phineas gage, 'tan' and the importance of case reports

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management of a severe infectionundoubtedly saved Phineas’ life. Threemonths later, Phineas was well enough to

return to his parents’ farm. After probablyspending most of 1849 regaining hisstrength, he travelled to Boston in theNovember to be examined by Henry JacobBigelow, the Professor of Surgery atHarvard, and was presented to the medicalstudents there (Bigelow, 1850; BostonSociety for Medical Improvement,1849;Harlow, 1848, 1868).

The post–accident history After the accident Phineas was unableto regain his job as a foreman. Probablysome time in 1850 he became anattraction at Barnum’s American Museumin New York, and visited the major citiesin New England to lecture and exhibithimself. He worked for some 18 monthsfor Jonathan Currier who ran a liverystable and coach-line service from hisDartmouth Inn, in Hanover, NH. ThenGage went to Chile with a man whoplanned to set up a stagecoach line inValparaiso (Harlow, 1868).

After many years driving stagecoaches,Phineas decided in June 1859 to return tohis family, now living in San Francisco. Hehad had some kind of illness and arrived

in a weakened condition. Several monthselapsed before he was strong enough towork on farms south of the city. Not longafter, in February 1860, and afterploughing the day before, ‘while sitting atdinner, he fell in a fit’. ‘Unquestionablyepileptic’, his seizures gradually increasedin severity and on 18 May he returned tohis mother’s house where he suffered asuccessive series of them. By 21 May 1860the seizures had killed him. He hadsurvived 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 adducedfour factors:I His ‘physique, will, and capacity of

endurance, could scarcely be excelled’;I The shape of the tamping iron left

Could you survive a small crowbarpassing completely through yourhead? Most psychologists would

answer ‘Yes’: almost all of them learnedthat Phineas Gage did. Although Phineas’accident occurred 160 years ago thismonth, its consequences are still discussedin most introductory textbooks of psychology, neuropsychology, andphysiology. You might therefore thinkmuch has been learned since 1848, whenthe accident happened, and the publication20 years later, in 1868, of a significantaccount of its psychological consequences.But in fact little has been added. Moreover,much of what has been written iscompletely wrong. So, why should Phineasstill be of interest?

Phineas and the accidentAt 25 years of age Phineas Gage was theforeman of a railway construction gangbuilding the bed for the Rutland andBurlington Railroad in central Vermontin the USA. He and his gang were blastinga cutting through a large rocky outcropabout three quarters of a mile south ofthe town of Cavendish. It was Gage whodecided where holes would be drilled inthe rock, and how much powder withwhich to charge them. To focus theexplosive force, the powder and fuse

would be gently ‘tamped’ down beforesand was added and a more vigoroustamping applied. Only then would thefuse be lit.

For tamping, Phineas used the larger

end of a special crowbar-like tool called atamping-iron. Three feet seven inches long,it weighed thirteen and a half pounds. Itwas 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 13September 1848 Phineas, apparentlydistracted, began tamping before the sandhad been poured. The tamping iron struckthe rock causing a spark to light thepowder. The resultant explosion propelledthe tamping iron out of the hole andcompletely through his head. It enteredpoint first, under the left cheekbone, orzygomatic arch and next penetrated thebase of the skull, just behind the bonysocket of the left eye. Finally it emerged

at the top of the skull, probably slightlyin front and to the left of the bregma (the junction of the coronal and sagittalsutures), and landed about 20 to 25 yardsbehind him.

For a short time Phineas may havebeen unconscious. His gang carried him toa nearby ox-cart where, sitting against itshead board, he was driven to theCavendish inn where he lived. He alightedunaided. Then from a chair on the ‘piazza’(New England=verandah) he told his storyto the bystanders. He greeted EdwardHigginson Williams, the first medicalpractitioner to arrive, with ‘Doctor, here

is business enough for you’.Dr John Martyn Harlow arrived

about an hour later and he and Williamsmanaged to stem the profuse haemorrhage.That action and Harlow’s subsequent

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A most remarkable case. (1851). AmericanPhrenological Journal and Repository of Science, Literature, and General

Intelligence, 13, 89, col. 3.Bigelow, H.J. (1850). Dr. Harlow’s case of

recovery from the passage of an ironbar through the head. American

Journal of the Medical Sciences, 20,13–22. [Copy in Macmillan, 2000]

Boston Society for Medical Improvement(1849). Records of Meetings (Vol. VI).

Countway Library Mss., B MS b 92.2.Damasio, H., Grabowski, T., Frank, R. et

al. (1994). The return of PhineasGage. Science, 264, 1102–1105.[Erratum, Science, 265, 1159 ]

Ferrier, D. (1876). The functions of thebrain. London: Smith, Elder.

Ferrier, D. (1877–1879). Correspondencewith Henry Pickering Bowditch.Countway Library Mss., H MS c 5.2.

Ferrier, D. (1878). The Goulstonian

lectures of the localisation of cerebral

disease. British Medical Journal, i,397–402, 443–447.

Harlow, J.M. (1848). Passage of an ironrod through the head. Boston Medicaland Surgical Journal, 39, 389–393.[Copy in Macmillan, 2000]

Harlow, J.M. (1849). Letter in ‘Medicalmiscellany’. Boston Medical and

Surgical Journal, 39, 506–507. [Copy inMacmillan, 2000]

Harlow, J.M. (1868). Recovery from the

passage of an iron bar through thehead. Publications of the

Massachusetts Medical Society, 2,327–347. [Copy in Macmillan, 2000]

Jackson, J.B.S. (1849). Medical Cases(Vol. 4, Cases Number 1358–1929,

pp.720 and 610). Countway Library Mss., H MS b 72.4.

Jackson, J.B.S. (1870). A descriptivecatalogue of the Warren Anatomical

r e f e r e n c e s

L O O K I N

G B A C K

Phineas Gage –Unravelling the mythMalcolm Macmillan updates a familiar tale, 160 years after its inception



behind no ‘prolonged concussion orcompression’;

I The entry of the tamping iron created

an opening for draining the infection,without which ‘recovery would havebeen impossible’; and

I The portion of the brain traversed bythe iron ‘was, for several reasons, thebest fitted…to sustain the injury.’

Here Harlow modestly disguised his ownvery considerable medical skill by sayingonly that, in Ambroise Paré’s famouswords, ‘I dressed him, God healed him’(Harlow, 1868).

The psychological aftermathThe damage to Phineas’ brain hadprofound psychological consequences.In 1868, in fewer than 200 words, Harlowsummarised why Phineas’ contractorswould not re-employ him. That summary,together with a few words from his 1848report, tell us practically everything weknow about Phineas.

Harlow said ‘the balance between hisintellectual faculties and animalpropensities seems to have been destroyed’.Phineas became:I ‘Fitful’, ‘irreverent’, grossly profane,

and showed ‘but little deference for his

fellows’;I ‘Impatient of restraint or advice’ thatconflicted with his desires;

I ‘Pertinaciously obstinate, capricious,and vacillating’ about his plans for thefuture – ‘no sooner arranged than theyare abandoned’; and

I ‘A child intellectually’ with ‘the animalpassions of a strong man’.

Previously he had been:I ‘Strong and active’ with ‘an iron will’

and of ‘nervo-bilious temperament’;I Of ‘temperate habits’ and ‘possessed

of considerable energy of character’;

I A ‘great favorite’ with his men;I ‘The most efficient and capable

foreman’ employed by his contractors;I In possession of ‘a well–balanced

mind’; and

I Regarded as a ‘shrewd, smart businessman, very energetic in executing all hisplans’.

So ‘radical’ was the change, his friendsand acquaintances said he was ‘no longerGage’ (Harlow, 1848, 1849, 1868).

Phineas’ mother told Harlowthat Phineas entertained ‘his littlenephews and nieces with themost fabulous recitals’ of hisadventures that had no‘foundation except in his fancy’.He ‘conceived a great fondnessfor pets, and souvenirs, especiallyfor children, horses and dogs –exceeded only by his attachmentto his tamping iron, which washis constant companion duringthe remainder of his life’. Afterhis first seizure she said he oftenchanged his employment, alwaysfinding ‘something that did notsuit him’.

Which parts of the brain

were damaged?There was no autopsy whenPhineas died. His body wasexhumed, probably late in 1867,and his skull given to Harlow in

early 1868. Nothing was left of his brain. Phineas’ skull is all wehave as a guide to the damage.

Concussion, pieces of bone,haemorrhage, and infectionwould have destroyed additionaltissue beyond that in theimmediate path of the tampingiron, even if we knew exactlywhat that was. And the preciseposition of Gage’s brain within his skullcannot be known. For those reasons, andbecause the areas in which variousfunctions are localised varies somewhatamong individuals, there will always be

uncertainty about which of them weredestroyed (Macmillan, 2000, pp.84–86).Three studies were made on the living

Phineas to determine the path of thetamping iron. They disagreed about the

exit area in relationto the bregma andwhether it wasright or left of themidline. Harlow(1868) made thefirst of the attemptsusing the skull.The entry fromunder the left

cheekbone to therear of the eyesocket posed littleproblem. Where

the tamping iron had emerged at the topof the skull was less certain. Opting for theexit being ‘near’ the bregma and ‘in’ the

median line, Harlow concluded that theleft frontal and middle left lobes had beendestroyed. His attribution of Gage’s ‘partial’recovery to their functions having been

taken over by the ‘intact’ right hemispheremeant that he did not think the right wassignificantly damaged.

Between 1982 and the present, threeCT–based methods have been used to

reconstruct the passage of the tamping ironthrough Phineas’ brain. They producedsomewhat varying pictures of its travel(Macmillan, 2000, Chapter 5, especiallyTables 5.1 and 5.2; Ratiu et al., 2004).

In 1982 Rick and Ken Tyler of Bostonused coronal and sagittal CT-scans of Gage’s skull to determine the limits of thebony damage. From those images, whichwere two-dimensional and static, theyconcluded the brain damage was mostly tothe left hemisphere but that the right mustalso have suffered (Macmillan, 2000,pp.77–79 and Appendix E).

After making X-rays, photographs,

and measurements of Gage’s skull, HannaDamasio and her colleagues linearlydeformed a 3-D reconstruction of a humanskull from a cadaver until it matched those

read discuss contribute at www.thepsychologist.org.uk 829

looking back

Museum. Boston, MA: Williams.

[Copies of relevant sections inMacmillan, 2000]

acmillan, M. (2000). An odd kind of fame:Stories of Phineas Gage. Cambridge,MA: MIT Press.

atiu P. & Talos I.F. (2004). The tale of

Phineas Gage, digitally remastered.New England Journal of Medicine, 351,e21–e21. [Paper: tinyurl.com/59ah3w;Video clips: tinyurl.com/5bhfaz]

Ratiu, P., Talos, I.F., Haker, S. et al. (2004).

The tale of Phineas Gage, digitallyremastered. Journal of Neurotrauma,

21, 637–643.

Broadside digitally restored by DavidWilliams, Knowledge Media Division,

Deakin University, Victoria, Australia.Reproduced by permission of the

copyright holders, New HampshireHistorical Society

The first independent evidence of Gage’s post-accident

travels to Boston, most of the larger New England towns,

and New York

R E P R O D U C E D B Y P E R MI S S I O N

O F T

H E C O P Y R I G H T H O L D E R S ,NE W

H A MP S H I R E H I S T O R I C A L S O C I E T Y ( S E E R E F E R E N C E S )



measurements. From their collection of brains of about the right size they thenplaced 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 thisGage-like brain inside the Gage-like skull.They had the tamping iron emerging fromunder the semi-detached but otherwiseundamaged right flap of frontal bone sothat the brain damage was more frontaland right of the midline than had beensuggested previously (Damasio et al.,1994).

Real light arrived when Ratiu et al.(2004) and Ratiu and Talos (2004) usedthin CT-scans to build a three-dimensionalrepresentation of Phineas’ skull itself,rather than an image of what it mighthave been like. How well they succeededis immediately obvious in an illustrationfrom the second of their papers (shownon this cover of The Psychologist) (Ratiu& Talos, 2004).

They were the first to see that thediameter of the entry area being smallerthan that of the tamping iron required theskull to have hinged open for the iron topass through it. They connected that factwith the continuous line of fracturebeginning under the cheekbone andrunning to the left parietal bone well

beyond the rear of the hole at the bregma.After the tamping iron passed through, thehinge must have been closed by the actionof the soft tissues.

From the video clips Ratiu and Talosincluded in their paper, it can be seen thatthe line of fracture and the hinging actionplace the exit left of the median line andslightly in front of the bregma. On theirreconstruction, the brain damage was left-frontal – almost exactly as Harlow said.

The implications and the contextIt was a long time before Phineas’

psychological changes became known.None were specifically mentioned byHarlow in 1848; nor did Bigelow report

any in 1850. Some memory impairmentwas recorded privately by Jackson (1849),and an anonymous report the same year

very briefly noted a great impairment of his mental powers (Standing Committeeon Surgery, 1850). Some detail firstappeared in an 1851 phrenological journal’s reply to Bigelow (‘A mostremarkable case’, 1851). However, notuntil Harlow’s little-known 1868 reportwas any real notice taken of thepsychological changes, and even incomments on it they were frequentlyignored (Macmillan, pp.113–116,197–199).

Some of this neglect is explicable bythe lack of knowledge in the early 1800sabout the functions of the brain. Apartfrom Franz Josef Gall’s organology(phrenology), there was no theory before1848 of what the brain did. That nervestransmitted sensations and controlledmovement was known, but it was not evengenerally accepted that damage to one sideof the brainaffectedmovement orsensation onthe other. Earlydescriptionslike Bigelow’sof Gage being

unimpairedprobably meantmerely that hismuscles andsense organs functioned normally.

Johannes Müller and AlexanderBain had argued that willing and moralbehaviour depended on an inhibitoryfunction localised vaguely in some ‘higher’part of the nervous system or even in thebrain, but could advance no supportingempirical evidence (Macmillan, 2000,pp.158–170). But functions like languageand personality had not been shown todepend on the way the brain worked.

The context began to change about themid-1860s; that is, by the time of Harlow’s1868 report. Paul Broca’s clinical

observations suggested thatlanguage functions werelocalised in the left frontal lobe.A little later, David Ferrier’smonkey experimentsdemonstrated that prefrontaldamage caused profoundpersonality changes (Ferrier,1873).

It was Ferrier who rescuedGage from the obscurity of the journal in which Harlow’s 1868

report was buried (Ferrier,1876, 1877–1879, 1878), but10 years elapsed before

Harlow’s findings gained

acceptance. A theory of frontal functioningwas even further away. Gage was literallyahead of his time.

Facts vs. the common pictureThere are just four primary sources of information about Gage: Harlow (1848),Bigelow (1850), then Harlow again(1868) – the only physicians to haveexamined him and published theirobservations – and finally J.B.S. Jackson(1870), who added a few facts of his ownto what Gage’s family and others had toldhim. Anything not from these sources, orsimilarly documented, is not a fact aboutPhineas Gage.

This is not to say these primarysources are entirely reliable. Harlow, forexample, writing in 1868 while in contactwith Phineas’ mother, reported thatPhineas died in 1861, whereas funeralparlour records prove conclusively that hedied in 1860. (In this article and elsewhere

I have silently corrected other datesdependent on this one.) Similarly, acurious relic recently found by DominicHall, Curator of Harvard’s WarrenAnatomical Museum, suggests thatPhineas went to Chile in 1854 and notin 1852 as reported by Harlow.

First the facts. Harlow’s picture of

Phineas is at total variance with mostlater portrayals. A fair composite of today’s accounts would have a pre-accidentGage who was reliable, industrious, mild-mannered, temperate, genial, friendly,affable, the favourite of his peers andelders, showing considerable promise –a peaceful, happy and tranquil man.

The composite of modern writers hasthe accident transforming this Phineas intoa restless, moody, unpredictable,untrustworthy, depraved, slovenly,violently quarrelsome, aggressive andboastful dissipated drunken bully,displaying fits of temper, and with

impaired sexuality. He is a waster:unwilling to work and unable to settledown. He spends most of the rest of hislife in travelling circuses or drifting aroundfairgrounds to exhibit himself as a humanfreak, and dies penniless.

The facts about the real Phineas mayhave a slight resemblance to the modernpre-accident representation, but he canhardly be recognised in the post–accidentpicture.

Second, interpretations. Manyinterpretations of Phineas’ behaviour havebeen made to support particular theories.Thus Vincent and others matched his

allegedly changed sexuality – notmentioned in the sources – to that of somepost-lobotomy patients; others, likeDamasio and colleagues, portrayed Gage’s

830 vol 21 no 9 september 2008

looking back

Gage outside scienceThe story of Phineas Gage has entered popular culture,leading to plays, films, TV programmes and YouTubeskits, poems and stories, sculptures, bands and songs,and even a team of lawyers who apply behaviouralscience to legal education. My favourites (partly becauseI was consulted on them!) are the plays ‘That ElusiveSpark’ by Janet Munsil (see tinyurl.com/3eua9q) and ‘The

Ballad of Phineas P. Gage’ by Crystal Skillman (seetinyurl.com/4ju2y4), and the song ‘Phineas Gage’ by DanLinder (see tinyurl.com/3hf6jx).

“The factual recordis small…most whohave written aboutPhineas have beentoo lazy or slipshod

to check it”



damage and behaviour such that theymatched those of a selection of their ownmodern patients (Macmillan, 2000,

pp.329–330). Distortions like these weregreat enough to justify devoting some 50pages of my book to analysing them, andfor MIT Press to allow me to includefacsimiles of the primary sources(Macmillan, 2000, Figure 15.2 andAppendix A).

Third, long-term effects. Everyscientific and popular picture of PhineasI know of has him impulsive andunreliable until his death. Yet his yearand a half working for Currier, and thedemanding motor and cognitive skillsrequired of a stagecoach driver areinconsistent 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 reportsof people with brain damage similar to hiswho recovered without formal treatment.In each instance, someone or somethinggave enough structure to their lives forthem to relearn lost social and personalskills.

Here we may speculate about Phineas’daily routine. Some detail may be inferred

from a recently discovered contemporaryaccount of stagecoach driving on whatseems to be the very route Phineas drove.He would have had to rise early eachdriving day, prepare himself, feed andgroom the horses, harness them to thecoach, and be at the departure point by4am. There he would have had to dealpolitely with the passengers, load theirluggage (up to 50 pounds each), andcollect fares, and so on, before beginninga 13-hour journey over 100 miles of poorroads, often in times of political instabilityor frank revolution. All this – in a land towhose language and customs Phineas

arrived an utter stranger – militates asmuch against permanent disinhibition asdo the extremely complex sensory-motorand cognitive skills required of a coachdriver (Macmillan, 2000, p.104–106).

As I understand it, relearning in astructured environment is the basis of many brain-damage rehabilitationprogrammes (such as that at the OliverZangwill Centre at Ely in Cambridgeshire).If Phineas Gage did recover, could hisemployment have provided a similarstructure?

Only by filling out the post-accidentrecord can this be determined. I have

found a poster advertising one of Phineas’lectures. Matthew L. Lena, my Bostoncolleague, and I hope to find someeyewitness report of it. Matthew has also

found a physician who said he saw a quitewell Phineas in Chile around 1858.

There would be practical and

theoretical consequences of a discoverythat Gage so recovered. It would add tocurrent evidence that rehabilitation can beeffective even in difficult and long-standingcases. But it would also mean thattheoreticians of frontal lobe functioningwould have to consider whether the lobesthemselves and their functions were muchmore plastic than we now think.Recognition of that kind would, of course,match the now accumulating evidenceabout the recovery of biological systems ingeneral.

Why bother? We will never know with certainty whatthe pre- and post-accident Phineas Gageswere really like; nor will we ever knowexactly the parts of his brain that weredamaged in the flash that transformedthe one into the other. So, why bother?

First, it is always worthwhilecorrecting the historicalrecord, though the degreeof rigor mortis, especiallyin textbooks, seems too faradvanced for even a DrFrankenstein to re-enliven

poor Phineas.Second, Phineas’ storyis worth rememberingbecause it illustrates howeasily a small stock of factscan be transformed intopopular and scientificmyth. I was much struckby David Ferrier’s remarkin an 1877 letter aboutPhineas to Henry PickeringBowditch in Boston. Heasked Bowditch for thefacts about Phineas as theywere originally reported

because he was ‘amazedat the inexactitude anddistortion to which theyare subject by men whohave some pet theory tosupport’. And as we haveseen, scientific mythsabout Phineas continueto be used to supportparticular theoreticalpositions.

The factual recordis small, and the mostimportant element of it –Harlow’s 1868 report – not

readily available, and mostwho have written aboutPhineas have been too lazyor slipshod to check it.

Paradoxically, the very slightness of reliablefact which allows myths about Phineas toflourish also makes disentangling those

myths a conceptually easy, if tedious, task.Phineas’ primary importance is as

a historical marker. We can see how hisskull was damaged, but we will only everhave estimates of his brain damage. Wealso know too little about him before andafter the accident to draw detailedconclusions about its effects. Phineashas to be remembered for being the firstreported case in which brain damagecaused alterations to personality. But wemay yet learn the extent of his recoveryand what brought it about.

I Malcolm Macmillan is Professorial Fellow

in the Department of Psychology at theUniversity 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]

read discuss contribute at www.thepsychologist.org.uk 831

looking back

Questions about GageMatthew Lena and I are interested in the following topics and

I would be pleased to supply more specific information toreaders who may be able to help.

I The fate of Dr John Martyn Harlow’s case notes andcorrespondence about Gage.

I Anything at all relating to Phineas in New England (toabout 1854), Chile (to about 1859) and San Francisco,Santa Clara, or Alameda Counties, California (died, 1860).

I Identity of the ‘distinguished Professor of Surgery in adistant city’ whom Harlow said had termed Gage a ‘Yankeeinvention’ (some time before 1868).

I Harlow and his wife, Frances Kimball Harlow, especiallywhen living in Stillwater, Minnesota (ca. 1857–1860).

I Departure/arrival/passenger lists for ships travellingamong New York/New England, Panama/Valparaiso, and

San Francisco (1850–1868).I 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 andpublications of physicians or of English-speaking persons.

I Dr Henry Trevitt and Dr William Trevitt in Wilton,Connecticut and Franklin Co., Ohio (resp.) approximately1861 forward.

I A Dr William J. Lo– – – – (full surname unknown) residingin Brooklyn Township (now Oakland, Alameda Co.)California in 1860, possibly a teacher of the deaf, or hiswife Cordelia (both originally of Maine).

I Dr Jacob Davis Babcock Stillman and Dr Henry Perrin

Coon of San Francisco (esp. personal papers ca. 1867).I The Starling Medical College in Columbus, Ohio, and

faculty member J. W. Hamilton (ca. 1860).

phineas gage, 'tan' and the importance of case reports

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