||The examples and perspective in this article may not include all significant viewpoints. (February 2014)|
|Phineas P. Gage|
|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 (1823–1860) was an American railroad construction foreman remembered for his improbable[C] 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 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" 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.:ch7-9
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. 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":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.
- 1 Background
- 2 Gage's injury
- 3 Subsequent life and travels
- 4 Death and subsequent travels
- 5 Brain damage and mental changes
- 6 Portraits
- 7 Analysis of sources
- 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, though he was almost certainly literate.:17,41
He may have gained skill with explosives on the family's farms or in nearby mines and quarries,:17-18 and by the time of his accident he was a blasting foreman 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 ¼ inches (3.2 cm) in diameter—for use in setting charges.
On September 13, 1848, Gage (aged 25)[B] 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.[D] 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." Contemporary sources do not state the quantity of blasting powder involved in the accident, nor have an estimate of the speed of the rod as it entered Gage's skull.
19th-century references to Gage as "the American Crowbar Case":54 reflect the contemporary use of the term to refer to straight metal rod. His tamping iron did not have the bend or claw associated with a modern crowbar; rather, it was a cylinder, "round and rendered comparatively smooth by use"::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.[E]
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.: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.
Harlow took charge of the case around 6 p.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.
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, leaving it partially open for drainage; the entrance wound in the cheek was bandaged only loosely, 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.'":390-1:333:31-2,60-1
Gage's subsequent recuperation was long and difficult. Pressure on the brain[F] left him semi-comatose beginning September 23, "seldom speaking unless spoken to, and then answering only in monosyllables." By September 27, "The friends and attendants are in hourly expectancy of his death, and have his coffin and clothes in readiness." Galvanized by this pessimism Harlow "cut off the fungi which were sprouting out from the top of the brain and filling the opening, and made free application of caustic to them. With a scalpel I laid open the integuments, between the [exit wound and the top of the nose] and immediately there were discharged eight ounces of ill-conditioned pus, with blood, and excessively fetid." ("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."):679-80[G]
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." 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 [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.":338-9
Harlow says that Gage, unable to return to his railroad work,: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 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.: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,[H] 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.:103-4:340-1
Death and subsequent travels
In February 1860,[H] Gage had the first in a series of increasingly severe convulsions; he died status epilepticus:E in or near:B San Francisco on May 21, just under twelve years after his injury, and was buried in San Francisco's Lone Mountain Cemetery.[H] (Though some accounts assert that Gage's iron was buried with him, there is no evidence for this.)[I]
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: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:22n:46-7 and made what he called "my iron bar" his "constant companion during the remainder of his life";:339 now it too was delivered to Harlow. After studying them for a triumphal[C] retrospective paper on Gage, Harlow redeposited the iron—this time with Gage's skull—in the Warren Museum, where they remain on display.: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)::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.
Brain damage and mental changes
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.:389[not in citation given] The 1994 conclusion of H.Damasio et al., that both frontal lobes were damaged, was drawn by modeling not Gage's skull but rather a "Gage-like" one.:829-30
In 2004 Ratiu et al. used CT scans of Gage's actual skull to confirm Harlow's conclusion (based on probing Gage's wounds with his finger):9[not in citation given] that the right hemisphere had remained intact. (Ratiu et al. was also 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.):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.[J]
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 are very uncertain: little is reliably known about what Gage was like (either before or after the accident), 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."[K] And after observing Gage for several weeks in late 1849, Harvard Professor of Surgery Henry Jacob Bigelow (in keeping with his anti-localizationist training) said that Gage was "quite recovered in faculties of body and mind," there being only "inconsiderable disturbance of function".: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":
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".:339–40
This oft-quoted:125 description appears to draw on Harlow's own notes set down soon after the accident,:90,375 but other behaviors he describes:117-8:340,345 appear to draw on later communications from Gage's friends or family, and it is difficult to match these various behaviors (which range widely in their implied level of functional impairment)[L] to the particular period of Gage's post-accident life during which each described behavior was present.:90-5 This complicates reconstruction of how Gage's behavior changed over time, a critical task in light of indications that his behavior at the end of his life was very different from his behavior (described by Harlow above) immediately after the accident.:6-9
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,:75 and was in later life far more functional, and socially far better adapted, than previously assumed.: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"—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. 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":831—and asks, if Gage could achieve such improvement without medical supervision, "what are the limits for those in formal rehabilitation programs?"
Distortion of mental changes
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. 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..."
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; as Kotowicz writes, "Harlow does not report a single act that Gage should have been ashamed of.":122–3
Theoretical use, misuse, and nonuse
Though Gage is considered the "index case for personality change due to frontal lobe damage" his scientific value is undermined by the uncertain extent of his brain damage combined with the lack of information about his behavioral changes.: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".: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...
More recently Sacks refers to the "interpretations and misinterpretations, from 1848 to the present," of Gage.
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;: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".:194 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. 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. 
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.
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.: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.: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.:250[not in citation given]
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.:22n:ii It shows "a disfigured yet still-handsome" Gage with one eye closed and scars clearly visible, "well dressed and confident, even proud" and holding his iron, on which portions of the inscription can be made out. 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.
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 2009-identified daguerreotype, according to Gage researchers consulted by the Smithsonian Institution.[A]
Analysis of sources
Macmillan compares differing accounts of Gage's life to draw his conclusions.:C:esp.116-19,ch13-14 For over a century, the available sources on Gage's life are few and only included Harlow (1848, 1849, 1868); Bigelow (1850); Jackson (1870);; Jackson (1849).
Macmillan's work contradicts Harlow's stated date of Gage's death.:108-9 Harlow (1868) gives the date of Gage's death as May 21, 1861, but undertaker's records show that Gage was buried on May 23, 1860. Macmillan alters certain other dates for events late in Gage's life, his move from Chile to San Francisco and the onset of his convulsions, to account for this discrepancy.
- 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. 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 (Lena & Macmillan, 2010) 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.
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—see Macmillan 2000;:319,327 these are descendents of certain of his relatives—see Macmillan& Lena 2010.):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 (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.
- Macmillan (2000):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 comprehensive Gage genealogy via Macmillan (2000),:16 which notes that while that date lacks citation it is consistent with agreement (among contemporary sources addressing the point):389:13:330 that Gage was 25 years old at the time of the accident, as well as with Gage's age—36 years—as shown in undertaker's records after his death on May 21, 1860.:109
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":336 and "his home":338 (probably that of his parents) to which he returned ten weeks after his accident.
There is no doubt Gage's middle initial was P:839fig.:389:13:330:490 but there is nothing to indicate what the P stood for (though his paternal grandfather was also named Phineas and 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
- 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, bridges, exploding firearms, a revolver shot to the nose, and "even falling gum tree branches").:62,63-7 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".: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.:329,344
Indeed 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.":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 (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"), 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 (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.":53-54
The reference to Gage's iron as an "abrupt and intrusive visitor" appears in the Boston Medical& Surgical Journal's review of Harlow (1868).
- See Macmillan (2000):25-7 and Macmillan (PGIP):A for the steps in setting a blast and the location and circumstances of the accident. The blast hole, about 1 ¾ inches (4.5cm) in diameter and up to 12 feet (4m) 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 statement that Gage's employers had considered him "the most efficient and capable foreman in their employ" prior to the accident.
- Bigelow describes the iron's taper as seven inches long, but the correct dimension is twelve (corrected in the quotation).:331:26[not in citation given]
- 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".: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.:54,61-2
- Barker (1995): "[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 (Barker further comments) 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
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" additionally mentions the decision (in diverence from the teachings of one of his medical school instructors) to not make an exhaustive search for bone fragments, thus avoiding risk of hemorrhage and further brain injury; and treatment of the "fungi" with caustic, thereby avoiding the risks of two more usual treatments: excision (which risked hemorrhage) and forcing the fungi into the wound (which risked compressing the brain).:12,60-2
As to his own role in Gage's survival, Harlow merely averred, "I can only say ... with good old Ambro[i]se Paré, I dressed him, God healed him":346—an assessment Macmillan (2000):62 calls far too modest. See Macmillan (2000),:12;ch4 Macmillan (2008),:828-9 and Barker (1995) :675,679-80 for further discussion of Harlow's management of the case.
- Gage's death and (original) burial are discussed at Macmillan (2000); see also Macmillan's "Corrections to An Odd Kind of Fame" regarding Gage's date of death.:108-9:D Harlow (1868) gives the date of Gage's death as May 21, 1861, but undertaker's records 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).
- Macmillan& Lena: "Only Harlow: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.":7
- Specifically, Van Horn etal. 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.)
- Harlow (1848).:393 Macmillan (2000):106-8,375-6 discusses potential reluctance on the part of Harlow, and of Gage's friends and family, to describe Gage negatively while he was still alive, and argues:350-1 that an 1850 communication calling Gage "gross, profane, coarse, and vulgar" was anonymously supplied by Harlow.
- 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 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,:106 citing Austin 1977)—and Macmillan notes Gage was hired by his employer in advance, in New England, to be part of the new coaching enterprise in Chile.:376-7:831
Sources and further reading
Macmillan, Malcolm B. (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)
• See also "Corrections to An Odd Kind of Fame".
- 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).
- 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.
- John Hodges (2001). "Book review: An odd kind of fame. Stories of Phineas Gage". Journal of Neurology, Neurosurgery, and Psychiatry 71 (1). doi:10.1136/jnnp.71.1.136c.
- Mike McRae (2011). Tribal Science: Brains, Beliefs and Bad Ideas. University of Queensland Press. pp. 9–11. ISBN 0702247340.
Harlow, John Martyn (1848). "Passage of an Iron Rod through the Head". Boston Med& Surg J 39 (20): 389–393. (Transcription.)
- "Incredible, but True Every Word". National Eagle (Claremont, New Hampshire). March 29, 1849. p. 2. Transcribed in Macmillan (2000), pp. 40–1
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).
Harlow, John Martyn (1868). "Recovery from the Passage of an Iron Bar through the Head". Publ Massachusetts Med Soc 2: 327–347.
Macmillan, Malcolm B. (2008). "Phineas Gage—Unravelling the myth". The Psychologist (British Psychological Society) 21 (9): 828–831.
Macmillan, Malcolm B. (PGIP). "The Phineas Gage Information Page". The University of Akron. Retrieved July 22, 2013. Includes:
- "Horrible Accident". Boston Post. September 21, 1848.
- Smith, William T (1886). "Lesions of the Cerebral Hemispheres]". TVermont Med Soc for the Year 1885. pp. 46–58.
- Sutton, W.L. (1850). "A Centre Shot". Boston Medical & Surgical Journal 3: 151–2.
- Jackson, J.B.S. "Frontis. and Nos. 949–51,3106". A Descriptive Catalog of the Warren Anatomical Museum. Reproduced in Macmillan (2000), in which see also p.107.
- Jewett, M. (1868). "Extraordinary Recovery after Severe Injury to the Head". Western Journal of Medicine 43: 241.
- Folsom, A.C. (May 1869). "Extraordinary Recovery from Extensive Saw-Wound of the Skull". Pacific Medical and Surgical Journal. pp. 550–555.
- "Medical Intelligence. Extraordinary Recovery". Boston Medical& Surgical Journal. 3n.s. (13): 230–1. April 29, 1869.
- "Bibliographical Notice". Boston Medical& Surgical Journal. 3n.s. (7): 116–7. March 18, 1869.
- Excerpted from Williams' statement in Bigelow (1850), pp. 15–16.
- Excerpted from Harlow (1848), p. 390.
- Harlow, John Martyn (1849). "Medical Miscellany (letter)". Boston Med& Surg J 39: 507. Reproduced in Macmillan (2000).
- 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.
- 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.
- Damasio A.R. (1994). Descartes' Error: Emotion, Reason, and the Human Brain. ISBN 0-14-303622-X. (2nd ed.:2005)
- Hockenbury, Don H.; Hockenbury, Sandra E. (2008). Psychology. p. 74. ISBN 978-1-429-20143-8.
Macmillan, Malcolm B.; Lena, M.L. (2010). "Rehabilitating Phineas Gage". Neuropsychological Rehabilitation 20 (5): 641–658. doi:10.1080/09602011003760527. PMID 20480430.
- "The Phineas Gage Case". Warren Museum. Retrieved 2013-01-10.
- Twomey, S. (January 2010). "Finding Phineas". Smithsonian 40 (10): 8–10.
- Eliot, Samuel Atkins, ed. (1911). "JohnM. Harlow". Biographical History of Massachusetts: Biographies and Autobiographies of the Leading Men in the State 1 (Massachusetts Biographical Society).
- 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.
- Ratiu, P.; 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.
- 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.
- "A most remarkable case". American Phrenological Journal 13: 89. 1851.
- Kotowicz, Z. (2007). "The strange case of Phineas Gage". History of the Human Sciences 20 (1): 115–131. doi:10.1177/0952695106075178.
- 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.
- Fleischman, J. (2002). Phineas Gage: A Gruesome but True Story About Brain Science. ISBN 0-618-05252-6.
Macmillan, Malcolm B.; Aggleton, John (March 6, 2011). Phineas Gage: The man with a hole in his head. Audio interview with Claudia Hammond; Dave Lee. Health Check. BBC World Service. http://www.bbc.co.uk/news/health-12649555.
Macmillan, Malcolm B. (July 2009). "More About Phineas Gage, Especially After the Accident". Retrieved July 27, 2013.
- 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.
- Fuster, Joaquin M. (2008). The prefrontal cortex. Elsevier/Academic Press. p. 172. ISBN 0-12-373644-7.
- Ferrier, David (1877–79). Correspondence with Henry Pickering Bowditch. Countway Library (Harvard Univ.) Mss., HMSc5.2. Transcribed in Macmillan (2000).:464-5
- Sacks, Oliver (1995). An Anthropologist on Mars. pp. 59–61. ISBN 0-679-43785-1. OCLC 30810706.
- 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.
- Ferrier, David (1878). "The Goulstonian lectures of the localisation of cerebral disease. LectureI (concluded)". Br Med J 1 (900): 443–7.
- Sizer, Nelson (1888). Forty years in phrenology; embracing recollections of history, anecdote, and experience. New York: Fowler& Wells.
- 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.
- Grafman, J. (2002). "The Structured Event Complex and the Human Prefrontal Cortex". In Stuss, D.T.; Knight, R.T. Principles of Frontal Lobe Function. pp. 292–310. doi:10.1093/acprof:oso/9780195134971.003.0019. ISBN 978-0-195-13497-1.
- Carlson, N.R. (1994). Physiology of Behavior. p. 341. ISBN 0-205-07264-X.
- Wilgus, B.&J. "Meet Phineas Gage". Retrieved October 2, 2009. [full citation needed]
- 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.
- Lena, M.L.; Macmillan, Malcolm B. (March 2010). "Picturing Phineas Gage (invited comment)". Smithsonian. p. 4.
- Wilgus, B.&J. "A New Image of Phineas Gage". Retrieved March 10, 2010.
- Jackson, J.B.S. (1849). Medical Cases 4 (Case 1777). Countway Library (Harvard Univ.) Mss., HMSb72.4.