Phineas Gage

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Phineas P. Gage
Phineas Gage Cased Daguerreotype WilgusPhoto2008-12-19 Unretouched Color.jpg
[Fig. 2]
The first identified (2009) portrait of Gage, here with his "constant companion for the remainder of his life"—​his inscribed tamping iron.​[C]
BornJuly 9, 1823 (date uncertain)
Grafton Co., New Hampshire[D]
DiedMay 21, 1860(1860-05-21) (aged 36)
In or near San Francisco[A]
Cause of deathStatus epilepticus
Resting place
Residence
Occupation
Known forPersonality change after brain injury
Home townLebanon, New Hampshire[D]
Spouse(s)None
ChildrenNone[3]:319,327
 
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Phineas P. Gage
Phineas Gage Cased Daguerreotype WilgusPhoto2008-12-19 Unretouched Color.jpg
[Fig. 2]
The first identified (2009) portrait of Gage, here with his "constant companion for the remainder of his life"—​his inscribed tamping iron.​[C]
BornJuly 9, 1823 (date uncertain)
Grafton Co., New Hampshire[D]
DiedMay 21, 1860(1860-05-21) (aged 36)
In or near San Francisco[A]
Cause of deathStatus epilepticus
Resting place
Residence
Occupation
Known forPersonality change after brain injury
Home townLebanon, New Hampshire[D]
Spouse(s)None
ChildrenNone[3]:319,327

Phineas P. Gage (1823–1860) was an American railroad construction foreman remembered for his improbable[E] survival of an accident in which a large iron rod was driven completely through his head, destroying much of his brain's left frontal lobe, and for that injury's reported effects on his personality and behavior over the remaining twelve years of his life—​effects so profound that (for a time at least) friends saw him as "no longer Gage."

[Fig. 1]The "abrupt and intru­sive visitor".​[E][F]

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"[34]—​Phineas Gage influenced nineteenth-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.​[3]:ch7-9[13]

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.[G] Despite this celebrity the body of established fact about Gage and what he was like (before or after his injury) is remarkably small,[H] which has allowed "the fitting of almost any theory [desired] to the small number of facts we have"[3]:290[I]—​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.[H]

Two photographic portraits of Gage, and a physician's report of his physical and mental condition late in life, were published in 2009 and 2010. This new evidence indicates that Gage's most serious mental changes may have been temporary, so that in later life he was far more functional, and socially far better adjusted, than was previously assumed. A social recovery hypothesis suggests that Gage's employment as a stagecoach driver in Chile provided daily structure allowing him to relearn lost social and personal skills.

Background[edit]

[Fig. 3]Caven­dish, Vermont about twenty years after Gage's accident. (A)The two possible accident sites; (T)Gage's lodgings; (H)Harlow's home and surgery.[J]
[Fig. 4]Line of the Rutland & Burling­ton Railroad passing through cut in rock south of Caven­dish. Gage met with his acci­dent while setting explo­sives to create either this cut or a similar one nearby.​[J]

Gage was the first of five children born to Jesse Eaton Gage and Hannah Trussell (Swetland) Gage, of Grafton County, New Hampshire.[D] Little is known about his upbringing and educa­tion, but he was almost certainly literate.​[3]:17,41

He may have gained skill with explosives on the family's farms or in nearby mines and quarries,​[3]:17-18 and by the time of his accident he was a blasting foreman (possibly an independ­ent contract­or) on railway construc­tion projects. His employers consid­ered him (as town doctor John Martyn Harlow later put it) "the most effi­­cient and capable foreman in their employ ... a shrewd, smart business­man, very energetic and persist­ent in executing all his plans of opera­tion", and he had even commis­sioned a custom-made tamping iron—​an iron rod three feet seven inches (1.1 m) long, and 1 ¼ inches (3.2 cm) in diameter—​for use in setting charges.

Gage's injury[edit]

External video
Video recon­struc­tion of tamping iron passing through Gage's skull (Ratiu et al. 2004).​[K]
[Fig. 5]The Boston Post for Sept. 21, 1848 (under­stat­ing the dimen­sions of Gage's tamp­ing iron and overstat­ing damage to the jaw).​[L]
[Fig. 6]Gage's skull "hinged" open as the iron passed through.[K]

On September 13, 1848 Gage (aged 25)[D] was directing a work gang blasting rock while preparing the roadbed for the Rutland & Burlington Railroad outside the town of Caven­dish, Vermont.(See[Fig. 3],[Fig. 4]) 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.[J]

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 rocketed 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."[L](See[Fig. 5],[Fig. 6])

Despite nineteenth-century refer­ences to Gage as "the American Crowbar Case"[54]:54[13] his tamping iron did not have the bend or claw sometimes associ­ated with the term crowbar; rather, it was simply a cylinder, "round and rendered compara­tively smooth by use":​[46]: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.[M](See[Fig. 2])

Weighing 13 14 pounds (6 kg) this "abrupt and intrusive visitor"[E] was found some 80 feet (25 m) away, "smeared with blood and brain."[1]:331

Gage "was thrown upon his back by the explosion, and gave a few convulsive motions of the extremities, but spoke in a few minutes," walked with little assis­tance, and sat upright in an oxcart for the 34-mile (1.2-km) ride to his lodgings in town.[1]:331 Dr. Edward H. Williams arrived some thirty 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.[N]

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.[N]

Convalescence[edit]

Despite Harlow's skillful care,[O] Gage's recupera­tion was long and difficult. Pressure on the brain[P] left him semi-comatose from September 23 to October 3, "seldom speaking unless spoken to, and then answering only in monosyllables. The friends and attendants are in hourly expectan­cy of his death, and have his coffin and clothes in readi­ness."[N]

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."[46]:392-3

Subsequent life and travels[edit]

[Fig. 7]"Disfig­ured yet still handsome".[8] Note ptosis of the left eye.

Injuries[edit]

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,(See[Fig. 7]) 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."[1]:338-9[47]

New England[edit]

Harlow says that Gage, unable to return to his railroad work,[1]:339 appeared for a time at Barnum's American Museum[Q] in New York City (the curious paying to see, presum­a­bly, both Gage and the instrument which had injured him) although there is no independ­ent confirma­tion of this.[citation needed] Recently, however, evidence has surfaced[citation needed] support­ing Harlow's statement that Gage made public appearances in "the larger New England towns". He subsequently worked in a livery stable in Hanover, New Hampshire.​[1]:340

Chile and California[edit]

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,[A] 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.​[3]:103-4[1]:340-1

Death and subsequent travels[edit]

[Fig. 8]Gage's skull (sawed to show inte­ri­or) and iron, photo­graphed for Harlow in 1868.​[R]

In February 1860[A] Gage had the first in a series of increasingly severe convulsions;[S] he died status epilepticus[2]:E in or near[2]:B San Francisco on May 21, just under twelve years after his injury, and was buried in San Francisco's Lone Mountain Cemetery.[A](See[Fig. 16]) (Some accounts[39][38][48] assert that Gage's iron was buried with him, but there appears to be no evidence for this.)[T]

Skull and iron[edit]

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 initiated a correspondence with Gage's family there. At Harlow's request they opened Gage's grave long enough to remove his skull, which the family then personally[21]:6 delivered to Harlow back 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[32]:22n[29][3]:46-7 and made what he called "my iron bar" his "constant companion during the remainder of his life";[1]:339 now it too was delivered to Harlow.(See[Fig. 8]) After studying them for a triumphal[E] retrospective paper on Gage,[1] Harlow redepos­ited the iron—​this time with Gage's skull—​in the Warren Museum, where they remain on display today.[U] The iron bears this inscrip­tion (though the date it gives for the accident is one day off, and Phinehas is not the way Gage spelled his name):[4]: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.[B](See[Fig. 17])

Much later Gage's headless remains were moved to Cypress Lawn Cemetery as part of a systematic reloca­tion of San Francisco's dead to new burial places outside city limits.[3]:119-20

Brain damage and mental changes[edit]

[Fig. 9]The left frontal lobe (red), the forward portion of which was dam­aged by Gage's injury, per Harlow's dig­ital exam­i­na­tion and the dig­ital analy­ses of Ratiu et al. and Van Horn et al.​[K]

Extent of brain damage[edit]

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.[V] The 1994 conclu­sion of H. Damasio et al.,[39] that both frontal lobes were damaged, was drawn by modeling not Gage's skull but rather a "Gage-like" one.[4]:829-30 In 2004 Ratiu et al. used CT scans of Gage's actual skull[22][23] to confirm Harlow's conclu­sion (based on probing Gage's wounds with his finger)[W] that the right hemisphere had remained intact.[K](See[Fig. 9]) 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.[X](See[Fig. 14])

[Fig. 10]"The leading feature of this case is its improba­bil­ity." Harvard's Henry J. Bigelow in 1854. His train­ing predis­posed him to minim­ize Gage's behav­ioral changes.[I]
[Fig. 11]"I dressed him, God healed him."[O] Dr. John M. Harlow, who attended Gage after the "rude missle had been shot through his brain",[41] and obtained his skull for study after his death, in later life. Harlow's interest in phrenol­ogy prepared him to accept that Gage's injury might change his behavior.[I]
[Fig. 12]"I have the pleasure of being able to present to you [a case] without parallel in the annals of surgery." Harlow's 1868 pre­sent­a­tion, to the Mass­a­chu­setts Medical Society, of Gage's skull, iron, and late-life history.[1]

First-hand reports of mental changes[edit]

Gage certainly displayed some kind of change in behavior after his injury,[21]: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),[H] 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[edit]

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."[46]:393 And after observing Gage for several weeks in late 1849, Harvard Professor of Surgery Henry Jacob Bigelow (in keeping with his anti-localiza­tion­ist training)[I] went so far as to say that Gage was "quite recovered in faculties of body and mind," there being only "inconsid­er­a­ble distur­bance of function".[32]:13-14

Harlow's 1868 report[edit]

Not until 1868 did Harlow (having obtained Gage's skull, tamping iron, and late-life history) deliver the "future communica­tion" he had promised twenty years earlier,(See[Fig. 12]) 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). In memorable language, 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".[1]

This oft-quoted descrip­tion appears to draw on Harlow's own notes set down soon after the accident,​[3]:90,375 but other behaviors he describes​[3]:117-8[1]:340,345 appear to draw on later communica­tions from Gage's friends or family,[Y] and it is difficult to match these various behaviors (which range widely in their implied level of func­tional impairment)[Z] to the particu­lar period of Gage's post-accident life during which each described behavior was present.[3]:90-5 This complicates recon­struc­tion of how Gage's behavior changed over time, a critical task in light of evidence that his behavior at the end of his life was very different from his behavior (described by Harlow above) immedi­ately post accident.[21]:6-9

Social recovery[edit]

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,[AA] and was in later life far more func­tional, and socially far better adapted, than previously assumed.[4]:831

Psychologist Malcolm 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"[4]—​in Gage's case, his highly structured employ­ment in Chile.[AB] 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"[4]:831—​and asks, if Gage could achieve such improvement without medical supervi­sion, "what are the limits for those in formal rehabili­ta­tion programs?"[5]

Distortion of mental changes[edit]

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

Anonymous[3]:307

In the only book dedicated to the case, An Odd Kind of Fame:Stories of Phineas Gage (2000),[3] 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 actual contact with him.[H] In the words of Barker,[13] "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 ..."[17]

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,[AC] 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's detailed analysis shows that none of these behaviors is mentioned by anyone who had met Gage or even his family;[H] as Kotowicz writes, "Harlow does not report a single act that Gage should have been ashamed of."[17][AD]

For example, Antonio Damasio and Hanna Damasio[39][38] misinter­pret a passage by Harlow—"'... contin­ued to work in various places;' could not do much, changing often, 'and always finding something that did not suit him in every place he tried'"[1]:341—​as implying Gage could not hold a job after his accident and "never returned to a fully independ­ent exist­ence". In fact Harlow's words refer not to Gage's post-accident life in general, but only to the months just before his death, after convul­sions had set in; and until then Gage had supported himself throughout his adult life.[AE]

Theoretical use, misuse, and nonuse[edit]

[Fig. 13]Phrenolo­gists contended that destruc­tion of Gage's mental "organs"​ of Venera­tion and Benevo­lence (upper-right)caused his behav­ioral changes.
[Fig. 14]False-color represen­ta­tion of cerebral fiber pathways affected, per Van Horn et al.​[26]

Though Gage is considered the "index case for personal­ity change due to frontal lobe damage"[13][55][14][48] his scien­tific value is under­mined by the uncertain extent of his brain damage[14] combined with the lack of information about his behav­ioral changes.[3]: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".[3]: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 ...[44][I]

More recently Sacks refers to the "interpreta­tions and misinterpreta­tions, from 1848 to the present," of Gage.[52]

Thus in the nineteenth-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;​[13][3]:ch9 for example, soon after Dupuy[40] wrote that Gage proved that the brain is not localized, Ferrier cited Gage as proof that it is.[45] 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".[53]:194[I](See[Fig. 13])

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.[38] But Damasio's depiction of Gage has been criticized as

grotesque fabrica­tion ... ["perpetrating"] the myth of Gage the psycho­path ... Damasio changes [Harlow's] narrative, omits facts, and adds freely to his story ... It seems that the growing commitment to the frontal lobe doctrine of emotions brought Gage to the limelight and shapes how he is described.[AF]

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.[AG]

Psychosurgery and lobotomy[edit]

It is frequently said that what happened to Gage played a part in the later develop­ment of various forms of psychosur­gery, particu­larly lobotomy.[AH] Aside from the question of why the unpleasant changes usually (if hyperboli­cally) attrib­uted to Gage would inspire surgical imita­tion,[AI] 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.[3]:250;ch10-11[2]:F

Portraits[edit]

[Fig. 15]The second portrait of Gage to be identified (2010).​[AJ]

In 2009 a daguerreotype portrait of Gage was discovered,(See[Fig. 2]) the first likeness of him identified other than a life mask taken by Bigelow in late 1849.​[32]:22n[3]:ii It shows "a disfigured yet still-handsome" Gage[8] with one eye closed and scars clearly visible, "well dressed and confident, even proud"[9][AK] and holding his iron, on which portions of the inscrip­tion (recited above) can be made out. (For decades the daguerre­otype's owners had imagined it showed an injured whaler with his harpoon.)[10] Authenticity was confirmed in several ways, including photo-overlay­ing the inscrip­tion visible in the portraits against that on the actual tamping iron in Harvard's Warren Anatomical Museum, and matching the injuries seen in the portraits against those preserved in the life mask.[9]

Macmillan cites the daguerre­otype as consistent with the social recovery hypothesis already described.[5] 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 (see "Phineas Gage: Unan­swered ques­tions" in External links, below) for which they hope readers will remain alert, such as letters or diaries of physicians whom their research indicates Gage may have met, or by persons in certain places Gage seems to have been.​[2]:B[4]:831

In 2010 a second portrait of Gage was identified.(See[Fig. 15]) This new image, copies of which are in the posses­sion of at least two different branches of the Gage family, depicts the same subject seen in the Wilgus daguerre­otype identi­fied in 2009, according to Gage research­ers consulted by the Smithson­ian Institu­tion.[AJ]

See also[edit]

Notes[edit]

Date of Burial: 1860 May 23Name: Phineas B.(sic) GageAge (yrs mos ds): 36Nativity: New HampshireDisease: EpilepsyPlace of Burial (tier grave plot): VaultUndertaker: GrayPhineasGage BurialRecord GageEntry.jpg

[Fig. 16]Excerpt from record book for Lone Mountain Cemetery, San Fran­cisco, reflect­ing the May 23, 1860 interment of Phineas B.[sic] Gage by under­takers N. Gray & Co.[A] (Mouse­over for transcrip­tion; click here for full page.)

Phineas Gage GageMillerPhoto2010-02-17 TampingIron EnhancedCropped.jpg

[Fig. 17]Detail (enhanced) of inscrip­tion from Miller–​Hartley image:[Fig. 15] [Phine]has P. Gage at Cavendish, Vermont, Sept. 14, 1848. He fully[B]

  1. ^ a b c d e f g (See[Fig. 16])Gage's death and (original) burial are discussed at Macmillan (2000).[3]:108-9 Harlow (1868)[1] gives the date of Gage's death as May 21, 1861, but undertaker's records[28] show conclusively that Gage was buried 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).
  2. ^ a b c (See[Fig. 17])Macmillan (PGIP)[2]:D gives the text of the inscription, which was commis­sioned by Bigelow[citation needed] in prepara­tion for the iron's deposit in the Warren Anatomical Museum. The Jan 6 1850 following Gage's "signa­ture" corresponds to the latter part of the period during which Gage was in Boston under Bigelow's observa­tion.[citation needed]
  3. ^ Daguerreotype 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.[7] Therefore, in presenting the image here a second, compensat­ing reversal has been applied in order to show Gage as he appeared in life. See Harlow (1868)[1]:340 for "constant companion".
  4. ^ a b c d Macmillan (2000)[3]:11,17,490-1 discusses Gage's ancestry and what is and isn't known about his birth and early life. Possible birth­places are Lebanon, Enfield, and Grafton (all in Grafton County, New Hampshire) though Harlow (1868) refers to Lebanon in particu­lar as Gage's "native place" and as "his home"​ (probably that of his parents) to which he returned ten weeks after the accident.

    The vital records of neither Lebanon nor Enfield list Gage's birth. The birthdate July 9, 1823 (the only definite date given in any source) is from a comprehen­sive Gage genealogy, via Macmillan (2000),[3]:16 and is consist­ent with agree­ment, among the numerous contemporary sources addres­sing the point, that Gage was 25 years old at the time of the accident, as well as with Gage's age—​36 years—​as given in undertaker's records after his death on May 21, 1860.

    There is no doubt Gage's middle initial was P[4]:839fig.[46][1][32] but there is nothing to indicate what the P stood for (though his paternal grandfather was also named Phineas).

    Gage's mother's maiden name is variously spelled Swetland, Sweatland, or Sweetland.

  5. ^ a b c d A tone of amused wonderment was common in 19th-century medical writing about Gage (as well as about victims of other unlikely-sounding brain-injury accidents—​see Macmillan 2000).[3]:66-7 Noting dryly that, "The leading feature of this case is its improba­bil­ity ... This is the sort of accident that happens in the pantomime at the theater, not else­where", Bigelow (1850) empha­sized that though "at first wholly skeptical, I have been person­ally convinced", calling the case "unparal­leled in the annals of surgery".[32]: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.[1]: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."[50]:v But after Gage was joined by such later cases as a miner who survived traversal of his head by a gas pipe,[citation needed] and a lumber­mill foreman who returned to work soon after a circular saw cut three inches (8 cm) 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"),[42] 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."[30] 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."[54]:53-54

    The reference to Gage's iron as an "abrupt and intrusive visitor" appears in the Boston Medical & Surgical Jouurnal's review[29] of Harlow (1868).

  6. ^ Harlow (1868): "Front and lateral view of the cranium, represent­ing the direction in which the iron traversed its cavity; the present appearance of the line of fracture, and also the large anterior fragment of the frontal bone, which was wholly detached, replaced and partially re-united."[1]:347,fig.2
  7. ^ For scientific and academic discussions see Macmillan;[3]:ch14 in particular, Macmillan found Gage cited in some 60% of introductory psychology textbooks in three university libraries. A small study found Gage to be easily the topic most frequently mentioned when, at the end of an introductory psychology course, students were asked to list "the first 10 things that come to your mind as you answer the question: What do you remember from this course?"; investigators noted that, "The Phineas Gage video [used in the course] re-creates the famous tamping rod piercing Gage’s skull. Students ... always react emotionally to this video clip."[25]:89

    For popular culture, see Macmillan (2000)[3]:ch13 and Macmillan (2008);[4]:830 for example, several musical groups call themselves Phineas Gage (or some variation).

  8. ^ a b c d e Accounts of Gage are compared to one another, and against the known facts, at Macmillan (PGIP)[2]:C and in Macmillan 2000.[3]:esp.116-19,ch13-14 According to Macmillan & Lena (2010, and see also Macmillan 2000)​[3]:11,89,93,116 available sources which offer detailed informa­tion on Gage, and for which there is evidence (if merely the source's own claim) of contact with him or with his family, were limited (until 2008) to Harlow (1848, 1849, 1868);[46][47][1] Bigelow (1850);[32] Jackson (1870);[50]; Jackson (1849).[49] Macmillan & Lena (2010) present previously unknown sources discovered post 2008.

    Macmillan (2001)[20]:161 and Macmillan (2000)[3]:94 discuss the high general reliability of Harlow (1868), and its primacy as a source.

    The contrast between Gage's celebrity, and the small amount known about him, is discussed in Macmillan (2000):[3]:1-2,11 "From my student days I had some apprecia­tion of the importance ascribed to the case and expected there would be a reasonably extensive litera­ture on it. This turned out not to be true. There were many mentions of him, but few papers solely or mainly about him ... [In my early research I had assumed that] because Phineas Gage was said to be important in psycholo­gy, everyone would have been interested in him; because his survival was so remark­a­ble, someone must have made a major study of him. Neither was the case."

  9. ^ a b c d e f See Macmillan (2000)[3]:pass. and Macmillan (2008)[4]:831 for surveys and discus­sion of theoret­ical misuse of Gage, and Barker (1995) for, specifically, the way in which 19th-century reports of Gage were colored by various writers' doctrinal leanings:
    The educa­tional backgrounds of Harlow and Bigelow [explain] their differing attitudes toward the case. Harlow's interest in phrenol­ogy prepared him to accept the change in character as a signifi­cant clue to cerebral function which merited publica­tion. Bigelow had [been taught] that damage to the cerebral hemispheres had no intellectual effect, and he was unwilling to consider Gage's deficit signifi­cant ... The use of a single case [including Gage's] to prove opposing views on phrenol­ogy was not un­common.[13]:abstr
    Smith (1886) noted "the ingenuity with which the advocates of various theories [of the brain] will explain away the evidence of their opponents."[54]:51
  10. ^ a b c See Macmillan (2000)[3]:25-7 and Macmillan (PGIP)[2]:A for the steps in setting a blast and the location and circum­stan­ces of the accident. The blast hole, about 1 ¾ inches (4.5 cm) in diameter and up to 12 feet (4 m) deep, might require three men working as much as a day to bore using hand tools. The labor invested in setting each blast, the judgment involved in selecting its location and the quantity of powder to be used, and the often explosive nature of employer-employee relations on this type of job, all under­score the signifi­cance of Harlow's statement that Gage's employers had consid­ered him "the most efficient and capable foreman in their employ" prior to the accident.
  11. ^ a b c d Ratiu et al.[23][22] was the first study to account for the hairline fracture running from behind the exit region down the front of Gage's skull, as well as 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.[4]:830
  12. ^ a b (See [Fig. 5])Boston Post, Septem­ber 21, 1848,[27] crediting an earlier report (unknown date) in the Ludlow Free Soil Union (Ludlow, Vermont). This early report misstates the length of the tamping iron, and confuses its circumfer­ence with its diameter. Also, despite its reference to the "shatter­ing [of the] the upper jaw", that did not in fact happen. See Harlow (1868) for a descrip­tion of the iron's path.[46]:342
  13. ^ Bigelow describes the iron's taper as seven inches long, but the correct dimension is twelve (corrected in the quotation).​[46]:331[3]:26
  14. ^ a b c Excerpted from Williams' and Harlow's statements in: Harlow (1848);[46]:390-2 Bigelow (1850);[32]:16 Harlow (1868).[1]:335-6
  15. ^ a b 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"[1]:346—​an assess­ment Macmillan (2000) calls far too modest.[3]:12,59-62,346-7 See Macmillan (2008), Macmillan (2001) and Barker (1995) for further discuss­sion of Harlow's management of the case.[4]:828-9[20][13]:679-80
  16. ^ 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".[1]: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.[3]:54,61-2
  17. ^ Unlike Barnum's later circus, his Barnum's American Museum was not a traveling show but a station­ary installa­tion in New York City. There is no evidence Gage exhib­ited with a troupe or circus, or on a fair­ground (Macmillan & Lena 2010).[21]:3-4
  18. ^ Here reproduced from Jackson (1870),[50] these images were commis­sioned by Harlow from photo­grapher Samuel Webster Wyman and were the basis for the woodcuts seen in Harlow (1868).​[1]:348[3]:26,115,479-80
  19. ^ Apparently[21]:6-7 quoting Gage's mother, Harlow narrates that
    while sitting at dinner, [Gage] fell in a fit, and soon after had two or three fits in succes­sion ... "[Phineas had] been ploughing the day before he had the first attack; got better in a few days, and continued to work in various places;" could not do much, changing often, "and always finding something which did not suit him in every place he tried." On the 18th of May, [1860][A] he left Santa Clara and went home to his mother. At 5 o'clock, A.M., on the 20th, he had a severe convul­sion. The family physician was called in, and bled him. The convul­sions were repeated frequently during the succeed­ing day and night.[1]
  20. ^ Macmillan & Lena: "Only Harlow[1]: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."[21]:7
  21. ^ Jackson (1870): "The most valuable specimen that has ever been added to the Museum, and probably ever will be, was given two years ago by Dr. John M. Harlow ... For the profes­sional zeal and the energy that Dr. H. showed, in getting posses­sion of this remark­a­ble specimen, he deserves the warmest thanks of the profes­sion, and still more, from the College [i.e. the "Medical College of Harvard University"], for his donation."[50]:v
  22. ^ Early authors attempting to estimate the extent of damage include: Harlow (1848);[46]:389 Bigelow (1850);[32]:21-2 Harlow (1868);[1]:343-5 Dupuy (1877);[40] Ferrier (1878).[45] See also Bramwell (1888);[33] Tyler & Tyler (1982);[24] Cobb (1940, 1943).[36][37]
  23. ^ See Macmillan & Lena (2010);[21]:9 Harlow (1868);[1]:332,345 Bigelow (1850);[32]:16-17 Harlow (1848);[46]:390 Macmillan (2000).[3]:86
  24. ^ Specifically, Van Horn et al.[26] 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.)
  25. ^ Macmillan (2000)[3]:106-8,375-6 also discusses potential reluctance on the part of Gage's friends and family (and of Harlow himself) to describe Gage negatively, especially while he was still alive, and argues[3]:350-1 that an 1850 communica­tion calling Gage "gross, profane, coarse, and vulgar" was anony­mously supplied by Harlow.[citation needed]
  26. ^ For example, the "fitful, irreverent ... capri­cious and vacillating" Gage described in Harlow (1868)[1] 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,[3]:106 citing Austin 1977)[31]—​and note Gage was hired by his employer in advance, in New England, to be part of the new coaching enterprise in Chile.[3]:376-7[4]:831
  27. ^ Fleischman (2002).[12]:75 See also Kotowicz (2007): "There is coher­ence and dignity in the way Gage dealt with his predicament. He deserves deep respect."[17]
  28. ^ Macmillan & Aggleton (2011):[6] "Phineas' survival and rehabili­ta­tion demon­strated a theory of recovery which has influenced the treatment of frontal lobe damage today. [Macmillan explains:] 'There are something like 15 or 20 cases of people who've recovered from very serious frontal brain injury, of the kind that Phineas suffered from, without any profes­sional assis­tance. In every case, what's common in the reports is that someone, or something, has taken over the lives of these people and given them structure.' 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 worked as a stage-coach driver,' continues Professor Macmillan. 'The job is one that has got an external structure. You've got to be here for this part, then there's that part, then there's something else. Just as with these cases who have recovered.'"
  29. ^ Though Macmillan (2000)[3]:327 refers to the complete lack of informa­tion on Gage's sexual life, and Macmillan & Lena (2010)[21] discusses the continued absence of such informa­tion, curricu­lar materials at one medical school[51] go so far as to present Gage as having been "accused of sexually molesting young children".
  30. ^ See also Van Horn (2012):[26] "Macmillan has noted that many reports on Gage's behav­ioral changes are anecdotal, largely in error, and that what we formally know of Mr. Gage's post-accident life comes largely from the follow-up report of Harlow according to which Gage, despite the descrip­tion of him having some early difficul­ties, appeared to adjust moder­ately well for someone experienc­ing such a profound injury."
  31. ^ For end-of-life employ­ment difficulties see Macmillan (2000), p. 107; for misinter­pre­ta­tion and self-support, see Macmillan & Lena (2010) passim, as well as Kotowicz (2007): "What Harlow is telling us is clear and unambigu­ous: Gage returns from South America to his mother to recuperate. As soon as he is fit, he goes back to work with horses, which is what he has been doing for years."
  32. ^ Kotowicz (2007),[17] which continues, "[A. Damasio's] account of Gage's last months [is] such a grotesque fabrica­tion that it leaves one baffled," then quotes á passage from A. Damasio (1994):[38]:9
    In my mind is a picture of 1860's San Francisco as a bustling place, full of adventur­ous entrepre­neurs engaged in mining, farming, and shipping. That is where we can find Gage's mother and sister, the latter married to a prosper­ous San Francisco merchant (D.D. Shattuck, Esquire), and that is where the old Phineas Gage might have belonged. But that is not where we would find him if we could travel back in time. We would probably find him drinking and brawling in a question­able district, not convers­ing with the captains of commerce, as astonished as anybody when the fault would slip and the earth would shake threaten­ingly. He had joined the tableau of dispir­ited people who, as Nathanael West would put it decades later, and a few hundred miles to the south, "had come to Califor­nia to die".
    Kotowizc comments: "This little literary flourish is pure inven­tion ... There is something callous in insinuat­ing that Gage was some riff-raff who in his final days headed for Califor­nia to drink and brawl himself to death."

    Macmillan (2000)[3]:116-19,326,331 gives detailed criticism of A. Damasio's various presenta­tions of Gage (some of them in joint work with H. Damasio and others).

  33. ^ Kihlstrom (2010).[16] See also Grafman:[15]:295: "Although [Gage] has been used to exemplify the problems that patients with ventromedial PFC [pre­frontal cor­tex] lesions have in obeying social rules, recogniz­ing social cues, and making appropriate social decisions, the details of this social cognitive impairment have occasion­ally been inferred or even embellished to suit the enthusiasm of the story teller—​at least regarding Gage" (citing Macmillan 2000).[3]
  34. ^ See for example Carlson (1994);[35]:341 addi­tional examples and discus­sion are at Macmillan (2000).[3]:246;252-3n9,10
  35. ^ "[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).[3]:250
  36. ^ a b Lena & Macmillan (2010),[7] citing also B.&J. Wilgus.. The image seen here 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;[3]:319,327 these are descendents of certain of his relatives—​see Macmillan & Lena 2010.)[21]: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; therefore a second, compen­sat­ing reversal has been applied here to show Gage as he appeared in life. 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.[11]
  37. ^ "Indeed, the recent discovery of daguerre­otype portraits of Mr. Gage show a 'hand­some ... well dressed and confident, even proud' man in the context of 19th-century portraiture. That he was any form of vagrant following his injury is belied by these remark­a­ble images."​ (Van Horn 2012,[26] quoting Wilgus 2009)[9]

Sources and further reading[edit]

For general audiences (Gage)
  1. ^ a b c d e f g h i j k l m n o p q r s t u v w x y z aa ab ac
    Harlow, John Martyn (1868). "Recovery from the Passage of an Iron Bar through the Head". Publ Massachusetts Med Soc 2: 327–347.  open access publication - free to read
  2. ^ a b c d e f g h i
    Macmillan, Malcolm B. (PGIP). "The Phineas Gage Informa­tion Page". The University of Akron. Retrieved July 22, 2013.  Includes:
    A. "Phineas Gage Sites in Cavendish".  open access publication - free to read
    B. "Phineas Gage: Unan­swered questions".  open access publication - free to read
    C. "Phineas Gage's Story".  open access publication - free to read
    D. "Correc­tions to An Odd Kind of Fame".  open access publication - free to read
    E. "Phineas Gage: Psychosoc­ial Adapta­tion".  open access publication - free to read
    F. "Phineas Gage and Frontal Loboto­mies".  open access publication - free to read
  3. ^ a b c d e f g h i j k l m n o p q r s t u v w x y z aa ab ac ad ae af ag ah ai aj ak al am an ao ap aq ar as at
    ——— (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), Bigelow (1850) and other key sources, some unavailable elsewhere. open access publication - free to read
     • See also "Correc­tions to An Odd Kind of Fame". open access publication - free to read
  4. ^ a b c d e f g h i j k l m
    ——— (2008). "Phineas Gage—​Unravell­ing the myth"". The Psychologist (British Psychological Society) 21 (9): 828–831.  open access publication - free to read
  5. ^ a b c
    ——— (July 2009). "More About Phineas Gage, Especially After the Accident". Retrieved July 27, 2013.  open access publication - free to read
  6. ^ a 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. open access publication - free to read

     For general audiences (portraits)
  7. ^ a b c d Lena, M.L.; Macmillan, Malcolm B. (March 2010). "Picturing Phineas Gage (invited comment)". Smithsonian. p. 4.  open access publication - free to read
  8. ^ a b c Twomey, S. (January 2010). "Finding Phineas". Smithsonian 40 (10): 8–10.  open access publication - free to read
  9. ^ a b c d Wilgus, B.&J (2009). "Face to Face with Phineas Gage". Journal of the History of the Neurosciences 18 (3): 340–345. doi:10.1080/09647040903018402. PMID 20183215.  Closed access
  10. ^ a b ———. "Meet Phineas Gage". Retrieved October 2, 2009.  open access publication - free to read[full citation needed]
  11. ^ a b ———. "A New Image of Phineas Gage". Retrieved March 10, 2010.  open access publication - free to read

     For middle-school students
  12. ^ a b c Fleischman, J. (2002). Phineas Gage: A Gruesome but True Story About Brain Science. ISBN 0-618-05252-6.  open access publication - free to read

     For researchers and specialists
  13. ^ a b c d e f g h 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.  Closed access
  14. ^ a b c Fuster, Joaquin M. (2008). The prefrontal cortex. Elsevier/Academic Press. p. 172. ISBN 0-12-373644-7.  Closed access
  15. ^ a b 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.  Closed access
  16. ^ a b Kihlstrom, J.F. (2010). "Social neuroscience: The footprints of Phineas Gage". Social Cognition 28 (6): 757–782. doi:10.1521/soco.2010.28.6.757.  open access publication - free to read
  17. ^ a b c d e Kotowicz, Z. (2007). "The strange case of Phineas Gage". History of the Human Sciences 20 (1): 115–131. doi:10.1177/0952695106075178.  Closed access
  18. ^ Macmillan, Malcolm B. (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. PMID 3513803.  Closed access
  19. ^ ——— (2000). "Restoring Phineas Gage: A 150th Retrospective". Journal of the History of the Neurosciences 9 (1): 46–66. doi:10.1076/0964-704X(200004)9:1;1-2;FT046. PMID 11232349.  Closed access
  20. ^ a b c
    ——— (2001). "John Martyn Harlow: Obscure Country Physician?". Journal of the History of the Neurosciences 10 (2): 149–162. doi:10.1076/jhin.10.2.149.7254. PMID 11512426.  Closed access
  21. ^ a b c d e f g h i j
    ———; Lena, M.L. (2010). "Rehabilitating Phineas Gage". Neuropsychological Rehabilitation 20 (5): 641–658. doi:10.1080/09602011003760527. PMID 20480430.  Closed access
  22. ^ a b c Ratiu, P.; Talos, I.F.; Haker, S.; Lieberman, D.; Everett, P. (2004). "The Tale of Phineas Gage, Digitally Remastered". Journal of Neurotrauma 21 (5): 637–643. doi:10.1089/089771504774129964. PMID 15165371.  Closed access
  23. ^ a b c ———; Talos, I.F. (2004). "The Tale of Phineas Gage, Digitally Remastered". New England Journal of Medicine 351 (23): e21. doi:10.1056/NEJMicm031024. PMID 15575047.  open access publication - free to read
  24. ^ a b Tyler, K.L.; Tyler, H.R. (1982). "A 'Yankee Inven­tion': the celebrated American crowbar case". Neurology 32: A191.  Closed access
  25. ^ a b Vanderstoep, S.W.; Fagerlin, A.; Feenstra, J.S. (2000). "What Do Students Remember from Introductory Psychology?". Teaching of Psychology 27 (2): 89. doi:10.1207/S15328023TOP2702_02.  open access publication - free to read
  26. ^ a b c d e 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.  open access publication - free to read

     Of historical interest
  27. ^ a b "Horrible Accident". Boston Post. September 21, 1848. 
  28. ^ a b 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.
  29. ^ a b c "Bibliographical Notice". Boston Medical & Surgical Journal. 3n.s. (7): 116–7. March 18, 1869. 
  30. ^ a b "Medical Intelligence. Extraordinary Recovery". Boston Medical & Surgical Journal. 3n.s. (13): 230–1. April 29, 1869. 
  31. ^ a b 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. 
  32. ^ a b c d e f g h i j
    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).[3]
  33. ^ a b Bramwell, B. (1888). BMJ 1 (1425): 835–840. doi:10.1136/bmj.1.1425.835. PMC 2197878. PMID 20752265.  open access publication - free to read
  34. ^ a b 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).
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External links[edit]

[Fig. 18]Gage's skull, Warren Museum