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What Is a Case Study?

When you’re performing research as part of your job or for a school assignment, you’ll probably come across case studies that help you to learn more about the topic at hand. But what is a case study and why are they helpful? Read on to learn all about case studies.

Deep Dive into a Topic

At face value, a case study is a deep dive into a topic. Case studies can be found in many fields, particularly across the social sciences and medicine. When you conduct a case study, you create a body of research based on an inquiry and related data from analysis of a group, individual or controlled research environment.

As a researcher, you can benefit from the analysis of case studies similar to inquiries you’re currently studying. Researchers often rely on case studies to answer questions that basic information and standard diagnostics cannot address.

Study a Pattern

One of the main objectives of a case study is to find a pattern that answers whatever the initial inquiry seeks to find. This might be a question about why college students are prone to certain eating habits or what mental health problems afflict house fire survivors. The researcher then collects data, either through observation or data research, and starts connecting the dots to find underlying behaviors or impacts of the sample group’s behavior.

Gather Evidence

During the study period, the researcher gathers evidence to back the observed patterns and future claims that’ll be derived from the data. Since case studies are usually presented in the professional environment, it’s not enough to simply have a theory and observational notes to back up a claim. Instead, the researcher must provide evidence to support the body of study and the resulting conclusions.

Present Findings

As the study progresses, the researcher develops a solid case to present to peers or a governing body. Case study presentation is important because it legitimizes the body of research and opens the findings to a broader analysis that may end up drawing a conclusion that’s more true to the data than what one or two researchers might establish. The presentation might be formal or casual, depending on the case study itself.

Draw Conclusions

Once the body of research is established, it’s time to draw conclusions from the case study. As with all social sciences studies, conclusions from one researcher shouldn’t necessarily be taken as gospel, but they’re helpful for advancing the body of knowledge in a given field. For that purpose, they’re an invaluable way of gathering new material and presenting ideas that others in the field can learn from and expand upon.


case study of phineas gage psychology

Phineas Gage: His Accident and Impact on Psychology

Kendra Cherry, MS, is an author and educational consultant focused on helping students learn about psychology.

case study of phineas gage psychology

Emily is a board-certified science editor who has worked with top digital publishing brands like Voices for Biodiversity,, GoodTherapy, Vox, and Verywell.

case study of phineas gage psychology

Author unknown / Wikimedia Commons

Frequently Asked Questions

Phineas Gage is often referred to as the "man who began neuroscience." He experienced a traumatic brain injury when an iron rod was driven through his skull, destroying much of his frontal lobe .

Gage miraculously survived the accident. However, his personality and behavior were so changed as a result of the frontal lobe damage that many of his friends described him as an almost different person entirely. The impact that the accident had has helped us better understand what the frontal lobe does, especially in relation to personality .

Phineas Gage's Accident

On September 13, 1848, 25-year-old Gage was working as the foreman of a crew preparing a railroad bed near Cavendish, Vermont. He was using an iron tamping rod to pack explosive powder into a hole.

Unfortunately, the powder detonated, sending the 43-inch-long, 1.25-inch-diameter rod hurling upward. The rod penetrated Gage's left cheek, tore through his brain , and exited his skull before landing 80 feet away.

Gage not only survived the initial injury but was able to speak and walk to a nearby cart so he could be taken into town to be seen by a doctor. He was still conscious later that evening and able to recount the names of his co-workers. Gage even suggested that he didn't wish to see his friends since he would be back to work in "a day or two" anyway.

The Recovery Process

After developing an infection, Gage spent September 23 to October 3 in a semi-comatose state. On October 7, he took his first steps out of bed, and, by October 11, his intellectual functioning began to improve.

Descriptions of Gage's injury and mental changes were made by Dr. John Martyn Harlow. Much of what researchers know about the case is based on Harlow's observations.

Harlow noted that Gage knew how much time had passed since the accident and remembered clearly how the accident occurred, but had difficulty estimating the size and amounts of money. Within a month, Gage was well enough to leave the house.

In the months that followed, Gage returned to his parent's home in New Hampshire to recuperate. When Harlow saw Gage again the following year, the doctor noted that while Gage had lost vision in his eye and was left with obvious scars from the accident, he was in good physical health and appeared recovered.

Theories About Gage's Survival and Recovery

The type of injury sustained by Phineas Gage could have easily been fatal. While it cannot be said with certainty why Gage was able to survive the accident, let alone recover from the injury and still function, several theories exist. They include:

The Effects of Gage's Injury

Popular reports of Gage often depict him as a hardworking, pleasant man prior to the accident. Post-accident, these reports describe him as a changed man, suggesting that the injury had transformed him into a surly, aggressive heavy drinker who was unable to hold down a job.

Harlow presented the first account of the changes in Gage's behavior following the accident. Where Gage had been described as energetic, motivated, and shrewd prior to the accident, many of his acquaintances explained that after the injury he was "no longer Gage."

Since there is little direct evidence of the exact extent of Gage's injuries aside from Harlow's report, it is difficult to know exactly how severely his brain was damaged. Harlow's accounts suggest that the injury did lead to a loss of social inhibition, leading Gage to behave in ways that were seen as inappropriate.

Some evidence suggests that many of the supposed effects of the accident may have been exaggerated and that Gage was actually far more functional than previously reported.

Severity of Gage's Brain Damage

In a 1994 study, researchers utilized neuroimaging techniques to reconstruct Phineas Gage's skull and determine the exact placement of the injury. Their findings indicate that he suffered injuries to both the left and right prefrontal cortices, which would result in problems with emotional processing and rational decision-making .

Another study conducted in 2004 used three-dimensional, computer-aided reconstruction to analyze the extent of Gage's injury. It found that the effects were limited to the left frontal lobe.

In 2012, new research estimated that the iron rod destroyed approximately 11% of the white matter in Gage's frontal lobe and 4% of his cerebral cortex.

Phineas Gage's Impact on Psychology

Gage's case had a tremendous influence on early neurology. The specific changes observed in his behavior pointed to emerging theories about the localization of brain function, or the idea that certain functions are associated with specific areas of the brain.

In those years, neurology was in its infancy. Gage's extraordinary story served as one of the first sources of evidence that the frontal lobe was involved in personality.

Today, scientists better understand the role that the frontal cortex has to play in important higher-order functions such as reasoning , language, and social cognition .

What Happened to Phineas Gage?

After the accident, Gage was unable to continue his previous job. According to Harlow, Gage spent some time traveling through New England and Europe with his tamping iron to earn money, supposedly even appearing in the Barnum American Museum in New York.

He also worked briefly at a livery stable in New Hampshire and then spent seven years as a stagecoach driver in Chile. He eventually moved to San Francisco to live with his mother as his health deteriorated.

After a series of epileptic seizures, Gage died on May 21, 1860, almost 12 years after his accident. Seven years after his death, Gage's body was exhumed. His brother gave his skull and the tamping rod to Dr. Harlow, who subsequently donated them to the Harvard University School of Medicine. They are still exhibited in its museum today.

Phineas Gage Summary

In 1948, Phineas Gage had a workplace accident in which an iron tamping rod entered and exited his skull. He survived but it is said that his personality changed as a result, leading to a greater understanding of the brain regions involved in personality, namely the frontal lobe.

A Word From Verywell

Gage's accident and subsequent experiences serve as a historical example of how case studies can be used to look at unique situations that could not be replicated in a lab. What researchers learned from Phineas Gage's skull and brain injury played an important role in the early days of neurology and helped scientists gain a better understanding of the human brain and the impact that damage could have on both functioning and behavior.

Gage died from an epileptic seizure almost 12 years after the accident. These seizures started a few months before his passing, though his health had started to decline several months before the seizures began.

The damage occurred to Phineas Gage's frontal lobe, the region of the brain at the front of the head. The frontal lobe plays a role in our ability to speak, make decisions, and move. It is also partially responsible for our personality.

Post-accident, Gage's demeanor was said to have changed from pleasant to surly and he went from being a hardworking, motivated man to a man who had trouble keeping a steady job. Some reports suggest that Gage's personality changes were exaggerated, and that they may also have been temporary, fading a couple of years after the accident.

Phineas Gage lived almost 12 years after the rod pierced his skull. He died on May 21, 1860. This would make him just short of 37 years old at the time of his death.

Gage's accident helped teach us that different parts of the brain play a role in different functions. Through studying Gage's frontal lobe damage, we gained a better understanding of what the frontal cortex does with regard to personality. We also began to know more about the effects of frontal lobe damage and how it may change a person.

Sevmez F, Adanir S, Ince R. Legendary name of neuroscience: Phineas Gage (1823-1860) . Child's Nervous System . 2020. doi:10.1007/s00381-020-04595-6

Twomey S. Phineas Gage: Neuroscience's most famous patient .  Smithsonian Magazine.

Harlow JM. Recovery after severe injury to the head . Bull Massachus Med Soc . 1848. Reprinted in  Hist Psychiat. 1993;4(14):274-281. doi:10.1177/0957154X9300401407

Harlow JM. Passage of an iron rod through the head . 1848. J Neuropsychiatry Clin Neurosci . 1999;11(2):281-3. doi:10.1176/jnp.11.2.281

Itkin A, Sehgal T. Review of Phineas Gage's oral and maxillofacial injuries . J Oral Biol . 2017;4(1):3.

de Freitas P, Monteiro R, Bertani R, et al. E.L., a modern-day Phineas Gage: Revisiting frontal lobe injury . The Lancet Regional Health - Americas . 2022;14:100340. doi:10.1016/j.lana.2022.100340

Macmillan M, Lena ML. Rehabilitating Phineas Gage . Neuropsycholog Rehab . 2010;20(5):641-658. doi:10.1080/09602011003760527

O'Driscoll K, Leach JP. "No longer Gage": An iron bar through the head. Early observations of personality change after injury to the prefrontal cortex . BMJ . 1998;317(7174):1673-4. doi:10.1136/bmj.317.7174.1673a

Macmillan M. An Odd Kind of Fame: Stories of Phineas Gage . MIT Press.

Damasio H, Grabowski T, Frank R, Galaburda AM, Damasio AR. The return of Phineas Gage: Clues about the brain from the skull of a famous patient . Science . 1994;264(5162):1102-5. doi:10.1126/science.8178168

Ratiu P, Talos IF. Images in clinical medicine. The tale of Phineas Gage, digitally remastered . N Engl J Med . 2004;351(23):e21. doi:10.1056/NEJMicm031024

Van Horn JD, Irimia A, Torgerson CM, Chambers MC, Kikinis R, Toga AW. Mapping connectivity damage in the case of Phineas Gage . PLoS One . 2012;7(5):e37454. doi: 10.1371/journal.pone.0037454

Shelley B. Footprints of Phineas Gage: Historical beginnings on the origins of brain and behavior and the birth of cerebral localizationism . Archives Med Health Sci . 2016;4(2):280-6. doi:10.4103/2321-4848.196182

Garcia-Molina A. Phineas Gage and the enigma of the prefrontal cortex . Neurologia . 2012;27(6):370-5. doi:10.1016/j.nrleng.2010.03.002

Johns Hopkins Medicine. Brain anatomy and how the brain works .

By Kendra Cherry Kendra Cherry, MS, is an author and educational consultant focused on helping students learn about psychology.

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“No longer Gage”: an iron bar through the head

In September 1848, in Cavendish, Vermont, an incident occurred which was to change our understanding of the relation between mind and brain. Phineas P Gage, a 25 year old railroad foreman, was excavating rock. In preparation for blasting he was tamping powder into a drill hole when a premature explosion drove the tamping iron—1.1 m long, 6 mm in diameter, and weighing 6 kg—through his left cheek and out of the vault of his skull with such force that it threw him on his back and fell several rods behind, “smeared with brain.” 1 Despite his injuries he remained conscious and only a few minutes later was sitting in an ox cart writing in his work book. He recognised and reassured Dr Harlow, who had been summoned to the scene. The wound continued to bleed for two days; then followed a virulent infection that rendered Gage semiconscious for a month. His condition was so poor that a coffin had been prepared. Nevertheless, Dr Harlow continued treatment, and by the fifth week the infection had resolved and Gage had regained consciousness. He was blind in the left eye and had left facial weakness but no focal neurological deficits. Had the story ended there it would have been a remarkable account of Gage’s endurance and Dr Harlow’s therapeutic skill.

What made the event historic, however, was Dr Harlow’s subsequent observations of the change in Gage’s personality. Immediately after physical recovery he described Gage as follows: “Remembers passing and past events correctly, as well before as since the injury. Intellectual manifestations feeble, being exceedingly capricious and childish, but with a will as indomitable as ever; is particularly obstinate; will not yield to restraint when it conflicts with his desires.” Dr Harlow reports that Gage’s employers, “who regarded him as the most efficient and capable foreman ... 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 or advice when it conflicts with his desires.... A child in his intellectual capacity and manifestations, he has the animal passions of a strong man.... His mind was radically changed, so decidedly that his friends and acquaintances said he was ‘no longer Gage.’” 2

Unemployed, Mr Gage travelled with his tamping iron throughout New England. At Barnum’s Circus he displayed himself as a curiosity. He then worked in livery stables, first in Vermont and then in Chile. In 1860 he returned to his family in San Francisco. He had developed epilepsy, and in May 1861, 12 years after the injury, he died in status epilepticus. Dr Harlow observed that “mentally the recovery certainly was only partial, his intellectual faculties being decidedly impaired, but not totally lost; nothing like dementia, but they were enfeebled in their manifestations, his mental operations being perfect in kind, but not in degrees or quantity.” 2

Against a background of phrenology and Brocas’s writings on aphemia (1861) there was considerable resistance to Dr Harlow’s hypothesis. It was 10 years before David Ferrier came to the rescue in the Goulstonian lectures of 1878. On the basis of experimental physiology he concluded, “There are certain regions in the cortex to which definite functions can be assigned; and that the phenomena of cortical lesions will vary according to their seat and also according to their character.” 3 On removing prefontal lobes in monkeys he had found that “removal or destruction by the cautery of the antero-frontal lobes is not followed by any definite physiological results.... And yet, notwithstanding this apparent absence of physiological symptoms, I could perceive a very decided alteration in the animal’s character and behaviour, while it is difficult to state in precise terms the nature of the change.” He noted that “while not actually deprived of intelligence, they had lost, to all appearance, the faculty of the attentive and intelligence observation.” 3 Tracing the trajectory of the tamping iron through Gage’s brain he concluded that its track included the prefrontal region, “and that, therefore, the absence of paralysis in this case is quite in harmony with the results of experimental physiology.” 3 Gage had through a tragic natural experiment caused Dr Harlow to observe what Ferrier’s animal studies later showed—that injury to the prefrontal cortex of the frontal lobes of the brain can cause profound personality changes, without other apparent neurological deficits.

If Dr Harlow were alive today he would witness an explosion of research into the frontal cortex. 4 He would know that the cardinal function of the prefrontal cortex is the temporal organisation of behaviour supported by the subordinate functions of short term memory, motor attention, and inhibitory control. 4 The change in Gage’s personality would be consistent with damage to the orbitofrontal cortex of the ventral aspect of his frontal lobe, affecting affect and emotion. Harlow might be surprised to read in a recent publication, “To date, that knowledge has remained by and large either ignored or shrouded in speculation.” 4 He could take comfort, however, in the knowledge that 150 years after his original observations, we are a step forward in our understanding of the relation between mind and brain and the reason why, following his injury, Mr Phineas Gage was “no longer Gage.”

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Gage’s skull, with the tamping iron

case study of phineas gage psychology

The Extraordinary and Questionable Case of Phineas Gage

The weird ones are always the best. Those studies which leave you questioning the conclusions and the methods seem to stick with us. However, remembering study after study can send you to sleep with little understanding of why you chose Psychology in the first place. Then there are those topics which everyone tends to hate. Biopsychology and statistics. To nerds such as myself they are fantastic, but to most they either fill you full of dread or switch off your brain quicker than the latest reality TV show.

Need help with your studies?

One key question for this topic is how do we know what different parts of the brain do? For example, how do we know which regions are crucial for personality, language or memory? Early and pioneering brain research in the 19 th and 20 th centuries powered our modern-day understanding of the functions of the brain and localisation of different functions. The case study of Phineas Gage is a prime and strange example of just this.


Phineas Gage

Gage was a railroad foreman who became one of the most well-known case studies in psychology. His job, amongst other roles, was to tamp down the gunpowder to allow controlled explosions for the construction of railroads. He did this by patting down sand on top of gunpowder using a large iron rod. This enabled his team to clear rocks and outcrops which impeded the continuation of the railway tracks. At the age of 25, on September 13, 1848, Gage was carrying out his job but failed to deposit sand within the hole in which he placed gunpowder. As a result, as the iron rod scraped across the rocks, a spark ignited the gunpowder and sent the rod flying through the front of his left eye and skull, leaving it some metres behind him.

Amazingly, he survived, after a tumultuous recovery which saw an infection that left his attendants preparing for the worst (e.g. his coffin was ready to go). In fact, the accident was so incredible that some, upon hearing of Mr Gage, sought out the iron rod (safely deposited at a local blacksmith’s) in order to inspect it for blood and brain. In the two months after his accident he steadily recovered, although not quite as quickly and fully as an optimistic Gage thought he would on the day of his accident. He reportedly claimed he would be back to work within a few days. Supposedly, he also remained conscious following the initial accident and was able to present himself to the local doctor whereupon he said, “Doctor, here is business enough for you”. This in itself is amazing enough. That alone wouldn’t make this much of a psychology study though, would it?

The most interesting part of this story is what effect the incident had on his personality and what it told us about the brain. The accident produced significant damage to his frontal lobe. The doctor who attended Gage, Dr J.M. Harlow, claimed that his patient changed from a mild-mannered and hard-working individual into a “profane” and “fitful” individual whom his friends no longer recognised as the same man he had been prior to the accident. The doctor also went on to say Gage became anti-social and impulsive and had problems in planning for the future. This led to the conclusion that the frontal lobes are responsible for personality and problem solving / planning. This was corroborated by the claims that following damage to his frontal lobe he started to exhibit wild risk-taking behaviours, aggression, and salacious behaviour. Understandably, he has been a prime fascination for contemporary and modern individuals interested in the brain and what it means to be human. His case highlighted that specific brain regions (e.g. frontal lobe) are crucial for specific psychical functions (e.g. personality) – termed localisation of function.


The findings from his case support what we currently know in the modern day about the frontal lobe and the effect of damage here. Frontal lobe syndrome which occurs following damage to the frontal lobes can present with a wide range of problems. Some examples include personality change, impulse control difficulties, aggression, problems in attention, and difficulty carrying simple tasks which require planning and decision making. For example, Wilder Penfield’s (an eminent and incredible cartographer of the brain whom we’ll come back to in a later article) reported on a rather interesting surgical case of his in the early 20 th century. The case just so happened to be his only sister, Ruth. She had a tumour removed from her right frontal lobe and following the surgery she showed evidence of difficulties in daily tasks such as preparing a family meal. This shouldn’t be too surprising if you consider the amount of planning and memory functioning required. Another instance of frontal lobe damage, reported on by Eslinger & Damasio 1985, found their patient’s IQ remained intact, at an impressive 130, but he also became unable to carry out simple tasks (e.g. choosing a restaurant could take hours).

By contrast, damage to the frontal lobe caused by the surgical procedure known as the transorbital lobotomy or prefrontal leucotomy produced apathy, passivity and a marked docility in those who underwent the questionable (at best) and barbaric procedure. It’s clear we’re still not certain exactly what roles the frontal lobes, and their subdivisions, play, even with our advances in neuroscience and brain imaging.

Although Gage is the earliest case study in the medical literature, his is not the earliest reported instance of altered behaviour following frontal lobe damage. The wordsmith Dr. Oliver Sacks, in “An Anthropologist on Mars”, recounted the changes seen in a Dr North, who went from being anxious, obsessive and prone to moralising to a man who was reported to be reckless, to drink to excess and who found a new joy in “improper jokes”. These changes were claimed to follow a stroke to the frontal lobes. Although the source for the location of the stroke is uncertain at best.

Source, sources, sources. There is, as there always is, debate here as to the extent of Gage’s change in behaviour! Those claims about his behaviour by Dr Harlow were not made shortly after he saw his patient, but actually after his death – eight years, in fact, as he made the statement that his “acquaintances said he was ‘no longer Gage” in 1868. Moreover, they were made about Gage’s final months, when he was too ill to work because of the epileptic fits which he was experiencing with increasing frequency. However, prior to this point, he had been supporting himself with hard work. He initially made money out of showing himself off as a wonder (in fact, many in surgical circles refused to believe such a case was possible) and prior to his death successfully held a difficult job as a stagecoach driver. In fact, modern accounts claim that the predictability and difficulty of the stagecoach job may have helped Gage’s social and cognitive recovery. Yet, the reports on Gage’s character as impulsive, irresponsible, and irascible are seemingly conjured out of his legend and legacy. There are contradictions in reports, even amongst those who treated or spoke to him and his family, and most of our “knowledge” about his personality is based largely on modern accounts of dubious truth.

Finally, for any students, the differences in reports can also be attributed to the viewpoints individual sources wanted to support (there’s a reason we keep asking you to evaluate, promise). Those who exaggerated Gage’s personality changes were supporters of localisation of function in the brain, and those that underplayed them – you guessed it – were against localisation of function. This makes it particularly hard to draw definite conclusions on Gage’s case, and the lack of contemporary reports limits us further. Nonetheless, his case is extraordinary and set the stage for our modern understanding of the brain and neuroscience. Whether we can believe he was “no longer Gage” is unclear, but the exaggerated reports fit loosely with modern reports of damage to the frontal lobes. If nothing else, it makes that lingering headache seem instantly more manageable…

case study of phineas gage psychology

Jack B. is a PhD student at the University of Manchester. His research looks at why sleep is vital for our mental health and how too little sleep may explain strange experiences such as hallucinations and delusions. He tutors Biology and Psychology with MyTutor.

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Wilder Penfield: Intrepid Cartographer of the Brain

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The Joys of Sweaty Science and Cave Dwelling

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Why brain scientists are still obsessed with the curious case of phineas gage.

Jon Hamilton 2010

Jon Hamilton

case study of phineas gage psychology

Cabinet-card portrait of brain-injury survivor Phineas Gage (1823–1860), shown holding the tamping iron that injured him. Wikimedia hide caption

Cabinet-card portrait of brain-injury survivor Phineas Gage (1823–1860), shown holding the tamping iron that injured him.

It took an explosion and 13 pounds of iron to usher in the modern era of neuroscience.

In 1848, a 25-year-old railroad worker named Phineas Gage was blowing up rocks to clear the way for a new rail line in Cavendish, Vt. He would drill a hole, place an explosive charge, then pack in sand using a 13-pound metal bar known as a tamping iron.

But in this instance, the metal bar created a spark that touched off the charge. That, in turn, "drove this tamping iron up and out of the hole, through his left cheek, behind his eye socket, and out of the top of his head," says Jack Van Horn , an associate professor of neurology at the Keck School of Medicine at the University of Southern California.

Gage didn't die. But the tamping iron destroyed much of his brain's left frontal lobe, and Gage's once even-tempered personality changed dramatically.

"He is fitful, irreverent, indulging at times in the grossest profanity, which was not previously his custom," wrote John Martyn Harlow, the physician who treated Gage after the accident.

This sudden personality transformation is why Gage shows up in so many medical textbooks, says Malcolm Macmillan, an honorary professor at the Melbourne School of Psychological Sciences and the author of An Odd Kind of Fame: Stories of Phineas Gage.

"He was the first case where you could say fairly definitely that injury to the brain produced some kind of change in personality," Macmillan says.

And that was a big deal in the mid-1800s, when the brain's purpose and inner workings were largely a mystery. At the time, phrenologists were still assessing people's personalities by measuring bumps on their skull.

Gage's famous case would help establish brain science as a field, says Allan Ropper , a neurologist at Harvard Medical School and Brigham and Women's Hospital.

One Account Of Gage's Personality Shift

Dr. John Harlow, who treated Gage following the accident, noted his personality change in an 1851 edition of the American Phrenological Journal and Repository of Science.

One doctor's account of the personality shift in Phineas Gage following the accident.

"If you talk about hard core neurology and the relationship between structural damage to the brain and particular changes in behavior, this is ground zero," Ropper says. It was an ideal case because "it's one region [of the brain], it's really obvious, and the changes in personality were stunning."

So, perhaps it's not surprising that every generation of brain scientists seems compelled to revisit Gage's case.

For example:

And, in 2012, Van Horn led a team that combined CT scans of Gage's skull with MRI scans of typical brains to show how the wiring of Gage's brain could have been affected .

"Neuroscientists like to always go back and say, 'we're relating our work in the present day to these older famous cases which really defined the field,' " Van Horn says.

And it's not just researchers who keep coming back to Gage. Medical and psychology students still learn his story. And neurosurgeons and neurologists still sometimes reference Gage when assessing certain patients, Van Horn says.

"Every six months or so you'll see something like that, where somebody has been shot in the head with an arrow, or falls off a ladder and lands on a piece of rebar," Van Horn says. "So you do have these modern kind of Phineas Gage-like cases."

case study of phineas gage psychology

Two renderings of Gage's skull show the likely path of the iron rod and the nerve fibers that were probably damaged as it passed through. Van Horn JD, Irimia A, Torgerson CM, Chambers MC, Kikinis R, et al./Wikimedia hide caption

Two renderings of Gage's skull show the likely path of the iron rod and the nerve fibers that were probably damaged as it passed through.

There is something about Gage that most people don't know, Macmillan says. "That personality change, which undoubtedly occurred, did not last much longer than about two to three years."

Gage went on to work as a long-distance stagecoach driver in Chile, a job that required considerable planning skills and focus, Macmillan says.

This chapter of Gage's life offers a powerful message for present day patients, he says. "Even in cases of massive brain damage and massive incapacity, rehabilitation is always possible."

Gage lived for a dozen years after his accident. But ultimately, the brain damage he'd sustained probably led to his death.

He died on May 21, 1860, of an epileptic seizure that was almost certainly related to his brain injury.

Gage's skull, and the tamping iron that passed through it, are on display at the Warren Anatomical Museum in Boston, Mass.

Phineas Gage: His Accident and Impact on Psychology

Olivia Guy-Evans

Associate Editor for Simply Psychology

BSc (Hons), Psychology, MSc, Psychology of Education

Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

Learn about our Editorial Process

Saul Mcleod, PhD

Educator, Researcher

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, Ph.D., is a qualified psychology teacher with over 18 years experience of working in further and higher education.

Key Takeaways

Phineas Gage’s accident

Phineas Gage was an American railroad construction foreman born in 1823.

On September 13th, 1848, when Gage was 25 years old, he was working in Cavendish in Vermont, leading a crew which were preparing the Rutland and Burlington Railroad by blasting rocks to make a roadbed.

This was done by using an iron tamping rod to pack the explosive powder into a hole. Whilst Gage was doing this however, the powder detonated and the tamping iron he was using launched from the hole and entered the left side of Gage’s face from the bottom up.

The iron rod (which was 43 inches long and 1.24 inches in diameter) penetrated Gage’s left cheek, traveling behind his left eye and entered through his left side brain and exited his skull, landing 80 feet away.

After the incident, Gage was thrown onto his back from the force of the iron rod and had some brief convulsions of the arms and legs. Within a few minutes however, Gage was able to get himself up, speak and walk with small assistance to a nearby cart so he could travel into town.

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.

Further Reading

Griggs, R. A. (2015). Coverage of the Phineas Gage Story in Introductory Psychology Textbooks: Was Gage No Longer Gage?. Teaching of Psychology, 42(3), 195-202.

Wilgus, J., & Wilgus, B. (2009). Face to face with Phineas Gage. Journal of the History of the Neurosciences, 18(3), 340-345.

Macmillan, M., & Lena, M. L. (2010). Rehabilitating Phineas Gage. Neuropsychological Rehabilitation, 20, 641–658.

Macmillan, M. (2000). Restoring phineas gage: a 150th retrospective. Journal of the History of the Neurosciences, 9(1), 46-66.

Kotowicz, Z. (2007). The strange case of Phineas Gage. History of the Human Sciences, 20(1), 115-131.

O”driscoll K, Leach JP. “No longer Gage”: an iron bar through the head. Early observations of personality change after injury to the prefrontal cortex. BMJ. 1998;317(7174):1673-4. doi:10.1136/bmj.317.7174.1673a

Phineas Gage with the tamping rod that was driven through his head

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".

Similarly, most popular accounts of Phineas Gage describe him as having undergone profound personality changes because of his injury. He is often reported as having permanently lost his inhibitions, so that he started to behave inappropriately in social situations. Some reports state that became violent and "uncontrollable", and even that he started to molest children.

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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Sep 24, 2015

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

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 ) and ‘The Ballad of Phineas P. Gage’ by Crystal Skillman (see ), and the song ‘Phineas Gage’ by Dan Linder (see ).

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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