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Phineas Gage

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Phineas P. Gage
The second identified portrait of Gage, here with his "constant companion" – his inscribed tamping iron.
Click to enlarge. [n 1]
BornJuly 9?, 1823
Grafton Co., N.H.
DiedMay 21, 1860(1860-05-21) (aged 36)
In or near San Francisco
Resting placeCypress Lawn Cem., Calif.
Warren Anatomical Museum, Boston
Occupation(s)Railroad construction foreman, blaster, stagecoach driver
Known forPersonality change after brain injury
SpouseNone
ChildrenNone

Phineas P. Gage (July 9?, 1823 – May 21, 1860)[n 2] was an American railroad construction foreman now remembered for his improbable[n 3] 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 – effects so profound that friends saw him as "no longer Gage".

Long called "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"[1] – Phineas Gage influenced 19th-century discussion about the brain, particularly debate on cerebral localization,[2] and was perhaps the first case suggesting that damage to specific regions of the brain might affect personality and behavior.

Gage is a fixture in the curricula of neurology, psychology and related disciplines, and is frequently mentioned in books and academic papers; he also has a minor place in popular culture.[n 4] Relative to this celebrity, the body of known fact about the case is remarkably small, which has allowed it to be cited, over the years, in support of various theories of the brain and mind wholly contradictory to one another. A survey of published accounts has found that even modern scientific presentations of Gage are usually greatly distorted – exaggerating and even directly contradicting the established facts.

A daguerreotype portrait of Gage – "handsome ... well dressed and confident, even proud," and holding the tamping iron which injured him – was identified in 2009 (see below). One researcher points to it as consistent with a social recovery hypothesis, under which Gage's most serious mental changes may have existed for only a limited time after the accident, so that in later life he was far more functional, and socially far better adapted, than has been thought. A second portrait (right) came to light in 2010.

Gage's accident

On September 13, 1848, 25-year-old Gage was foreman of a work gang blasting rock while preparing the roadbed for the Rutland & Burlington Railroad outside the town of Cavendish, Vermont. After a hole was bored into a body of rock, one of Gage's duties was to add blasting powder, a fuse, and sand, then compact the charge into the hole using a large iron rod.[n 5] Possibly because the sand was omitted, around 4:30 PM:

the powder exploded, carrying an instrument through his head an inch and a fourth in [diameter], and three feet and [seven] inches in length, which he was using at the time. The iron entered on the side of his face...passing back of the left eye, and out at the top of the head.[n 6]

Nineteenth-century sources refer to Gage as "the American Crowbar Case". For Americans of the time a crowbar did not have the bend or claw sometimes associated with that term today. Gage's tamping iron was simply a cylinder, "round and rendered comparatively smooth by use":[3]

The end which entered first is pointed; the taper being [twelve] inches 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.[n 7]

Weighing 13+1⁄4 lb (6 kg), this "abrupt and intrusive visitor"[n 3] was said to have landed some 80 feet (25 m) away "smeared with blood and brain."[4]

Amazingly, Gage spoke within a few minutes, walked with little or no assistance, and sat upright in a cart for the 3⁄4-mile (1.2 km) ride to his lodgings in town. The first physician to arrive was Dr. Edward H. Williams:

I first noticed the wound upon the head before I alighted from my carriage, the pulsations of the brain being very distinct. 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.[5]

Dr. John Martyn Harlow took charge of the case about an hour later:

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. Pulse 60, and regular. His person, and the bed on which he was laid, were literally one gore of blood.[6]

Despite Harlow's skillful care,[n 8] Gage's recuperation was long and difficult. Pressure on the brain[n 9] 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."[7]

But 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."[8]

The Boston Post for September 21, 1848 (understating the dimensions of Gage's tamping iron and overstating damage to the jaw).[n 6]

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." 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 "upon the top of the head...a deep depression, two inches by one and one-half inches wide, beneath which the pulsations of the brain can be perceived. Partial paralysis of the left side of the face." Despite all this, "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."[9]

Unable to return to his railroad work, Harlow says, Gage appeared for a time at Barnum's American Museum[n 10] in New York City (the curious paying to see, presumably, both Gage and the instrument that injured him) although there is no independent confirmation of this. Recently however, evidence has surfaced supporting Harlow's statement that Gage made public appearances in "the larger New England towns."[10] (On Gage's job-loss and public appearances, see more below.)

Gage later worked in a livery stable in Hanover, New Hampshire and then for some years in Chile as a long-distance stagecoach driver on the Valparaiso–Santiago route. After his health began to fail around 1859, 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.[11]

"Front and lateral view of the cranium, representing the direction in which the iron traversed its cavity..."[12]

Death

In February 1860, Gage had the first in a series of increasingly severe convulsions, and he died in or near[13] San Francisco on May 21 – just under twelve years after his accident. He was buried in San Francisco's Lone Mountain Cemetery.[n 11]

In 1866, Harlow somehow learned where Gage had been and opened a correspondence with his family, still in San Francisco. At his request they unearthed his patient long enough to remove the skull, which was then delivered to Harlow back in New England. About a year after the accident, Gage had allowed his tamping iron to be placed in Harvard Medical School's Warren Anatomical Museum, but he later reclaimed it and (according to Harlow) made what he called "my iron bar" his "constant companion during the remainder of his life";[11] now it accompanied the skull on its journey to Harlow. After studying them for his second (1868) paper, Harlow redeposited the iron, this time with Gage's skull, in the Warren Museum, where they remain on display today. The iron bears this inscription:[n 12]

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 [sic] 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.[14]

Brain damage and mental changes

North-facing view of "cut" through rock along what was once the track of the R&BRR, 3/4 mile south of Cavendish, Vt. Gage may have met with his accident while setting explosives either here or at a similar cut nearby.[n 5]

Significant brain injury is often fatal, but Harlow called Gage "the man for the case. His physique, will, and capacity of endurance could scarcely be excelled," and as noted earlier the iron's 1/4-inch leading point may have reduced its destructiveness.[n 8] Nonetheless, the brain tissue destroyed must have been substantial (considering not only the initial trauma but the subsequent infection as well) though debate as to whether this was in both frontal lobes, or primarily the left, began with the earliest papers by physicians who had examined Gage.[15] A 1994 study by Damasio et. al[16] (modeling not Gage's skull but a similar one)[17] concluded there was damage to the frontal lobes on both sides, but a 2004 study by Ratiu et. al.[n 13] (based on CT scans of Gage's actual skull, and presenting a video reconstruction of the tamping iron passing through it) confirms Harlow's conclusion (based on probing Gage's wound with his finger)[18] that the right hemisphere remained intact.

Neurologist Antonio Damasio uses Gage to illustrate a hypothesized link between the frontal lobes, emotion and practical decision-making.[19] But any theory that looks to Gage for support faces the difficulty that the nature, extent, and duration of the injury's effects on his mental state are very uncertain. In fact, little is known about what Phineas was like either before or after his injury (almost none of it first-hand),[n 14] the mental changes described after his death were much more dramatic than anything reported while he was alive, and even those descriptions which seem credible do not specify the period of his post-accident life to which they are meant to apply.

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."[20] And after observing Gage for several weeks in late 1849, Henry Jacob Bigelow, Professor of Surgery at Harvard, went so far as to say that Gage was "quite recovered in faculties of body and mind," there being "inconsiderable disturbance of function."[n 7]

It was not until 1868 that Harlow gave particulars of the mental changes found today (though usually in exaggerated or distorted form – see below) in most presentations of the case. In memorable language, he now described the pre-accident Gage as having been 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 businessman, 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."[11]

Of the handful of available primary sources,[n 14] Harlow's 1868 presentation of the case is by far the most informative, and despite certain errors in dating (see below) there seems no reason to doubt its general reliability.[21] The description above, although not published until two decades after Harlow last saw Phineas, appears to draw on Harlow's own notes made soon after the accident.[22] But other behaviors of Gage's which Harlow describes[23] appear to draw on later communications from Gage's friends or family,[n 15] and it is difficult to match these various behaviors (which range widely in their implied level of functional impairment)[n 16] to the period of Gage's life during which each behavior was present.[24] This complicates reconstruction of what Gage was like during those several periods, a problem which takes on renewed importance in light of recent research (see below) indicating that Gage's behavior at the end of his life differed significantly from that in the years immediately after the accident.

Distortion and misuse of case

The left frontal lobe (red), the forward portion of which was damaged by Gage's injury, according to Ratiu et. al. as well as Harlow's direct examination.[n 13]

There is no question Gage displayed some kind of change in behavior after his accident, but books and articles usually describe these changes in terms well beyond anything given by Harlow or others who had contact with Gage. Psychologist Malcolm Macmillan, in his book An Odd Kind of Fame: Stories of Phineas Gage, surveys scores of accounts of the case (both scientific and popular), finding that they are varying and inconsistent, typically poorly supported by the evidence, and often in direct contradiction to it.

Attributes ascribed to Gage which are either unsupported by, or in contradiction to, the known facts include drunkenness, mistreatment of wife and children (of which Gage had neither), an "utter lack of foresight," inability or refusal to hold a job, braggadocio, "a vainglorious tendency to show off his wound," lying, gambling, brawling, bullying, and thievery.[25] Curricular materials at one medical school[26] go so far as to present Gage as having been "accused of sexually molesting young children." None of these behaviors is mentioned by Harlow nor by anyone else claiming actual knowledge of Gage's life.[n 14] [n 17]

Harlow himself, writing in 1868 while in contact with Gage's mother, somehow mistakes the year of Gage's death as 1861, whereas Macmillan shows conclusively[n 11] that Gage actually died in 1860 – a striking if relatively unimportant illustration of the difficulty of establishing even basic facts about the case. In another example, several sources[16][27][28] state that Gage's iron was buried with him, but there appears to be no evidence for this.[n 18]

More substantively, Macmillan points out[29] that in a passage mistakenly interpreted[27] as implying Gage could not hold a job after his accident – "'... 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'" – Harlow[11] is referring not to Gage's post-accident life in general, but only to the months between the onset of his convulsions and his death.

Beyond the obvious importance of correcting the record of a much-cited case, Macmillan writes, "Phineas' story is 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 to the small number of facts we have."[30] A similar concern was expressed as far back as 1877, when British neurologist David Ferrier, writing to America 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."[31]

Thus in the 19th-century controversy over whether or not the various mental functions are localized in specific regions of the brain, both sides found ways to cite Gage in support of their theories.[n 19] Phrenologists made use of Gage as well, claiming that his mental changes resulted from destruction of his "organ of Veneration" and/or the adjacent "organ of Benevolence."[32]

It is often said[33] that what happened to Gage played a part in the later development of various forms of psychosurgery, particularly frontal lobotomy. Aside from the question of why the unpleasant changes usually attributed to Gage would inspire surgical imitation,[n 20] careful inquiry turns up no such link, according to Macmillan:

[T]here is no evidence that Gage's case contributed directly to psychosurgery ... As with surgery for the brain generally, what his case did show came solely from his surviving his accident: major operations could be performed on the brain without the outcome necessarily being fatal.[34]

Current research

The first known photograph of Gage (identified in 2009)[n 21]

By late 2008 an advertisement for a previously unknown public appearance by Gage had been discovered, as well as a report of his physical and mental condition during his time in Chile, a description of what may well have been his daily work routine there as a stagecoach driver, and more recently an ad for a second public appearance. This new information suggests that the seriously maladapted Gage described by Harlow may have existed for only a limited time after the accident – that Phineas eventually "figured out how to live" despite his injury,[35] and was in later life far more functional, and socially far better adapted, than has been thought.[36]

Macmillan hypothesizes that this change represents a social recovery undergone by Gage over time, citing persons with similar injuries for whom "someone or something gave enough structure to their lives for them to relearn lost social and personal skills" (in Gage's case, his highly structured employment in Chile). If this is so then along with theoretical implications, it "would add to current evidence that rehabilitation can be effective even in difficult and long-standing cases," according to Macmillan,[36] who asks, if Phineas could achieve such improvement without medical supervision, "what are the limits for those in formal rehabilitation programs?"[37]

In 2009 a daguerreotype portrait of Gage (left) was identified – the first likeness of him known other than a life mask taken around 1850. It shows "a disfigured yet still-handsome" Gage[38] with one eye closed and scars clearly visible, "well dressed and confident, even proud"[39] and holding his iron, on which portions of the inscription (recited above) can be made out. (For decades the daguerreotype's owners had imagined that it showed an injured whaler with his harpoon.[40]) Authenticity was confirmed in several ways, including photo-overlaying the inscription visible in the portrait against that on the actual tamping iron in Harvard's Warren Anatomical Museum; and similarly, matching the injuries seen in the portrait against those preserved in the life mask.[39]

Macmillan cites the daguerreotype as consistent with the social recovery hypothesis already described.[37] To better understand the question, he and collaborators are actively seeking additional evidence on Gage's life and behavior, and describe certain kinds of historical material[41] for which they hope readers will remain alert, such as letters or diaries by physicians whom their research indicates Gage may have met, or by persons in certain places Gage seems to have been.[13][36]

In 2010 a second image of Gage was identified (see head of article). This new image, copies of which are in the possession of at least two different branches of the Gage family, depicts the same subject as the daguerreotype identified in 2009, according to Gage researchers consulted by the Smithsonian Institution.[n 1]

See also

Notes

  1. ^ a b Lena & Macmillan (2010), citing also B. & J. Wilgus. The image seen here is in the possession of Tara Gage Miller of Texas; an identical image is in the possession of Phyllis Gage Hartley of New Jersey. (Phineas had no known children – see Macmillan 2000, pp. 319,327; these are descendents of certain of his relatives – see Macmillan & Lena 2010, p. 4.) Unlike the Wilgus portrait, which is an original daguerreotype, the Miller-Hartley photos are 19th-century photographic reproductions of a single original which remains undiscovered, itself a daguerreotype or other laterally (left-right) reversing early-process photograph; a second, compensating reversal has been applied here to show Gage as he appeared in life. Gage's shirt and tie are different in the Miller-Hartley image than in the Wilgus image, though he is wearing the same waistcoat and possibly the same jacket; see Wilgus, B. & J. "A New Image of Phineas Gage". Retrieved 2010-03-10. See Harlow 1868, p. 340 for "constant companion."
  2. ^ a b Gage's parents were Jesse Eaton Gage and Hannah Trussell (née Swetland, Sweatland, or Sweetland) Gage (Macmillan (2000), pp. 490–1), but see Macmillan (2000), pp. 11, 16 for the uncertainty regarding other circumstances of his birth and upbringing. Possible birthplaces are Lebanon, Enfield, and Grafton (all of these in Grafton County, N.H.) 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. There is no doubt Gage's middle initial was P (figure, Macmillan 2008, p. 839; Harlow 1848/1868; Bigelow 1850) but there is nothing to indicate what the P stood for. See also note below on tamping iron's inscription.
  3. ^ a b Bibliographical notices. Recovery from the Passage of an Iron Bar through the Head. By John M. Harlow, M.D., of Worburn. (1869). Boston Medical and Surgical Journal, March 18, 1869. 3(7)n.s.:116–117. A tone of bemused wonderment was common in 19th-century medical writing about Gage (as well as other victims of unlikely-sounding brain-injury accidents – see Macmillan 2000, pp. 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, pp. 13,19) emphasized that though "at first wholly skeptical, I have been personally convinced," calling the case "unparalled in the annals of surgery." Bigelow's stature largely ended scoffing about Gage among physicians in general – one of whom, Harlow (1868, p. 344) later wrote, had dismissed the matter as a "Yankee invention."

    After Gage was joined by the cases of a miner who survived traversal of his head by a gas pipe, and of a lumbermill foreman who returned to work soon after a "picket saw" cut into his forehead to a depth of nine inches, the Boston Med. & Surg. J. (1870)[citation needed] 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 these days." The Transactions of the Vermont Medical Society (1870)[citation needed] was similarly facetious: " 'The times have been,' says Macbeth, '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."

  4. ^ LeUnes, A. (1974). "Contributions to the history of psychology: 20. A review of selected aspects of texts in abnormal psychology". Psychological Reports. 35 (3): 1319–26. PMID 4614305. LeUnes' survey found Harlow (1868) to be the second most frequently cited work in twentieth-century psychology texts; see also Macmillan (2000) ch. 14, esp. pp. 307–8, 311 and 313–14. For popular culture, see Macmillan (2000), ch. 13; for example, several musical groups call themselves Phineas Gage (or some variation).
  5. ^ a b See Macmillan 2000 pp. 25–27 for the steps in setting a blast and the location and circumstances of the accident. The blast hole, about 1+1⁄2 inches (38 mm) in diameter and up to six feet (1.8 m) deep, might require two men working half a day or more to "drill" using hand tools. The labor invested in setting each blast, and the judgment involved in determining the precise location and the amount of powder to be used, underscores 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. Cite error: The named reference "OKFp25-27" was defined multiple times with different content (see the help page).
  6. ^ a b Boston Post, September 21, 1848, crediting an earlier report (unknown date) in the Ludlow Free Soil Union (Ludlow, Vermont). The text given here corrects the misstatement in the published report (see image) of the length and diameter (versus "circumference") of the tamping iron. Also, the words "shattering the upper jaw" have been omitted in quoting this early report here, because that did not in fact happen; see Harlow 1868, p. 342 for a description of the iron's path.
  7. ^ a b Bigelow (1850), pp. 13–14. Harlow (1868, p. 344) listed among circumstances favoring Gage's survival "The shape of the missile – being pointed, round and comparatively smooth, not leaving behind it prolonged concussion or compression." Bigelow describes the iron's taper as seven inches long, but the correct dimension is twelve (corrected in the quotation); see Harlow (1848), p. 331 and Macmillan (2000), p. 26.
  8. ^ a b Harlow wrote that Gage had been "a perfectly healthy, strong and active young man...nervo-bilious temperament, five feet six inches in height, average weight one hundred and fifty pounds, 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 this injury." (Nervo-bilious describes 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.")[citation needed] He also emphasized the importance of the opening, created by the tamping iron, connecting Gage's cranium to his mouth, as "without this opening in the base of the skull, for drainage, recovery would have been impossible." As to his own role in Gage's survival, he merely averred, "I can only say, along with good old Ambro[i]se Paré, I dressed him, God healed him" (Harlow 1868, pp. 330, 344, 346) – an assessment Macmillan calls far too modest (Macmillan 2000, pp. 12, 59–62, 346–7; and see Macmillan 2008, p. 828–9; Macmillan (2001); and Barker 1995, pp. 679–80 for further discussion of Harlow's management of the case).
  9. ^ 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" (Harlow 1868, p. 335). Here fungus does not mean a biological mycosis but rather (Oxford English Dictionary) a "spongy morbid growth or excrescence, such as exuberant granulation in a wound" i.e. part of the body's own reaction to the injury (Macmillan 2000, pp. 54, 61–2).
  10. ^ Contrary to common reports,[citation needed] Barnum's American Museum was a stationary installation in New York City and not a travelling show. There is no evidence Gage exhibited with a troupe or circus, or on a fairground (Macmillan & Lena 2010, pp. 3–4).
  11. ^ a b Macmillan (2000), p. 108. Harlow is exactly one year off in the date of Gage's death. As discussed by Macmillan, this means that certain other dates given by Harlow for events late in Gage's life – his move from Chile to San Francisco, and the onset of his convulsions – must also be mistaken, probably by the same amount; this article follows Macmillan in correcting those dates.
  12. ^ Text of inscription from Macmillan, M. "Corrections to An Odd Kind of Fame". Retrieved Oct 2, 2009. The date given for the accident is of course a day off, and Phinehas seems not to be how Gage spelled his name (figure, Macmillan 2008, p. 839); but the standardization of spelling may not have been well enough established at the time for this to be considered an error strictly speaking. See also earlier note re Gage's middle initial. The inscription was commissioned by Harvard's Dr. Bigelow[citation needed] in preparation for the iron's becoming part of Warren Anatomical Museum's collection; the date following Gage's "signature" corresponds to the latter part of the period during which Gage was in Boston under Bigelow's medical observation.
  13. ^ a b Ratiu et. al (2004) is the only study addressing the hairline fracture running from behind the exit region down the front of the skull, as well as fact that the hole in the base of the cranium (made as the iron passed through) seems to have a smaller diameter than does the iron itself – hypothesizing (as seen in their video reconstruction) that the skull "hinged" open as the iron entered the base of the cranium, then was pulled closed by the resilience of soft tissues once the iron had exited at the top. See Macmillan (2008), p. 830.
  14. ^ a b c According to Macmillan& Lena 2010, (and see also Macmillan 2000, pp. 11, 89, 116) available sources which offer detailed information on Gage, and for which there is evidence (if even just the source's own claim) of direct contact with Gage or his family were limited, until 2008, to Harlow (1848, 1849 and 1868), Bigelow (1850) and
    • Jackson, J.B.S. (1849) Medical Cases (Vol 4, Case 1777) Countway Library (Harvard University) Mss., H MS b 72.4 (quoted at Macmillan 2000, p. 93)
    • Jackson, J.B.S. (1870) A Descriptive Catalog of the Warren Anatomical Museum Nos. 949–51, 3106 (Republished in Macmillan 2000, in which see also p. 107).
    Macmillan & Lena 2010 passim presents previously unknown sources discovered post 2008.
  15. ^ A further consideration is potential reluctance of Gage's friends, family, and physician to describe him negatively, especially while he was still alive (Macmillan 2000, pp. 106–8, 375–6). At Macmillan (2000) pp. 350–1 it is argued that an 1850 communication calling Gage "gross, profane, coarse, and vulgar" was anonymously supplied by Harlow.
  16. ^ For example, the "fitful, irreverent...capricious and vacillating" Gage described in Harlow (1868) is somewhat at variance with Gage's stagecoach work in Chile, which required drivers "to 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, p. 106, citing Austin K.A. (1977). A Pictorial History of Cobb and Co.: The Coaching Age in Australia, 1854–1924. Sydney, Australia: Rigby. ISBN 072700316X.); see also Macmillan (2000), pp. 376–7 and Macmillan (2008), p. 839.
  17. ^ Macmillan 2000, p. 327 refers to the complete lack of information on Gage's sexual life, and Macmillan & Lena (2010) discusses the continued absence of such data.
  18. ^ "Only Harlow 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" (Macmillan & Lena 2010, p. 7, referring Harlow 1868, p. 342).
  19. ^ Barker (1995); Macmillan (2000), Ch. 9, esp. p. 188. For example, Dupuy (1877) cited Gage as proof the brain is not localized, while Ferrier (1878) cited Gage as evidence for the opposite view.
  20. ^ "[No one involved in the early development of psychosurgery] argued that psychiatric patients would benefit from having disinhibited behaviors like [Gage's] deliberately induced in them" (Macmillan 2000, p. 250).
  21. ^ Photograph of daguerreotype portrait 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; however, there is no question that 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.

References

  1. ^ Campbell, H.F. (1851) "Injuries of the Cranium–Trepanning". Ohio Med. & Surg. J. 4(1):31–5, crediting the Southern Med. & Surg. J. (unknown date)
  2. ^ Barker (1995); Macmillan (2000) chs. 7–9.
  3. ^ Harlow (1848), p. 331
  4. ^ Harlow 1848, p. 331
  5. ^ Excerpted from Williams' statement in Bigelow (1850), pp. 15–16.
  6. ^ Excerpted from Harlow (1848), p. 390.
  7. ^ Excerpted from Harlow 1848 and Harlow 1868.
  8. ^ Harlow (1848), pp. 391–3; Bigelow (1850), pp. 17–19; Harlow (1868), pp. 334–8.
  9. ^ Harlow (1849); Harlow (1868), p. 338–9.
  10. ^ Harlow (1868), p. 340.
  11. ^ a b c d Harlow (1868), pp. 339–342.
  12. ^ Harlow (1868), Fig. 2, p. 347
  13. ^ a b Macmillan, M. "Phineas Gage: Unanswered questions". Retrieved Oct 2, 2009.
  14. ^ Macmillan (2000), pp. 119–120
  15. ^ Harlow (1848) p. 389; Bigelow (1850) pp. 21–2; Harlow (1868) pp. 343, 345; Dupuy (1877); Ferrier (1878). See also:
    • Bramwell, B. (1888) The Process of Compensation and some of its Bearings on Prognosis and Treatment Br. Med. J. 1(1425):835–840 doi: 10.1136/bmj.1.1425.835
    • Cobb, S. (1940) Review of neuropsychiatry for 1940. Arch. Internal Medicine. 66:1341–54
    • Cobb, S. (1943) Borderlands of psychiatry. Harvard University Press.
    • Tyler, K.L. and Tyler, H.R. (1982) A "Yankee Invention": the celebrated American crowbar case. Neurology 32:A191.
  16. ^ a b Damasio H., Grabowski T., Frank R., Galaburda AM., Damasio AR (1994). "The return of Phineas Gage: clues about the brain from the skull of a famous patient". Science. 264 (5162): 1102–5. doi:10.1126/science.8178168. PMID 8178168.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  17. ^ See Macmillan (2008), pp. 829–30.
  18. ^ Macmillan & Lena 2010, p. 9; Harlow 1868 pp. 332, 345; Bigelow 1850, pp. 16–17; Bigelow 1848, p. 390; Macmillan 2000, p. 86.
  19. ^ Damasio A.R.; Everitt, B. J.; Bishop, D. (1996). "The somatic marker hypothesis and the possible functions of the prefrontal cortex". Phil. Trans. Royal Soc. of London, Series B – Biological Sciences. 351 (1346): 1413–20. doi:10.1098/rstb.1996.0125. PMID 8941953.
  20. ^ Harlow (1848), p. 393.
  21. ^ Macmillan (2001) p. 161 ; Macmillan (2000), p. 94.
  22. ^ Macmillan (2000), pp. 90, 375
  23. ^ Macmillan 2000, pp. 117–8 (Table 6.1); Harlow 1868, pp. 339–41,345
  24. ^ Macmillan (2000) pp. 90–95.
  25. ^ Accounts of Gage are analyzed at Macmillan, M. "Phineas Gage's Story". Retrieved Oct 2, 2009. and in Macmillan (2000) (esp. pp. 116–119 and chs. 13–14).
  26. ^ Nicholl, Jeffrey S., M.D. (2009). "Dementia Cases – Problem #1". Neurology Clerkship. New Orleans: Tulane University School of Medicine. Retrieved November 1, 2009.{{cite web}}: CS1 maint: multiple names: authors list (link)
  27. ^ a b Damasio A.R. (2005). "A Modern Phineas Gage". Descartes' Error: Emotion, Reason, and the Human Brain. ISBN 014303622X. (1st ed.: 1994)
  28. ^ Hockenbury D.H. and S.E. Hockenbury (1997) Psychology
  29. ^ Macmillan (2000), p. 107
  30. ^ Macmillan (2000), p. 290; Macmillan (2008), p. 831.
  31. ^ Ferrier, D. (1877–79) Correspondence with Henry Pickering Bowditch. Countway Library (Harvard University) Mss., H MS c 5.2 (transcribed in Macmillan 2000, pp. 464–5).
  32. ^ Sizer, Nelson (1888). Forty years in phrenology; embracing recollections of history, anecdote, and experience. Fowler & Wells. p. 194.
  33. ^ For example, Carlson, N.R. (1994). Physiology of Behavior. p. 341. ISBN 020507264X. See additional discussion at Macmillan (2000), p. 246.
  34. ^ Macmillan (2000), p. 250, and see chs. 10–11 generally; see also Macmillan, M. "Phineas Gage and Frontal Lobotomies". Retrieved Oct 2, 2009.
  35. ^ Fleischman (2002)
  36. ^ a b c Macmillan (2008), p. 831
  37. ^ a b Macmillan, M. "More About Phineas Gage". Retrieved Oct 2, 2009.
  38. ^ Twomey (2010)
  39. ^ a b Wilgus (2009)
  40. ^ Wilgus, B. & J. "Meet Phineas Gage". Retrieved Oct 2, 2009.
  41. ^ Deakin.edu.au

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