Cypress Lawn Cem. Cypress Lawn Memorial Park, established by Hamden Holmes Noble in 1892, is a cemetery located in Colma, California, a place known as the "City of the Silent". It is the final resting site for several members of the celebrated Hearst family plus other prominent citizens from the greater San Francisco area. The cemetery was among those, Calif.

Phineas P. Gage (July 9?, 1823 – May 21, 1860)^{[n 2]} was an American railroad construction foreman now remembered for his incredible 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 The frontal lobe is an area in the brain of mammals. It is located at the front of each cerebral hemisphere and positioned anterior to the parietal lobes and above and anterior to the temporal lobes. It is separated from the parietal lobe by the primary motor cortex, which controls voluntary movements of specific body parts associated with the, 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 Physiology is the science of the functioning of living systems. It is a subcategory of biology. In physiology, the scientific method is applied to determine how organisms, organ systems, organs, cells and biomolecules carry out the chemical or physical function that they have in a living system. The word physiology is from Ancient Greek: φύσις doctrines"^[1]—Phineas Gage influenced 19th-century discussion about the brain, particularly debate on cerebral localization Phineas Gage became one of the first lesion case studies in 1848 when an explosion drove a large iron rod completely through his head, destroying one or both of his frontal lobes. He recovered with no apparent sensory, motor, or gross cognitive deficits, but with behaviour so altered that friends described him as “no longer being Gage,",^[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 Neurology is a medical specialty dealing with disorders of the nervous system. Specifically, it deals with the diagnosis and treatment of all categories of disease involving the central, peripheral, and autonomic nervous systems, including their coverings, blood vessels, and all effector tissue, such as muscle. The corresponding surgical specialty, psychology Psychology is the scientific study of human or other animal mental functions and behaviors. In this field, a professional practitioner or researcher is called a psychologist. Psychologists are classified as social or behavioral scientists. Psychological research can be considered either basic or applied. Psychologists attempt to understand the and related disciplines Furthermore, neuroscience is at the frontier of investigation of the brain and mind. The study of the brain is becoming the cornerstone in understanding how we perceive and interact with the external world and, in particular, how human experience and human biology influence each other. It is likely that the study of the brain will become one of, and is frequently mentioned in books and academic papers; he also has a minor place in popular culture.^{[n 3]} 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 It was developed by Louis Daguerre together with Joseph Nicéphore Niépce. Niepce had produced the first photographic image in the camera obscura using asphaltum on a copper plate sensitised with lavender oil that required very long exposures 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 blasting is the controlled use of explosives to excavate or remove rock. It is a technique used most often in mining and civil engineering such as dam construction rock while preparing the roadbed for the Rutland & Burlington Railroad The Rutland Railway was a small railroad in the northeastern United States, primarily in the state of Vermont but extending into the state of New York. The earliest ancestor of the Rutland, the Rutland & Burlington Railroad, was chartered in 1843 by the state of Vermont to build between Rutland and Burlington. A number of other railroads were outside the town of Cavendish, Vermont Originally inhabited by Native American tribes , much of the territory that is now Vermont was claimed by France but became a British possession after France's defeat in the French and Indian War. For many years, the surrounding colonies disputed control of the area (referred to at the time as the New Hampshire Grants) especially New Hampshire and. 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 4]} 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 5]}

Nineteenth-century references to Gage as "the American Crowbar Case" may mislead some readers. For Americans of the time a crowbar A crowbar, a wrecking bar, pry bar, or prybar, or sometimes a prise bar or prisebar more informally a jimmy, jimmy bar[citation needed], jemmy or gooseneck is a tool consisting of a metal bar with a single curved end and flattened points, often with a small fissure on one or both ends for removing nails. In the United Kingdom, Ireland and 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 6]}

Weighing 13–1/4 lb (6 kg), this "abrupt and intrusive visitor"^{[n 7]} was said to have landed some 80 feet (25 m) away.

Amazingly, Gage spoke within a few minutes, walked with little or no assistance, and sat upright in a cart for the 3/4-mile 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.^[4]

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.^[5]

Despite Harlow's skillful care,^{[n 8]} Gage's recuperation was long and difficult. Pressure on the brain^{[n 9]} left him semi-comatose In medicine, a coma is a profound state of unconsciousness. A person in a coma cannot be awakened, fails to respond normally to pain, light or sound, does not have sleep-wake cycles, and does not take voluntary actions. A person in a state of coma can be described as 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."^[6]

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."^[7]

Subsequent life and travels

By November 25 Gage was strong enough to return to his parents' home in Lebanon, New Hampshire Lebanon is a city in Grafton County, New Hampshire, United States. The population was 12,568 at the 2000 census. Lebanon is located in western New Hampshire, south of Hanover, near the Connecticut River. It is the home to Dartmouth-Hitchcock Medical Center and Dartmouth Medical School, together comprising the largest medical facility between, 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 Ptosis is an abnormally low position of the upper eyelid. The drooping may be worse after being awake longer, when the individual's muscles are tired. This condition is sometimes called "lazy eye", but that term normally refers to amblyopia. If severe enough and left untreated, the drooping eyelid can cause other conditions, like) 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."^[8]

Unable to return to his railroad work, Harlow says, Gage appeared for a time at Barnum's American Museum Barnum's American Museum was located at the corner of Broadway and Ann Street in New York City, USA, from 1841 to 1865. The museum was owned by famous showman P.T. Barnum and his partner and original owner, John Scudder. Prior to their partnership, the museum was known as Scudder's American Museum. The museum offered both strange, and educational^{[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."^[9] (On Gage's job-loss and public appearances, see more below.)

Gage later worked in a livery stable in Hanover, New Hampshire Hanover is a town along the Connecticut River in Grafton County, New Hampshire, United States. The population was 10,850 at the 2000 census. In 2007, CNN and Money magazine rated Hanover the second best place to live in America and then for some years in Chile as a long-distance stagecoach driver on the Valparaiso Valparaíso is a city of Chile, center of its third largest conurbation (Greater Valparaíso) and one of the country's most important seaports and an increasing cultural center in the Southwest Pacific hemisphere. The city is the capital of the Valparaíso Region. Although Santiago is Chile's official capital, the National Congress of Chile was–Santiago Santiago, (Spanish: Santiago de Chile ), is the capital and largest city of Chile, and the center of its largest conurbation (Greater Santiago). It is located in the country's central valley, at an elevation of 520 m (1,706.04 ft) Above mean sea level. Although Santiago is the capital, legislative bodies meet in the coastal town of Valparaíso, a 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 Santa Clara County is a county located at the southern end of the San Francisco Bay Area in the U.S. state of California. As of 2000 it had a population of 1,682,585. The U.S. Census estimate for 2008 was 1,764,499. The county seat is San Jose. The highly urbanized Santa Clara Valley within Santa Clara County, is also known as Silicon Valley. It.^[10]

Death and subsequent travels

In February 1860, Gage had the first in a series of increasingly severe convulsions, and he died in or near^[12] San Francisco on May 21 — just under twelve years after his accident. He was buried in San Francisco's Lone Mountain Cemetery Lone Mountain is a hill in western San Francisco, California and is the site of the University of San Francisco - Lone Mountain Campus, which in turn was previously the San Francisco Lone Mountain College for Women.^{[n 11]} In 1866, Harlow somehow learned where Phineas 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 The Warren Anatomical Museum, located at Harvard Medical School in Boston, Massachusetts, USA, was founded in 1847 by Dr. John Collins Warren, a professor at the university and a collector of unusual anatomical and pathological specimens. Open to the public, it features a rotating exhibit of some 13,000 pieces. These include the sorts of oddities, 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";^[10] 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 M^r Phinehas [sic Sic is a Latin word meaning "thus", "so", "as such", or "in such a manner". It is used when writing quoted material to indicate that an incorrect or unusual spelling, phrase, punctuation or meaning in the quote has been reproduced verbatim from the original and is not a transcription error . It is normally] P. Gage at Cavendish, Vermont, Sept. 14, [sic Sic is a Latin word meaning "thus", "so", "as such", or "in such a manner". It is used when writing quoted material to indicate that an incorrect or unusual spelling, phrase, punctuation or meaning in the quote has been reproduced verbatim from the original and is not a transcription error . It is normally] 1848. He fully recovered from the injury & deposited this bar in the Museum of the Medical College of Harvard University. Phinehas [sic Sic is a Latin word meaning "thus", "so", "as such", or "in such a manner". It is used when writing quoted material to indicate that an incorrect or unusual spelling, phrase, punctuation or meaning in the quote has been reproduced verbatim from the original and is not a transcription error . It is normally] P. Gage Lebanon Grafton Cy N-H Jan 6 1850.

Much later, Gage's headless remains were moved to Cypress Lawn Cemetery Cypress Lawn Memorial Park, established by Hamden Holmes Noble in 1892, is a cemetery located in Colma, California, a place known as the "City of the Silent". It is the final resting site for several members of the celebrated Hearst family plus other prominent citizens from the greater San Francisco area. The cemetery was among those as part of a systematic relocation of San Francisco's dead to new resting places outside city limits.^[13]

Brain damage and mental changes

Significant brain injury Traumatic brain injury occurs when an external force traumatically injures the brain. TBI can be classified based on severity, mechanism (closed or penetrating head injury), or other features (e.g. occurring in a specific location or over a widespread area). Head injury usually refers to TBI, but is a broader category because it can involve damage 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.^[14] A 1994 study by Damasio et. al^[15] (modeling not Gage's skull but a similar one)^[16] concluded there was damage to the frontal lobes on both sides, but a 2004 study by Ratiu et. al.^{[n 13]} (based on CT Computed tomography is a medical imaging method employing tomography created by computer processing. Digital geometry processing is used to generate a three-dimensional image of the inside of an object from a large series of two-dimensional X-ray images taken around a single axis of rotation 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)^[17] that the right hemisphere remained intact.

Neurologist Antonio Damasio António Rosa Damásio, GOSE is a Portuguese behavioral neurologist and neuroscientist living and working in the United States. He is David Dornsife Professor of Neuroscience at the University of Southern California, where he heads USC's Brain and Creativity Institute. Prior to taking up his posts at USC, in 2005, Damásio was M.W. Van Allen uses Gage to illustrate a hypothesized link The somatic-marker hypothesis proposes a mechanism by which emotional processes can guide (or bias) behavior, particularly decision-making. This hypothesis has been formulated by Antonio Damasio between the frontal lobes, emotion and practical decision-making.^[18] 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."^[19] And after observing Gage for several weeks in late 1849, Henry Jacob Bigelow Henry Jacob Bigelow was an American surgeon and Professor of Surgery at Harvard University. He was a vocal opponent of vivisection and was best known for his description of the hip joint and for a technique for treating patients with kidney stones, Professor of Surgery at Harvard Harvard Medical School is one of the graduate schools of Harvard University. It is currently ranked first among American research medical schools by U.S. News and World Report, went so far as to say that Gage was "quite recovered in faculties of body and mind," there being "inconsiderable disturbance of function."^{[n 6]}

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":

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.^[20] 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.^[21] But other behaviors of Gage's which Harlow describes^[22] 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 was present.^[23] 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

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. 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. Accounts^[24] commonly ascribe to Gage drunkenness, braggadocio, "a vainglorious tendency to show off his wound," an "utter lack of foresight," inability or refusal to hold a job —even "sexually molesting small children," according to curricular materials at one medical school—^[25] none of these 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 fact about the case. In another example, several sources^[15][26][27] 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^[28] that in a passage mistakenly interpreted^[26] 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^[10] 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."^[29] A similar concern was expressed as far back as 1877, when British neurologist David Ferrier Sir David Ferrier was a pioneer Scottish neurologist and psychologist, 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...."^[30]

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 Phrenology is a hypothesis stating that the personality traits of a person can be derived from the shape of the skull. It is now considered a pseudoscience. Developed by German physician Franz Joseph Gall in 1796, the discipline was very popular in the 19th century. The principal British centre for phrenology was Edinburgh, where the Edinburgh 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."^[31]

It is often said^[32] that what happened to Gage played a part in the later development of various forms of psychosurgery Psychosurgery is a subset of neurosurgery intended to modulate the performance of the brain, and thus effect changes in cognition, with the intent to treat or alleviate severe mental illness. It was originally thought that by severing the nerves that give power to ideas you would achieve the desirable result of a loss of affect and an emotional, particularly frontal lobotomy Lobotomy (Greek: λοβός – lobos: "lobe "; τομή – tome: "cut/slice") is a neurosurgical procedure, a form of psychosurgery, also known as a leukotomy or leucotomy (from the Greek λευκός – leukos: "clear/white" and tome). It consists of cutting the connections to and from the prefrontal cortex, the. 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.^[33]

Current research

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,^[34] and was in later life far more functional, and socially far better adapted, than has been thought.^[35]

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,^[35] who asks, if Phineas could achieve such improvement without medical supervision, "what are the limits for those in formal rehabilitation programs?"^[36]

In 2009 a daguerreotype It was developed by Louis Daguerre together with Joseph Nicéphore Niépce. Niepce had produced the first photographic image in the camera obscura using asphaltum on a copper plate sensitised with lavender oil that required very long exposures 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^[37] with one eye closed and scars clearly visible, "well dressed and confident, even proud"^[38] 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 A harpoon is a long spear-like instrument used in fishing to catch fish or large marine mammals such as whales. It accomplishes this task by impaling the target animal, allowing the fishermen to use a rope or chain attached to the butt of the projectile to catch the animal. A harpoon can also be used as a weapon.^[39] 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.)^[38]

Macmillan cites the daguerreotype as consistent with the social recovery hypothesis already described.^[36] 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 (listed here) for which they hope readers will remain alert, such as letters or diaries by physicians who their research indicates Gage may have met, or by persons in certain places Gage seems to have been.^{[12] [35]}

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]}

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"". http://www.brightbytes.com/phineasgage/new_image.html. 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 Lebanon is a city in Grafton County, New Hampshire, United States. The population was 12,568 at the 2000 census. Lebanon is located in western New Hampshire, south of Hanover, near the Connecticut River. It is the home to Dartmouth-Hitchcock Medical Center and Dartmouth Medical School, together comprising the largest medical facility between, Enfield Enfield is a town in Grafton County, New Hampshire, United States. The population was 4,618 at the 2000 census. Enfield includes the villages of Enfield, Enfield Center, Upper Shaker Village, Lower Shaker Village and Lockehaven, and Grafton, NH (all of these in Grafton County Grafton County is a county located in the U.S. state of New Hampshire. As of the 2000 census, the population was 81,743. Its county seat is North Haverhill, which is a village within the town of Haverhill. Until 1972, the county courthouse and other offices were located in downtown Woodsville, a larger village within the town of Haverhill. Grafton) 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. ^ 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 A PMID is a unique number assigned to each PubMed citation of life sciences and biomedical scientific journal articles. The related Pubmed Central archive may additionally assign a separate number, a PMCID (PubMed Central Identifier), normally written with a PMC prefix 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).
4. ^ ^{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 1½ inches in diameter and up to six feet 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.
5. ^ ^{a b} Boston Post Throughout the 1940s, facing increasing competition from the Hearst-run papers in Boston and New York and from radio and television news, the paper began an inevitable decline from which it was never to recover, 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.
6. ^ ^{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.
7. ^ 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, p.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."

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 Ambroise Paré was a French surgeon. He was the great official royal surgeon for the kings Henry II, Francis II, Charles IX and Henry III and is considered as one of the fathers of surgery. He was a leader in surgical techniques and battlefield medicine, especially the treatment of wounds. He was also an anatomist and the inventor of several, 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 The globe of the eye, or bulbus oculi, is the eyeball apart from its appendages. A hollow structure, the bulbus oculi is composed of a wall enclosing a cavity filled with fluid with three coat: the Sclera, Choroid, and the Retina. Normally, the bulbus oculi is bulb-like structure. However, the bulbus oculi is not completely Its anterior surface, 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 (O.E.D.) 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". http://www.deakin.edu.au/hmnbs/psychology/gagepage/PgBook.php. 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. ); 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 than. 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. ^ Excerpted from Williams' statement in Bigelow (1850), pp.15–16.
5. ^ Excerpted from Harlow (1848), p.390.
6. ^ Excerpted from Harlow 1848 and Harlow 1868.
7. ^ Harlow (1848), pp. 391–3; Bigelow (1850), pp. 17–19; Harlow (1868), pp. 334–8.
8. ^ Harlow (1849); Harlow (1868), p.338–9.
9. ^ Harlow (1868), p.340.
10. ^ ^{a b c d} Harlow (1868), pp.339–342.
11. ^ Harlow (1868), Fig. 2, p.347
12. ^ ^{a b} Macmillan, M. ""Phineas Gage: Unanswered questions"". http://www.deakin.edu.au/hmnbs/psychology/gagepage/PgQuestn.php. Retrieved Oct 2, 2009.
13. ^ Macmillan (2000), pp. 119–120
14. ^ 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.
15. ^ ^{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.
16. ^ See Macmillan (2008), pp.829–30.
17. ^ Macmillan & Lena 2010, p. 9; Harlow 1868 pp. 332, 345; Bigelow 1850, pp.16–17; Bigelow 1848, p.390; Macmillan 2000, p.86.
18. ^ Damasio A.R. (1996). "The somatic marker hypothesis and the possible functions of the prefrontal cortex". Phil. Trans. Royal Soc. of London, Series B —Biological Sciences 351: 1413–20.
19. ^ Harlow (1848), p. 393.
20. ^ Macmillan (2001) p.161 ; Macmillan (2000), p.94.
21. ^ Macmillan (2000), pp.90, 375
22. ^ Macmillan 2000, pp.117–8 (Table 6.1); Harlow 1868, pp.339–41,345
23. ^ Macmillan (2000) pp. 90–95.
24. ^ Accounts of Gage are analyzed at Macmillan, M. "Phineas Gage's Story". http://www.deakin.edu.au/hmnbs/psychology/gagepage/Pgstory.php. Retrieved Oct 2, 2009. and in Macmillan (2000) (esp. pp.116–119 and chs. 13–14).
25. ^ Nicholl, Jeffrey S., M.D. (2009). "Dementia Cases — Problem #1". Neurology Clerkship.. New Orleans: Tulane University School of Medicine. http://tulane.edu/som/departments/psych_neuro/education/neuro_clerkship/neuroclerk-dementia-cases.cfm. Retrieved November 1, 2009.
26. ^ ^{a b} Damasio A.R. (2005). "A Modern Phineas Gage". Descartes' Error: Emotion, Reason, and the Human Brain. ISBN 014303622X. (1st ed.: 1994)
27. ^ Hockenbury D.H. and S.E. Hockenbury (1997) Psychology
28. ^ Macmillan (2000), p.107
29. ^ Macmillan (2000), p.290; Macmillan (2008), p.831.
30. ^ 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).
31. ^ Sizer, Nelson (1888). Forty years in phrenology; embracing recollections of history, anecdote, and experience. Fowler & Wells. p. 194. http://books.google.com/books?id=xicZAAAAYAAJ&pg=PA313#PPA194.
32. ^ For example, Carlson, N.R. (1994). Physiology of Behavior. p. 341. See additional discussion at Macmillan (2000), p.246.
33. ^ Macmillan (2000), p. 250, and see chs. 10-11 generally; see also Macmillan, M. "Phineas Gage and Frontal Lobotomies". http://www.deakin.edu.au/hbs/GAGEPAGE/PgLobot.htm. Retrieved Oct 2, 2009.
34. ^ Fleischman (2002)
35. ^ ^{a b c} Macmillan (2008), p.831
36. ^ ^{a b} Macmillan, M. ""More About Phineas Gage"". http://brightbytes.com/phineasgage/more.html. Retrieved Oct 2, 2009.
37. ^ Twomey (2010)
38. ^ ^{a b} Wilgus (2009)
39. ^ Wilgus, B. & J. "Meet Phineas Gage". http://161.58.72.244/phineasgage/index.html. Retrieved Oct 2, 2009.

Further reading

Further reading (and viewing) for general audiences:

• Fleischman, J. (2002). Phineas Gage: A Gruesome but True Story About Brain Science. ISBN 0-618-05252-6. (Aimed at middle-school students)
• Macmillan, M. The Phineas Gage Information page, School of Psychology, Deakin University, Victoria, Australia, including "Phineas Gage: Unanswered questions". http://www.deakin.edu.au/hmnbs/psychology/gagepage/PgQuestn.php. Retrieved 2009-10-02.
• — (2008). "Phineas Gage – Unravelling the myth The Psychologist ( British Psychological Society), 21(9):828–831". http://www.thepsychologist.org.uk/archive/archive_home.cfm/volumeID_21-editionID_164-ArticleID_1399-getfile_getPDF/thepsychologist%5C0908look.pdf.
• — (2000). An Odd Kind of Fame: Stories of Phineas Gage. MIT Press. ISBN 0262133636. (Appendices reproduce Harlow 1848, 1849, and 1868; Bigelow 1850; and other key sources, some unavailable elsewhere.)
  • Paperback edition, 2002. ISBN 0-262-63259-4.
  • See also Macmillan, Corrections to An Odd Kind of Fame.
  • Review: Seamus Sweeney. "An odd kind of fame". nthposition.com. http://www.nthposition.com/anoddkindoffame.php.
• Ratiu et. al., Video reconstruction of tamping iron passing through Gage's skull in P. Ratiu and I.F. Talos (2004). "Images in Clinical Medicine: The Tale of Phineas Gage, Digitally Remastered". New England Journal of Medicine 351 (23): e21 (Web only). doi:10.1056/NEJMicm031024. PMID 15575047. http://content.nejm.org/cgi/content/full/351/23/e21. Technical description at Ratiu P., I.F. Talos, S. Haker, S. Lieberman, P. Everett (2004). "The tale of Phineas Gage, digitally remastered". Journal of Neurotrauma 21 (5): 637–43.
• Twomey, S. (2010). "Finding Phineas". Smithsonian Magazine 40 (10): 8–10 (January 2010). http://www.smithsonianmag.com/history-archaeology/78437017.html.
• Wilgus, B. & J. (2009). "Face to Face with Phineas Gage". J. Hist. Neurosciences 18 (3): 340–345.

For specialists:

• Barker, F.G. II (1995) Phineas among the phrenologists: the American crowbar case and nineteenth-century theories of cerebral localization. J. Neurosurg 82:672–682
• Harlow, John Martyn (1868). "Recovery from the Passage of an Iron Bar through the Head." Publications of the Massachusetts Medical Society 2:327–347 (Republished in Macmillan 2000).
• Macmillan, M. (1986). "A wonderful journey through skull and brains: The travels of Mr. Gage's tamping iron". Brain and Cognition 5 (1): 67–107. doi:10.1016/0278-2626(86)90062-X.
• — (2000). "Restoring Phineas Gage: A 150th retrospective". Journal of the History of the Neurosciences 9 (1): 42–62. doi:10.1076/0964-704X(200004)9:1;1-2;FT046.
• — (2001). "John Martyn Harlow: 'Obscure Country Physician'?". Journal of the History of the Neurosciences 10 (2): 149–162 at 161.
• Macmillan, M. and M.L. Lena (May 17, 2010). "Rehabilitating Phineas Gage". Neuropsychological Rehabilitation 20. doi:10.1080/09602011003760527. PMID 20480430. http://www.informaworld.com/smpp/section?content=a922289041&fulltext=713240928.

Other works cited:

• Bigelow, Henry Jacob (1850). Dr. Harlow's case of Recovery from the passage of an Iron Bar through the Head. American Journal of the Medical Sciences 20:13–22 (Republished in Macmillan 2000).
• Dupuy, E. (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. Part II. Medical Times and Gazette v.II pp. 356–8.
• Ferrier, D. (1878) The Goulstonian lectures of the localisation of cerebral disease. Lecture I (concluded). Br. Med. J., 1(900):443–7
• Harlow, John Martyn (1848). "Passage of an iron rod through the head". Boston Medical and Surgical Journal 39:389–393 (Republished in Neylan, T.C. (1999) "Frontal Lobe Function: Mr. Phineas Gage's Famous Injury." Journal of Neuropsychiatry and Clinical Neuroscience. 11, 281–283; and in Macmillan 2000).
• — (1849). Letter in "Medical Miscellany." Boston Medical and Surgical Journal 39:506–7 (Republished in Macmillan 2000).
• Lena, M.L. and M. Macmillan (March 2010). "Picturing Phineas Gage". Invited comment. Smithsonian Magazine: 4. http://www.smithsonianmag.com/arts-culture/Letters-201003.html.

External links

• Macmillan, M.. "Phineas Gage: Unanswered questions". http://www.deakin.edu.au/hmnbs/psychology/gagepage/PgQuestn.php. Retrieved Oct 2, 2009. Lists research questions related to Gage in localities throughout the United States and Chile, for which Gage researchers request assistance from the public.
• Meet Phineas Gage — the story of how the owners of the daguerreotype portrait learned it depicted Gage.
• Phineas Gage roadside memorial, Cavendish, Vermont

Categories: 1823 births | 1860 deaths | History of neuroscience | People with severe brain damage | People from Vermont | Cavendish, Vermont | American people in rail transport | American expatriates in Chile

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