User:ChrisGualtieri/Gage

Phineas P. Gage (1823–1860) was an American railroad construction foreman remembered for his improbable survival of an accident in which a large iron rod was driven completely through his head, destroying much of his brain's left frontal lobe, and for that injury's reported effects on his personality and behavior over the remaining 12 years of his life, effects so profound that (for a time at least) friends saw him as "no longer Gage".

Long known as "the American Crowbar Case", once termed "the case which more than all others is calculated to excite our wonder, impair the value of prognosis, and even to subvert our physiological doctrines" Phineas Gage influenced 19th-century discussion about the mind and brain, particularly debate on cerebral localization, and was perhaps the first case to suggest that damage to specific parts of the brain might affect personality.

Gage is a fixture in the curricula of neurology, psychology and related disciplines, and is frequently mentioned in books and academic papers; he even has a minor place in popular culture. Despite this celebrity the body of established fact about Gage and what he was like (before or after his injury) is small, which has allowed "the fitting of almost any theory [desired] to the small number of facts we have"—Gage having been cited, over the years, in support of various theories of the brain entirely inconsistent with one another. A survey of published accounts, including scientific ones, has found that they almost always severely distort Gage's behavioral changes, exaggerating the known facts when not directly contradicting them.

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

Background


The details and records on Gage's early life are few in number, but Phineas Gage was the first of five children born to Jesse Eaton Gage and Hannah Trussell Swetland Gage. According to C.V. Gage's genealogy, Gage's father, Jesse Gage, was born in Enfield, New Hampshire on April 1, 1798. His mother Hannah Swetland was born on December 27, 1797 in Lebanon, New Hampshire. The two married on April 27, 1823 in Lebanon. No record gives location of Gage's birth or birthdate, but the genealogy states it was July 9, 1823 in Lebanon. Gage's second name is unknown, but it is most commonly listed as P, but has also been written as B. There are no known surviving records for Gage's early life, but Macmillan assumes that Gage may have been raised in Lebanon and that Gage attended school and was literate. The schools in Grafton County at the time were criticized for their inadequacy, Macmillan wrote that if Gage grew up on his grandfather's farm, the nearest school would have been Grafton Pond school. Macmillan writes that Gage may have gained skill with explosives on the farms or from isinglass mines.

By the time of his accident he was a blasting foreman on railway construction projects. He was not employed by Rutland and Burlington Railroad, but instead a construction firm, possibly Decker and Warner. It is unknown if he was a subcontractor or employed directly by his employer, but Macmillan writes that he may have been a subcontractor. His employers considered him as an effi­cient and capable foreman. Gage commissioned a custom-made tamping iron—an iron rod 43 in long, and 1.25 in in diameter—for use in setting charges.

Gage's injury
On September 13, 1848, Gage (aged 25) was directing a work gang blasting rock while preparing the roadbed for the Rutland & Burlington Railroad outside Cavendish, Vermont. Setting a blast involved boring a hole deep into an outcropping of rock; adding blasting powder, a fuse, and sand; then compacting this charge into the hole using the tamping iron. The blast holes, about $1 3⁄4$ inches (4.5 cm) in diameter and up to 12 feet (4 m) deep, might require three men working as much as a day to bore using hand tools. The labor invested in setting each blast, the judgment involved in selecting its location and the quantity of powder to be used, and the nature of employer-employee relations on this type of job, all underscore the significance of Harlow's statement that Gage's employers had considered him "the most efficient and capable foreman in their employ" prior to the accident.

Gage was doing this around 4:30 p.m. when (possibly because the sand was omitted) the tamping iron struck a spark against the rock and the powder exploded.

The tamping iron was fired out of the hole and "entered on the [left] side of his face... passing back of the left eye, and out at the top of the head."

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

Weighing $13 1/4$ pounds (6 kg), this "abrupt and intrusive visitor" was found 80 feet (25 m) away, "smeared with blood and brain."

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 $undefined 3/4$-mile (1.2-km) ride to his lodgings in town. Dr. Edward H. Williams arrived 30 minutes after the accident: "I first noticed the wound upon the head before I alighted from my carriage, the pulsations of the brain being very distinct. The top of the head appeared somewhat like an inverted funnel, as if some wedge-shaped body had passed from below upward. Mr. Gage, during the time I was examining this wound, was relating the manner in which he was injured to the bystanders. I did not believe Mr. Gage's statement at that time, but thought he was deceived. Mr. Gage persisted in saying that the bar went through his head. Mr.G. got up and vomited; the effort of vomiting pressed out about half a teacupful of the brain, which fell upon the floor."

Harlow took charge of the case around 6p.m.: "The patient bore his sufferings with the most heroic firmness. He recognized me at once, and said he hoped he was not much hurt. He seemed to be perfectly conscious, but was getting exhausted from the hemorrhage. His person, and the bed on which he was laid, were literally one gore of blood."

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

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

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."

Injuries
By November 25, Gage was strong enough to return to his parents' home in Lebanon, New Hampshire, where by late December he was "riding out, improving both mentally and physically." In April 1849 he returned to Cavendish and paid a visit to Harlow, who noted at that time loss of vision (and ptosis) of the left eye, a large scar on the forehead, and depression on the top of his head. Harlow reported that Gage was not in pain, "but says he has a queer feeling which he is not able to describe."

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

Chile and California
In August 1852, Gage was invited to Chile to work as a long-distance stagecoach driver there, "caring for horses, and often driving a coach heavily laden and drawn by six horses" on the Valparaiso–Santiago route. After his health began to fail around 1859, 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.

Death and subsequent travels


In February 1860, Gage had the first in a series of increasingly severe convulsions; he died status epilepticus in or near San Francisco on May 21, just under twelve years after his injury, and was buried in San Francisco's Lone Mountain Cemetery. (Some accounts assert that Gage's iron was buried with him, but there appears to be no evidence for this.) Macmillan & Lena: "Only Harlow writes of the exhumation and he does not say the tamping iron was recovered then. Although what he says may be slightly ambiguous, it does not warrant the contrary and undocumented account[s]... that Gage's tamping iron was recovered from the grave."

Skull and iron
In 1866, Harlow (who had "lost all trace of [Gage], and had well nigh abandoned all expectation of ever hearing from him again") somehow learned that Gage had died in California, and wrote to Gage's family there. At Harlow's request they opened Gage's grave long enough to remove his skull, which the family then personally delivered to Harlow in New England.

About a year after the accident, Gage had given his tamping iron to Harvard Medical School's Warren Anatomical Museum, but he later reclaimed it and made what he called "my iron bar" his "constant companion during the remainder of his life"; now it too was delivered to Harlow. After studying them for a triumphal retrospective paper on Gage, Harlow redeposited the iron—this time with Gage's skull—in the Warren Museum, where they remain on display.

The iron bears the following inscription (though the date it gives for the accident is one day off, and Phinehas is not the way Gage spelled his name):: "This is the bar that was shot through the head of Mr Phinehas$[sic]$ P. Gage at Cavendish, Vermont, Sept. 14,$[sic]$ 1848. He fully recovered from the injury & deposited this bar in the Museum of the Medical College of Harvard University. Phinehas P. Gage Lebanon Grafton Cy N–H Jan 6 1850."

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

Brain damage and mental changes






Extent of brain damage
Debate as to whether the trauma and subsequent infection had damaged both of Gage's frontal lobes, or only the left, began almost immediately after his accident. The 1994 conclusion of H.Damasio et al., that both frontal lobes were damaged, was drawn by modeling not Gage's skull but rather a "Gage-like" one. In 2004 Ratiu et al. used CT scans of Gage's actual skull to confirm Harlow's conclusion (based on probing Gage's wounds with his finger) that the right hemisphere had remained intact. Ratiu et al. was the first study to account for the hairline fracture running from behind the exit region down the front of Gage's skull, as well as the fact that the hole between the roof of the mouth and the base of the cranium (created as the iron passed through) has a diameter about half that of the iron itself—hypothesizing that the skull "hinged" open as the iron entered the base of the cranium, and was afterward pulled closed by the resilience of soft tissues once the iron had exited at the top.

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. Specifically, Van Horn et al. 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 ... 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.)

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

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

Harlow's 1868 report
In 1868 Harlow (having obtained Gage's skull, tamping iron, and late-life history) delivered the "future communication" he had promised 20 years earlier, detailing the mental changes found today in most presentations of the case (though usually in exaggerated or distorted form—see Distortion of mental changes, below). He described the pre-accident Gage as hard-working, responsible, and "a great favorite" with the men in his charge, his employers having regarded him as "the most efficient and capable foreman in their employ". But these same employers, after Gage's accident, "considered the change in his mind so marked that they could not give him his place again".

The description that Gage was "no longer Gage" appears to draw on Harlow's own notes set down soon after the accident, but other behaviors he describes appear to draw on later communications from Gage's friends or family, to the particular period of Gage's post-accident life during which each described behavior was present. Macmillan 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 that an 1850 communication calling Gage "gross, profane, coarse, and vulgar" was anonymously supplied by Harlow.

The "fitful, irreverent... capricious and vacillating" Gage described in Harlow (1868) is somewhat at variance with Gage's stagecoach work in Chile, which demanded that drivers "be reliable, resourceful, and possess great endurance. But above all, they had to have the kind of personality that enabled them to get on well with their passengers" (Macmillan 2000, citing Austin 1977)—and note Gage was hired by his employer in advance, in New England, to be part of the new coaching enterprise in Chile. 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 immediately after the accident.

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

Psychologist Malcolm Macmillan hypothesizes that this change represents a social recovery by Gage over time, citing people with similar injuries for whom "someone or something gave enough structure to their lives for them to relearn lost social and personal skills"—in Gage's case, his highly structured employment in Chile. "Phineas' survival and rehabilitation demonstrated a theory of recovery which has influenced the treatment of frontal lobe damage today. In modern treatment, adding structure to tasks by, for example, mentally visualising a written list, is considered a key method in coping with frontal lobe damage. Phineas job as a stage-coach driver provided that external structure to aid in his recovery. If this is so, Macmillan points out, then along with theoretical implications it "would add to current evidence that rehabilitation can be effective even in difficult and long-standing cases"—and asks, if Gage could achieve such improvement without medical supervision, "what are the limits for those in formal rehabilitation programs?"

Distortion of mental changes
Macmillan carries out a comprehensive analysis of accounts of Gage (scientific and popular), finding that they almost always distort and exaggerate his behavioral changes well beyond anything described by anyone who had contact with him. In the words of Barker, "As years passed, the case took on a life of its own, accruing novel additions to Gage's story without any factual basis", and even today (writes historian Zbigniew Kotowicz) "Most commentators still rely on hearsay and accept what others have said about Gage, namely, that after the accident he became a psychopath..."

Attributes typically ascribed to the post-accident Gage which are either unsupported by, or in contradiction to, the known facts include mistreatment of wife and children (of which Gage had neither), inappropriate sexual behavior, an "utter lack of foresight", "a vainglorious tendency to show off his wound", inability or refusal to hold a job, plus drinking, bragging, lying, gambling, brawling, bullying, thievery, and acting "like an idiot". Macmillan shows that none of these behaviors is mentioned by anyone who had met Gage or even his family; as Kotowicz writes, "Harlow does not report a single act that Gage should have been ashamed of."

Theoretical use, misuse, and nonuse




Though Gage is considered the "index case for personality change due to frontal lobe damage" his scientific value is undermined by the uncertain extent of his brain damage combined with the lack of information about his behavioral changes. 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". A similar concern had been expressed as far back as 1877, when British neurologist David Ferrier (writing to Harvard's Henry Pickering Bowditch in an attempt "to have this case definitely settled") complained that "In investigating reports on diseases and injuries of the brain, I am constantly amazed at the inexactitude and distortion to which they are subject by men who have some pet theory to support. The facts suffer so frightfully..."

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

Thus in the 19th century controversy over whether or not the various mental functions are localized in specific regions of the brain, both sides managed to enlist Gage in support of their theories; for example, soon after Dupuy wrote that Gage proved that the brain is not localized, Ferrier cited Gage as proof that it is.

Phrenologists made use of Gage as well, contending that his mental changes resulted from destruction of his "organ of Veneration" and/or the adjacent "organ of Benevolence". Antonio Damasio, in support of his somatic marker hypothesis (relating decision-making to emotions and their biological underpinnings), draws parallels between behaviors he attributes to Gage and those of modern patients with damage to the orbitofrontal cortex and amygdala. Damasio's depiction of Gage has been criticized as changing the narrative and the last months of Gage being labeled a "grotesque fabrication" by Kotowicz.

Or as Kihlstrom put it: "[M]any modern commentators exaggerate the extent of Gage's personality change, perhaps engaging in a kind of retrospective reconstruction based on what we now know, or think we do, about the role of the frontal cortex in self-regulation."

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

Psychosurgery and lobotomy
It is frequently said that what happened to Gage played a part in the later development of various forms of psychosurgery, particularly lobotomy. Aside from the question of why the unpleasant changes usually (if hyperbolically) attributed to Gage would inspire surgical imitation, Macmillan states there is no such link.

Portraits


In 2009, a daguerreotype portrait of Gage was discovered. It was the first likeness of Gage identified since the life mask taken by Bigelow in late 1849. It shows "a disfigured yet still-handsome" Gage with one eye closed and scars clearly visible, "well dressed and confident, even proud" and holding his iron, on which portions of the inscription can be made out. Authenticity was confirmed in several ways, including photo-overlaying the inscription visible in the portraits against that on the tamping iron in Harvard's Warren Anatomical Museum, and matching the injuries seen in the portraits against those preserved in the life mask.

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

Unlike the Wilgus portrait, which is a daguerreotype, the Miller and Hartley images are 19th-century photographic reproductions of a common original which remains undiscovered, itself a daguerreotype or other laterally (left-right) reversing early-process photograph; here again a second, compensating reversal has been applied. The shirt and tie Gage is wearing in the Miller–Hartley image are different from those seen in the Wilgus image, though he is wearing the same waistcoat in both, and possibly the same jacket.

Analysis of sources
Macmillan compares differing accounts of Gage's life to draw his conclusions.$ch13-14$ For over a century, the available sources on Gage's life are few and only included Harlow (1848, 1849, 1868); Bigelow (1850); Jackson (1870);; Jackson (1849).

Macmillan's work contradicts Harlow's stated date of Gage's death. Harlow (1868) gives the date of Gage's death as May 21, 1861, but undertaker's records show that Gage was buried on May 23, 1860. Macmillan alters certain other dates for events late in Gage's life, his move from Chile to San Francisco and the onset of his convulsions, to account for this discrepancy.