case study of phineas gage psychology

A physician called Dr Edward H. Williams attended to Gage and reported that he could see ‘the pulsations of the brain being very distinct. The top of the head appeared somewhat like an inverted funnel.

Williams claimed that Gage was recounting his injuries to bystanders and he did not initially believe the story, thinking that Gage was ‘deceived’. Apparently, Gage had greeted Williams by angling his head at him and saying, ‘Here’s business enough for you.’

Williams recalled that Gage vomited which lead to about a teacupful of his brain to fall upon the floor from the hole at the top of his skull.

What happened after the accident?

Dr. John Martyn Harlow took over the case of Gage soon after. Harlow (1848) reported that Gage was fully conscious and recognized Harlow at once but was tired from the bleeding.

In the next couple of days, Harlow observed that Gage spoke with some difficulty but could name his friends and the bleeding ceased. Gage then spent September 23rd to October 3rd in a semi-comatose state but then was able to take steps out of bed by October 7th.

By October 11th, Harlow claimed Gage’s intellectual functioning began to improve, he recognized how much time had passed since the accident and could describe the accident clearly.

Four years after his injury, Gage moved to Chile and worked in taking care of horses and being a stagecoach driver. In 1860, he moved to San Francisco, California, where his mother and sister lived and was suffering from an illness, of which Harlow did not know the nature of.

On May 21st, 1861, twelve years after his accident, Gage died after having a series of repeated epileptic convulsions.

Seven years after Gage’s death, his body was unearthed and his skull and the iron rod were given to Harlow and to this day, both are on display at the Harvard School of Medicine.

How did Phineas Gage’s personality change?

From Harlow’s written account, Gage was considered to be fully recovered and felt fit enough to reapply for his previous role as a foreman.

However, his contractors, who had regarded Gage as ‘efficient and capable’ before the accident, could no longer offer him work due to considerable changes in Gage’s personality. Marlow (1868) described him as follows:

“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, though untrained in the schools, he possessed a well-balanced mind, and was looked upon by those who knew him as a shrewd, smart business man, 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.”

Through Harlow’s reports, it can be suggested that Gage’s personality changed due to the accident he endured.

The accounts imply that the injury led to a loss of social inhibition, meaning that Gage would behave in ways that were considered inappropriate.

Damage to the brain

When Gage died in 1861, no autopsies were performed until his skull was later recovered by Harlow years later. The brain damage which caused the significant personality changes were presumed to have involve the left frontal region of the brain.

It was not until 1994 that complex computer-based methods to examine the brain damage could be used to investigate whether other areas of the brain were affected.

Phineas Gage brain image from Damasio et al. (1994)

Damasio et al., (1994) used measurements from Gage’s skull and neuroimaging techniques to determine the exact placement of the entry and exit point of the iron rod on a replica model (see Fig. 1).

They found that the damage caused by the rod involved both the left and right prefrontal cortices.

The left and right cortices are responsible for emotional processing and rational decision-making; therefore, it can be assumed that Gage had deficits in these areas.

Phineas Gage brain image from Ratiu et al., (2004)

A later study by Ratiu et al., (2004) also investigated Gage’s injury and location of where the iron rod entered and exited the head. They used Gage’s actual skull, rather than a model of it as Damasio et al., (1994) had used.

Ratiu et al., (2004) generated three-dimensional reconstructions of the skull using computed tomography scans (CAT) and found that the extent of the brain injury was limited to the left frontal lobe only and did not extend to the right lobe (see Fig. 2).

Phineas Gage MRI brain image from Van Horn et al., (2012)

More recently, Van Horn et al. (2012) used a CAT scan of Gage’s skull as well as magnetic resonance imaging (MRI) data obtained from male participants of a similar age to Gage at the time (aged 25-36).

Their results supported Ratiu et al. (2004) in that they always concluded that the rod only damaged the left lobe and not the right.

Van Horn, however, went a step further in their research and investigated the potential levels of white and grey matter damaged due to Gage’s injury. White matter is deep in the brain and provides vital connections around the brain, essential to normal motor and sensory function.

Grey matter in the brain is essential to many areas of higher learning, including attention, memory, and thought.

The research by Van Horn proposed that Gage lost about 11% of his white matter and about 4% of his grey matter. White matter has the ability to regenerate so this could explain why Gage recovered as well as he did.

Van Horn et al., (2012) in their study compared Gage’s white matter damage to the damage that is caused by neurogenerative diseases such as Alzheimer’s.

This is supported by other studies that have found that changes in white matter is significantly associated with Alzheimer’s disease (Nasrabady, Rizvi, Goldman & Brickman, 2018; Kao, Chou, Chen & Yang, 2019).

It could be suggested that Gage’s apparent change in personality could have been the result of an early onset of Alzheimer’s.

However, as Dr. Harlow, who examined Gage, only reported on Gage’s behaviors shortly after his accident, rather than months or years later when Alzheimer’s symptoms may have emerged, we cannot be certain whether Gage actually had this condition.

All studies investigating the brain damage suffered by Gage is essentially all speculation as we cannot know for certain the extent of the accident’s effects. We know that some brain tissue got destroyed, but any infections Gage may have suffered after the accident may have further destroyed more brain tissue.

We also cannot determine the exact location that the iron rod entered Gage’s skull to the millimetre. As brain structure varies from person to person, researchers cannot ever know for certain what areas of Gage’s brain were destroyed.

The influence of Phineas Gage

Gage’s case is important in the field of neuroscience . The reported changes in his behavior post-accident is strong evidence for the localisation of brain function, meaning that specific areas of the brain are associated with certain functions.

Neuroscientists have a better understanding today of the function of the frontal cortex. They understand that the frontal cortex is associated with functions of language, decision-making, intelligence, and reasoning. Gage’s case became one of the first pieces of evidence suggesting that the frontal lobe was directly involved in personality.

It was believed that brain lesions caused permanent deficits to a person. However, Gage was proven to have recovered remarkably and live a mostly normal life despite his injury. It was even suggested by a psychologist called Malcolm Macmillan that Gage may have relearnt lost skills.

People with damage to their frontal lobes tend to have trouble completing tasks, get easily distracted and have trouble planning. Despite this damage to his frontal lobe, Gage was reported to have worked as a coach driver which would have involved Gage being focused and having a routine, as well as knowing his routes and multitasking.

Macmillan (2002) therefore suggests that Gage’s damage to the frontal lobe could have somewhat repaired itself and recovered lost functions. The ability for the brain to change in this way is called brain plasticity .

Over time, Gage’s story has been retold and this has sometimes led to a lot of exaggeration as to the personality changes of Gage. Some popular reports described him as a hard-working, kind man prior to the accident and then described him as an aggressive, dishonest, and drunk man who could not hold down a job and died pennilessly.

Gage’s story seemed to take on a life of its own and some even went as far to say that Gage become a psychopath after his accident, without any facts behind this.

From the actual reports from the people in contact with Gage at the time, it appears that his personality change was no where near as extreme, and that Gage was far more functional than some reports would have us believe (Macmillan, 2002).

Damasio, H., Grabowski, T., Frank, R., Galaburda, A. M., & Damasio, A. R. (1994). The return of Phineas Gage: clues about the brain from the skull of a famous patient . Science, 264 (5162), 1102-1105.

Harlow J. M. (1848). Passage of an iron rod through the head. Boston Medical and Surgical Journal, 39 , 389–393.

Harlow, J. M. (1868). Recovery from the Passage of an Iron Bar through the Head . Publications of the Massachusetts Medical Society. 2 (3), 327-347.

Kao, Y. H., Chou, M. C., Chen, C. H., & Yang, Y. H. (2019). White matter changes in patients with Alzheimer’s disease and associated factors . Journal of clinical medicine, 8 (2), 167.

Macmillan, M. (2002). An odd kind of fame: Stories of Phineas Gage. MIT Press.

Nasrabady, S. E., Rizvi, B., Goldman, J. E., & Brickman, A. M. (2018). White matter changes in Alzheimer’s disease: a focus on myelin and oligodendrocytes . Acta neuropathologica communications, 6 (1), 1-10.

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.

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.

Phineas Gage and the effect of an iron bar through the head on personality

The photograph above, which was uncovered earlier this year, is one of only two known images of an otherwise unremarkable man named Phineas Gage who attained near-legendary status in the history of neuroscience and psychology one fateful day in 1848 at the age of 25.

Gage earned his place in the neurological hall of fame in a most unusual – and extremely unfortunate – way. A railroad construction foreman in the US, he was in charge of a crew of men who were working on the construction of the Rutland and Burlington Railroad near Cavendish, Vermont. On 18 September, he and his crew were excavating rocks to make way for the railroad. Gage was preparing for an explosion, using the tamping iron he holds in the photograph to compact explosive charge in a borehole. As he was doing so, the iron produced a spark that ignited the powder, and the resulting blast propelled the tamping iron straight through his head.

John Harlow, the physician who attended to Gage at the scene, noted that the tamping iron was found some 10 metres away, "where it was afterward picked up by his men, smeared with blood and brain". He provides a detailed description of the "hitherto unparalleled case" in a letter to the editor of the Boston Medical and Surgical Journal , entitled "Passage of an Iron Rod Through the Head":

.css-cumn2r{height:1em;width:1.5em;margin-right:3px;vertical-align:baseline;fill:#C70000;} [The tamping iron] entered the cranium, passing through the anterior left lobe of the cerebrum, and made its exit in the medial line, at the junction of the coronal and sagittal sutures, lacerating the longitudinal sinus, fracturing the parietal and frontal bones extensively, breaking up considerable portions of the brain, and protruding the globe of the left eye from its socket, by nearly half its diameter.

Remarkably, Gage survived this horrific ordeal, and by all accounts was conscious and walking within minutes. Back at Gage's nearby lodgings, Harlow removed small bone fragments from the wounds, replaced larger fragments that had been displaced by the passage of the tamping iron, and closed the large wound at the top of Gage's head with adhesive straps.

Several days later, one of the wounds became infected and he fell into a semi-comatose state. Fearing the worst, his family prepared a coffin, but Gage soon recovered and by January 1849 was leading an apparently normal life. But those closest to him began to notice dramatic changes in his behaviour. Twenty years later, Harlow described the "mental manifestations" of Gage's injury in the Bulletin of the Massachusetts Medical Society:

.css-cumn2r{height:1em;width:1.5em;margin-right:3px;vertical-align:baseline;fill:#C70000;} His contractors, who regarded him as the most efficient and capable foreman in their employ previous to his injury, considered the change in his mind so marked that they could not give him his place again. 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 of advice when it conflicts with his desires, at times pertinaciously obstinent, yet capricious and vacillating, devising many plans of future operation, which are no sooner arranged than they are abandoned in turn for others appearing more feasible. In this regard, his mind was radically changed, so decidedly that his friends and acquaintances said he was "no longer Gage".

We actually know next to nothing about Gage's personality before the injury, so it is difficult to understand exactly how it changed afterward, and the story is further complicated by our incomplete knowledge of the extent of his injury. Despite this, the case of Phineas Gage has been used and abused ever since it first appeared. Neurologists have cited it as evidence in support their pet theories, and even creationists have been known to cite it as evidence that personality is not a product of brain function .

According to psychologist Malcolm Macmillan, however, many of the reports are inconsistent and unsubstantiated by the evidence . Macmillan's research suggests that the behavioural changes observed in Gage lasted for only a short time after the injury. "Phineas' story," he writes in his book An Odd Kind of Fame, "is worth remembering because it illustrates how easily a small stock of facts becomes transformed into popular and scientific myth."

Of Gage's subsequent life, we also know very little. He is said to have travelled around the larger towns in New England, making public appearances with his tamping iron, to which he had apparently become curiously attached. Harlow states that he exhibited himself in Barnum's American Museum in New York City, where people would presumably have paid to see him, but this has not been confirmed.

Ultimately, it is impossible to separate the facts of this extraordinary story from the fictions. Regardless, Gage's was the first – and arguably the most important – case to reveal that some faculties can be associated with specific regions of the brain. Despite the exaggerated stories and fabrications, Gage taught us that complex functions such as decision-making and social cognition are largely dependent upon the frontal lobes.

What does seem well established is that he managed to hold down several jobs in the years following his injury. He worked in a livery stable in Hanover, New Hampshire, and later as a long-distance coach driver on the Valparaiso-Santiago route in Chile. He left Chile for California around 1859, where he worked for a short time on a small farm in Santa Clara.

At around this time, Gage apparently started to experience convulsions of increasing severity, and consequently died in 1860, somewhere near San Francisco. His skull is now kept at the Warren Anatomical Museum at Harvard Medical School, alongside the tamping iron that penetrated it, which is inscribed as follows:

.css-cumn2r{height:1em;width:1.5em;margin-right:3px;vertical-align:baseline;fill:#C70000;} 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.

Mo Costandi writes the Neurophilosophy blog

Further reading Macmillan, M. (2008) Phineas Gage – Unravelling the myth. The Psychologist; 21: 828-831.

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What Really Happened to Phineas Gage? — Psychology’s Most Famous Case Study

If you have ever studied psychology, you probably know the name “Phineas Gage.” He was an American railway worker whose life changed dramatically on September 13, 1848. He was removing rocks so a railway to be laid, which sometimes requires drilling holes into the big boulders that can’t be pushed aside, and pushing in gun powder with an iron rod before exploding them from a safe distance. That day, however, he accidentally scraped the boulder which ignited the gun powder, projecting the rod into the air. It went straight through his head… but he lived. His legacy lives on as psychology’s most famous case study; but his legend is usually distorted in myth.

The meter-long (3cm in diameter) rod went straight up into his skull, from under his left eye, and it exited out the top of his head. He regained consciousness a few moments later, 30 meters from where the iron rod landed. There’s no telling how calmly he got up, but with what I am sure is a lot of blood gushing out of him, he began his oxcart ride back into town for some much-needed medical attention.

As the British Psychological Society (BPS) notes, this is where things become confused. Emeritus Professor Richard Griggs from the University of Florida analyzed the accounts of Gage within 23 textbooks used in universities, and he found that most of them are either misleading, inaccurate, or leave out important information.

For example, the general account of Gage is that he never worked again. Some sources claim that he became a vagrant, or a circus freak who grossed people out with the hole in his head. According to Griggs, the worst falsehood that he came across was that Gage survived for 20 years with the iron rod still stuck in his head.

So… what actually happened?

Not what you had imagined, I suspect.

We know the answer because of the extensive historical analysis of primary sources by University of Melbourne Professor Malcolm Macmillan and his colleague Matthew Lena, in Boston. Also, the relatively recent discovery of actual photographic evidence helps paint that picture. The picture, that is, of a major recovery.

For someone who was impaled with a meter-long iron rod, Gage was pretty lucky. It seems that the rod only damaged the left side of his brain, and it created an opening to drain the infection; so he lived on. His was the first recorded case of a personality changing from brain damage, which is why it’s so famous. Gage’s personality went from a charming, pleasant, energetic man to a grossly profane jackass, totally uncharacteristic of his former self.

However, over time it seems that his life became more normalized, and he worked mostly by driving stagecoaches, always with his rod in hand (as it had become his inanimate companion). Sometime in the early 1850s, he decided to leave America with a colleague who set up routes for him to drive stagecoaches in Chile. He did that for several years before returning to his family in 1859, where he died in February the following year from epilepsy. He lived eleven and a half years after his accident.

Working in a foreign environment would have necessitated being polite, probably picking up some foreign words, and otherwise being a good worker for his customers. Neuroscientists have demonstrated that damaged brain areas can be retrained to compensate for deficiencies, this environment may have been very beneficial to him. While such neural healing doesn’t always work out well (e.g., phantom pain ), I suspect that this helped Gage live quite a normal life. However, Griggs found that modern textbooks tend not to mention these facts. As the BPS reports:

[ . . . ] Fourteen of the books tell you about the first research that attempted to identify the extent of his brain injuries, but just four of the books give you the results from the most technically advanced effort, published in 2004 , that first suggested his brain damage was limited to the left frontal lobe ( watch video ).” [ . . . ] Only 9 of the books feature either of the two photos to have emerged of Gage in recent times. [ . . . ] Only three detail his mental recovery. [ . . . Only] 4 mention the years he worked in Chile.

Clearly, contemporary texts sometimes have intellectually lazy accounts of historically significant events and cases. As Griggs says, “It is important to the psychological teaching community to identify inaccuracies in our textbooks so that they can be corrected, and we as textbook authors and teachers do not continue to ‘give away’ false information about our discipline.”

The only way we keep psychology as a scientific study is by keeping it from being shrouded in myth, folklore, urban legend, and nonsense. After the accident, Phineas Gage lived on to lead a life that might not have been as “exciting” as many textbooks claim… but it’s the truth.

I think the fact that someone whose head was impaled with an iron rod lived a pretty normal life afterward is an interesting story all on its own.

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Phineas Gage – Unravelling the myth

Malcolm Macmillan updates a familiar tale, 160 years after its inception.

03 September 2008

Could you survive a small crowbar passing completely through your head? Most psychologists would answer ‘Yes’: almost all of them learned that Phineas Gage did. Although Phineas’ accident occurred 160 years ago this month, its consequences are still discussed in most introductory textbooks of psychology, neuropsychology, and physiology. You might therefore think much has been learned since 1848, when the accident happened, and the publication 20 years later, in 1868, of a significant account of its psychological consequences. But in fact little has been added. Moreover, much of what has been written is completely wrong. So, why should Phineas still be of interest?

Phineas and the accident

At 25 years of age Phineas Gage was the foreman of a railway construction gang building the bed for the Rutland and Burlington Railroad in central Vermont in the USA. He and his gang were blasting a cutting through a large rocky outcrop about three quarters of a mile south of the town of Cavendish. It was Gage who decided where holes would be drilled in the rock, and how much powder with which to charge them. To focus the explosive force, the powder and fuse would be gently ‘tamped’ down before sand was added and a more vigorous tamping applied. Only then would the fuse be lit. For tamping, Phineas used the larger end of a special crowbar-like tool called a tamping-iron. Three feet seven inches long, it weighed thirteen and a half pounds. It was a one-and-a-quarter inch cylinder, tapered to a point of about one quarter of an inch at one end. At 4:30pm on Wednesday 13 September 1848 Phineas, apparently distracted, began tamping before the sand had been poured. The tamping iron struck the rock causing a spark to light the powder. The resultant explosion propelled the tamping iron out of the hole and completely through his head. It entered point first, under the left cheekbone, or zygomatic arch and next penetrated the base of the skull, just behind the bony socket of the left eye. Finally it emerged at the top of the skull, probably slightly in front and to the left of the bregma (the junction of the coronal and sagittal sutures), and landed about 20 to 25 yards behind him. For a short time Phineas may have been unconscious. His gang carried him to a nearby ox-cart where, sitting against its head board, he was driven to the Cavendish inn where he lived. He alighted unaided. Then from a chair on the ‘piazza’ (New England=verandah) he told his story to the bystanders. He greeted Edward Higginson Williams, the first medical practitioner to arrive, with ‘Doctor, here is business enough for you’. Dr John Martyn Harlow arrived about an hour later and he and Williams managed to stem the profuse haemorrhage. That action and Harlow’s subsequent management of a severe infection undoubtedly saved Phineas’ life. Three months later, Phineas was well enough to return to his parents’ farm. After probably spending most of 1849 regaining his strength, he travelled to Boston in the November to be examined by Henry Jacob Bigelow, the Professor of Surgery at Harvard, and was presented to the medical students there (Bigelow, 1850; Boston Society for Medical Improvement, 1849; Harlow, 1848, 1868).

The post–accident history

After the accident Phineas was unable to regain his job as a foreman. Probably some time in 1850 he became an attraction at Barnum’s American Museum in New York, and visited the major cities in New England to lecture and exhibit himself. He worked for some 18 months for Jonathan Currier who ran a livery stable and coach-line service from his Dartmouth Inn, in Hanover, NH. Then Gage went to Chile with a man who planned to set up a stagecoach line in Valparaiso (Harlow, 1868). After many years driving stagecoaches, Phineas decided in June 1859 to return to his family, now living in San Francisco. He had had some kind of illness and arrived in a weakened condition. Several months elapsed before he was strong enough to work on farms south of the city. Not long after, in February 1860, and after ploughing the day before, ‘while sitting at dinner, he fell in a fit’. ‘Unquestionably epileptic’, his seizures gradually increased in severity and on 18 May he returned to his mother’s house where he suffered a successive series of them. By 21 May 1860 the seizures had killed him. He had survived for eleven and a half years (Harlow, 1868; Macmillan, 2000, pp.106–109). How had Phineas survived the injury and lived for so long? Harlow adduced four factors: - His ‘physique, will, and capacity of endurance, could scarcely be excelled’; - The shape of the tamping iron left behind no ‘prolonged concussion or compression’; - The entry of the tamping iron created an opening for draining the infection, without which ‘recovery would have been impossible’; and - The portion of the brain traversed by the iron ‘was, for several reasons, the best fitted…to sustain the injury.’ Here Harlow modestly disguised his own very considerable medical skill by saying only that, in Ambroise Paré’s famous words, ‘I dressed him, God healed him’ (Harlow, 1868).

The psychological aftermath

The damage to Phineas’ brain had profound psychological consequences. In 1868, in fewer than 200 words, Harlow summarised why Phineas’ contractors would not re-employ him. That summary, together with a few words from his 1848 report, tell us practically everything we know about Phineas. Harlow said ‘the balance between his intellectual faculties and animal propensities seems to have been destroyed’. Phineas became: - ‘Fitful’, ‘irreverent’, grossly profane, and showed ‘but little deference for his fellows’; - ‘Impatient of restraint or advice’ that conflicted with his desires; - ‘Pertinaciously obstinate, capricious, and vacillating’ about his plans for the future – ‘no sooner arranged than they are abandoned’; and - ‘A child intellectually’ with ‘the animal passions of a strong man’. Previously he had been: - ‘Strong and active’ with ‘an iron will’ and of ‘nervo-bilious temperament’; - Of ‘temperate habits’ and ‘possessed of considerable energy of character’; - A ‘great favorite’ with his men; - ‘The most efficient and capable foreman’ employed by his contractors; - In possession of ‘a well–balanced mind’; and - Regarded as a ‘shrewd, smart business man, very energetic in executing all his plans’. So ‘radical’ was the change, his friends and acquaintances said he was ‘no longer Gage’ (Harlow, 1848, 1849, 1868). Phineas’ mother told Harlow that Phineas entertained ‘his little nephews and nieces with the most fabulous recitals’ of his adventures that had no ‘foundation except in his fancy’. He ‘conceived a great fondness for pets, and souvenirs, especially for children, horses and dogs – exceeded only by his attachment to his tamping iron, which was his constant companion during the remainder of his life’. After his first seizure she said he often changed his employment, always finding ‘something that did not suit him’.

Which parts of the brain were damaged?

There was no autopsy when Phineas died. His body was exhumed, probably late in 1867, and his skull given to Harlow in early 1868. Nothing was left of his brain. Phineas’ skull is all we have as a guide to the damage. Concussion, pieces of bone, haemorrhage, and infection would have destroyed additional tissue beyond that in the immediate path of the tamping iron, even if we knew exactly what that was. And the precise position of Gage’s brain within his skull cannot be known. For those reasons, and because the areas in which various functions are localised varies somewhat among individuals, there will always be uncertainty about which of them were destroyed (Macmillan, 2000, pp.84–86). Three studies were made on the living Phineas to determine the path of the tamping iron. They disagreed about the exit area in relation to the bregma and whether it was right or left of the midline. Harlow (1868) made the first of the attempts using the skull. The entry from under the left cheekbone to the rear of the eye socket posed little problem. Where the tamping iron had emerged at the top of the skull was less certain. Opting for the exit being ‘near’ the bregma and ‘in’ the median line, Harlow concluded that the left frontal and middle left lobes had been destroyed. His attribution of Gage’s ‘partial’ recovery to their functions having been taken over by the ‘intact’ right hemisphere meant that he did not think the right was significantly damaged. Between 1982 and the present, three CT–based methods have been used to reconstruct the passage of the tamping iron through Phineas’ brain. They produced somewhat varying pictures of its travel (Macmillan, 2000, Chapter 5, especially Tables 5.1 and 5.2; Ratiu et al., 2004). In 1982 Rick and Ken Tyler of Boston used coronal and sagittal CT-scans of Gage’s skull to determine the limits of the bony damage. From those images, which were two-dimensional and static, they concluded the brain damage was mostly to the left hemisphere but that the right must also have suffered (Macmillan, 2000, pp.77–79 and Appendix E). After making X-rays, photographs, and measurements of Gage’s skull, Hanna Damasio and her colleagues linearly deformed a 3-D reconstruction of a human skull from a cadaver until it matched those measurements. From their collection of brains of about the right size they then placed a 3-D reconstruction of the one that best fitted into this Gage–like skull. Damasio et al. then modelled the passage of the tamping iron through this Gage-like brain inside the Gage-like skull. They had the tamping iron emerging from under the semi-detached but otherwise undamaged right flap of frontal bone so that the brain damage was more frontal and right of the midline than had been suggested previously (Damasio et al., 1994). Real light arrived when Ratiu et al. (2004) and Ratiu and Talos (2004) used thin CT-scans to build a three-dimensional representation of Phineas’ skull itself, rather than an image of what it might have been like. How well they succeeded is immediately obvious in an illustration from the second of their papers (shown on this cover of The Psychologist) (Ratiu & Talos, 2004). They were the first to see that the diameter of the entry area being smaller than that of the tamping iron required the skull to have hinged open for the iron to pass through it. They connected that fact with the continuous line of fracture beginning under the cheekbone and running to the left parietal bone well beyond the rear of the hole at the bregma. After the tamping iron passed through, the hinge must have been closed by the action of the soft tissues. From the video clips Ratiu and Talos included in their paper, it can be seen that the line of fracture and the hinging action place the exit left of the median line and slightly in front of the bregma. On their reconstruction, the brain damage was left-frontal – almost exactly as Harlow said.

The implications and the context

It was a long time before Phineas’ psychological changes became known. None were specifically mentioned by Harlow in 1848; nor did Bigelow report any in 1850. Some memory impairment was recorded privately by Jackson (1849), and an anonymous report the same year very briefly noted a great impairment of his mental powers (Standing Committee on Surgery, 1850). Some detail first appeared in an 1851 phrenological journal’s reply to Bigelow (‘A most remarkable case’, 1851). However, not until Harlow’s little-known 1868 report was any real notice taken of the psychological changes, and even in comments on it they were frequently ignored (Macmillan, pp.113–116, 197–199). Some of this neglect is explicable by the lack of knowledge in the early 1800s about the functions of the brain. Apart from Franz Josef Gall’s organology (phrenology), there was no theory before 1848 of what the brain did. That nerves transmitted sensations and controlled movement was known, but it was not even generally accepted that damage to one side of the brain affected movement or sensation on the other. Early descriptions like Bigelow’s of Gage being unimpaired probably meant merely that his muscles and sense organs functioned normally. Johannes Müller and Alexander Bain had argued that willing and moral behaviour depended on an inhibitory function localised vaguely in some ‘higher’ part of the nervous system or even in the brain, but could advance no supporting empirical evidence (Macmillan, 2000, pp.158–170). But functions like language and personality had not been shown to depend on the way the brain worked. The context began to change about the mid-1860s; that is, by the time of Harlow’s 1868 report. Paul Broca’s clinical observations suggested that language functions were localised in the left frontal lobe. A little later, David Ferrier’s monkey experiments demonstrated that prefrontal damage caused profound personality changes (Ferrier, 1873). It was Ferrier who rescued Gage from the obscurity of the journal in which Harlow’s 1868 report was buried (Ferrier, 1876, 1877–1879, 1878), but 10 years elapsed before Harlow’s findings gained acceptance. A theory of frontal functioning was even further away. Gage was literally ahead of his time.

Facts vs. the common picture

There are just four primary sources of information about Gage: Harlow (1848), Bigelow (1850), then Harlow again (1868) – the only physicians to have examined him and published their observations – and finally J.B.S. Jackson (1870), who added a few facts of his own to what Gage’s family and others had told him. Anything not from these sources, or similarly documented, is not a fact about Phineas Gage. This is not to say these primary sources are entirely reliable. Harlow, for example, writing in 1868 while in contact with Phineas’ mother, reported that Phineas died in 1861, whereas funeral parlour records prove conclusively that he died in 1860. (In this article and elsewhere I have silently corrected other dates dependent on this one.) Similarly, a curious relic recently found by Dominic Hall, Curator of Harvard’s Warren Anatomical Museum, suggests that Phineas went to Chile in 1854 and not in 1852 as reported by Harlow. First the facts. Harlow’s picture of Phineas is at total variance with most later portrayals. A fair composite of today’s accounts would have a pre-accident Gage who was reliable, industrious, mild-mannered, temperate, genial, friendly, affable, the favourite of his peers and elders, showing considerable promise – a peaceful, happy and tranquil man. The composite of modern writers has the accident transforming this Phineas into a restless, moody, unpredictable, untrustworthy, depraved, slovenly, violently quarrelsome, aggressive and boastful dissipated drunken bully, displaying fits of temper, and with impaired sexuality. He is a waster: unwilling to work and unable to settle down. He spends most of the rest of his life in travelling circuses or drifting around fairgrounds to exhibit himself as a human freak, and dies penniless. The facts about the real Phineas may have a slight resemblance to the modern pre-accident representation, but he can hardly be recognised in the post–accident picture. Second, interpretations. Many interpretations of Phineas’ behaviour have been made to support particular theories. Thus Vincent and others matched his allegedly changed sexuality – not mentioned in the sources – to that of some post-lobotomy patients; others, like Damasio and colleagues, portrayed Gage’s damage and behaviour such that they matched those of a selection of their own modern patients (Macmillan, 2000, pp.329–330). Distortions like these were great enough to justify devoting some 50 pages of my book to analysing them, and for MIT Press to allow me to include facsimiles of the primary sources (Macmillan, 2000, Figure 15.2 and Appendix A). Third, long-term effects. Every scientific and popular picture of Phineas I know of has him impulsive and unreliable until his death. Yet his year and a half working for Currier, and the demanding motor and cognitive skills required of a stagecoach driver are inconsistent with this long-term outcome (Macmillan, 2000, pp.104–106).

A social recovery?

Could Phineas have made some kind of ‘social recovery’? There are a few reports of people with brain damage similar to his who recovered without formal treatment. In each instance, someone or something gave enough structure to their lives for them to relearn lost social and personal skills. Here we may speculate about Phineas’ daily routine. Some detail may be inferred from a recently discovered contemporary account of stagecoach driving on what seems to be the very route Phineas drove. He would have had to rise early each driving day, prepare himself, feed and groom the horses, harness them to the coach, and be at the departure point by 4am. There he would have had to deal politely with the passengers, load their luggage (up to 50 pounds each), and collect fares, and so on, before beginning a 13-hour journey over 100 miles of poor roads, often in times of political instability or frank revolution. All this – in a land to whose language and customs Phineas arrived an utter stranger – militates as much against permanent disinhibition as do the extremely complex sensory-motor and cognitive skills required of a coach driver (Macmillan, 2000, p.104–106). As I understand it, relearning in a structured environment is the basis of many brain-damage rehabilitation programmes (such as that at the Oliver Zangwill Centre at Ely in Cambridgeshire). If Phineas Gage did recover, could his employment have provided a similar structure? Only by filling out the post-accident record can this be determined. I have found a poster advertising one of Phineas’ lectures. Matthew L. Lena, my Boston colleague, and I hope to find some eyewitness report of it. Matthew has also found a physician who said he saw a quite well Phineas in Chile around 1858. There would be practical and theoretical consequences of a discovery that Gage so recovered. It would add to current evidence that rehabilitation can be effective even in difficult and long-standing cases. But it would also mean that theoreticians of frontal lobe functioning would have to consider whether the lobes themselves and their functions were much more plastic than we now think. Recognition of that kind would, of course, match the now accumulating evidence about the recovery of biological systems in general.

Why bother?

We will never know with certainty what the pre- and post-accident Phineas Gages were really like; nor will we ever know exactly the parts of his brain that were damaged in the flash that transformed the one into the other. So, why bother? First, it is always worthwhile correcting the historical record, though the degree of rigor mortis, especially in textbooks, seems too far advanced for even a Dr Frankenstein to re-enliven poor Phineas. Second, Phineas’ story is worth remembering because it illustrates how easily a small stock of facts can be transformed into popular and scientific myth. I was much struck by David Ferrier’s remark in an 1877 letter about Phineas to Henry Pickering Bowditch in Boston. He asked Bowditch for the facts about Phineas as they were originally reported because he was ‘amazed at the inexactitude and distortion to which they are subject by men who have some pet theory to support’. And as we have seen, scientific myths about Phineas continue to be used to support particular theoretical positions. The factual record is small, and the most important element of it – Harlow’s 1868 report – not readily available, and most who have written about Phineas have been too lazy or slipshod to check it. Paradoxically, the very slightness of reliable fact which allows myths about Phineas to flourish also makes disentangling those myths a conceptually easy, if tedious, task. Phineas’ primary importance is as a historical marker. We can see how his skull was damaged, but we will only ever have estimates of his brain damage. We also know too little about him before and after the accident to draw detailed conclusions about its effects. Phineas has to be remembered for being the first reported case in which brain damage caused alterations to personality. But we may yet learn the extent of his recovery and what brought it about.

Box: Gage outside science

The story of Phineas Gage has entered popular culture, leading to plays, films, TV programmes and YouTube skits, poems and stories, sculptures, bands and songs, and even a team of lawyers who apply behavioural science to legal education. My favourites (partly because I?was consulted on them!)?are the plays ‘That Elusive Spark’ by Janet Munsil (see tinyurl.com/3eua9q ) and ‘The Ballad of Phineas P. Gage’ by Crystal Skillman (see tinyurl.com/4ju2y4 ), and the song ‘Phineas Gage’ by Dan Linder (see tinyurl.com/3hf6jx ).

Box: Questions about Gage

Matthew Lena and I are interested in the following topics and I would be pleased to supply more specific information to readers who may be able to help. - The fate of Dr John Martyn Harlow’s case notes and correspondence about Gage. - Anything at all relating to Phineas in New England (to about 1854), Chile (to about 1859) and San Francisco, Santa Clara, or Alameda Counties, California (died, 1860). - Identity of the ‘distinguished Professor of Surgery in a distant city’ whom Harlow said had termed Gage a ‘Yankee invention’ (some time before 1868). - Harlow and his wife, Frances Kimball Harlow, especially when living in Stillwater, Minnesota (ca. 1857–1860). - Departure/arrival/passenger lists for ships travelling among New York/New England, Panama/Valparaiso, and San Francisco (1850–1868). - In Valparaiso and Santiago, Chile, 1850–1860: Livery or transportation businesses (particularly an ‘American’ or ‘(James) McGill & Co.’ coach line); Dr William Trevitt (American consul) or his nephew Henry; the hospital for American seamen; and activities and publications of physicians or of English-speaking persons. - Dr Henry Trevitt and Dr William Trevitt in Wilton, Connecticut and Franklin Co., Ohio (resp.) approximately 1861 forward. - A Dr William J. Lo– – – – (full surname unknown) residing in Brooklyn Township (now Oakland, Alameda Co.) California in 1860, possibly a teacher of the deaf, or his wife Cordelia (both originally of Maine). - Dr Jacob Davis Babcock Stillman and Dr Henry Perrin Coon of San Francisco (esp. personal papers ca. 1867). - The Starling Medical College in Columbus, Ohio, and faculty member J. W. Hamilton (ca. 1860). - Malcolm Macmillan is Professorial Fellow in the Department of Psychology at the University of Melbourne. He is much indebted to his partner, Edith Bavin, of Latrobe University Melbourne, to Matthew L. Lena of Boston, and to Peter Ratiu of Arad Romania for valuable cooperation, many important findings, and helpful suggestions. [email protected]

- Interested in writing for our 'Looking back' section, on the history of psychology and the psychology of history? E-mail the editor, Dr Jon Sutton, on [email protected]

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COMMENTS

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