Phineas Gage Case Study Psychology

PHINEAS GAGE (1823-1860) is one of the earliest documented cases of severe brain injury. Gage is the index case of an individual who suffered major personality changes after brain trauma. As such, he is a legend in the annals of neurology, which is largely based on the study of brain-damaged patients.

Gage was foreman of a crew of railroad construction workers who were excavating rocks to make way for the railroad track. This involved drilling holes deep into the rock and filling them with dynamite. A fuse was then inserted, and the entrance to the hole plugged with sand, so that the force of the explosion would be directed into the boulder. This was done with a crow bar-like tool called a tamping iron.

On 13th September, 1848, 25-year-old Gage and his crew were working on the Rutland and Burlington Railroad near Cavendish in Vermont. Gage was preparing for an explosion by compacting a bore with explosive powder using a tamping iron. While he was doing this, a spark from the tamping iron ignited the powder, causing the iron to be propelled at high speed straight through his skull. It entered under the left cheek bone and exited through the top of the head, and was later recovered some 30 yards from the site of the accident.

John Martin Harlow, the doctor who attended to him, later noted that the tamping iron was found “several rods [1 rod= 5.02m] behind him, where it was afterward picked up by his men smeared with blood and brain”. The tamping iron was 3 ft. 8 inches in length and 1.25 inches in diameter at one end, not 1.25 inches in circumference, as reported in the newspaper report on the left. It tapered at one end, over a distance of about 1 ft., to a blunt end 0.25 inches in diameter, and weighed more than 6 kg.

Whether or not Gage lost consciousness is not known, but, remarkably, he was conscious and able to walk within minutes of the accident. He was then seated in an oxcart, on which he was transported three-quarters of a mile to the boarding house where he was staying. Here, he was attended to by Harlow, the local physician. At the boarding house, Harlow cleaned Gage’s wounds by removing small fragments of bone, and replaced some of the larger skull fragments that remained attached but had been displaced by the tamping iron. He then closed the larger wound at the top of Gauge’s head with adhesive straps, and covered the opening with a wet compress. Gage’s wounds were not treated surgically, but were instead left open to drain into the dressings.

Within a few days of his accident, Gage’s exposed brain became infected with a “fungus”, and he lapsed into a semi-comatose state. His family prepared a coffin for him, but Gage recovered. Two weeks after the accident, Harlow released 8 fluid ounces of pus from an abscess under Gage’s scalp, which would otherwise have leaked into the brain, with fatal consequences. By 1st January 1849, Gage was leading an apparently normal life.

Harlow’s case report of Gage’s injuries appeared as a letter to the editor of the Boston Medical and Surgical Journal. The report of the “hitherto unparalleled case” contains few neurological details, and was at first met with skepticism, because it was thought that no-one could survive such an extreme injury. Harlow describes Gage’s injury as follows:

[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.

Harlow goes on to describe how, while examining Gage, he determined that no bone fragments remained inside the skull:

…in searching to ascertain if there were other foreign bodies there, I passed in the index finger its whole length, without the least resistance, in the direction of the sound [of the hemorrhaging?] in the cheek, which received the other finger in like manner.

A second report was published in 1850 by Henry J. Bigelow, a professor of surgery at Harvard University. Bigelow emphasised Gage’s lack of symptoms, and reported that Gage was “quite recovered in faculties of body and mind”. Because of the disbelief with which Harlow’s 1848 report was met, it was, for the next 20 years, Bigelow’s account that came to be generally accepted by the medical community.

Gage did, according to Harlow, retain “full possession of his reason” after the accident, but his wife and other people close to him soon began to notice dramatic changes in his personality. It wasn’t until 1868 that Harlow documented the “mental manifestations” of Gage’s brain injuries, in a report published in the Bulletin of the Massachusetts Medical Society:

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.”

On the right is one of three figures from Harlow’s 1868 paper. The legend reads:

Front and lateral view of the cranium, representing the direction in which the iron traversed its cavity; the present appearance of the line of fracture, and also the large anterior fragment of the frontal bone, which was entirely detached, replaced and partially re-united.

Thus, the damage to Gage’s frontal cortex had resulted in a complete loss of social inhibitions, which often led to inappropriate behaviour. In effect, the tamping iron had performed a frontal lobotomy on Gage, but the exact nature of the damage incurred to his brain has been a subject of debate ever since the accident occurred. This is because the damage can only be inferred from the path of the tamping iron through Gage’s skull, which in turn can only be inferred from the damage to the skull.

Gage’s skull was damaged in three places: there is a small wound under the left zygomatic arch (cheek bone) where the tamping iron entered; another is located in the orbital bone in the base of the skull behind the orbit of the eye; and the third, and largest, wound is in the top of the skull, where the tamping iron exited. The exit wound was enormous, and never healed. It can be seen today in Gage’s as an irregularly-shaped triangular hole, about 2 inches wide and 4 inches in circumference, and another, nearly 3 inches in circumference. These are separated by one of the flaps of skull that was replaced by Harlow upon arriving at Gage’s boarding house. Because the circumference of the wound in the frontal bone is much larger than the maximum diameter of the tamping iron, it is difficult to determine precisely the trajectory of the iron and where it exited Gage’s skull.

In 1994, Hannah Damasio and her colleagues at the University of Iowa used neuroimaging techniques to reconstruct Gage’s skull. The conclusion of this study was that Gage incurred damage to both the left and right prefrontal cortices. But according to computer-generated three-dimensional reconstructions of a thin slice computed tomography scan of Gage’s skull performed by Ratiu et al(see image and film clip above), the damage to Gage’s brain was limited to the left hemisphere.

Nevertheless, the case of Phineas Gage made important contributions to early modern neurology. The opposition to Harlow’s 1848 report was due in no small part to the popularity of phrenology at that time. The publication of Harlow’s 1868 report of Gage’s personality changes was significant, as it coincided with reports from other neurologists of the effects of specific lesions on behaviour.

This was a time when modern neuropsychology had begun to replace phrenology. In 1865, Paul Broca (1824-1880) described the speech centre in the left hemisphere of right-handed people; that brain region, in the inferior frontal gyrus, is now known as Broca’s area. Also in the 1860s, John Hughlings-Jackson (1835-1911) and David Ferrier carried out (1843-1928) physiological studies which pointed to the localization of cerebral function.

Jackson had been the first to hypothesize that psychopathological conditions could be correlated to brain damage. He also localized the auditory cortex and in 1864, confirmed Broca’s findings that, in right-handed people, speech was localized to a specific area of the left temporal lobe. Ferrier, an early proponent of the localization of cerebral function, used Gage’s case as the highlight of his famous Goulstonian lecture in 1878. In the same lecture, he also described experiments on monkeys, which led him to the conclusion that:

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 to their character…removal or destruction…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…while not actually deprived of intelligence, they had lost, to all appearance, the faculty of the attentive and intelligent observation [Regarding the trajectory of the tamping iron through Gage’s brain]…the absence of paralysis in this case is quite in harmony with the results of experimental physiology.

Gage’s case, therefore, had confirmed Ferrier’s findings that damage to the prefrontal cortex could result in personality changes while leaving other neurological functions intact. Gage’s case is one of the very first which provides evidence that the frontal cortex is involved in personality. Today, the role of frontal cortex in social cognition and executive function is relatively well established; however, this area of research is yet to blossom, and neuroscientists know little more about the relationship between the mind and the brain than did the early neurologists of the 19th century.

So, what of Phineas Gage himself? Unable to return to his previous job as a foreman after his accident, Gage is said to have travelled around New England, and even to Europe, with his tamping iron trying to earn money. It is also said that he even displayed himself as a curiosity at Barnum’s Museum in New York. However, the story of Phineas Gage is as much folklore as it is fact. Not only the exact nature of the neurological damage Gage sustained, but also the details of his life after the accident, are disputed to this day.

It is known that, from 1851 until just before his death, Gage worked as a coach driver, first in a livery stable at the Dartmouth Inn, in Hanover, New Hampshire, for about 18 months, and then in Chile for some 7 years. At some point in 1859, with his health deteriorating, Gage went to live with his mother. He died in San Francisco on 20th May, 1860, some 12 years after his accident, of complications arising as a result of epileptic convulsions. An autopsy on Gage’s brain was not conducted.

In 1867, Gage’s body was exhumed from its burial place in San Francisco’s Lone Mountain Cemetery. Gage’s brother-in-law took the skull and the tamping iron to Dr. Harlow, who was then living in Woburn, Massachusetts. They are now housed in the Warren Anatomical Museum at Harvard University School of Medicine.


Boston Post newspaper report and Webster Wyman photo of skull and tamping iron reproduced with permission from An Odd Kind of Fame: Stories of Phineas Gage, by Malcolm Macmillan. MIT Press, 2000.

ByChristian Jarrett

These ten characters have all had a huge influence on psychology and their stories continue to intrigue each new generation of students. What’s particularly fascinating is that many of their stories continue to evolve – new evidence comes to light, or new technologies are brought to bear, changing how the cases are interpreted and understood. What many of these 10 also have in common is that they speak to some of the perennial debates in psychology, about personality and identity, nature and nurture, and the links between mind and body.

Phineas Gage
One day in 1848 in Central Vermont, Phineas Gage was tamping explosives into the ground to prepare the way for a new railway line when he had a terrible accident. The detonation went off prematurely, and his tamping iron shot into his face, through his brain, and out the top of his head. Remarkably Gage survived, although his friends and family reportedly felt he was changed so profoundly (becoming listless and aggressive) that “he was no longer Gage.” There the story used to rest – a classic example of frontal brain damage affecting personality. However, recent years have seen a drastic reevaluation of Gage’s story in light of new evidence. It’s now believed that he underwent significant rehabilitation and in fact began work as a horse carriage driver in Chile. A simulation of his injuries suggested much of his right frontal cortex was likely spared, and photographic evidence has been unearthed showing a post-accident dapper Gage. Not that you’ll find this revised account in many psychology textbooks: a recent analysis showed that few of them have kept up to date with the new evidence.

Find out more: Using brain imaging to reevaluate psychology’s three most famous cases
Neuroscience still haunted by Phineas Gage
Phineas Gage – Unravelling the Myth
Looking back: Blasts from the past
Coverage of Phineas Gage in the book Great Myths of the Brain

H.M.
Henry Gustav Molaison (known for years as H.M. in the literature to protect his privacy), who died in 2008, developed severe amnesia at age 27 after undergoing brain surgery as a form of treatment for the epilepsy he’d suffered since childhood. He was subsequently the focus of study by over 100 psychologists and neuroscientists and he’s been mentioned in over 12,000 journal articles! Molaison’s surgery involved the removal of large parts of the hippocampus on both sides of his brain and the result was that he was almost entirely unable to store any new information in long-term memory (there were some exceptions – for example, after 1963 he was aware that a US president had been assassinated in Dallas). The extremity of Molaison’s deficits was a surprise to experts of the day because many of them believed that memory was distributed throughout the cerebral cortex. Today, Molaison’s legacy lives on: his brain was carefully sliced and preserved and turned into a 3D digital atlas and his life story is reportedly due to be turned into a feature film based on the book researcher Suzanne Corkin wrote about him: Permanent Present Tense, The Man With No Memory and What He Taught The World.

Find out more: Using brain imaging to reevaluate psychology’s three most famous cases
Henry Molaison: the amnesiac we’ll never forget
Understanding amnesia – Is it time to forget HM?

Leborgne’s brain is housed at
the Musée Dupuytren museum in Paris

Victor Leborgne (nickname “Tan”)
The fact that, in most people, language function is served predominantly by the left frontal cortex has today almost become common knowledge, at least among psych students. However, back in the early nineteenth century, the consensus view was that language function (like memory, see entry for H.M.) was distributed through the brain. An eighteenth century patient who helped change that was Victor Leborgne, a Frenchman who was nicknamed “Tan” because that was the only sound he could utter (besides the expletive phrase “sacre nom de Dieu”). In 1861, aged 51, Leborgne was referred to the renowned neurologist Paul Broca, but died soon after. Broca examined Leborgne’s brain and noticed a lesion in his left frontal lobe – a segment of tissue now known as Broca’s area. Given Leborgne’s impaired speech but intact comprehension, Broca concluded that this area of the brain was responsible for speech production and he set about persuading his peers of this fact – now recognised as a key moment in psychology’s history. For decades little was known about Leborgne, besides his important contribution to science. However, in a paper published in 2013, Cezary Domanski at Maria Curie-Sklodowska University in Poland uncovered new biographical details, including the possibility that Leborgne muttered the word “Tan” because his birthplace of Moret, home to several tanneries.

Find out more: Glimpsed at last – the life of neuropsychology’s most important patient
Using brain imaging to reevaluate psychology’s three most famous cases

Wild Boy of Aveyron
The “Wild boy of Aveyron” – named Victor by the physician Jean-Marc Itard – was found emerging from Aveyron forest in South West France in 1800, aged 11 or 12, where’s it’s thought he had been living in the wild for several years. For psychologists and philosophers, Victor became a kind of “natural experiment” into the question of nature and nurture. How would he be affected by the lack of human input early in his life? Those who hoped Victor would support the notion of the “noble savage” uncorrupted by modern civilisation were largely disappointed: the boy was dirty and dishevelled, defecated where he stood and apparently motivated largely by hunger. Victor acquired celebrity status after he was transported to Paris and Itard began a mission to teach and socialise the “feral child”. This programme met with mixed success: Victor never learned to speak fluently, but he dressed, learned civil toilet habits, could write a few letters and acquired some very basic language comprehension. Autism expert Uta Frith believes Victor may have been abandoned because he was autistic, but she acknowledges we will never know the truth of his background. Victor’s story inspired the 2004 novel The Wild Boy and was dramatised in the 1970 French film The Wild Child.

Find out more: Case Study: The Wild Boy of Aveyron (BBC Radio 4 documentary).

Kim Peek
Nicknamed ‘Kim-puter’ by his friends, Peek who died in 2010 aged 58, was the inspiration for Dustin Hoffman’s autistic savant character in the multi-Oscar-winning film Rain Man. Before that movie, which was released in 1988, few people had heard of autism, so Peek via the film can be credited with helping to raise the profile of the condition. Arguably though, the film also helped spread the popular misconception that giftedness is a hallmark of autism (in one notable scene, Hoffman’s character deduces in an instant the precise number of cocktail sticks – 246 – that a waitress drops on the floor). Peek himself was actually a non-autistic savant, born with brain abnormalities including a malformed cerebellum and an absent corpus callosum (the massive bundle of tissue that usually connects the two hemispheres). His savant skills were astonishing and included calendar calculation, as well as an encyclopaedic knowledge of history, literature, classical music, US zip codes and travel routes. It was estimated that he read more than 12,000 books in his life time, all of them committed to flawless memory. Although outgoing and sociable, Peek had coordination problems and struggled with abstract or conceptual thinking.

Find out more: New York Times Obit for Kim Peek.
Autism – myth and reality
Calendar calculating savants with autism – how do they do it?
I Am a Calendar Calculator

Image: Wikipedia

Anna O.
“Anna O.” is the pseudonym for Bertha Pappenheim, a pioneering German Jewish feminist and social worker who died in 1936 aged 77. As Anna O. she is known as one of the first ever patients to undergo psychoanalysis and her case inspired much of Freud’s thinking on mental illness. Pappenheim first came to the attention of another psychoanalyst, Joseph Breuer, in 1880 when he was called to her house in Vienna where she was lying in bed, almost entirely paralysed. Her other symptoms include hallucinations, personality changes and rambling speech, but doctors could find no physical cause. For 18 months, Breuer visited her almost daily and talked to her about her thoughts and feelings, including her grief for her father, and the more she talked, the more her symptoms seemed to fade – this was apparently one of the first ever instances of psychoanalysis or “the talking cure”, although the degree of Breuer’s success has been disputed and some historians allege that Pappenheim did have an organic illness, such as epilepsy. Although Freud never met Pappenheim, he wrote about her case, including the notion that she had a hysterical pregnancy, although this too is disputed. The latter part of Pappenheim’s life in Germany post 1888 is as remarkable as her time as Anna O. She became a prolific writer and social pioneer, including authoring stories, plays, and translating seminal texts, and she founded social clubs for Jewish women, worked in orphanages and founded the German Federation of Jewish Women.

Find out more: Freud’s Anna O. Social work’s Bertha Pappenheim [pdf document]
A Dangerous Method is a feature film about another influential patient of psychoanalysis, Sabina Spielrein, who subsequently became a psychoanalyst herself.

Image: Wikipedia

Kitty Genovese
Sadly, it is not really Kitty Genovese the person who has become one of psychology’s classic case studies, but rather the terrible fate that befell her. In 1964 in New York, Genovese was returning home from her job as a bar maid when she was attacked and eventually murdered by Winston Mosely. What made this tragedy so influential to psychology was that it inspired research into what became known as the Bystander Phenomenon – the now well-established finding that our sense of individual responsibility is diluted by the presence of other people. According to folklore, 38 people watched Genovese’s demise yet not one of them did anything to help, apparently a terrible real life instance of the Bystander Effect. However, the story doesn’t end there because historians have since established the reality was much more complicated – at least two people did try to summon help, and actually there was only one witness the second and fatal attack. While the main principle of the Bystander Effect has stood the test of time, modern psychology’s understanding of the way it works has become a lot more nuanced. For example, there’s evidence that in some situations people are more likely to act when they’re part of a larger group, such as when they and the other group members all belong to the same social category (such as all being women) as the victim.

Find out more: The truth behind the story of Kitty Genovese and the bystander effect
Foundations of sand? The lure of academic myths in psychology
37 is a short film about the Genovese murder

Little Albert

“Little Albert” was the nickname that the pioneering behaviourist psychologist John Watson gave to an 11-month-old baby, in whom, with his colleague and future wife Rosalind Rayner, he deliberately attempted to instill certain fears through a process of conditioning. The research, which was of dubious scientific quality, was conducted in 1920 and has become notorious for being so unethical (such a procedure would never be given approval in modern university settings). Interest in Little Albert has reignited in recent years as an academic quarrel has erupted over his true identity. A group led by Hall Beck at Appalachian University announced in 2011 that they thought Little Albert was actually Douglas Merritte, the son of a wet nurse at John Hopkins University where Watson and Rayner were based. According to this sad account, Little Albert was neurologically impaired, compounding the unethical nature of the Watson/Rayner research, and he died aged six of  hydrocephalus (fluid on the brain). However, this account was challenged by a different group of scholars led by Russell Powell at MacEwan University in 2014. They established that Little Albert was more likely William A Barger (recorded in his medical file as Albert Barger), the son of a different wet nurse. Earlier this year, textbook writer Richard Griggs weighed up all the evidence and concluded that the Barger story is the more credible, which would mean that Little Albert in fact died 2007 aged 87.

Find out more: Little Albert – one of the most famous research participants in psychology’s history – but who was he?
Looking back: Finding Little Albert

Chris Sizemore
Chris Costner Sizemore is one of the most famous patients to be given the controversial diagnosis of multiple personality disorder, known today as dissociative identity disorder. Sizemore’s alter egos apparently included Eve White, Eve Black, Jane and many others. By some accounts, Sizemore expressed these personalities as a coping mechanism in the face of traumas she experienced in childhood, including seeing her mother badly injured and a man sawn in half at a lumber mill. In recent years, Sizemore has described how her alter egos have been combined into one united personality for many decades, but she still sees different aspects of her past as belonging to her different personalities. For example, she has stated that her husband was married to Eve White (not her), and that Eve White is the mother of her first daughter. Her story was turned into a movie in 1957 called The Three Faces of Eve (based on a book of the same name written by her psychiatrists). Joanne Woodward won the best actress Oscar for portraying Sizemore and her various personalities in this film. Sizemore published her autobiography in 1977 called I’m Eve. In 2009, she appeared on the BBC’s Hard Talk interview show.

Find out more: the Chris Costner Sizemore Papers at Duke University. 

David Reimer
One of the most famous patients in psychology, Reimer lost his penis in a botched circumcision operation when he was just 8 months old. His parents were subsequently advised by psychologist John Money to raise Reimer as a girl, “Brenda”, and for him to undergo further surgery and hormone treatment to assist his gender reassignment. Money initially described the experiment (no one had tried anything like this before) as a huge success that appeared to support his belief in the important role of socialisation, rather than innate factors, in children’s gender identity. In fact, the reassignment was seriously problematic and Reimer’s boyishness was never far beneath the surface. When he was aged 14, Reimer was told the truth about his past and set about reversing the gender reassignment process to become male again. He later campaigned against other children with genital injuries being gender reassigned in the way that he had been. His story was turned into the book As Nature Made Him, The Boy Who Was Raised As A Girl by John Colapinto, and he is the subject of two BBC Horizon documentaries. Tragically, Reimer took his own life in 2004, aged just 38.

Find out more: What were the real reasons behind David Reimer’s suicide?
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main sources and further reading
The Rough Guide to Psychology
Great Myths of the Brain.
10 of The Most Counter-Intuitive Psychology Findings Ever Published
The 10 Most Controversial Psychology Studies Ever Published

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

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