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With Williams' assistance Harlow shaved the scalp around the region of the tamping iron's exit, and removed coagulated blood, small bone fragments, and an ounce of protruding brain. After probing for foreign bodies and replacing two large detached pieces of bone, Harlow closed the wound with [[wikt:resin#English-plant secretion|resin]]-impregnated (i.e. adhesive) cloth strips,{{Citation needed|date=December 2013}} leaving it partially open for drainage; the entrance wound in the cheek was left loosely bandaged for the same reason. A wet [[wikt:compress#English-folded cloth|compress]] was applied, then a [[nightcap (garment)|nightcap]] and further bandaging added to secure these dressings. Harlow also dressed Gage's hands and forearms (which along with his face had been "deeply burned") and ordered that his head be kept elevated. Later that evening Harlow wrote: "Mind clear. Says he 'does not care to see his friends, as he shall be at work in a few days.{{'"}}{{r|harlow1848|page1=390-1|harlow1868|page2=333|okf|page3=31-2,60-1}}
With Williams' assistance Harlow shaved the scalp around the region of the tamping iron's exit, and removed coagulated blood, small bone fragments, and an ounce of protruding brain. After probing for foreign bodies and replacing two large detached pieces of bone, Harlow closed the wound with [[wikt:resin#English-plant secretion|resin]]-impregnated (i.e. adhesive) cloth strips,{{Citation needed|date=December 2013}} leaving it partially open for drainage; the entrance wound in the cheek was left loosely bandaged for the same reason. A wet [[wikt:compress#English-folded cloth|compress]] was applied, then a [[nightcap (garment)|nightcap]] and further bandaging added to secure these dressings. Harlow also dressed Gage's hands and forearms (which along with his face had been "deeply burned") and ordered that his head be kept elevated. Later that evening Harlow wrote: "Mind clear. Says he 'does not care to see his friends, as he shall be at work in a few days.{{'"}}{{r|harlow1848|page1=390-1|harlow1868|page2=333|okf|page3=31-2,60-1}}


Despite Harlow's skillful care, Gage's recuperation was long and difficult. Pressure on the brain left him semi-comatose from September&nbsp;23 to October&nbsp;3, "seldom speaking unless spoken to, and then answering only in monosyllables. The friends and attendants are in hourly expectancy of his death, and have his coffin and clothes in readiness."<!--add surgery performed-->{{efn-ua|name=accident_excerpts}} Harlow's notes for September 24: "Failing strength... During the three succeeding days the coma deepened; the [[Globe (human eye)|globe]] of the left eye became more protuberant, with fungus pushing out rapidly from the internal [[canthus]]... also large fungi pushing up rapidly from the wounded brain, and coming out at the top of the head".{{r|harlow1868|page=335}} Here ''fungus'' does not mean an infecting [[mycosis]] but instead (Oxford English Dictionary) a "spongy morbid growth or excrescence, such as exuberant granulation in a wound"—that is, part of the body's own reaction to the injury.{{r|okf|page=54,61-2}}
Despite Harlow's skillful care,{{efn-ua
|name=skillful<!--BEGIN NOTE-->
|As to his own role in Gage's survival, Harlow merely averred, "I can only say... with good old [[Ambroise Paré|Ambro[i]se Paré]], I dressed him, God healed him"{{r|harlow1868|page=346}}—an assessment
Macmillan (2000) calls far too modest.{{r|okf|page=12,59-62,346-7}}
See Macmillan (2008), Macmillan (2001) and Barker (1995) for further discusssion of Harlow's management of the case.{{r|macm_unravelling|page=828-9}}{{r|macm_obscure<!--add specific pg #s-->}}{{r|barker|page=679-80}}
}}<!--<<END NOTE--> Gage's recuperation was long and difficult. Pressure on the brain{{efn-ua
|name=failingstrength<!--BEGIN NOTE-->
|Harlow's notes for September 24: "Failing strength... During the three succeeding days the coma deepened; the [[Globe (human eye)|globe]] of the left eye became more protuberant, with fungus pushing out rapidly from the internal [[canthus]]... also large fungi pushing up rapidly from the wounded brain, and coming out at the top of the head".{{r|harlow1868|page=335}}
Here ''fungus'' does not mean an infecting [[mycosis]] but instead (Oxford English Dictionary) a "spongy morbid growth or excrescence, such as exuberant granulation in a wound"—that is, part of the body's own reaction to the injury.{{r|okf|page=54,61-2}}
}}<!--<<END NOTE--> left him semi-comatose from September&nbsp;23 to October&nbsp;3, "seldom speaking unless spoken to, and then answering only in monosyllables. The friends and attendants are in hourly expectancy of his death, and have his coffin and clothes in readiness."<!--add surgery performed-->{{efn-ua|name=accident_excerpts}}


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."{{r|harlow1848|page=392-3}}
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."{{r|harlow1848|page=392-3}}

Revision as of 05:17, 25 December 2013

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.
BornJuly 9, 1823 (date uncertain)
Grafton Co., New Hampshire[A]
DiedMay 21, 1860(1860-05-21) (aged 36)
In or near San Francisco[B]
Cause of deathStatus epilepticus
Resting place
Occupations
  • Railroad construction foreman
  • blaster
  • stagecoach driver
Known forPersonality change after brain injury
SpouseNone
ChildrenNone[1]: 319, 327 

Phineas P. Gage (1823–1860) was an American railroad construction foreman remembered for his improbable survival of an 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 12 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"[2]—Phineas Gage influenced 19th-century discussion about the mind and brain, particularly debate on cerebral localization, and was perhaps the first case to suggest that damage to specific parts of the brain might affect personality.[1]: ch7-9 [3]

Gage is a fixture in the curricula of neurology, psychology and related disciplines, 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, which has allowed "the fitting of almost any theory [desired] to the small number of facts we have"[1]: 290 —Gage having been cited, over the years, in support of various theories of the brain entirely inconsistent with one another. A survey of published accounts, including scientific ones, has found that they almost always severely distort Gage's behavioral changes, exaggerating the known facts when not directly contradicting them.

Two photographs of Gage, and a physician's report of his physical and mental condition late in life, were published in 2009 and 2010. This new evidence indicates that Gage's most serious mental changes may have been temporary, so that in later life he was far more functional, and socially far better adjusted, than was previously assumed. 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.

Background

Cavendish, Vermont about 20 years after Gage's accident.(A) The two possible accident sites; (T) Gage's lodgings; (H) Harlow's home and surgery.
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.

Gage was the first of five children born to Jesse Eaton Gage and Hannah Trussell (Swetland) Gage, of Grafton County, New Hampshire.[A] Little is known about his upbringing and education, though he was almost certainly literate.[1]: 17,41 

He may have gained skill with explosives on the family's farms or in nearby mines and quarries,[1]: 17-18  and by the time of his accident he was a blasting foreman (possibly an independent contractor) on railway construction projects. His employers considered him (as town doctor John Martyn Harlow later put it) "the most effi­cient and capable foreman in their employ... a shrewd, smart businessman, very energetic and persistent in executing all his plans of operation", and he had even commissioned a custom-made tamping iron—an iron rod three feet seven inches (1.1 m) long, and 1+1⁄4 inches (3.2 cm) in diameter—for use in setting charges.

Gage's injury

An early news report of Gage's accident, from the Boston Post, September 21, 1848

On September 13, 1848, Gage (aged 25) was directing a work gang blasting rock while preparing the roadbed for the Rutland & Burlington Railroad outside 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. The blast holes, 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 nature of employer-employee relations on this type of job, all underscore the significance of Harlow's statement that Gage's employers had considered him "the most efficient and capable foreman in their employ" prior to the accident.[9]: A [1]: 25-7 

Gage was doing this around 4:30 p.m. when (possibly because the sand was omitted) the tamping iron struck a spark against the rock and the powder exploded. The tamping iron was fired out of the hole and "entered on the [left] side of his face... passing back of the left eye, and out at the top of the head."

Despite 19th-century references to Gage as "the American Crowbar Case"[10]: 54 [3] his tamping iron did not have the bend or claw associated with a crowbar; rather, it was a cylinder, "round and rendered comparatively smooth by use":[6]: 331 

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.[D]

Weighing 13+1⁄4 pounds (6 kg), this "abrupt and intrusive visitor"[E] was found 80 feet (25 m) away, "smeared with blood and brain."[7]: 331 

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 his lodgings in town.[7]: 331  Dr. Edward H. Williams arrived 30 minutes after the accident:

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.[F]

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

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.[F]

Treatment and convalescence

With Williams' assistance Harlow shaved the scalp around the region of the tamping iron's exit, and removed coagulated blood, small bone fragments, and an ounce of protruding brain. After probing for foreign bodies and replacing two large detached pieces of bone, Harlow closed the wound with resin-impregnated (i.e. adhesive) cloth strips,[citation needed] leaving it partially open for drainage; the entrance wound in the cheek was left loosely bandaged for the same reason. A wet compress was applied, then a nightcap and further bandaging added to secure these dressings. Harlow also dressed Gage's hands and forearms (which along with his face had been "deeply burned") and ordered that his head be kept elevated. Later that evening Harlow wrote: "Mind clear. Says he 'does not care to see his friends, as he shall be at work in a few days.'"[6]: 390-1 [7]: 333 [1]: 31-2,60-1 

Despite Harlow's skillful care, Gage's recuperation was long and difficult. Pressure on the brain left him semi-comatose from September 23 to October 3, "seldom speaking unless spoken to, and then answering only in monosyllables. The friends and attendants are in hourly expectancy of his death, and have his coffin and clothes in readiness."[F] Harlow's notes for September 24: "Failing strength... During the three succeeding days the coma deepened; the globe of the left eye became more protuberant, with fungus pushing out rapidly from the internal canthus... also large fungi pushing up rapidly from the wounded brain, and coming out at the top of the head".[7]: 335  Here fungus does not mean an infecting mycosis but instead (Oxford English Dictionary) a "spongy morbid growth or excrescence, such as exuberant granulation in a wound"—that is, part of the body's own reaction to the injury.[1]: 54,61-2 

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."[6]: 392-3 

Subsequent life and travels

Injuries

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." 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, and depression on the top of his head. Harlow reported that Gage was not in pain, "but says he has a queer feeling which he is not able to describe."[7]: 338-9 [15]

New England

Harlow says that Gage, unable to return to his railroad work,[7]: 339  appeared for a time at Barnum's American Museum in New York City (the curious paying to see, presumably, both Gage and the instrument which had injured him). Recently, however, evidence has surfaced[citation needed] supporting Harlow's statement that Gage made public appearances in "the larger New England towns". He subsequently worked in a livery stable in Hanover, New Hampshire.[7]: 340 

Chile and California

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. After his health began to fail around 1859,[B] he left Chile for San Francisco, where he recovered under the care of his mother and sister (who had gone there from New Hampshire around the time Gage went to Chile). For the next few months, he did farm work in Santa Clara.[1]: 103-4 [7]: 340-1 

Death and subsequent travels

Gage's skull (sawed to show interior) and iron, photographed for Harlow in 1868.

In February 1860,[B] Gage had the first in a series of increasingly severe convulsions;[G] he died status epilepticus[9]: E  in or near[9]: B  San Francisco on May 21, just under twelve years after his injury, and was buried in San Francisco's Lone Mountain Cemetery.[B] (Some accounts[18][19][20] assert that Gage's iron was buried with him, but there appears to be no evidence for this.)[H]

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 Gage's family there. At Harlow's request they opened Gage's grave long enough to remove his skull, which the family then personally[17]: 6  delivered to Harlow in New England.

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[8]: 22n [14][1]: 46-7  and made what he called "my iron bar" his "constant companion during the remainder of his life";[7]: 339  now it too was delivered to Harlow. After studying them for a triumphal[E] retrospective paper on Gage,[7] Harlow redeposited the iron—this time with Gage's skull—in the Warren Museum, where they remain on display.[11]: v  The iron bears the following inscription (though the date it gives for the accident is one day off, and Phinehas is not the way Gage spelled his name):[5]: 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.

Much later Gage's headless remains were moved to Cypress Lawn Cemetery as part of a systematic relocation of San Francisco's dead to new burial places outside city limits.[1]: 119-20 

Brain damage and mental changes

"The leading feature of this case is its improbability." Harvard's Henry J. Bigelow in 1854. His training predisposed him to minimize Gage's behavioral changes.[I]
"I dressed him, God healed him."[J] Dr. John M. Harlow, who attended Gage after the "rude missile had been shot through his brain",[21] and obtained his skull for study after his death, in later life. Harlow's interest in phrenology prepared him to accept that Gage's injury might change his behavior.[I]
"I have the pleasure of being able to present to you [a case] without parallel in the annals of surgery." Harlow's 1868 presentation, to the Massachusetts Medical Society, of Gage's skull, iron, and late-life history.[7]

Extent of brain damage

Debate as to whether the trauma and subsequent infection had damaged both of Gage's frontal lobes, or only the left, began almost immediately after his accident.[6]: 389  The 1994 conclusion of H.Damasio et al.,[18] that both frontal lobes were damaged, was drawn by modeling not Gage's skull but rather a "Gage-like" one.[5]: 829-30  In 2004 Ratiu et al. used CT scans of Gage's actual skull[22][23] to confirm Harlow's conclusion (based on probing Gage's wounds with his finger)[17]: 9  that the right hemisphere had remained intact. Ratiu et al. was the first study to account for the hairline fracture running from behind the exit region down the front of Gage's skull, as well as the fact 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—hypothesizing that the skull "hinged" open as the iron entered the base of the cranium, and was afterward pulled closed by the resilience of soft tissues once the iron had exited at the top.[23][22][5]: 830  Van Horn et al. (2012) agree that the right hemisphere was undamaged, and make detailed estimates of the locus and extent of damage to Gage's white matter, suggesting that this damage may have been more significant to Gage's mental changes than the cerebral cortex (gray matter) damage.[K]

First-hand reports of mental changes

Gage certainly displayed some kind of change in behavior after his injury,[17]: 12-15  but the nature, extent, and duration of this change are very uncertain: little is reliably known about what Gage was like (either before or after the accident),[L] the mental changes described after his death were much more dramatic than anything reported while he was alive, and the few descriptions which seem credible do not specify the period of his post-accident life to which they are meant to apply.

Harlow's 1848 report

In his 1848 report, as Gage was just completing his physical recovery, Harlow had only hinted at possible psychological symptoms: "The mental manifestations of the patient, I leave to a future communication. I think the case... is exceedingly interesting to the enlightened physiologist and intellectual philosopher."[6]: 393  And after observing Gage for several weeks in late 1849, Harvard Professor of Surgery Henry Jacob Bigelow (in keeping with his anti-localizationist training)[I] said that Gage was "quite recovered in faculties of body and mind," there being only "inconsiderable disturbance of function".[8]: 13-14 

Harlow's 1868 report

In 1868 Harlow (having obtained Gage's skull, tamping iron, and late-life history) delivered the "future communication" he had promised 20 years earlier, detailing the mental changes found today in most presentations of the case (though usually in exaggerated or distorted form—see Distortion of mental changes, below). He 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".[citation needed]

The description that Gage was "no longer Gage" appears to draw on Harlow's own notes set down soon after the accident,[1]: 90,375  but other behaviors he describes[1]: 117-8 [7]: 340,345  appear to draw on later communications from Gage's friends or family,[M] to the particular period of Gage's post-accident life during which each described behavior was present.[1]: 90-5  The "fitful, irreverent... capricious and vacillating" Gage described in Harlow (1868)[7] is somewhat at variance with Gage's stagecoach work in Chile, which demanded 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" (Macmillan 2000,[1]: 106  citing Austin 1977)[27]—and note Gage was hired by his employer in advance, in New England, to be part of the new coaching enterprise in Chile.[1]: 376-7  This complicates reconstruction of how Gage's behavior changed over time, a critical task in light of evidence that his behavior at the end of his life was very different from his behavior (described by Harlow above) immediately after the accident.[17]: 6-9 

Social recovery

In 2008 a report was discovered calling Gage mentally unimpaired during his last years in Chile (from a physician who had known him "well" there), and since then a description of what may have been his daily work routine there as a stagecoach driver, and advertisements for two previously unknown public appearances. This new evidence implies that the seriously maladapted Gage described by Harlow existed for only a limited time after the accident—that Gage eventually "figured out how to live" despite his injury,‍[28]: 75  and was in later life far more functional, and socially far better adapted, than previously assumed.[5]: 831 

Psychologist Malcolm Macmillan hypothesizes that this change represents a social recovery by Gage 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"[5]—in Gage's case, his highly structured employment in Chile. "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. Phineas job as a stage-coach driver provided that external structure to aid in his recovery.[29] If this is so, Macmillan points out, then along with theoretical implications it "would add to current evidence that rehabilitation can be effective even in difficult and long-standing cases"[5]: 831 —and asks, if Gage could achieve such improvement without medical supervision, "what are the limits for those in formal rehabilitation programs?"[30]

Distortion of mental changes

A moral man, Phineas Gage
Tamping powder down holes for his wage
Blew his special-made probe
Through his left frontal lobe
Now he drinks, swears, and flies in a rage.

—Anonymous[1]: 307 

Macmillan carries out a comprehensive analysis of accounts of Gage (scientific and popular), finding that they almost always distort and exaggerate his behavioral changes well beyond anything described by anyone who had contact with him.[L] In the words of Barker,[3] "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..."[31]

Attributes typically 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, an "utter lack of foresight", "a vainglorious tendency to show off his wound", inability or refusal to hold a job, plus drinking, bragging, lying, gambling, brawling, bullying, thievery, and acting "like an idiot". Macmillan shows that none of these behaviors is mentioned by anyone who had met Gage or even his family;[L] as Kotowicz writes, "Harlow does not report a single act that Gage should have been ashamed of."[31]

Theoretical use, misuse, and nonuse

Phrenologists contended that destruction of Gage's mental "organs" of veneration and benevolence (upper right) caused his behavioral changes.
False-color representation of cerebral fiber pathways affected, per Van Horn et al.[24]

Though Gage is considered the "index case for personality change due to frontal lobe damage"[3][32][33][20] his scientific value is undermined by the uncertain extent of his brain damage[33] combined with the lack of information about his behavioral changes.[1]: 290  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," the paucity of evidence having allowed "the fitting of almost any theory [desired] to the small number of facts we have".[1]: 290  A similar concern had been 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") 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...[34][I]

More recently Sacks refers to the "interpretations and misinterpretations, from 1848 to the present," of Gage.[35]

Thus in the 19th century controversy over whether or not the various mental functions are localized in specific regions of the brain, both sides managed to enlist Gage in support of their theories;[3][1]: ch9  for example, soon after Dupuy[36] wrote that Gage proved that the brain is not localized, Ferrier cited Gage as proof that it is.[37] 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".[38]: 194 [I]

Antonio 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.[19] Damasio's depiction of Gage has been criticized as changing the narrative and the last months of Gage being labeled a "grotesque fabrication" by Kotowicz. [31]

Or 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.[39]

According to Grafman, Gage's case has been used to exemplify the social problems arising from patients with ventromedial PFC [prefrontal cortex] lesions, but the impairment could be the subject of embellishment by storytellers. [40]: 295 

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.[41]: 341  Aside from the question of why the unpleasant changes usually (if hyperbolically) attributed to Gage would inspire surgical imitation, Macmillan states there is no such link.[1]: 250 

Portraits

The second portrait of Gage to be identified (2010)

In 2009, a daguerreotype portrait of Gage was discovered. It was the first likeness of Gage identified since the life mask taken by Bigelow in late 1849.[8]: 22n [1]: ii  It shows "a disfigured yet still-handsome" Gage[42] with one eye closed and scars clearly visible, "well dressed and confident, even proud" and holding his iron, on which portions of the inscription (recited above) can be made out. (For decades the daguerreotype's owners had imagined it showed an injured whaler with his harpoon.)[43] Authenticity was confirmed in several ways, including photo-overlaying the inscription visible in the portraits against that on the tamping iron in Harvard's Warren Anatomical Museum, and matching the injuries seen in the portraits against those preserved in the life mask.[44]

In 2010, a second portrait of Gage was identified. This new image, copies of which are in the possession of at least two different branches of the Gage family, depicts the same subject seen in the Wilgus daguerreotype identified in 2009, according to Gage researchers consulted by the Smithsonian Institution.[45] The 2009-identified image is from the collection of Jack and Beverly Wilgus. The original, like almost all daguerreotypes, shows its subject laterally (left-right) reversed, making it appear that Gage's right eye is injured.[45] In presenting the image here a second, compensating reversal has been applied in order to show Gage as he appeared in life.

Unlike the Wilgus portrait, which is 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 (left-right) reversing early-process photograph; here again a second, compensating reversal has been applied. The shirt and tie Gage is wearing in the Miller–Hartley image are different from those seen in the Wilgus image, though he is wearing the same waistcoat in both, and possibly the same jacket.[46]

See also

Notes

  1. ^ a b c Macmillan (2000)[1]: 11,17,490-1  discusses Gage's ancestry and what is and is not known about his birth and early life. Possible birthplaces are Lebanon, Enfield, and Grafton (all in Grafton County, New Hampshire) though Harlow (1868) refers to Lebanon in particular as Gage's "native place" and as "his home" (probably that of his parents) to which he returned ten weeks after the accident. The vital records of neither Lebanon nor Enfield list Gage's birth. The birthdate July 9, 1823 (the only definite date given in any source) is from a comprehensive Gage genealogy, via Macmillan (2000),[1]: 16  and is consistent with numerous contemporary sources, that Gage was 25 years old at the time of the accident, as well as with Gage's age—36 years—as given in undertaker's records after his death on May 21, 1860. There is no doubt Gage's middle initial was P[5]: 839fig. [6][7][8] but there is nothing to indicate what the P stood for (though his paternal grandfather was also named Phineas). Gage's mother's maiden name is variously spelled Swetland, Sweatland, or Sweetland.
  2. ^ a b c d e Gage's death and (original) burial are discussed at Macmillan (2000).[1]: 108-9  Harlow (1868)[7] gives the date of Gage's death as May 21, 1861, but undertaker's records[16] show that Gage was buried on May 23, 1860. That Harlow (though in contact with Gage's mother as he was writing) was mistaken by exactly one year implies that certain other dates he gives for events late in Gage's life—his move from Chile to San Francisco and the onset of his convulsions—must also be mistaken, presumably by the same amount; this article follows Macmillan in correcting those dates (each of which carries this annotation).
  3. ^ For scientific and academic discussions see Macmillan;[1]: 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."[4]: 89  For popular culture, see Macmillan (2000)[1]: ch13  and Macmillan (2008);[5]: 830  for example, several musical groups call themselves Phineas Gage (or some variation).
  4. ^ Bigelow describes the iron's taper as seven inches long, but the correct dimension is twelve (corrected in the quotation).[6]: 331 [1]: 26 
  5. ^ a b 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—see Macmillan 2000).[1]: 66-7  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 (1850) emphasized that though "at first wholly skeptical, I have been personally convinced", calling the case "unparalleled in the annals of surgery".[8]: 13,19  This endorsement by Bigelow, Professor of Surgery at Harvard, helped end scoffing about Gage among medical men—one of whom, Harlow (1868) later recalled, had dismissed the matter as a "Yankee invention":
    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.[7]: 329,344  Jackson (1870) wrote 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."[11]: v 
    But after Gage was joined by such later cases as a miner who survived traversal of his head by a gas pipe,[citation needed] and a lumbermill foreman who returned to work soon after a circular saw cut three inches (8cm) into his skull from just between the eyes to behind the top of his head (the surgeon removing from this incision "thirty-two pieces of bone, together with considerable sawdust"),[12] 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."[13] The Transactions of the Vermont Medical Society (Smith 1886) 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."[10]: 53-54  The reference to Gage's iron as an "abrupt and intrusive visitor" appears in the Boston Medical & Surgical Journal's review[14] of Harlow (1868).
  6. ^ a b c Excerpted from Williams' and Harlow's statements in: Harlow (1848);[6]: 390-2  Bigelow (1850);[8]: 16  Harlow (1868).[7]: 335-6 
  7. ^ Apparently[17]: 6-7  quoting Gage's mother, Harlow narrates that
    while sitting at dinner, [Gage] fell in a fit, and soon after had two or three fits in succession... "[Phineas had] been ploughing the day before he had the first attack; got better in a few days, and continued to work in various places;" could not do much, changing often, "and always finding something which did not suit him in every place he tried." On May 18, 1860[B] he left Santa Clara and went home to his mother. At 5 A.M. on May 20, 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.[7]
  8. ^ Macmillan& Lena: "Only Harlow[7]: 342  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[s]... that Gage's tamping iron was recovered from the grave."[17]: 7 
  9. ^ a b c d e See Macmillan (2000)[1] and Macmillan (2008)[5]: 831  for surveys and discussion of theoretical misuse of Gage, and Barker (1995) for, specifically, the way in which 19th-century reports of Gage were colored by various writers' doctrinal leanings:
    The educational backgrounds of Harlow and Bigelow [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 [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.[3]: abstr 
    Smith (1886) noted "the ingenuity with which the advocates of various theories [of the brain] will explain away the evidence of their opponents."[10]: 51 
  10. ^ Cite error: The named reference skillful was invoked but never defined (see the help page).
  11. ^ Specifically, Van Horn etal.[24] estimated that although "extensive damage occurred to left frontal, left temporal polar, and insular cortex, the best fit rod trajectory did not result in the iron crossing the midline as has been suggested by some authors" (such as H.Damasio). "Fiber pathway damage extended beyond the left frontal cortex to regions of the left temporal, parietal, and occipital cortices as well as to basal ganglia, brain stem, and cerebellum. Inter-hemispheric connections of the frontal and limbic lobes as well as basal ganglia were also affected."​ (Quotations abridged to remove quantitative estimates of damage to each locus.)
  12. ^ a b c Accounts of Gage are compared to one another, and against the known facts, at Macmillan (PGIP)[9]: C  and in Macmillan 2000.[1]: esp.116-19, ch13-14 According to Macmillan& Lena (2010, and see also Macmillan 2000)[1]: 11,89,93,116  available sources which offer detailed information on Gage, and for which there is evidence (if merely the source's own claim) of contact with him or with his family, were limited (until 2008) to Harlow (1848, 1849, 1868);[6][15][7] Bigelow (1850);[8] Jackson (1870);[11]; Jackson (1849).[25] Macmillan & Lena (2010) present previously unknown sources discovered post-2008. Macmillan (2001)[26]: 161  and Macmillan (2000)[1]: 94  discuss the high general reliability of Harlow (1868), and its primacy as a source. The contrast between Gage's celebrity, and the small amount known about him, is discussed in Macmillan (2000):[1]: 1-2,11  "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."
  13. ^ Macmillan (2000)[1]: 106-8,375-6  also discusses potential reluctance on the part of Gage's friends and family (and of Harlow himself) to describe Gage negatively, especially while he was still alive, and argues[1]: 350-1  that an 1850 communication calling Gage "gross, profane, coarse, and vulgar" was anonymously supplied by Harlow.[citation needed]

Sources and further reading

  1. ^ a b c d e f g h i j k l m n o p q r s t u v w x y z aa ab ac ad ae af ag ah ai aj
    ——— (2000). An Odd Kind of Fame: Stories of Phineas Gage. MIT Press. ISBN 0-262-13363-6 (hbk, 2000) ISBN 0-262-63259-4 (pbk, 2002). Appendices reproduce Harlow (1848, 1849, and 1868) and Bigelow (1850)Open access icon
     • See also "Corrections to An Odd Kind of Fame". Open access icon
  2. ^ Campbell, H.F. (1851). "Injuries of the Cranium—Trepanning". Ohio Med& Surg J. 4 (1): 20–24. (crediting the Southern Med& Surg J (unknown date).
  3. ^ a b c d e f Barker, F.G.II (1995). "Phineas among the phrenologists: the American crowbar case and nineteenth-century theories of cerebral localization". JNeurosurg. 82: 672–682. PMID 7897537. Closed access icon
  4. ^ Vanderstoep, S.W.; Fagerlin, A.; Feenstra, J.S. (2000). "What Do Students Remember from Introductory Psychology?" (PDF). Teaching of Psychology. 27 (2): 89. doi:10.1207/S15328023TOP2702_02. Open access icon
  5. ^ a b c d e f g h i
    ——— (2008). "Phineas Gage—Unravelling the myth" (PDF). The Psychologist. 21 (9). British Psychological Society: 828–831. Open access icon
  6. ^ a b c d e f g h i
    Harlow, John Martyn (1848). "Passage of an Iron Rod through the Head". Boston Med& Surg J. 39 (20): 389–393. Open access icon (Transcription.)
  7. ^ a b c d e f g h i j k l m n o p q r s t u
    Harlow, John Martyn (1868). "Recovery from the Passage of an Iron Bar through the Head". Publ Massachusetts Med Soc. 2: 327–347. Open access icon
  8. ^ a b c d e f g
    Bigelow, Henry Jacob (July 1850). "Dr. Harlow's Case of Recovery from the Passage of an Iron Bar through the Head". Am J Med Sci. 20: 13–22. Reproduced in Macmillan (2000).[1]
  9. ^ a b c d e
    Macmillan, Malcolm B. (PGIP). "The Phineas Gage Information Page". The University of Akron. Retrieved July 22, 2013. {{cite web}}: Check date values in: |year= (help)CS1 maint: year (link) Includes:
    A. "Phineas Gage Sites in Cavendish". Open access icon
    B. "Phineas Gage: Unanswered questions". Open access icon
    C. "Phineas Gage's Story". Open access icon
    D. "Corrections to An Odd Kind of Fame". Open access icon
    E. "Phineas Gage: Psychosocial Adaptation". Open access icon
    F. "Phineas Gage and Frontal Lobotomies". Open access icon
  10. ^ a b c Smith, William T (1886). "Lesions of the Cerebral Hemispheres]". TVermont Med Soc for the Year 1885. pp. 46–58. Open access icon
  11. ^ a b c ———. "A Descriptive Catalog of the Warren Anatomical Museum". {{cite journal}}: |chapter= ignored (help); Cite journal requires |journal= (help) Reproduced in Macmillan (2000),[1] in which see also p.107. Open access icon
  12. ^ Folsom, A.C. (1869). "Extraordinary Recovery from Extensive Saw-Wound of the Skull". Pacific Medical and Surgical Journal. pp. 550–555. {{cite news}}: Unknown parameter |month= ignored (help)
  13. ^ "Medical Intelligence. Extraordinary Recovery". Boston Medical& Surgical Journal. 3n.s. (13): 230–1. April 29, 1869.
  14. ^ a b "Bibliographical Notice". Boston Medical& Surgical Journal. 3n.s. (7): 116–7. March 18, 1869.
  15. ^ a b ——— (1849). "Medical Miscellany (letter)". Boston Med& Surg J. 39: 506–7. Reproduced in Macmillan (2000).[1]
  16. ^ Volume 3: Lone Mountain register, 1850-1862, Halsted N.Gray – Carew& English Funeral Home Records (SFH 38), San Francisco History Center, San Francisco Public Library. p. 285.
  17. ^ a b c d e f
    ———; Lena, M.L. (2010). "Rehabilitating Phineas Gage". Neuropsychological Rehabilitation. 20 (5): 641–658. doi:10.1080/09602011003760527. PMID 20480430. Closed access icon
  18. ^ a b Damasio, H.; Grabowski, T.; Frank, R.; Galaburda, A.M.; Damasio, A.R. (1994). "The return of Phineas Gage: Clues about the brain from the skull of a famous patient". Science. 264 (5162): 1102–1105. doi:10.1126/science.8178168. PMID 8178168. Closed access icon
  19. ^ a b Damasio A.R. (1994). Descartes' Error: Emotion, Reason, and the Human Brain. ISBN 0-14-303622-X. (2nd ed.:2005)
  20. ^ a b Hockenbury, Don H.; Hockenbury, Sandra E. (2008). Psychology. p. 74. ISBN 978-1-429-20143-8. Closed access icon
  21. ^ Eliot, Samuel Atkins, ed. (1911). "JohnM. Harlow". Vol. 1. Massachusetts Biographical Society. {{cite book}}: |work= ignored (help); Missing or empty |title= (help) Open access icon
  22. ^ a b Ratiu, P.; Talos, I.F.; Haker, S.; Lieberman, D.; Everett, P. (2004). "The Tale of Phineas Gage, Digitally Remastered". Journal of Neurotrauma. 21 (5): 637–643. doi:10.1089/089771504774129964. PMID 15165371. Closed access icon
  23. ^ a b ———; Talos, I.F. (2004). "The Tale of Phineas Gage, Digitally Remastered". New England Journal of Medicine. 351 (23): e21. doi:10.1056/NEJMicm031024. PMID 15575047. Open access icon
  24. ^ a b Van Horn, J.D.; Irimia, A.; Torgerson, C.M.; Chambers, M.C.; Kikinis, R.; Toga, A.W. (2012). "Mapping Connectivity Damage in the Case of Phineas Gage". PLoS ONE. 7 (5): e37454. doi:10.1371/journal.pone.0037454. PMC 3353935. PMID 22616011.{{cite journal}}: CS1 maint: unflagged free DOI (link) Open access icon
  25. ^ Jackson, J.B.S. (1849). Medical Cases. 4 (Case 1777). {{cite journal}}: Missing or empty |title= (help) Countway Library (Harvard Univ.) Mss., HMSb72.4.
  26. ^
    ——— (2001). "John Martyn Harlow: Obscure Country Physician?". Journal of the History of the Neurosciences. 10 (2): 149–162. doi:10.1076/jhin.10.2.149.7254. PMID 11512426. Closed access icon
  27. ^ Austin, K.A. (1977). A Pictorial History of Cobb and Co.: The Coaching Age in Australia, 1854–1924. Sydney: Rigby. ISBN 0-7270-0316-X.
  28. ^ a b Fleischman, J. (2002). Phineas Gage: A Gruesome but True Story About Brain Science. ISBN 0-618-05252-6. Open access icon
  29. ^
    ———; Aggleton, John (March 6, 2011). "Phineas Gage: The man with a hole in his head" (Audio interview). Interviewed by Claudia Hammond; Dave Lee. {{cite interview}}: Unknown parameter |callsign= ignored (help); Unknown parameter |program= ignored (help)CS1 maint: multiple names: interviewers list (link) Open access icon
  30. ^
    ——— (July 2009). "More About Phineas Gage, Especially After the Accident". Retrieved July 27, 2013. Open access icon
  31. ^ a b c Kotowicz, Z. (2007). "The strange case of Phineas Gage". History of the Human Sciences. 20 (1): 115–131. doi:10.1177/0952695106075178. Closed access icon
  32. ^ Stuss, D.T.; Gow, C.A.; Hetherington, C.R. (1992). "'No longer Gage': Frontal lobe dysfunction and emotional changes". Journal of Consulting and Clinical Psychology. 60 (3): 349–359. doi:10.1037/0022-006X.60.3.349. PMID 1619089. Closed access icon
  33. ^ a b Fuster, Joaquin M. (2008). The prefrontal cortex. Elsevier/Academic Press. p. 172. ISBN 0-12-373644-7. Closed access icon
  34. ^ Ferrier, David (1877–79). "Correspondence with Henry Pickering Bowditch". {{cite journal}}: Cite journal requires |journal= (help) Countway Library (Harvard Univ.) Mss., HMSc5.2. Transcribed in Macmillan (2000).[1]: 464-5 
  35. ^ Sacks, Oliver (1995). An Anthropologist on Mars. pp. 59–61. ISBN 0-679-43785-1. OCLC 30810706. Closed access icon
  36. ^ Dupuy, Eugene (1877). "A critical review of the prevailing theories concerning the physiology and the pathology of the brain: localisation of functions, and mode of production of symptoms. PartII". Med Times& Gaz. II: 356–8. Open access icon
  37. ^ ——— (1878). "The Goulstonian lectures of the localisation of cerebral disease. LectureI (concluded)". Br Med J. 1 (900): 443–7.
  38. ^ Sizer, Nelson (1888). Forty years in phrenology; embracing recollections of history, anecdote, and experience. New York: Fowler& Wells. Open access icon
  39. ^ Kihlstrom, J.F. (2010). "Social neuroscience: The footprints of Phineas Gage". Social Cognition. 28 (6): 757–782. doi:10.1521/soco.2010.28.6.757. Open access icon
  40. ^ Grafman, J. (2002). "The Structured Event Complex and the Human Prefrontal Cortex". pp. 292–310. doi:10.1093/acprof:oso/9780195134971.003.0019. ISBN 978-0-195-13497-1. {{cite book}}: |work= ignored (help); Missing or empty |title= (help); Unknown parameter |editors= ignored (|editor= suggested) (help) Closed access icon
  41. ^ Carlson, N.R. (1994). Physiology of Behavior. p. 341. ISBN 0-205-07264-X.
  42. ^ Twomey, S. (January 2010). "Finding Phineas". Smithsonian. 40 (10): 8–10. Open access icon
  43. ^ ———. "Meet Phineas Gage". Retrieved October 2, 2009. Open access icon[full citation needed]
  44. ^ Wilgus, B.&J (2009). "Face to Face with Phineas Gage". Journal of the History of the Neurosciences. 18 (3): 340–345. doi:10.1080/09647040903018402. PMID 20183215. Closed access icon
  45. ^ a b c Lena, M.L.; Macmillan, Malcolm B. (March 2010). "Picturing Phineas Gage (invited comment)". Smithsonian. p. 4. Open access icon
  46. ^ ———. "A New Image of Phineas Gage". Retrieved March 10, 2010. Open access icon

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