Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contact us Login 
  • Users Online:663
  • Home
  • Print this page
  • Email this page

 Table of Contents  
Year : 2016  |  Volume : 4  |  Issue : 2  |  Page : 280-286

Footprints of phineas gage: Historical beginnings on the origins of brain and behavior and the birth of cerebral localizationism

Department of Neurology, Yenepoya Medical College, Mangalore, Karnataka, India

Date of Web Publication20-Dec-2016

Correspondence Address:
Bhaskara P Shelley
Department of Neurology, Yenepoya Medical College, Mangalore - 575 018, Karnataka
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2321-4848.196182

Rights and Permissions

The intellectual revolution led by ancient Greek philosophers and physicians witnessed the extraordinary evolution of the birth of neuroscience from speculations of cardiocentrism (Aristotelism) and encephalocentrism (Galenism). Later further development of neurosciences was hallmarked by the development of anatomic theories of phrenology by the German physician Franz Joseph Gall in 1796. Although phrenology was a pseudoscience, it was Gall who laid the foundations for the subsequent biologically based doctrine of brain behavior localization. The amazing story of Phineas Gage is a classic case in the nineteenth-century neurosciences literature that played a pivotal role in the concept of cerebral localizationism, a theory that moved beyond phrenology. This iconic case marked the historical beginnings of brain origins of human behavior and elucidated a link between brain trauma, prefrontal brain damage and personality change.

Keywords: Behaviour, brain injury, localizationism, personality change, Phineas Gage, phrenology

How to cite this article:
Shelley BP. Footprints of phineas gage: Historical beginnings on the origins of brain and behavior and the birth of cerebral localizationism. Arch Med Health Sci 2016;4:280-6

How to cite this URL:
Shelley BP. Footprints of phineas gage: Historical beginnings on the origins of brain and behavior and the birth of cerebral localizationism. Arch Med Health Sci [serial online] 2016 [cited 2023 Mar 23];4:280-6. Available from: https://www.amhsjournal.org/text.asp?2016/4/2/280/196182

No physiologist who calmly considers the question in connection with the general truths of his science, can long resist the conviction that different parts of the cerebrum subserve different kinds of mental action. Localization of function is the law of all organization whatever: Separateness of duty is universally accompanied with separateness of structure: And it would be marvellous were an exception to exist in the cerebral hemispheres.

–Herbert Spencer

A moral man, Phineas Gage

Tamping powder down holes for his wage,

Blew the last of his probes,

Through his two frontal lobes;

Now he drinks, swears, and flies in a rage

–Author unknown

  Introduction Top

The 21st century, “the century of the brain,” a golden age of brain exploration dedicated to unravel the mysteries of the human brain, the last biological frontier, has powerful new devices that peer through the skull and see the brain at work. With the advent of state of art, imaging neuroscience tools to map brain functions, we now have gained further insights regarding the neural substrates and neurobiological blueprints of human behavior. Thus, the neuroscientists are now able to seek the wellsprings of thoughts and emotions, the genesis of intelligence, and language.

The terra incognita is the gelatinous pudding-like three-pound world called the brain which is the seat of human behaviorism. For a long time, before we developed an appreciation of the neuroanatomy and neurophysiology of the brain, there was uncertainty as to the nature and source of the human mind. This led to pre-Socrates philosophical and theological ideas. Greek philosophy by way of an astounding assortment of conjectures and extraordinary panorama of ideas has made fundamental contribution to the origins of brain, mind, and soul.[1] These conflicting ideas included encephalocentrism (Galenism) and cardiocentrism (Aristotelianism). Further development of neurosciences was subsequently hallmarked by the discoveries of Herophilus and Erasistratus on neuroanatomical structure and brain anatomy. The origins of human behavior and the interface of brain, mind, and soul began with the work of Pythagoras, Hippocrates, Plato, Erasistratus, and Galen.

Galen's view hypothesized that vital humors moved to and from the brain ventricles through the hollow nerves to create sensations and movements. This evolved to Descartes' view that conceptualized hydraulic theory of brain and proposed the brain-mind duality. Despite these early views, it was Franz Joseph Gall, in the early 19th century who developed the theory of phrenology based on the notion that specific mental processes are correlated with discrete regions of the brain, conceptualized the brain to have at least 35 organs where each “organ” corresponds to a specific mental faculty. This was the pseudoscience of phrenology, a crude precursor of modern cerebral localization theories. As each of these centers increased in size as a result of use, he proposed that specific patterns of bumps and ridges were created on the skull. His concept of phrenology was based on such anatomical skull changes to be correlated with personality and human behavior. The external craniological signs and phrenological measurements of size and shape of the cranium were believed to reflect the size and shape of the underlying portions of the cerebrum that determined the mental abilities and personality. Although phrenology had no merit, it introduced the idea of cerebral localization of mental functions. Indeed, it was Gall who laid the foundations for the biologically based doctrine of brain-behavior localization.[2],[3]

The “American Crowbar Case” was essentially and undoubtedly an index case to the history of neuroscience. Dr. James Martyn Harlow's report of the case of Phineas Gage in 1848 was one of the earliest descriptions of the personality and behavioral changes following frontal lobe damage. It was one of the great medical curiosities of all time that had influenced nineteenth-century discussion about the mind and brain, and made Phineas Gage the most famous posttraumatic brain injury (work-related freak accident) near-legendary patient in the annals of behavioral and social neurosciences. The astonishing “Phineas Gage story” elucidated a link between brain trauma, prefrontal brain damage, and personality change. This neuroscience case marked the historical beginnings of the study of the biological basis of behavior, the beginnings of neuropsychology, the science of brain localizationism as well as the iconic classic case study in cognitive and social neurosciences. It is to be appreciated that the Gage case had played a role in the debate over phrenology and localization of brain functions more than a decade before Broca and Wernicke.

The Gage story became a classic case in the textbooks of neurology and allied neurosciences, and now, one of the most frequently cited articles from nineteenth-century neurology literature. This remarkable historical event played an influential and pivotal role in the discovery of behavioral syndromes resulting from frontal lobe dysfunction in the era of cortical localization. Later 19th-century cerebral investigations by Paul Broca, Pierre Flourens, David Ferrier, Carl Wernicke, John Hughlings Jackson, and others ushered in the era of cerebral localization, in which cognitive processes were linked to particular parts of the brain. At this juncture, it is worth noting that the current neuroscientific wisdom has now shifted from the doctrine of cerebral localizationism or the traditional belief of neurolocalizationism to “connectionism.” Imaging neuroscience and functional cartography has led to a conceptual shift in understanding of brain functional architecture from the traditional “functional segregation approach” (segregated circuitry) to a “dynamic network approach” mediated by multidimensional distributed neural network connectivity (distributed circuitry).

  Mr. Phineas Gage's Accident and Famous Injury Top

Mr. Phineas Gage, 25 years of age, a railroad foreman, was the company's most efficient and capable foreman. Gage was 5 foot 6 inches tall, physically strong, and had been a responsible, intelligent, temperate habit, possessed considerable energy of character, and a socially well-adapted man, a favorite with his peers and elders.

On Wednesday, 13th of September in 1848 upon the line of the Rutland and Burlington Rail Road, Cavendish, Vermont, New England, where work was going on for building of railroad lines, Phineas Gage was incharge of controlled detonations to level the uneven terrain to lay new rail tracks. This involved drilling holes in the rock stone, partially filling the holes with explosive powder, using a long metal rod called a tamping iron (a crowbar-like tool), covering the powder with sand, and using a fuse to trigger an explosion to excavate rock [Figure 1] and [Figure 2].
Figure 1: Neuroscience's most famous patient: The travel of a tamping iron rod though Gage's skull changed neuroscience forever; phrenology to localizationism of brain functions.

Click here to view
Figure 2: Phineas Gage's famous injury: His skull and the tamping iron rod.

Click here to view

The iron rod was 3 feet 7 inches long; at its widest, had a diameter of 1¼ inches; weighed 13¼ pounds where the top last foot tapered to a point akin to a javelin. On that fateful day, while he was charging a drill hole with gunpowder, a momentary distraction by his men working behind him let Gage tamp the iron rod directly with the rock before his assistant had had a chance to cover it with sand. This spark ignited the gunpowder and the powder exploded that propelled the tamping iron upward from the hole toward Gage and entered his left cheek, the left side of the face, immediately anterior to the angle of the inferior maxillary bone. The tamping iron landed point- first some 80 feet away smeared with blood and brain. It was the last normal moment of his life as he fell victim to a bizarre accidental explosion at 4.30 pm. Taking a direction upward and backward toward the median line, it penetrated the integuments, masseter, and temporal muscles, passed under the zygomatic arch and (probably) fracturing the temporal portion of the sphenoid bone and the floor of the orbit of the left eye, entered the cranium, passing through the anterior left lobe of the cerebrum, and made its exit in the median 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 brain, and protruding the globe of the left eye from its socket, by nearly one half its diameter.[4] After exiting through the top of his head, the momentum of the tamping iron threw Gage on his back and he landed some 25–30 yards away, developed a few convulsive movements but spoke in a few minutes. Despite his horrific injury, Phineas recovered. He could walk, speak, and had normal awareness. He felt steady enough to climb into an oxcart and sat upright for the entire mile-long trip to the hotel of Mr. Jospeh Adams at Cavendish. Gage could get out of the cart himself, and with a little assistance walked up a long flight of stairs, into the hall, where he was dressed. He greeted Edward Higginson Williams, the first medical practitioner to arrive, with “Doctor, here is business enough for you.” Dr. Edward then gave the case over to Dr. John Martyn Harlow who saw Mr. Gage around 6 pm. Dr. Harlow left the wound in the face patulous only to be covered by a simple dressing. The hands and forearms were both deeply burned nearly to the elbows, which were dressed, and the patient was left with the head elevated. The head wound had fragments of skull bone that were uplifted and the brain matter was seen protruding. Mr. Gage's scalp was shaven and his lacerated scalp and skull wounds were closed and dressed. Dr. Harlow and medical practitioner Edward Higginson Williams managed to stem the profuse hemorrhage that stopped around 11 pm and Gage rested that night. From the 23rd of September till the 3rd of October, he was in a semicomatose state as he developed delirium and infection [Figure 3].[4],[5],[6]
Figure 3: Dr. John Martyn Harlow (1819-1907): An American physician remembered in the history of neuroscience for attending Phineas Gage, followed up his case, and who gave primary evidence by his publications in 1848 and 1868.

Click here to view

  Phineas Gage: After the Accident Top

The rod was found later “smeared with blood and brains,” washed in a stream, and eventually, returned to Phineas Gage. Gage lost sight in his left eye, which remained sewn shut the rest of his life. However, he eventually stabilized, and in late November, he returned home to Lebanon, New Hampshire. On January 1, 1849, Gage was able to recover sufficiently from his physical injuries and returned to his family in nearby New Hampshire.

The astonishing fact of Mr. Gage's survival and to medical disbelief was the description of his ability to walk immediately after the event, communicate sensibly, and remain lucid though most of the period following the injury of such magnitude. This “preserved neurological status” postfrontal lobe injury did facilitate P. T. Barnum, who employed Mr. Gage for a short period following his recovery. However, reports of profound personality changes indicate that he was unable to return to his previous job and caused coworkers to comment that “Gage was no longer Gage.”

After probably spending most of the year 1849 for regaining his strength, he traveled to Boston, in the November to be examined by Henry Jacob Bigelow, the Professor of Surgery at Harvard, and was presented to a meeting of the Boston Society for Medical Improvement and the medical students there.[7] Bigelow probably only tested Gage for hard neurological deficits and report and failed to note the changes in Gage's behavior which lends credence to his account that Gage did not have behavioral consequences. He proclaimed that Gage had no demonstrable “mental status” sequelae of the injury.[5]

For several years, Gage undertook manual labor jobs and traveled throughout New England and eventually to Valparaiso, Chile, always in the company of “his iron.” Phineas Gage returned and reunited with his mother and sister in (California) San Francisco, in 1859. After arriving home, he was weak with some kind of illness, and it took several months for recovery after which he was strong enough to work on the farms south of the city. In February 1860, he developed an epileptic fit while sitting at dinner. On May 18, 1860, he returned to his mother's house where he suffered from a series of epileptic seizures and succumbed to it on 21st May 1860, aged 36, and was buried in Lone Mountain Cemetery. He had survived for eleven and a half years after his injury.[8],[9]

Dr. Harlow lost track of Gage, and finally, Harlow obtained consent from Mr. Gage's family to obtain the skull and tamping iron. Later, in 1867, his body was exhumed from San Francisco's Lone Mountain Cemetery, in the presence of Dr. J. D. B. Stillman, Dr. Henri Perrin Coon, the Mayor of San Francisco, and David Dustin Shattuck, Gage's brother-in-law. Gage's skull and the tamping iron sent to Dr. Harlow, then in Woburn, Massachusetts. Harlow reported his findings, including his estimate of the brain damage, in 1868. He then gave the skull and tamping iron to what became the Warren Museum of the Medical School in the Francis A. Countway Library of Medicine of Harvard University.[9] Gage's skull exhibited and tamping iron rod paved the way for modern neurological explorations and investigations to define the precise anatomical location, and quantify the extent and degree of brain damage of Phineas Gage would have sustained without primary autopsy findings [Figure 4].
Figure 4: The skull of Phineas Gage on display at the Warren Anatomical Museum at Harvard Medical School.

Click here to view

  Aftermath: No Longer Gage Top

In this regard, his mind was radically changed, so decidedly that his friends and acquaintances said he was “no longer Gage.”[8] This John Martyn Harlow's famous sentence summarizing the changes in Phineas Gage is chiseled in the annals of history of neurology, cognitive and social neurosciences, and neuropsychology. Amazingly, Gage not only survived this momentous injury, but also he survived as a different man with profound changes to his personality, both of which earned him a place in the annals of neurology and neuropsychiatry. Indirectly, the case also led to psychosurgery, and the abuse of frontal lobotomy that came a century later.

What made the event historic, however, was Dr. Harlow's subsequent observations of the change in Gage's personality.[8] The damage to Phineas' brain had profound psychological consequences. Dr. Harlow's narrative of Gage's mental status in a few hundred words did sum up Gage's personality changes. As a result of this change, the railroad refused to reinstate Gage as foreman. The second report, in 1868 by Dr. John Harlow, was prepared years after Gage's death. In it, he included all the material from the first report and recounted Gage's subsequent life. Harlow based his account on information that he had obtained from Gage's family. Gage's behavior immediately after the injury and tell us how Gage's life subsequently unfolded. In his report published in the Journal of the Massachusetts Medical Society in 1868, Dr. Harlow described the following:

“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, or advice when it conflicts with his desires, at times pertinaciously obstinate, 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.”

Gage's personality, reasoning, and capacity to understand and follow social norms had been diminished or destroyed. He illustrated little to no interest in hobbies or other involvements that at one time, he cared for greatly. “After the accident, Gage became a nasty, vulgar, irresponsible vagrant. His former employer, who regarded him as the most efficient and capable foreman with exemplary work before his accident, refused to rehire him because he was so different.” History labeled Phineas Gage transformation from a clean-cut, virtuous foreman into a dirty, scary, sociopathic drifter.

  the Birth of Neurosciences and Localizationism Top

The era at the time of Phineas Gage injury was entrenched in the field of phrenology which was the only prominent discipline. In phrenological parlance, Nelson Sizer, a prominent American proponent of phrenology (and probably the author of the 1851 APJarticle), suggested that the tamping iron had passed out Gage's head “in the neighborhood of benevolence and the front part of veneration.”[9] Adherents of phrenology contended that Gage's mental changes stemmed from destruction of his mental “organ of benevolence,” the part of the brain responsible for “goodness, benevolence, the gentle character, and the maintenance of social order” and/or the adjacent “organ of Veneration,” an area related to religion and God and respect for peers and those in authority.

Since Dr. Bigelow's report in 1850 pronounced Gage “quite recovered in his faculties of body and mind” history owes its credit to Dr. Harlow who put into context though superficial in about a few hundred words, the behavioral narrative, mental manifestations, and pervasive change in personality and character of Phineas Gage post injury. Dr. Harlow wrote on “Passage of an Iron Rod Through the Head” that originally appeared as a “letter to the editor” of the Boston Medical and Surgical Journal.[4] This report gave a timeline chronology of events of Mr. Gage's condition and Dr. Harlow's treatment from his initial arrival at 6 pm on September 13–November 18 of 1848 when Phineas Gage left for home. It is sad, however, to note that Dr. Harlow published his second report on the aftermath of Phineas Gage injury only 20 years after the accident in 1868.[8] Although unsupported by anatomical autopsy evidence, unlike Broca and Wernicke, in addition to evidence from the modern experimental neuropsychology, Dr. Harlow did still correlate Gage's cognitive and behavioral changes with a presumed area of focal damage in the frontal region.

The role of Harlow and Gage in the annals of history of medicine is worth remembering. After having come to learn of Gage's death about 5 years after its occurrence, it is interesting to note how Dr. Harlow was determined and persisted to have the body exhumed in order that Gage's skull and the tamping iron buried alongside could be recovered and kept as a medical record. This scientific fervor of Dr. Harlow enabled this exhibit to be displayed at the Warren Anatomical Medical Museum at Harvard University. Indeed, Dr. Harlow's medical exhibit later facilitated the modern reconstructions of Gage's skull and promulgating the localizationist concept of brain functions.

Although the Journal of the Massachusetts Medical Society was a periodical with very limited circulation, history of Neuroscience saw light at the end of the tunnel as Dr. David Ferrier, a British physiologist and one of the leaders of the localizationist movement, discovered Harlow's second report and used it as the highlight of his famous 1878 Goulstonian lectures.[10] Dr. Ferrier cited the Gage case as a primary example of how frontal lobe injury can result in changes of personality and higher executive function that are not demonstrable by sensory and motor exam.

  Recent Discoveries Top

It is quintessential to note that the recent discoveries of the classic case can never be confident due to lack of a recorded autopsy and in the absence of the original brain tissue of Phineas Gage. Instead, these recent studies may be only an estimate of the precise location and extent of brain damage (prefrontal gray matter, white matter [WM] connectivity, and region-specific network connectivity) extrapolated from the cranial bony structures.

Since there is little direct evidence of the exact extent of Gage's injuries aside from Harlow's report, bearing in mind Gage's brain was not available for autopsy examination in 1860, it is difficult to know exactly how severely his brain was damaged. This was not the case with Paul Broca's patient “Tan-tan” that provided the milestone for the demonstration of cerebral localization for language production just as patient H.M. (Henry Gustav Molaison) became the index case for the new cognitive neuroscience. However, from the descriptions of Dr. Harlow in 1868, and from the modern reconstructions of the exhumed skull exhibit, Phineas Gage is considered a classic, index case for social neuroscience.

The Phineas Gage case was revisited in 1994 by two Portuguese neurobiologists, Hanna and Antonio Damasio who examined the skull and the trajectory of the tamping iron through the skull with modern computer three-dimensional (3D) reconstruction techniques after making X-rays, photographs, and measurements of Gage's skull.[11] This study, in the modern era of behavioral neurology, neuropsychiatry, cognitive and social neurosciences, extrapolated that most of the damage was done to the ventromedial region of both the left and right prefrontal lobes involving the “social brain” (anterior half of orbitofrontal cortex, polar and anterior mesial frontal regions, and anterior cingulate cortex, sparing supplementary motor cortex, frontal operculum, with subcortical WM damage in the frontal that was more extensive on the left hemisphere than the right) causing

aberrations in rational decision-making, moral/social behavior, and processing of emotion.

Another study by Ratiu et al. 2004, using 3D, computer-aided reconstruction sought to illustrate the trajectory of the tamping iron, characterize the pattern of skull damage and explain the extent of Gage's potential brain damage.[12],[13] In their measurements, Damasio et al. estimated the damage to be more frontal and right sided, whereas Ratiu et al. concluded that damage was limited to the left frontal lobe and that it did not cross the midline. While many authors have focused on the gross damage done by the iron to Gage's frontal cortical gray matter, little consideration has been given to the degree of damage to and destruction of major connections between discretely affected regions and the rest of his brain. In 2012, Van Horn of UCLA's laboratory of neuroimaging reanalyzed the high-resolution scans from the 2004 study to reestimate the path of the projectile, and map the quantum of WM damage, using modern anatomical magnetic resonance imaging and diffusion imaging data to extrapolate the consequences of network-level brain damage.[14] Based on this research, Van Horn et al. concluded that considerable damage was localized to the left frontal cortex and estimated that the iron rod destroyed approximately 11% of the WM in Gage's frontal lobe, and 4% of his cerebral cortex. The WM fascicular damage involved the uncinate fasciculus, cingulum, and superior longitudinal fasciculus that disrupted Gage's region specific network of WM connectivity that explains his putative behavioral issues originally reported by Harlow. The direct damage by the rod was limited to the Gage's left cerebral hemisphere whereas the extensive loss of WM connectivity occurred intra- as well as inter-hemispherically (both hemispheres) [Figure 5].
Figure 5: The studies of Ratiu and Talos (2004) and Van Horn et al. (2012) on the degree and quantum of brain damage extrapolated from modern imaging neurosciences (three-dimensional computed tomography reconstruction) and modeling the path of the tamping iron through the Gage skull to map the white matter connectivity damage in Gage's brain (Skull rendering and modeling using magnetic resonance imaging and diffusion-weighted imaging).

Click here to view

  Unraveling Historical Myths Top

The Phineas Gage accident occurred about 168 years ago and the information of Gage stems from few primary sources, namely, Harlow (1848), Bigelow (1850), then Harlow again (1868), the only physicians fortunate to have examined him and published their observations. There are reasons to believe that some of the accounts of Gage's aftermath and behavioral outcome may not be entirely reliable given the fact that Phineas Gage had survived for eleven and a half years before succumbing to status epilepticus on 21st May 1860. Furthermore, these uncertainties of the precise accounts of the behavioral consequences of the freak accident in 1848 occurred in an era where phrenology was prevailing. In the early 1800s, there was the lack of knowledge of the currently known localizationist concept of brain functions, brain-behavior relationships, apart from Franz Josef Gall's phrenology. Human functions such as language and personality had not been shown to depend on the way the brain worked. The works of Paul Broca on aphasic patients and later Dr. David Ferrier changed the context of phrenology. It was around 1873 that Dr. David Ferrier's monkey experiments that reconceptualized the link between personality changes and prefrontal damage. It is fair to state that it was Dr. Ferrier who rescued Gage from the obscurity of the journal in which Harlow's 1868 report was buried since the Journal of the Massachusetts Medical Society was a periodical with very limited circulation then.

Dr. Harlow's description in few hundred words established in the annals of the history of medicine that damage to Phineas Gage's brain produced profound psychological consequences and personality changes quoted as “No longer Gage.” This would lend credence as to why Phineas' contractors would not reemploy him. Nevertheless, it is astonishing to take cognizance of the fact that (i) Gage traveled around to Boston (1850), Chile (either in 1852 or 1854), and returned to San Francisco in 1859, (ii) Gage had worked for some 18 months for Jonathan Currier who ran a livery stable and coachline service from his Dartmouth Inn, in Hanover, and (iii) Gage went to Chile and worked for almost 7 years in a stagecoach line and drove coaches and cared for horses in Valparaiso. The provoking questions that would arise in this context are (i) How could such a brain damaged Gage live through these stages of his life? (ii) How did Gage learn and practice the complex cognitive-motor skills required of a coach driver in Valparaiso? (iii) Could Phineas Gage have made a reasonable good social and behavioral recovery? (iv) How long did his behavioral aberrations last? (v) Was this mental alteration permanent? and (vi) Did Gage eventually made a surprisingly good psychosocial adaptation to his injury due to neuroplasticity?”

Until recently, there were no known photographs depicting Gage. Another noteworthy addition to this famous tale was the identification of Phineas Gage's daguerreotypes [Figure 6] by Jack and Beverly Wilgus in 2009 where he was seen as a good-looking young man holding his tamping iron with a self-assured, seemingly confident, and assertive in a well-dressed composed demeanor. This would also cast doubts on the well-documented tale of “No longer Gage.” [Figure 6].
Figure 6: Phineas Gage holding the iron bar that caused his injury, in a daguerreotype recently discovered in Southern California and first published by the Los Angeles Times in 2009.

Click here to view

The view that Phineas Gage's accident made him permanently “no longer Gage” needs to be scrutinized critically, and the interested reader may seek answers to these uncertainties by referring to the publications of Malcolm Macmillan of the University of Melbourne, Australia, and that of Zbigniew Kotowicz. Psychologist and historian Malcolm Macmillan stressed the mismatch between what we actually know about Gage and the popular understanding of him.[9],[15],[16],[17] Macmillan suggested that many modern commentators did exaggerate the extent of Gage's personality change perhaps by engaging in a kind of retrospective reconstruction based on what we now know about the role of the frontal cortex in self-regulation.

  Conclusion Top

This case, indeed Neuroscience's the most famous case, played a pivotal role in the discovery of behavioural phenotype after prefrontal brain damage thus making important contributions to early modern neurology. Much of our knowledge about our clinic-anatomical correlation method of brain and complex human behavior derives from the description of historic seminal cases that did help shape neuroscience. The seminal cases of Phineas Gage (on social behavior and decision making) and Broca's famous patient (1861) Monsieur Louis Victor Leborgne, nicknamed “Tan-tan” with slow growing frontal (posterior inferior frontal gyrus) tumour (on language production), Karl Wernicke's stroke patient (1873), and the case of patient H.M. (Henry Gustave Molaison, 1955 on temporal lobe damage and declarative memory post epilepsy surgery of bilateral temporal lobectomy) were groundbreaking realizations on neuro-localizationism that became historical seminal teaching lessons in the annals of Neurology and Neuropsychiatry. We have come a long way from the days of phrenology. The Phineas Gage legend in the annals of neurology illustrates the role of the human prefrontal cortex in understanding the brain-mind interface, the origins of the theory of brain localization and the subsequent understanding of the role of the frontal cortex in self-regulation. The historical case heralds the subsequent transformation in thinking from phrenology to the science of cerebral localizationism in order to explicate the modern biological basis, the region specific networks and WM connectivism that underpins human social and emotional behavior, decision and planning, morality, and reasoning and rationality.

Lives of great men all remind us/We can make our lives sublime

And, departing, leave behind us/Footprints on the sands of time.

Henry Wadsworth Longfellow

, “A Psalm of Life” (1838)

Something, and indeed the ultimate thing, must be left over for the mind to do

–Arthur Schopenhauer (1859)

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Crivellato E, Ribatti D. Soul, mind, brain: Greek philosophy and the birth of neuroscience. Brain Res Bull 2007;71:327-36.  Back to cited text no. 1
Harrington A. Beyond phrenology: Localization theory in the modern era. In: Corsi P, editor. The Enchanted Loom: Chapters in the History of Neuroscience. New York: Oxford University Press; 1991. p. 207-39.  Back to cited text no. 2
Zola-Morgan S. Localization of brain function: The legacy of Franz Joseph Gall (1758-1828). Annu Rev Neurosci 1995;18:359-83.  Back to cited text no. 3
Neylan TC. Frontal lobe function: Mr. Phineas Gage's famous injury. J Neuropsychiatry Clin Neurosci 1999;11:280-1.  Back to cited text no. 4
Harlow JM. Passage of an iron rod through the head. Boston Med Surg J 1848;39:389-93.  Back to cited text no. 5
Barker FG 2nd. Phineas among the phrenologists: The American crowbar case and nineteenth-century theories of cerebral localization. J Neurosurg 1995;82:672-82.  Back to cited text no. 6
Bigelow HJ. Harlow's case of recovery from the passage of an iron bar through the head. Am J Med Sci 1850;20:13-22.  Back to cited text no. 7
Harlow JM. Recovery from the passage of an iron bar through the head. Publ Mass Med Soc 1868;2:327-47.  Back to cited text no. 8
Macmillan M. An Odd Kind of Fame: Stories of Phineas Gage. Cambridge, MA: MIT Press; 2000.  Back to cited text no. 9
Ferrier D. The Goulstonian lectures on the localisation of cerebral disease. Br Med J 1878;1:443-7.  Back to cited text no. 10
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;264:1102-5.  Back to cited text no. 11
Ratiu P, Talos IF. Images in clinical medicine. The tale of Phineas Gage, digitally remastered. N Engl J Med 2004;351:e21.  Back to cited text no. 12
Ratiu P, Talos IF, Haker S, Lieberman D, Everett P. The tale of Phineas Gage, digitally remastered. J Neurotrauma 2004;21:637-43.  Back to cited text no. 13
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:e37454.  Back to cited text no. 14
Macmillan M. Restoring Phineas Gage: A 150th retrospective. J Hist Neurosci 2000;9:46-66.  Back to cited text no. 15
Macmillan M, Lena ML. Rehabilitating Phineas Gage. Neuropsychol Rehabil 2010;20:641-58.  Back to cited text no. 16
Kotowicz Z. The strange case of Phineas Gage. Hist Human Sci 2007;20:115-31.  Back to cited text no. 17


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

This article has been cited by
1 The adaptive unconscious in psychoanalysis
Jessica Leonardi,Francesco Gazzillo,Nino Dazzi
International Forum of Psychoanalysis. 2021; : 1
[Pubmed] | [DOI]
2 Clinical cases and metaphysical theories of personal identity
Gabriel Andrade
Medicine, Health Care and Philosophy. 2018;
[Pubmed] | [DOI]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Mr. Phineas Gage...
Phineas Gage: Af...
Aftermath: No Lo...
the Birth of Neu...
Recent Discoveries
Unraveling Histo...
Article Figures

 Article Access Statistics
    PDF Downloaded920    
    Comments [Add]    
    Cited by others 2    

Recommend this journal