No Longer Gage

Phineas Gage was twenty five and in charge of a gang blasting a cutting for the Rutland and Burlington Railroad outside Cavendish, Vermont. The job was to drill a hole in the rock, pour in powder, add a fuse, cover it with sand, and tamp the whole thing down with an iron bar before lighting it.

On 13 September 1848 the sand had not gone in yet. Gage brought the bar down onto the powder, the charge went off, and the iron came back out of the hole through his head.

It was forty three inches long and weighed thirteen pounds. It entered under his left cheekbone, passed behind his eye, went through the front of his brain and out through the top of his skull, and landed some distance away.

He did not lose consciousness for long. Within a few minutes he was sitting up and talking, and he walked with a little help to the cart that took him back to the village.

What the doctor wrote

John Martyn Harlow, a country physician in Cavendish, took the case. Gage survived the injury, survived the infection that followed it, and was walking about within a couple of months, which was the extraordinary part at the time. Harlow published an account of the survival in 1849.

Twenty years later, in 1868, he published a second one, and it is the second that made Gage famous. Harlow wrote that the balance between Gage's intellectual faculties and his animal propensities seemed to have been destroyed. He described a man who had become fitful, irreverent, impatient of restraint, and unable to settle on a plan and stick to it.

Then he reported what the people who had worked with Gage said about him. They said he was no longer Gage.

That is the phrase the whole thing rests on. Three words, reported second hand, twenty years after the event, by the one doctor who had an interest in the case being significant.

Why it mattered so much

In 1848 the argument about whether different parts of the brain did different jobs was live and unresolved. Gage was the case that pushed it. Here was a man with a specific, visible, survivable hole in the front of his brain, who could still walk, speak, remember, calculate and work, but whose judgement and self control were said to have altered.

That combination is the whole thesis of the frontal lobes in one patient. It is why every introductory psychology course still runs the story, and why his skull and the iron are in a museum collection at Harvard rather than in a grave in California.

The seven years nobody mentions

Here is what does not usually get told alongside it.

Gage recovered enough to work. He did farm jobs, then drove a coach in New Hampshire. In 1852 he went to Chile and spent about seven years driving stagecoaches on the road between Valparaiso and Santiago.

Think about what that job requires. A team of six horses handled together on mountain roads. Fares taken and counted from strangers in a language he had to learn. A timetable. A route held in the head. Passengers whose safety depends on the driver's judgement, every day, for seven years.

That is not the man in the popular version of the story. The popular version has Gage as a wreck, drifting, unemployable, a drunk, a fairground exhibit, sometimes a criminal. There is no historical evidence for any of that. It accreted onto the case over a century of retelling because a ruined man makes a cleaner illustration of frontal lobe damage than a man who got a difficult job and kept it.

Researchers who went back to the primary material, principally the psychologist Malcolm Macmillan, have argued that Gage recovered substantially in the decade after the injury, and that the Chilean years are the strongest evidence of it.

What actually happened to him

He left Chile in 1859 and went to his family in California. In early 1860 he began having seizures, which grew more frequent and more severe. He died on 21 May 1860, aged thirty six, nearly twelve years after the bar went through his head.

He was buried in San Francisco. Some years later Harlow, who had lost touch and only learned of the death by writing to the family, arranged for the skull to be exhumed and sent to him, and it went with the tamping iron into the Warren Anatomical Museum.

What the case is actually evidence of

It is worth separating two claims that get merged.

The first is that damage to the front of the brain can change personality and judgement while leaving movement, speech and memory intact. Gage supports that, and a great deal of later work with better records supports it too.

The second is the specific portrait of what Gage became, and that rests on very little. One doctor's recollection, published two decades later, of what other people had said. No systematic examination. No baseline description of what Gage was like before, beyond that his employers had thought him their most efficient and capable foreman. Nothing written by Gage himself.

A field was founded on a case study with a sample size of one, no controls, and a twenty year gap between the event and the description of its most important consequence. That is not an attack on Harlow, who was a careful man doing his best in a Vermont village. It is a comment on how much weight a single vivid story can be made to carry once it becomes the story everybody uses.

The skull is still at Harvard, sawn into pieces so the path can be seen. The iron is beside it. Gage himself is the part that got simplified.

Sources

• Science History Institute, "Everything You Know About Phineas Gage Is Wrong" (Harlow's record of Gage becoming less planful and coarser in speech and the ambiguity of the animal propensities phrase; Gage's recovery on the family farm, his work as a carriage driver in New Hampshire, his move to Chile in 1852 and about seven years driving horse coaches between Valparaiso and Santiago, involving a team of six horses, fare collection and route memorisation; the argument by modern historians that he recovered substantially in the decade after the accident; the absence of any historical evidence for the rumours that he became a criminal, a drinker or a confidence man; and his departure from Chile in 1859, the onset of seizures in early 1860 and his death on 21 May 1860 at the age of thirty six, nearly twelve years after the injury).
• Smithsonian Magazine, "Phineas Gage: Neuroscience's Most Famous Patient" (the accident of 13 September 1848 at Cavendish, Vermont while working on the Rutland and Burlington Railroad; the tamping iron of forty three inches and thirteen pounds entering under the left cheekbone, passing behind the eye and out through the top of the skull; Gage remaining conscious and able to speak; Harlow's treatment and his 1868 account; and the reported judgement of those who knew him that he was no longer Gage).
• Malcolm Macmillan, discussed in The British Psychological Society, "Phineas Gage: unravelling the myth" (the reassessment of the primary sources, the thinness of the contemporary record, and the case for social recovery in the years after the injury).
• Countway Library, Harvard Medical School, "Phineas Gage's skull and tamping iron, Warren Anatomical Museum" (the survival of the skull and the iron in the museum collection and the condition in which the skull is held).
• Simply Psychology, "What Happened to Phineas Gage?" (the sequence of the blasting work at Cavendish, the dimensions and weight of the tamping iron, the path of the injury and Harlow's role as attending physician).
• NPR, "The Face Of A Famous Skull, Found On Flickr" (the identification of the surviving portrait of Gage holding the tamping iron, and the reassessment of his condition that followed it).