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Phineas Gage: The claim of Williams' priority

by Malcolm Macmillan

Every nineteenth century published account of or reference to Gage's treatment of which I am aware credits the treatment to Harlow. On 1st. February, 1923, in a letter to a Springfield, Vermont, newspaper, a contrary version appeared. It claimed that Harlow had not begun the treatment at all, and had stolen the whole glory from the Proctorsville physician, Dr. Edward Higginson Williams, who had. The writer was Edward H. Williams, Jr., the eldest son of this Dr. Williams, who had indeed been the first physician to see Gage, and who Gage greeted with his famous "Doctor, here is business enough for you." Five years later the claim was repeated by the President of Jefferson Medical College. Eventually it was incorporated into a biographical entry on Williams in a history of Philadelphia, and lives to this day as part of the Williams' family history. What do we make of the claim? My comments about it are in two parts. In the first I try to clarify just what was claimed; in the second I try to evaluate them.

Edward H. Williams, Jr., began his letter with an account of his father's education. His first career was in engineering, and he first worked on the Michigan Central Railroad. During that time he contracted a severe fever, and what was thought to be asthma, and gave up engineering. He then trained as a physician at Woodstock Medical College in Vermont and at the Bellevue Hospital in New York, before setting up in practise in Proctorsville. Without too much medicine to practise, and having studied the rudiments of surveying under Hosea Doton [or Doten], who was by then the engineer in charge of construction for the Rutland and Burlington Railroad, "he employed his spare time by running transit or level on the new road." It was in that capacity that he became acquainted with Phineas Gage. On the 13th. September, 1848, "an extremely hot day," Dr. Williams was stopped by an Irish railroad hand as he was driving home. He told Williams that:

Mr. Gage wanted to see him. On being asked what was the matter he said 'he is hurted, doctor, he had a tampimg bar blown through his head." To further questions he said, "he is waiting for you at the hotel beyant."

When Dr. Williams drove up he found Gage sitting on the lowest step with his feet in the road; with his elbows on his knees; holding his head between his hands and spitting blood. On being asked what was the matter, he did not speak but raised up his hat with one hand showing the hole in his skull. (Springfield Reporter, 1st. February, 1923)

The letter continued with an account of how Williams had had Gage carried up to the third story of the hotel, placed on a rough operating table made of a pile of mattresses, washed, and made comfortable. He was not expected to survive but when he showed unexpected vitality:

Dr. Williams trephined and cleansed the wound. Owing to the entrance hole through the roof of the mouth, there was good drainage. Then a fungus-growth appeared around the edges of the wound and these were cut away. Then Dr. Harlow appeared and, as he was the surgeon of the company, the case was placed in his hands (ibid.)

And when it came to reporting Gage's recovery:

According to medical etiquette the physician in charge makes the report and according to the medical rules this was a case under Dr. Harlow. This was an anomalous case -- a unique case -- and it seems that Dr. Harlow wished to take the whole glory. He did not do this at once, as it was well known to the teachers and pupils of the medical school at Woodstock that Dr. Williams was the first to reach and treat Gage.

When these matters came out in a distorted form, Dr. Williams let them alone, as the facts were known. (ibid.)

Soon after Gage's accident, Dr. Williams regained his health and resumed his career as an engineer.

Alba B. Johnson, President of the Board of Trustees of Jefferson Medical College, added to the story in his Commencement Address at the University of Vermont.on 18th. June 1928. Having commenced work for the locomotive manufacturing company in which Williams was a partner in 1876, Johnson knew Williams personally but it was not until after Williams' death that he learned of his role in Gage's treatment. Williams did speak of Gage as an old friend, however. In Johnson's version of the incident, Williams is homeward bound in 1846 when he finds Gage sitting by roadside in Cavendish itself. He has him carried to the hotel, cleans the wound, trepans the skull, and "From time to time as fungus growth gathered, the Doctor took it away and eventually Gage recovered." Johnson did not mention Harlow, either directly or by implication, but he included among the facts well known to the Woodstock faculty, and to Doten as well, "that Dr. Williams had done all the surgical work" (Johnson 1928, p. 4).

In February 1930, in an account of the case he gave to a Philadelphia newspaper, Johnson added a caricature of the treatment. The paper had published a Ripley "Believe It or Not" cartoon portraying the accident, and Johnson had commented on it. The long newspaper interview quoted extensively from the commencement address before adding that Norman Williams had once asked his brother how he had performed the operation. According to Johnson, Dr. Williams said:

The parts of the brain that looked good for something, I put back. Those that were too badly injured and looked as if they would be no good, I threw away. I kept the wound clean, sewed it up, and Gage got well. (Evening Bulletin, Philadelphia, 15th. February, 1930)

This 'treatment' is placed between two paragraphs from the address, and, like them, reads as if Johnson were being quoted.

No details of a treatment like this are given in the short biography of the one time Proctorsville physician that the Rev. Edward H. Williams, IV, compiled in 1981, from letters, newspaper clippings, and recollections of conversations with E. H. Williams, Jr. and E. H. Williams, III. What this account adds is that Gage's:

became a noted case -- the first in American medical annals, of trephining, a procedure but recently described in a European medical journal. Dr Williams cared for Mr. Gage for the first two days until the company doctor, Harlow, by name could be summoned from Rutland. This man later claimed the entire responsibility for the case, which Dr. Williams took no special pains to challenge, since Dr. Harlow was the doctor in charge, and there were many at the Woodstock medical college who knew the facts. (E. H. Williams, IV, 1981 pp. 3-4)

The Butler family website includes the whole of Edward H. Williams IV compilation.

The story of the case in the biographical note in the Philadelphia history concentrates on the attempt to deprive Williams of the kudos:

The case was one of the most celebrated in medical annals, and for its successful achievement Dr. Williams was given full credit by all those who knew of his, the first and most important, connection with it at the time -- although the regular railroad surgeon, to whom the case was turned over and who made the official report of it, sought eventually to take the whole glory of the successful outcome. (Collins, 1941, p. 160)

Putting to one side some of the obviously incorrect minor points, such as the date of 1846 which may be a typographical error, and others, such as the uniqueness of trephining in the United States, which may be due to a misunderstanding on the part of a non-medical member of the family, what do we make of this claim?

There are four points central to the story. Dr. Williams: 1. comes upon Gage not long after he had been injured, either as he is sitting on the roadside near the site of the accident, or outside of the hotel; 2. has Gage taken upstairs where cleans the wound, trephines the skull, dresses and/or drains the wound, and cuts away the fungus; 3. looks after Gage until Harlow comes, either after a matter of hours or after two days; and 4. defers to Harlow as the railroad surgeon.

Williams' own account, written in 1849 and reproduced in Bigelow (1850), differs over the circumstances and place of Williams' first seeing Gage:

Dr. Harlow being absent at time of the accident, I was sent for, and was the first physician who saw Mr G., some twenty-five or thirty minutes after he received the injury; he at that time was sitting in a chair upon the piazza of Mr. Adam's hotel, in Cavendish. When I drove up, he said, "Doctor, here is business enough for you."

The second point is also at variance:

Soon after Dr. Harlow arrived, Mr. Gage walked upstairs, with little or no assistance, and laid down upon a bed, when Dr. H. made a thorough examination of the wounds, passing the whole length of his forefinger into the superior opening without difficulty; and my impression is that he did the same with the inferior one, but of that I am not absolutely certain; after this we proceeded to dress the wounds in the manner described by Dr. H. in the Journal

A reasonable estimate of the time Williams had Gage solely under his care is at variance with point three. About an hour elapsed between Williams' arrival, at about 5 p.m. ("some twenty-five or thirty minutes after he received the injury"), and Harlow's ("I did not arrive at the scene of the accident until near 6 o'clock, P. M."). This interval is shorter than any in the claim and also rules out Williams treating the fungus -- as products of infection, they could not have developed so quickly. Trephining would not have been appropriate. It was a well-known technique of removing a circular disc of bone from the skull in order to relieve pressure on the brain -- and Gage probably did not need more openings than he already had. Nor, given the nature and extent of the fracture, would it have been appropriate to use the instrument in a way sometimes reported to raise pieces of bone that had been pushed down on to the brain.

No difference can be seen in what Williams and Harlow wrote about who was first in attendance: in his 1848 report, Harlow clearly acknowledged that Williams was there first, Williams also said this in the 1849 letter, and Harlow repeated it just as clearly in 1868. It may also be worth noting that in both his reports, Harlow refers to "my friend Dr. Williams." Similarly, although Williams' letter was addressed to Bigelow, his reponse to Harlow's request to send his description opens with Williams saying that "I hasten to do so with pleasure." I do not sense any disagreement between the two in these remarks.

The picture of Harlow as having some prior claim on the case because he was a railroad surgeon warrants two comments. First, physicians were commonly retained by railroad companies, but I have been unable to establish whether this was true of Harlow (I also do not recall the point being made other than in this claim). Second, even were he on a retainer, one would think the seriousness of Gage's injury would warrant overriding the "medical etiquette" of the day. What those proprieties might just account for, however, is Williams' seeming passivity during that first hour. But was he really passive? Would Williams really have had time to do much more than he said he had, that is, examine and assess the extent of the fracture, obtain Gage's story, and examine the slit in the cheek? It seems to have taken the two of them about an hour and a half to complete the examination and initial treatment. An hour for only one of them to establish the facts may not be unreasonable. Gage's story of how he came to be injured was, after all, a most unusual one, and may well have found the unbelieving Williams as unprepared as Harlow.

At my request, Mrs. Susan Czaja, the niece of the Rev. Edward H. Williams, IV, asked her uncle if the family possessed any original material on the dispute over Harlow's priority. Through her, the Rev. Williams told me he had "never seen any first hand account" and drew on "just what his father and grandfather told him." None of Dr. Edward Higginson Williams' manuscripts seem to have survived. Had there been such, and had they come into the possession of his son, E. H. Williams Jr., they were probably lost in the fire that completely destroyed his Woodstock home in the winter of 1921. The only written material bearing on the claim seems to be that which I have drawn on here.


Malcolm Macmillan

School of Psychology
Deakin University
Burwood. 3125
Victoria. Australia

E-mail: m.macmillan@deakin.edu.au

See also: Phineas Gage Website

Copyright Malcolm Macmillan. Reprinted by permission of the author.