|Phineas P. Gage|
The first identified (2009) portrait of Gage, here with his "constant companion for the remainder of his life"—his inscribed tamping iron.[A]
|Born||July 9, 1823 (date uncertain)
Grafton Co., New Hampshire[B]
|Died||May 21, 1860
In or near San Francisco
Cause of death
|Known for||Personality change after brain injury|
|Home town||Lebanon, New Hampshire[B]|
Phineas P. Gage (1823 – May 21, 1860) was an American railroad construction foreman remembered for his improbable:19 survival of a rock-blasting accident in which a large iron rod was driven completely through his head, destroying much of his brain's left frontal lobe, and for that injury's reported effects on his personality and behavior over the remaining twelve years of his life—effects so profound that (for a time at least) friends saw him as "no longer Gage."
Long known as "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 nineteenth-century discussion about the mind and brain, particularly debate on cerebral localization,:ch7–9 and was perhaps the first case to suggest that damage to specific parts of the brain might induce specific personality changes.:1:C
Gage is a fixture in the curricula of neurology, psychology, and related disciplines (see neuroscience),:149 and is frequently mentioned in books and academic papers; he even has a minor place in popular culture.[C] Despite this celebrity the body of established fact about Gage and what he was like (before or after his injury) is small,[D] which has allowed "the fitting of almost any theory [desired] to the small number of facts we have"[E]—Gage having been cited, over the years, in support of various theories of the brain entirely contradictory to one another. Historically, published accounts (including scientific ones) have almost always severely distorted and exaggerated Gage's behavioral changes, frequently contradicting the known facts.[D]
A report of Gage's physical and mental condition shortly before his death implies that Gage's most serious mental changes were temporary, so that in later life he was far more functional, and socially far better adapted, than in the years immediately after his accident. A social recovery hypothesis suggests that Gage's employment as a stagecoach driver in Chile provided daily structure allowing him to relearn lost social and personal skills.
- 1 Background
- 2 Gage's accident
- 3 Subsequent life and travels
- 4 Death
- 5 Brain damage and mental changes
- 6 Early medical opinions
- 7 Portraits
- 8 See also
- 9 Notes
- 10 Sources and further reading
- 11 External links
Gage was the first of five children born to Jesse Eaton Gage and Hannah Trussell (Swetland) Gage, of Grafton County, New Hampshire.[B] Little is known about his upbringing and education, but he is known to have been literate.:17,41,90:3
Town doctor John Martyn Harlow described Gage 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.":4 (In phrenology—popular at the time—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".:346–7:6)
Gage may have first worked with explosives on his family's farms or in nearby mines and quarries.:17–18 He is known to have worked, during a period ending mid-1848, on construction of the Hudson River Railroad in Cortlandt Town, New York,:3 and by the time of his accident he was a blasting foreman (possibly an independent contractor) on railway construction projects.:18–22,32n9 His employers considered him "the most efficient and capable foreman in their employ ... a shrewd, smart business man, very energetic and persistent in executing all his plans of operation",:13 and he had even commissioned a custom-made tamping iron—a large iron rod—for use in setting charges.:5:25
On September 13, 1848, Gage was directing a work gang blasting rock while preparing the roadbed for the Rutland & Burlington Railroad south of the town of Cavendish, Vermont. Setting a blast involved boring a hole deep into an outcropping of rock; adding blasting powder, a fuse, and sand; then compacting this charge into the hole using the tamping iron.[F] Gage was doing this around 4:30 p.m. when (possibly because the sand was omitted):13–14:5:27 the iron "struck fire" against the rock and the powder exploded. Rocketing from the hole, the tamping iron—three feet seven inches (1.1 m) long and 1 1⁄4 inches (3.2 cm) in diameter—:5:25"entered on the [left] side of [Gage's] face ... passing back of the left eye, and out at the top of the head."[G]
Despite nineteenth-century references to Gage as "the American Crowbar Case":54:678 his tamping iron did not have the bend or claw sometimes associated with the term crowbar; rather, it was a pointed cylinder something like a javelin, "round and rendered comparatively smooth by use"::5
|The end which entered [Gage's cheek] first is pointed; the taper being [twelve] inches [30 cm] 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.[H]|
|Video reconstruction of tamping iron passing through Gage's skull (Ratiu et al. 2004)|
Weighing 13 1⁄4 pounds (6.0 kg), the tamping iron was found some 80 feet (25 m) away, "smeared with blood and brain.":5
Gage "was thrown upon his back by the explosion, and gave a few convulsive motions of the extremities, but spoke in a few minutes," walked with little assistance, and sat upright in an oxcart for the 3⁄4-mile (1.2 km) ride to town.:5 About thirty minutes after the accident, Dr. Edward H. Williams found him sitting in a chair outside his lodgings:
|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, which fell upon the floor.[I]|
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.[I]|
With Williams' assistance Harlow shaved the scalp around the region of the tamping iron's exit, then removed coagulated blood, small bone fragments, and an ounce [30 g] 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;: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 remain elevated.
Late that evening Harlow noted: "Mind clear. Constant agitation of his legs, being alternately retracted and extended like the shafts of a fulling mill. Says he 'does not care to see his friends, as he shall be at work in a few days.'"[I]
Despite his own optimism, Gage's convalescence was long, difficult, and uneven. Though recognizing his mother and uncle (summoned from Lebanon, thirty miles away:12:30) on the first day after the accident, on the second day he "lost control of his mind, and became decidedly delirious". Two days later he was again "rational ... knows his friends", and after a further week of improvement it occurred to Harlow, for the first time, "that it was possible for Gage to recover ... This improvement, however, was of short duration."[I]
Beginning September 25:53 Gage was semi-comatose, "seldom speaking unless spoken to, and then answering only in monosyllables" and the next day Harlow noted, "Failing strength ... coma deepened; the globe of the left eye became more protuberant, with [granulation tissue][J] pushing out rapidly from the internal canthus [as well as] from the wounded brain, and coming out at the top of the head."[I]
By September 27, "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." Galvanized, Harlow "cut off the [granulation tissue] sprouting out from the top of the brain and filling the opening, and made free application of caustic [i.e. crystalline silver nitrate]:54 to them. With a scalpel I laid open the [frontalis muscle,:392 from the exit wound to the top of the nose] and immediately there were discharged eight ounces [250 ml] of ill-conditioned pus,[K] with blood, and excessively fetid."[I] ("Gage was lucky to encounter Dr. Harlow when he did," wrote 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."[L])
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.":392–3
Subsequent life and travels
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" and (as recorded in the notes of a physician who spoke to Gage's mother) "abt. February he was able to do a little work abt. ye horses & barn, feedg. ye cattle &c; that as ye time for ploughing came he was able to do half a days work after that & bore it well.":ix,93–4
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 (from Harlow's draining of the abscess):392 and
|upon the top of the head ... a deep depression, two inches by one and one-half inches [5 cm by 4 cm] 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."[M]|
New England and New York (1849–1852)
In November 1849 Harvard's Professor of Surgery, Henry Jacob Bigelow, brought Gage to Boston "at very considerable expense [and after having] satisfied himself that the bar had actually passed through the man's head",:149 presented him to a meeting of the Boston Society for Medical Improvement and (possibly) to a Harvard Medical School class.:20:43,95 (This appears to have been one of the earliest cases of a patient entering a hospital primarily to further medical research, rather than for treatment.)
Unable to return to his railroad work (see § Early observations) Gage appeared for a time, with his iron, at Barnum's American Museum in New York City (not the later Barnum's circus—there is no evidence Gage ever exhibited with a troupe or circus, or on a fairground).:14:14,98–9:3–4 Advertisements have also been found for public appearances by Gage—which he may have arranged and promoted himself—in New Hampshire and Vermont,:3–4 supporting Harlow's statement that Gage made public appearances in "most of the larger New England towns".:14:829 (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 had given up such efforts because "[that] sort of thing has not much interest for the general public".:28:3–4)
Chile and California (1852–1858)
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 Valparaiso–Santiago route. (A visitor wrote that "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.":73)
In mid-1859, after his health began to fail,:14–15[N] he left Chile for San Francisco, where he recovered under the care of his mother and sister,:15 who had relocated there from New Hampshire around the time Gage went to Chile.:103–4 Then, "anxious to work", he found employment with a farmer in Santa Clara.:15
In February 1860[N] Gage had several epileptic seizures.:14:16 He lost his job, and (wrote Harlow) as the seizures increased in frequency and severity over the succeeding three months he "continued to work in various places [though he] could not do much."
On May 18 he "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,":15 and he died during status epilepticus,:E in or near:B San Francisco, late on May 21, 1860, just under twelve years after his injury. He was buried in San Francisco's Lone Mountain Cemetery.[N] (Though some accounts assert that Gage's iron was buried with him, there is no evidence for this.[P])
Skull and iron
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 wrote to his family there. At his request they opened Gage's grave long enough to remove his skull, which the family then personally delivered to Harlow,:108–11:341–2:6 by then a prominent physician, business man, and civic leader in Woburn, Massachusetts.:351–64
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:22n:46–7 and made what he called "my iron bar" his "constant companion during the remainder of his life";:13 now it too was delivered to Harlow.:6 After studying them for a triumphal 1868 retrospective paper on his patient:679:3 Harlow redeposited the iron—this time with Gage's skull—in the Warren Museum, where they remain on display today.[Q]
The iron bears the following inscription, commissioned by Bigelow in conjunction with the iron's first deposit in the Museum:116 (though the date it gives for the accident is one day off, and Phinehas is not the way Gage spelled his name:839fig):
|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.:D|
Brain damage and mental changes
Extent of brain damage
Debate about whether the trauma and subsequent infection had damaged both of Gage's frontal lobes, or only the left, began almost immediately after his accident.[R] The 1994 conclusion of Hanna Damasio et al., that damage was bilateral, was drawn not from Gage's skull but from a "Gage-like" one—a cadaver skull deformed to match the dimensions of Gage's.:829-30:1103–4 Using CT scans of Gage's actual skull, Ratiu et al. and Van Horn et al. both rejected that conclusion, agreeing with Harlow's belief (based on probing Gage's wounds with his fingers[S]) that only the left frontal lobe had been damaged.:19
In addition, Ratiu et al. were the first to note that the hole between the roof of the mouth and the base of the cranium (created as the iron passed through) has a diameter about half that of the iron itself; combining this with the hairline fracture running from behind the exit region down the front of the skull, they concluded that the skull "hinged" open as the iron entered the cranium, then (once the iron had exited at the top) was pulled closed by the resilience of soft tissues.:640:830
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.:abstr
First-hand reports of mental changes
Gage certainly displayed some kind of change in behavior after his injury,:12–15 but the nature, extent, and duration of this change have been difficult to establish. Only a handful of sources give direct information on what Gage was like (either before or after the accident),[D] the mental changes described after his death were much more dramatic than anything reported while he was alive,:375–6 and few of the sources are explicit about the period of Gage's life to which their various descriptions of him (which vary widely in their implied level of functional impairment) are meant to apply.:6–7
Early observations (1849–1852)
Harlow 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". 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 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".:13–14|
This description ("now routinely quoted", says Kotowicz:125) is from Harlow's notes set down soon after the accident,:90,375:6–9 but Harlow—perhaps hesitant to describe his patient negatively while he was still alive:375–6—left them unpublished until 1868, after Gage had died and his family had brought him "what we so much desired to see" (as Harlow termed Gage's skull).:16
In the interim, Harlow's 1848 report, published just as Gage was emerging from his convalescence, only hinted at psychological symptoms::169
|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.:393|
But after Bigelow (who had kept Gage in Boston for several weeks' observation in late 1849:20:4n:43) termed Gage "quite recovered in faculties of body and mind", with only "inconsiderable disturbance of function",:13–14 a rejoinder in the American Phrenological Journal—
That there was no difference in his mental manifestations after the recovery is not true ... The man was gross, profane, coarse, and vulgar, to such a degree that his society was intolerable to decent people.
—was apparently based on information anonymously supplied by Harlow.:350–1 Barker explains these contradictory evaluations (only six months apart) by differences in Bigelow's and Harlow's educational backgrounds:
|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 [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.:abstr,678[E]|
Later observations (1852–1858)
In 1860, an American physician who had known Gage "well" in Chile from mid-1858 to early 1859 reported that Gage remained "engaged in stage driving [and] in the enjoyment of good health, with no impairment whatever of his mental faculties.":8 Together with the fact that Gage was hired by his employer in advance, in New England, to be part of the new coaching enterprise in Chile,:15:15 this implies that Gage's most serious mental changes had been temporary, so that the "fitful, irreverent ... capricious and vacillating" Gage described by Harlow (who last saw Gage less than a year after the accident) became, over time, far more functional, and socially far better adapted.:831:2,15
This conclusion is reinforced (writes psychologist Malcolm Macmillan) by the responsibilities and challenges faced by drivers on the stagecoach route worked by Gage in Chile, including the general 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.":104–6:4–5 A day's work for Gage meant "a 13-hour journey over 100 miles 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.":5:831
Macmillan hypothesizes that the contrast between Gage's early post-accident behavior and later post-accident behavior represents a social recovery over time, citing people with similar injuries for whom "someone or something gave enough structure to their lives for them to relearn lost social and personal skills"::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.|
According to a contemporary account by visitors to Chile,:831 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.|
Enroute (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.:5,11–12,15
Macmillan adds that if Gage made such a recovery—if he eventually "figured out how to live" (as Fleischman put it):75 despite his injury—then it "would add to current evidence that rehabilitation can be effective even in difficult and long-standing cases";:831 and if Gage could achieve such improvement without medical supervision, "what are the limits for those in formal rehabilitation programs?" As author Sam Kean put it, "If even Phineas Gage bounced back—that's a powerful message of hope."
Exaggeration and distortion of mental changes
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 contact with him.[D] 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", and even today (writes historian 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 ...":123
Behaviors ascribed to the post-accident Gage which are either unsupported by, or in contradiction to, the known facts include mistreatment of wife and children (of which Gage had neither); inappropriate sexual behavior, promiscuity, or impaired sexuality; lack of forethought, concern for the future, or capacity for embarassment; parading his self-misery, and vainglory in showing his wounds; inability or refusal to hold a job; irresponsibility and untrustworthiness; aggressiveness and violence; vagrancy and begging; plus drifting, drinking, bragging, lying, brawling, bullying, psychopathy, inability to make ethical decisions, loss of all respect for social conventions, and acting "like an idiot".[T] None of these behaviors was mentioned by anyone who had met Gage or even his family;[D] as Kotowicz put it, "Harlow does not report a single act that Gage should have been ashamed of.":122–3
For example, several authors misinterpret[U] a passage by Harlow—"'... 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'":15—as meaning Gage could not hold a regular job after his accident, "was prone to quit in a capricious fit or be let go because of poor discipline",:8–9 "never returned to a fully independent existence",:1102 and died "in careless dissipation". In fact, after his initial post-recovery months spent traveling and exhibiting, Gage supported himself—at a total of just two jobs—from early 1851 until just before his death in 1860.:14–15 In Kotowicz's words, "What Harlow is telling us is clear and unambiguous: Gage returns from South America to his mother to recuperate. As soon as he is fit, he goes back to work with horses, which is what he has been doing for years.":130n6 (Harlow's "changing often" refers only to Gage's final months, after convulsions had set in, and even then Gage remained "anxious to work".:107:6)
Theoretical use and misuse
Though Gage is considered the "index case for personality change due to frontal lobe damage":abstr:1 his scientific value is undermined by the uncertain extent of his brain damage and the lack of information about his behavioral changes.[D] Instead, Macmillan writes, "Phineas' story is [primarily] worth remembering because it illustrates how easily a small stock of facts becomes transformed into popular and scientific myth,":831 the paucity of evidence having allowed "the fitting of almost any theory [desired] to the small number of facts we have".[E] A similar concern was expressed as far back as 1877, when British neurologist David Ferrier (writing to Harvard's Henry Pickering Bowditch in an attempt "to have this case definitely settled as it is one of more than usual interest in a localisation point of view") 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 ...:1,75,197–9,464–5|
Thus in the nineteenth-century controversy over whether the various mental functions are, or are not, localized in specific regions of the brain, both sides managed to enlist Gage in support of their theories;:678:ch9 for example, soon after Dupuy wrote that Gage proved that the brain is not localized, Ferrier cited Gage as proof that it is. Phrenologists made use of Gage as well, contending that his mental changes resulted from destruction of his "organ of Veneration" and/or the adjacent "organ of Benevolence".[V]
In a more recent example A. Damasio, in support of his somatic marker hypothesis (relating decision-making to emotions and their biological underpinnings), draws parallels between behaviors he attributes to Gage and those of modern patients with damage to the orbitofrontal cortex and amygdala.:ch3 But A. Damasio's depiction of Gage has been criticized by Kotowicz as "grotesque fabrication ... ['perpetrating'] the myth of Gage the psychopath ... Damasio changes [Harlow's] narrative, omits facts, and adds freely ... It seems that the growing commitment to the frontal lobe doctrine of emotions brought Gage to the limelight and shapes how he is described."[W] 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.[X]|
Psychosurgery and lobotomy
It is frequently said that what happened to Gage played a part in the later development of various forms of psychosurgery, particularly lobotomy.[Y] Aside from the question of why the unpleasant changes usually (if hyperbolically) attributed to Gage would inspire surgical imitation, 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: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.:250|
Early medical opinions
A tone of amused wonderment was common in 19th-century medical writing about Gage (as well as about victims of other unlikely-sounding brain-injury accidents—including encounters with axes, bolts, low bridges, exploding firearms, a revolver shot to the nose, more tamping irons, and "even falling gum tree branches").:62–7 The Boston Medical & Surgical Journal, for example, referred to Gage as "the patient whose cerebral organism had been comparatively so little disturbed by its abrupt and intrusive visitor."
Noting dryly 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", calling the case "unparalleled in the annals of surgery";:13,19 and this endorsement by Bigelow (the Professor of Surgery at Harvard and "a majestic and authoritative figure on the medical scene of those times") "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".:116 Even so (Bigelow wrote just before Harlow's 1868 presentation) though "the nature of [Gage's] injury and its reality are now beyond doubt ... I have recd a letter within a month to prove that ... the accident could not have happened."
Indeed, Harlow later recalled, "a distinguished Professor of Surgery in a distant city" had dismissed Gage as a "Yankee invention"::18
|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 [of] his head, [see Doubting Thomas] 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.:3,18|
Even as late as 1870, Jackson was able to write that, "Unfortunately, and notwithstanding the evidence that Dr. H. has furnished, the case seems, generally, to those who have not seen the skull, too much for human belief.":v
But after Gage was joined by such later cases as a miner who survived traversal of his head by a gas pipe,:66 and a lumbermill foreman who returned to work soon after a circular saw cut three inches (8 cm) into his skull from just between the eyes to behind the top of his head (the surgeon removing from this wound "thirty-two pieces of bone, together with considerable sawdust"), the Boston Medical & Surgical Journal (1869) 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.":53–4
Two daguerreotype portraits of Gage, identified in 2009 and 2010,[A] are the only known likenesses:343:8 of him other than a life mask taken for Bigelow in late 1849 (and now in the Warren Museum along with Gage's skull and iron).:22n:149:ii,42 The first shows "a disfigured yet still-handsome" Gage with one eye closed and scars clearly visible, "well dressed and confident, even proud":343 and holding his iron, on which portions of its inscription can be made out. (For decades the portrait's owners had imagined it showed an injured whaler with his harpoon.)
The second, copies of which were found in the possession of two different branches of the Gage family, shows Gage in a somewhat different pose, wearing a different shirt and different tie, but the same waistcoat and possibly the same jacket.
Authenticity was confirmed in several ways (including photo-overlaying the inscriptions seen in the portraits against that on the actual tamping iron, and matching the subject's injuries to those preserved in the life mask:342–3) but about when, where, and by whom they were taken nothing is known, except that they were created no earlier than January 1850 (when the inscription was added to the tamping iron),:4 on two different occasions, and are likely by different photographers.:8
The portraits reinforce the social recovery hypothesis already described. "That [Gage] was any form of vagrant following his injury is belied by these remarkable images", wrote Van Horn.:13 "Although just one picture," Kean commented in reference to the first image, "it exploded the common image of Gage as a dirty, disheveled misfit. This Phineas was proud, well-dressed, and disarmingly handsome."
- Anatoli Bugorski—scientist through whose head a particle-accelerator proton beam accidentally passed
- Eadweard Muybridge—another early case of head injury leading to mental changes
- The 2009-identified image is from the collection of Jack and Beverly Wilgus. This artifact, like almost all daguerreotypes, shows its subject laterally (left-right) reversed, making it appear that Gage's right eye is injured; however, all Gage's injuries, including to his eye, were on the left. Therefore in presenting the image here a second, compensating reversal has been applied in order to show Gage as he appeared in life.
The 2010-identified image is in the possession of Tara Gage Miller of Texas; an identical image belongs to Phyllis Gage Hartley of New Jersey. (Gage had no known children;:319,327 these are descendents of his brother Roswell Rockwell Gage.:4) Unlike the Wilgus portrait, which is itself a daguerreotype, the Miller and Hartley images are 19th-century photographic reproductions of a common original which remains undiscovered, itself a daguerreotype or other laterally reversing early-process photograph; here again a second, compensating reversal has been applied.
- Macmillan:14–17,31n5,490–1 discusses Gage's ancestry and what is and isn't known about his birth and early life. His parents were married April 27, 1823.
The birthdate July 9, 1823 (the only definite date given in any source) is from a Gage family genealogy; Macmillan:16 notes that though the genealogy gives no source, this date is consistent with agreement among contemporary sources:389:13:4 that Gage was 25 years old on the date of his accident, as well as with his age (36 years) as given in undertaker's records after his death in May 1860.:108–9
Possible homes in childhood and youth are Lebanon or nearby East Lebanon, Enfield, and/or Grafton (all in Grafton County, New Hampshire), though Harlow refers to Lebanon in particular as Gage's "native place":10 and "his home":12 (probably that of his parents),:30 to which he returned ten weeks:C after his accident.
There is no doubt Gage's middle initial was P :389:13:4:490:839fig but there is nothing to indicate what the P stood for (though his paternal grandfather was also a Phineas and his brother Dexter's middle name was Pritchard).:490 Gage's mother's first and middle names are variously given as Hannah or Hanna and Trussell, Trusel, or Trussel; her maiden name is variously spelled Swetland, Sweatland, or Sweetland.:490
- For scientific and academic discussions see Macmillan;:ch14 in particular, Macmillan found Gage cited in some 60% of introductory psychology textbooks in three university libraries. A small study found Gage to be easily the topic most frequently mentioned when, at the end of an introductory psychology course, students were asked to list "the first 10 things that come to your mind as you answer the question: What do you remember from this course? "; investigators noted that, "The Phineas Gage video [used in the course] re-creates the famous tamping rod piercing Gage's skull. Students ... always react emotionally to this video clip.":89
- Macmillan:116–19,ch13–14:C compares accounts of Gage (especially relating to his pre- and post-accident behavior) to one another and to the known facts. Until 2008:2–3:830 the available sources offering significant information on Gage, and for which there is evidence (if even merely the source's own claim) of contact with him or with his family, were limited to Harlow (1848, 1849, 1868); Bigelow (1850); and Jackson (1849, 1870). Macmillan notes that descriptions of Gage's behavior total just 300 words:90 and emphasizes the primacy of Harlow's three papers as sources.:94 (Harlow case notes have not survived.:90 A Warren Museum curator referred to the "stately elegance" of his writings on Gage.) Macmillan & Lena:3–6,8 present previously unknown sources found since 2008.
The contrast between Gage's celebrity and the small amount known about him is discussed by Macmillan: "From my student days I had some appreciation of the importance ascribed to the case and expected there would be a reasonably extensive literature on it. This turned out not to be true. There were many mentions of him, but few papers solely or mainly about him ... [In my early research I had assumed that] because Phineas Gage was said to be important in psychology, everyone would have been interested in him; because his survival was so remarkable, someone must have made a major study of him. Neither was the case.":1–2,11
- :290 See Macmillan:ch5–6,9–14:831 for surveys and discussion of theoretical use and misuse of Gage. Smith noted "the ingenuity with which the advocates of various theories [of the brain] will explain away the evidence of their opponents.":51
- Macmillan gives the steps in setting a blast, the location and circumstances of the accident, and the location of Gage's lodgings and Harlow's home and surgery.:23–9:151-2:A The blast hole, about 1 3⁄4 inches (4.5 cm) in diameter and up to 12 feet (4 m) deep, might require three men working as much as a day to bore using hand tools. The labor invested in setting each blast, the judgment involved in selecting its location and the quantity of powder to be used, and the often explosive nature of employer-employee relations on this type of job, all underscore the significance of Harlow's statements that Gage has been a "great favorite" with his men, and that his employers had considered him "the most efficient and capable foreman in their employ" prior to the accident.:13,22–3,25
-  The Boston Post credits an earlier report (of unknown date) in the Ludlow (Vermont) Free Soil Union, which appears to have been the first printed report of Gage's accident anywhere;:11 although reprinted by several New England papers:35–36 it is itself no longer extant.:70–1n1 This report confuses the iron's circumference with its diameter,:12 and despite the reference to "shattering the upper jaw", that did not in fact happen.:389:21:16:36–7
- :14 Bigelow describes the iron's taper as seven inches (18 cm) long, but the correct dimension is twelve (30 cm).:5:25–6 Among the circumstances favoring Gage's survival, Harlow listed "The shape of the missile—being pointed, round and comparatively smooth, not leaving behind it prolonged concussion or compression.":18 Despite its very large diameter and mass (compared to a weapon-fired projectile) the tamping iron's relatively low velocity drastically reduced the energy available to compressive and concussive "shock waves".:56,68n3 Ratiu et al.'s conclusion, that Gage's skull "hinged open" as the iron passed through,:639 implies a further reduction in such effects because of the increased volume available into which the brain could shift temporarily.
Macmillan: "If we grant that concussive damage may be indexed by loss of consciousness, [that kind of] damage was probably slight [but] the statements that Gage is not lose consciousness at all seem to derive from Gage himself, and should perhaps be regarded with reserve.":56
- Excerpted from Williams' and Harlow's statements in: Harlow (1848);:390–2 Bigelow (1850);:16 Harlow (1868).:7–10
- In keeping with usage of the day:107 Harlow used the term fungus (a word possibly related to the Greek word for "sponge") in reference to the sponge-like granulation tissue.:53
- In the pre-asepsis era in which Harlow practiced,:62 wrote surgeon Frederick Treves, "Practically all major wounds suppurated. Pus was the most common subject of converse, because it was the most prominent feature in the surgeon's work. It was classified according to degrees of vileness.":347 But pus of the right kind was considered desirable.:80 "If a patient was lucky ... a thick cream-colored odorless fluid would appear within five or six days"; such "laudable" pus was considered "a sure sign that the wound would heal":344 because it meant "Nature has put up a bold fight against the invader". "On the other hand, if the pus gradually became watery, blood tinged and foul smelling, it was designated 'sanious' [or 'ill-conditioned'] and the wound condition was considered unfavorable". (It later came to be understood that "laudable" pus generally implied an invasion of relatively benign staphylococci, while "ill-conditioned" pus usually meant the more dangerous streptococcus.:345:247)
- :679–80 Barker writes that "[Head injuries] from falls, horse kicks, and gunfire, were well known in pre–Civil War America [and] every contemporary course of lectures on surgery described the diagnosis and treatment" of such injuries. But to Gage's benefit, surgeon Joseph Pancoast had performed "his most celebrated operation for head injury before Harlow's medical school class, [trephining] to drain the pus, resulting in temporary recovery. Unfortunately, symptoms recurred and the patient died. At autopsy, reaccumulated pus was found: granulation tissue had blocked the opening in the dura." By keeping the exit wound open and elevating Gage's head to encourage drainage from the cranium through the hole in the roof of the mouth, Harlow "had not repeated Professor Pancoast's mistake.":675:58
Noting that Harlow had been a "relatively inexperienced local physician ... graduated four and a half years earlier", Macmillan's discussion of Harlow's "skillful and imaginative adaptation of traditional methods":12,60 emphasizes that Harlow "did not apply rigidly what he had learned", for example foregoing an exhaustive search for bone fragments (which risked hemorrhage and further brain injury) and applying caustic silver nitrate to the granulation tissue instead of excising it (which risked hemorrhage) or forcing it into the wound (which risked compressing the brain).:58–62
As to his own role in Gage's survival, Harlow merely averred, "I can only say ... with good old Ambro[i]se Parè, I dressed him, God healed him":20—an assessment Macmillan calls far too modest.:62 See Macmillan:12,ch4,355–9:828–9:151-3 for further discussion of Harlow's management of the case and level of medical skill generally.
- :12–13 A year later some physical weakness was still manifest.:93 Much later Harlow wrote that "physically, the recovery was quite complete during the four years immediately succeeding the injury".:19
Bigelow:20–1 gives a more detailed description of Gage's post-recovery appearance: "A linear cicatrix of an inch in length occupies the left ramus of the jaw near its angle. A little thickening of the soft tissues is discovered about the corresponding malar bone. The eyelid of this side is shut, and the patient unable to open it. [This] eye considerably more prominent than the other ... In addition to a ptosis of the lid, the eye is found to be incapable of executing either the outward or upward motion; while the other muscles animated by the motor communis are unimpaired. Upon the head, and covered by hair, is a large unequal depression and elevation ... A piece of cranium of about the size of the palm of the hand, its posterior border lying near the coronal suture, its anterior edge low upon the forehead, was raised upon the latter as a hinge to allow the egress of the bar [and] still remains raised and prominent. Behind it is an irregular and deep sulcus several inches in length, beneath which the pulsations of the brain can be perceived."
- Gage's death and original burial are discussed by Macmillan:108–9 (and see "Corrections to An Odd Kind of Fame").:D Because bound, consecutive interment records show that Gage was buried May 23, 1860,:122n17 Macmillan:122n15:6 concludes that Harlow's:15 May 21 for Gage's death is correct, but that the year was 1860, not Harlow's 1861. (Harlow's informant was Gage's mother;:15:6 Macmillan:376 points out that, when combined with Gage's age at death, the 1861 date obscures the fact that Gage had been conceived out of wedlock.) This implies that certain other dates Harlow gives for events late in Gage's life—his move from Chile to San Francisco and the onset of his convulsions—are also mistaken, presumably by the same one year; this article follows Macmillan:122n15 in correcting those dates (each of which carries this annotation).
- :16 Here reproduced from Jackson's Descriptive Catalog of the Warren Anatomical Museum, these images were commissioned by Harlow from photographer Samuel Webster Wyman and were the basis for the woodcuts seen in Harlow (1868).:21:26,115,479–80
- Macmillan & Lena: "Only Harlow:16 writes of the exhumation and he does not say the tamping iron was recovered then. Although what he says may be slightly ambiguous, it does not warrant the contrary and undocumented account [of H. Damasio:1103 and A. Damasio:22] that Gage's tamping iron was recovered from the grave.":7
-  Jackson (1870): "The most valuable specimen that has ever been added to the [Warren Anatomical] Museum, and probably ever will be, was given two years ago by Dr. John M. Harlow ... For the professional zeal and the energy that Dr. H. showed, in getting possession of this remarkable specimen, he deserves the warmest thanks of the profession, and still more, from the College [i.e. the "Medical College of Harvard University"], for his donation.":v In 1958 the Warren's curator wrote that of its hundreds of objects, "there are few which have attracted more visitors and spread farther the fame of the Museum" than have Gage's skull and iron.
- Early authors attempting to estimate the extent of damage include: Harlow;:389 Bigelow;:21–2 Harlow;:343–5 Dupuy; Ferrier; Bramwell; Cobb; Tyler & Tyler.
- See Macmillan & Lena;:9 Harlow;:332,345 Bigelow;:16–17 Harlow;:390 Macmillan.:86
- Sources attributing behaviors to Gage, or discussing or falsifying these attributions: wife and children:39,327 sexuality;:319,327–8 lack of forethought/concern/embarassment, parading self-misery, vainglory;:9,11,51:119,331 employment inability;:323 employment refusal:107,323 irresponsibility, untrustworthiness;:1102:116 aggressiveness, violence;:321,331 vagrancy, begging;:323 drifting;:316,323 drinking;:118,316,321 bragging; lying;:119,321 brawling;:9:119 bullying;:321:830 psychopathy;:321 ethical decisions, social conventions, "idiot".:116,119,321
- Misinterpreations of Gage's work history are discussed by Macmillan:119,316,323:830 and Kotowicz.:130n6
- :194 According to phrenology's founder Franz Joseph Gall, the organ of Benevolence was responsible for "goodness, benevolence, the gentle character ... [and] to dispose man to conduct himself in a manner conformed too the maintenance of social order". Immediately adjacent was an organ for religion and God, later named Veneration by Johann Spurzheim (who expanded its responsiblity to include respect for peers and, especially, for those in authority).:150,171n10
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.
- :125 Kotowicz continues, "Damasio's account of Gage's last months [is] such a grotesque fabrication that it leaves one baffled,":130n6 then quotes a passage from A. Damasio::9–10
In my mind is a picture of 1860's San Francisco as a bustling place, full of adventurous entrepreneurs engaged in mining, farming, and shipping. That is where we can find Gage's mother and sister, the latter married to a prosperous San Francisco merchant (D. D. Shattuck, Esquire), and that is where the old Phineas Gage might have belonged. But that is not where we would find him if we could travel back in time. We would probably find him drinking and brawling in a questionable district, not conversing with the captains of commerce, as astonished as anybody when the fault would slip and the earth would shake threateningly. He had joined the tableau of dispirited people who, as Nathanael West [see The Day of the Locust] would put it decades later, and a few hundred miles to the south, "had come to California to die."
Kotowicz comments: "This little literary flourish is pure invention ... There is something callous in insinuating that Gage was some riff-raff who in his final days headed for California to drink and brawl himself to death."
Macmillan:116–19,326,331 gives detailed criticism of A. Damasio's various presentations of Gage (some of them in joint work with H. Damasio and others).
-  See also Grafman: "Although [Gage] has been used to exemplify the problems that patients with ventromedial prefrontal cortex lesions have in obeying social rules, recognizing social cues, and making appropriate social decisions, the details of this social cognitive impairment have occasionally been inferred or even embellished to suit the enthusiasm of the story teller—at least regarding Gage":295 (citing Macmillan).
- See for example Carlson;:341 additional examples and discussion are given by Macmillan.:246;252–3n9,10
Sources and further reading
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• See also "Corrections to An Odd Kind of Fame".
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- Warren Anatomical Museum, Center for the History of Medicine, Francis A. Countway Library of Medicine (Harvard Medical School) – Home of Gage's skull and iron.
- Meet Phineas Gage – How the owners of the 2009-identified daguerreotype learned it depicted Gage.
- Phineas Gage roadside memorial, Cavendish, Vermont.