's] authenticity upon the credence of the pro­fes­sion ... as could hardly have been done by any one in whose sagacity and surgical knowledge his confrères had any less confidence".[36] Noting 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 emphasized that though "at first wholly skeptical, I have been personally convinced".[note 17]

Nonetheless (Bigelow wrote just before Harlow's 1868 presentation of Gage's skull) though "the nature of [Gage's] injury and its reality are now beyond doubt ... I have received a letter within a month [purporting] to prove that ... the accident could not have happened." ^[B2]

"[Few objects] have at­tract­ed more vis­i­tors and spread farther the fame of the Museum"​​[27] than its "most val­u­a­ble specimen"‍—‌Gage's skull.​​[82]^:v

As the reality of Gage's accident and survival gained credence, it became "the standard against which other injuries to the brain were judged", and it has retained that status despite competition from a growing list of other unlikely-sounding brain-injury accidents, including encounters with axes, bolts, low bridges, exploding firearms, a revolver shot to the nose, other tamping irons, and falling Eucalyptus branches.^[M]:62-7 For example, after a miner survived traversal of his skull by a gas pipe ⁵⁄₈ inch (16 mm) in diameter (extracted "not without considerable difficulty and force, owing to a bend in the portion of the rod in his skull") his physician invoked Gage as the "only case comparable with this, in the amount of brain injury, that I have seen reported".[note 18]

Often these comparisons carried hints of humor, competitiveness, or both.^[M]:66 The Boston Medical and Surgical Journal, for example, alluded to Gage's astonishing survival by referring to him as "the patient whose cerebral organism had been comparatively so little disturbed by its abrupt and intrusive visitor";[36] and a Kentucky doctor, reporting a patient's survival of a gunshot through the nose, bragged, "If you Yankees can send a tamping bar through a fellow's brain and not kill him, I guess there are not many can shoot a bullet between a man's mouth and his brains, stopping just short of the medulla oblongata, and not touch either."[102] Similarly, when a lumbermill foreman returned to work soon after a saw cut three inches (8 cm) into his skull from just between the eyes to behind the top of his head, his surgeon (who had removed from this wound "thirty-two pieces of bone, together with considerable sawdust") termed the case "second to none reported, save the famous tamping-iron case of Dr. Harlow", though apologizing that "I cannot well gratify the desire of my professional brethren to possess [the patient's] skull, until he has no further use for it himself."[103]

As these and other remarkable brain-injury survivals accumulated, the Boston Medical and Surgical Journal pretended to wonder whether the brain has any function at all: "Since the antics of iron bars, gas pipes, and the like skepticism is discomfitted, and dares not utter itself. Brains do not seem to be of much account now-a-days." The Transactions of the Vermont Medical Society 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." ​​^[L1]:183[104][18]^:53-4

In the 19th-century debate over whether the various mental functions are or are not localized in specific regions of the brain (see Cerebral localization), both sides managed to enlist Gage in support of their theories.^{[B]:678[M]:ch9} For example, after Eugene Dupuy wrote that Gage proved that the brain is not localized (characterizing him as a "striking case of destruction of the so-called speech centre without consequent aphasia") Ferrier replied by using Gage (along with the woodcuts of his skull and tamping iron from Harlow's 1868 paper) to support his thesis that the brain is localized.​​[87][89]^[M]:188​​^[M5]:198,253

Phrenologists contended that destruction of the mental "organs" of Veneration and Benevolence caused Gage's behavioral changes. Harlow may have believed that the Organ of Comparison was damaged as well.

Throughout the 19th century, adherents of phrenology contended that Gage's mental changes (his profanity, for example) stemmed from destruction of his mental "organ of Benevolence"‍—‌as phrenologists saw it, the part of the brain responsible for "goodness, benevolence, the gentle character ... [and] to dispose man to conduct himself in a manner conformed to the maintenance of social order"‍—‌and/or the adjacent "organ of Veneration"‍—‌related to religion and God, and respect for peers and those in authority.​​^{[M]:150-1,171n10}​​[109]​​[1]​​[45] (Phrenology held that the organs of the "grosser and more animal passions are near the base of the brain; literally the lowest and nearest the animal man [while] highest and farthest from the sensual are the moral and religions feelings, as if to be nearest heaven". Thus Veneration and Benevolence are at the apex of the skull‍—‌the region of exit of Gage's tamping iron.)[110]

Harlow wrote that Gage, during his convalescence, did not "estimate size or money accurately[,] would not take $1000 for a few pebbles"^[H1]:392 and was not particular about prices when visiting a local store;^[H]:337 by these examples Harlow may have been implying damage to phrenology's "Organ of Comparison".[note 19]

It is frequently asserted that what happened to Gage played a role in the later development of various forms of psychosurgery‍—‌particularly lobotomy[111]‍—‌or even that Gage's accident constituted "the first lobotomy".[112][113] Aside from the question of why the unpleasant changes usually (if hyperbolically) attributed to Gage would inspire surgical imitation,[114] there is no such link, according to Macmillan:

There is simply no evidence that any of these operations were deliberately designed to produce the kinds of changes in Gage that were caused by his accident, nor that knowledge of Gage's fate formed part of the rationale for them^[M2]:F‍... [W]hat his case did show came solely from his surviving his accident: major operations [such as for tumors] could be performed on the brain without the outcome necessarily being fatal.^[M]:250

Memorial plaque, Cavendish, Vermont

Antonio Damasio, in support of his somatic marker hypothesis (relating decision-making to emotions and their biological underpinnings), draws parallels between behaviors he ascribes to Gage and those of modern patients with damage to the orbitofrontal cortex and amygdala.[58]^:ch3[115] But Damasio's depiction of Gage[58]^:ch1 has been severely criticized, for example by Kotowicz:

Damasio is the principal perpetrator of the myth of Gage the psycho­path ... Damasio changes [Harlow's] nar­ra­tive, omits facts, and adds freely ... His account of Gage's last months [is] a gro­tesque fab­ri­ca­tion [insin­u­at­ing] that Gage was some riff-raff who in his final days headed for Cal­i­for­nia to drink and brawl himself to death ... It seems that the growing com­mit­ment to the frontal lobe doctrine of emotions brought Gage to the lime­light and shapes how he is described.^{[K2]:125,130n6}

As Kihlstrom put it, "[M]any modern commentators exaggerate the extent of Gage's personality change, perhaps engaging in a kind of retrospective reconstruction based on what we now know, or think we do, about the role of the frontal cortex in self-regulation."^[K1] Macmillan​​^{[M]:116-9,326,331} gives detailed criticism of Antonio Damasio's various presentations of Gage (some of which are joint work with Hannah Damasio and others).