Phineas among the phrenologists: the American crowbar case and nineteenth-century theories of cerebral localization.

In 1848, Mr. Phineas Gage suffered destruction of his left frontal lobe in a unique fashion: passage of a metal rod through his head after a freak explosion. His change in character after the accident is the index case for personality change due to frontal lobe damage. Yet, from 1848 to 1868, it was widely believed among American physicians that he was mentally intact. The case was used as evidence against phrenology, a crude precursor of modern cerebral localization theories. The two original reports of the case by Drs. John Harlow (Gage's physician) and Henry J. Bigelow show subtle differences in attitude toward Gage's posttraumatic character change. In his 1848 report, Harlow promised a further communication that would address Gage's "mental manifestations." Bigelow's article portrayed Gage as fully recovered. Although delayed by 20 years, Harlow's second report rapidly changed the perception of the case in the medical community, as reflected by contemporary citations. The educational backgrounds of Harlow and Bigelow are examined to explain their differing attitudes toward the case. Harlow's interest in phrenology prepared him to accept the change in character as a significant clue to cerebral function which merited publication. Bigelow had learned that damage to the cerebral hemispheres had no intellectual effect, and he was unwilling to consider Gage's deficit significant. Although Bigelow's paradigm was initially more influential, Harlow's more closely matched emerging theories of cerebral localization. His version of the case was used by David Ferrier as the keystone in the first modern theory of frontal lobe function, and this is how the case is remembered today.