what does the case study of phineas gage teach us

Phineas Gage: His Accident and Impact on Psychology

Olivia Guy-Evans, MSc

Associate Editor for Simply Psychology

BSc (Hons) Psychology, MSc Psychology of Education

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

Learn about our Editorial Process

Saul McLeod, PhD

Editor-in-Chief for Simply Psychology

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

Saul McLeod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

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Key Takeaways

• In 1848, 25-year-old Phineas Gage survived an accident where an iron rod was propelled through his left cheek and skull. He made an improbable recovery and lived for 12 more years.

Examination of Gage’s exhumed skull in 1867 revealed the probable trajectory of the tamping iron through left frontal lobe structures, offering insight into his improbable survival and selective changes in behavior following this massive traumatic brain injury.

• Gage’s case is famous in psychology as it shows the resilience of the human brain and profoundly influenced early understanding of cerebral localization.

What happened to Phineas Gage?

Phineas Gage was an American railroad construction foreman born in 1823 near Lebanon, New Hampshire.

On September 13, 1848, when Gage was 25 years old, he was working in Cavendish, Vermont, leading a crew preparing a railroad bed for the Rutland and Burlington Railroad by blasting away rock using explosives.

Around 4:30 pm, as Gage was using a 43-inch-long, 13-pound iron tamping rod to pack the explosive powder into a hole in the rock, the powder detonated unexpectedly.

The tamping iron launched from the hole and entered the left side of Gage’s face from the bottom up.

The iron rod entered Gage’s left cheek near the lower jaw hinge, passing behind his left eye socket, penetrating the base of his skull, traversing the left frontal lobe upwards at an angle, and exiting through the top frontal portion of his skull before landing about 25-30 yards behind him.

After the incident, Gage was thrown onto his back from the force of the iron rod and had some brief convulsions of the arms and legs.

Within minutes, however, assisted by his crew, Gage could stand, speak, and walk to an oxcart to be transported nearly a mile to the inn where he resided in Cavendish village.

Dr. Edward H. Williams arrived about an hour later to examine Gage. In his 1848 report, Williams noted visible pulsations of Gage’s exposed brain through an inverted funnel-shaped opening at the top of his skull from which brain tissue protruded.

Williams claimed that Gage was recounting his injuries to bystanders, and he did not initially believe the story, thinking that Gage was ‘deceived.’

Apparently, Gage had greeted Williams by angling his head at him and saying, ‘Here’s business enough for you.’

During repeated episodic vomiting, Williams observed additional small amounts of Gage’s brain matter expelled onto the floor through the frontal exit wound, as the cerebral tissue had likely detached from the skull during the passage of the tamping iron.

From Harlow’s written account, Gage was considered to be fully recovered and felt fit enough to reapply for his previous role as a foreman.

After an arduous early recovery, Gage eventually regained physical health, though his personality was markedly altered. He lived another 11 years before dying from severe epilepsy in 1860 at age 36.

How Did Phineas Gage’s Personality Change?

The descriptions of Gage’s personality and behavior before the accident are limited.

Before his accident, 25-year-old Gage was described by his railroad employers as a capable and efficient foreman, displaying a strong work ethic, drive, and dependability in overseeing his crews.

However, after surviving passage of the tamping iron through his frontal lobe in 1848, significant changes in Gage’s personality emerged during his physical recovery.

The contractors, who had regarded Gage as ‘efficient and capable’ before the accident, could no longer offer him work due to considerable changes in Gage’s personality.

In medical reports by Dr. John Martyn Harlow in 1848 and 1868, Gage is depicted as struggling with volatility, profanity, little deference for others, impatience, obstinance, unpredictability, and devising plans hastily abandoned.

Harlow wrote that Gage’s equilibrium between intellectual faculties and animal propensities was destroyed, reverting to childlike mental capacity regarding self-restraint and social appropriateness.

Though the specific neuroanatomical links were unclear at the time, Friends and colleagues felt Gage was “no longer Gage” after the traumatic brain injury, unable to process emotions or control impulsive behavior like his pre-accident self.

The shocking changes aligned with emerging localization theories that the frontal lobes regulate personality.

Marlow (1868) described Gage as follows:

“The equilibrium or balance, so to speak, between his intellectual faculties and animal propensities, seems to have been destroyed. He is fitful, irreverent, indulging at times in the grossest profanity (which was not previously his custom), manifesting but little deference for his fellows, impatient of restraint or advice when it conflicts with his desires, at times pertinaciously obstinate, yet capricious and vacillating, devising many plans of future operations, which are no sooner arranged than they are abandoned in turn for others appearing more feasible. A child in his intellectual capacity and manifestations, he has the animal passions of a strong man.”

“Previous to his injury, though untrained in the schools, he possessed a well-balanced mind, and was looked upon by those who knew him as a shrewd, smart business man, very energetic and persistent in executing all his plans of operation. In this regard his mind was radically changed, so decidedly that his friends and acquaintances said he was ‘no longer Gage.”

Through Harlow’s reports, it can be suggested that Gage’s personality changed due to the accident he endured.

The accounts imply that the injury led to a loss of social inhibition, meaning that Gage would behave in ways that were considered inappropriate.

Accuracy of Sources

In his 1848 and 1868 reports, Dr. Harlow provides a limited description of Gage’s pre-accident, stating he was “temperate inhabit, of great energy of character, possessed of considerable stamina of both brain and body” and was “a great favorite” with his men (Harlow, 1848, 1868).

However, later accounts add exaggerated positive traits not found in Harlow’s description. For example, Suinn (1970) describes Gage as enjoying “the respect as well as the favor of his men,” while Myers (1998) calls him “soft-spoken,” and Lahey (1992) says he was “polite and reasonable.”

Other sources paint him as friendly, affable, dependable, conscientious, and happy (Macmillan, 2000).

Similarly, post-accident descriptions often emphasize Gage’s negative qualities while ignoring any positive traits he retained.

Harlow documents personality changes but notes Gage remained employable for a period as a long-distance stagecoach driver in Chile (Harlow, 1868).

However, many accounts focus solely on traits like aggression, unreliability, or aimlessness (Macmillan, 2000). Damasio goes so far as to describe him as behaving violently with no self-control (Blakeslee, 1994).

In this way, later accounts tend to polish Gage’s pre-accident image as an upstanding citizen while presenting an almost cartoonishly perturbed version post-injury – neither in keeping with Harlow’s more nuanced clinical descriptions.

This likely reflects enthusiasm for fitting Gage’s case to localization theories. Macmillan (2000) argues that we must cautiously analyze such embellished personality descriptions when assessing Phineas Gage’s legacy.

Severity of Gage’s Brain Damage

When Gage died in 1861, no autopsies were performed until his skull was later recovered by Harlow years later. The brain damage that caused the significant personality changes was presumed to have involved the left frontal region of the brain.

It was not until 1994 that complex computer-based methods to examine brain damage could be used to investigate whether other areas of the brain were affected.

Damasio et al. (1994) used measurements from Gage’s skull and neuroimaging techniques to determine the exact placement of the entry and exit point of the iron rod on a replica model (see Fig. 1).

They found that the damage caused by the rod involved both the left and right prefrontal cortices.

The left and right cortices are responsible for emotional processing and rational decision-making; therefore, it can be assumed that Gage had deficits in these areas.

A later study by Ratiu et al. (2004) also investigated Gage’s injury and the location of where the iron rod entered and exited the head. They used Gage’s actual skull rather than a model of it, as Damasio et al. (1994) had used.

Ratiu et al. (2004) generated three-dimensional reconstructions of the skull using computed tomography scans (CAT) and found that the extent of the brain injury was limited to the left frontal lobe only and did not extend to the right lobe (see Fig. 2).

More recently, Van Horn et al. (2012) used a CAT scan of Gage’s skull as well as magnetic resonance imaging (MRI) data obtained from male participants of a similar age to Gage at the time (aged 25-36).

Their results supported Ratiu et al. (2004) in that they always concluded that the rod only damaged the left lobe and not the right.

Van Horn, however, went a step further in their research and investigated the potential levels of white and grey matter damaged due to Gage’s injury. White matter is deep in the brain and provides vital connections around the brain, essential to normal motor and sensory function.

Grey matter in the brain is essential to many areas of higher learning, including attention, memory, and thought.

The research by Van Horn proposed that Gage lost about 11% of his white matter and about 4% of his grey matter. White matter has the ability to regenerate, so this could explain why Gage recovered as well as he did.

Van Horn et al. (2012) compared Gage’s white matter damage to the damage that is caused by neurogenerative diseases such as Alzheimer’s.

This is supported by other studies that have found that changes in white matter is significantly associated with Alzheimer’s disease (Nasrabady, Rizvi, Goldman & Brickman, 2018; Kao, Chou, Chen & Yang, 2019).

It could be suggested that Gage’s apparent change in personality could have been the result of an early onset of Alzheimer’s.

However, as Dr. Harlow, who examined Gage, only reported on Gage’s behaviors shortly after his accident, rather than months or years later when Alzheimer’s symptoms may have emerged, we cannot be certain whether Gage actually had this condition.

All studies investigating the brain damage suffered by Gage is essentially all speculation as we cannot know for certain the extent of the accident’s effects.

We know that some brain tissue got destroyed, but any infections Gage may have suffered after the accident may have further destroyed more brain tissue.

We also cannot determine the exact location where the iron rod entered Gage’s skull to the millimeter. As brain structure varies from person to person, researchers cannot ever know for certain what areas of Gage’s brain were destroyed.

What Happened to Phineas Gage After the Brain Damage?

Dr. John Martyn Harlow took over Gage’s case soon after. Harlow (1848) reported that Gage was fully conscious and recognized Harlow immediately but was tired from the bleeding.

In the next couple of days, Harlow observed that Gage spoke with some difficulty but could name his friends, and the bleeding ceased. Gage then spent September 23rd to October 3rd in a semi-comatose state but was able to take steps out of bed by October 7th.

By October 11th, Harlow claimed Gage’s intellectual functioning began to improve. He recognized how much time had passed since the accident and could describe the accident clearly.

Four years after his injury, Gage moved to Chile and worked taking care of horses and being a stagecoach driver.

Harlow noted emerging personality changes in this period, with Gage becoming more erratic in behavior and responsibility.

In 1860, Gage moved to San Francisco to live near family but began suffering epileptic seizures – likely related to scar tissue and injury sequelae.

The convulsions worsened over months, and on May 21, 1861, almost 13 years after his shocking accident, Gage died at age 38 from complications of severe epilepsy.

How did Phineas Gage die?

On May 21st, 1861, twelve years after his accident, Gage died after having a series of repeated epileptic convulsions.

In 1867, Harlow arranged an exhumation of Gage’s body, claiming his skull and tamping iron for medical study.

These historic artifacts remain on display at the Harvard School of Medicine.

Though Gage initially survived, it was the secondary long-term effects of this massive brain injury that ultimately led to his premature death over a decade later.

Why Is Phineas Gage Important to Psychology?

Gage’s case is important in the field of neuroscience . The reported changes in his behavior post-accident are strong evidence for the localization of brain function , meaning that specific brain areas are associated with certain functions.

Neuroscientists have a better understanding of the function of the frontal cortex today. They understand that the frontal cortex is associated with language, decision-making, intelligence, and reasoning functions. Gage’s case became one of the first pieces of evidence suggesting that the frontal lobe was directly involved in personality.

It was believed that brain lesions caused permanent deficits in a person. However, Gage was proven to have recovered remarkably and lived a mostly normal life despite his injury. It was even suggested by a psychologist called Malcolm Macmillan that Gage may have relearned lost skills.

People with damage to their frontal lobes tend to have trouble completing tasks, get easily distracted, and have trouble planning.

Despite this damage to his frontal lobe, Gage was reported to have worked as a coach driver which would have involved Gage being focused and having a routine, as well as knowing his routes and multitasking.

Macmillan (2002), therefore, suggests that Gage’s damage to the frontal lobe could have somewhat repaired itself and recovered lost functions. The ability of the brain to change in this way is called brain plasticity .

Over time, Gage’s story has been retold, and this has sometimes led to a lot of exaggeration as to the personality changes of Gage.

Some popular reports described him as a hard-working, kind man prior to the accident and then described him as an aggressive, dishonest, and drunk man who could not hold down a job and died pennilessly.

Gage’s story seemed to take on a life of its own, and some even went as far as to say that Gage became a psychopath after his accident, without any facts behind this.

From the actual reports from the people in contact with Gage at the time, it appears that his personality change was nowhere near as extreme and that Gage was far more functional than some reports would have us believe (Macmillan, 2002).

Blakeslee, S. (1994, July 6). A miraculous recovery that went wrong . New York Times.

Damasio, H., Grabowski, T., Frank, R., Galaburda, A. M., & Damasio, A. R. (1994). The return of Phineas Gage: clues about the brain from the skull of a famous patient . Science, 264 (5162), 1102-1105.Harlow J. M. (1848). Passage of an iron rod through the head. Boston Medical and Surgical Journal, 39 , 389–393.

Harlow, J. M. (1868). Recovery from the Passage of an Iron Bar through the Head . Publications of the Massachusetts Medical Society. 2 (3), 327-347.

Kao, Y. H., Chou, M. C., Chen, C. H., & Yang, Y. H. (2019). White matter changes in patients with Alzheimer’s disease and associated factors . Journal of Clinical Medicine, 8 (2), 167.

Lahey, B. B. (1992). Psychology: An introduction . Wm. C. Brown Publishers.

Macmillan, M. (2000). Restoring Phineas Gage: A 150th retrospective. Journal of the History of the Neurosciences, 9 (1), 46-66.

Macmillan, M. (2002). An odd kind of fame: Stories of Phineas Gage. MIT Press.

Myers, D. G. (1998). Psychology (5th ed.). Worth Publishers.

Nasrabady, S. E., Rizvi, B., Goldman, J. E., & Brickman, A. M. (2018). White matter changes in Alzheimer’s disease: a focus on myelin and oligodendrocytes. Acta neuropathologica communications, 6 (1), 1-10.

Ratiu, P., Talos, I. F., Haker, S., Lieberman, D., & Everett, P. (2004). The tale of Phineas Gage, digitally remastered . Journal of neurotrauma, 21 (5), 637-643.

Suinn, R. M. (1970). Fundamentals of behavior pathology. Wiley.

Van Horn, J. D., Irimia, A., Torgerson, C. M., Chambers, M. C., Kikinis, R., & Toga, A. W. (2012). Mapping connectivity damage in the case of Phineas Gage . PloS one, 7(5) , e37454.

Further Reading

• Griggs, R. A. (2015). Coverage of the Phineas Gage Story in Introductory Psychology Textbooks: Was Gage No Longer Gage?. Teaching of Psychology, 42(3), 195-202.
• Wilgus, J., & Wilgus, B. (2009). Face to face with Phineas Gage. Journal of the History of the Neurosciences, 18(3), 340-345.
• Macmillan, M., & Lena, M. L. (2010). Rehabilitating Phineas Gage. Neuropsychological Rehabilitation, 20, 641–658.
• Macmillan, M. (2000). Restoring phineas gage: a 150th retrospective. Journal of the History of the Neurosciences, 9(1), 46-66.
• Kotowicz, Z. (2007). The strange case of Phineas Gage. History of the Human Sciences, 20(1), 115-131.
• O”driscoll K, Leach JP. “No longer Gage”: an iron bar through the head. Early observations of personality change after injury to the prefrontal cortex. BMJ. 1998;317(7174):1673-4. doi:10.1136/bmj.317.7174.1673a

If a person suffers from a traumatic brain injury in the prefrontal cortex, similar to that of Phineas Gage, what changes might occur?

A traumatic brain injury to the prefrontal cortex could result in significant changes in personality, emotional regulation, and executive function. This region is vital for impulse control, decision-making, and moderating social behavior.

A person may exhibit increased impulsivity, poor judgment, and reduced ability to plan or organize. Emotional volatility and difficulty in interpersonal relationships may also occur.

Just like the case of Phineas Gage, who became more impulsive and less dependable, the injury could dramatically alter one’s character and abilities.

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Phineas Gage: His Accident and Impact on Psychology

Author unknown / Wikimedia Commons

• Phineas Gage's Accident
• Change in Personality
• Severity of Brain Damage
• Impact on Psychology

What Happened to Phineas Gage After the Brain Damage?

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

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

At a Glance

In 1848, Phineas Gage had a workplace accident in which an iron tamping rod entered and exited his skull. He survived but it is said that his personality changed as a result, leading to a greater understanding of the brain regions involved in personality, namely the frontal lobe.

Phineas Gage's Accident

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

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

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

The Recovery Process

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

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

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

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

Theories About Gage's Survival and Recovery

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

• The rod's path . Some researchers suggest that the rod's path likely played a role in Gage's survival in that if it had penetrated other areas of the head—such as the pterygoid plexuses or cavernous sinus—Gage may have bled to death.
• The brain's selective recruitment . In a 2022 study of another individual who also had an iron rod go through his skull—whom the researchers referred to as a "modern-day Phineas Gage"—it was found that the brain is able to selectively recruit non-injured areas to help perform functions previously assigned to the injured portion.
• Work structure . Others theorize that Gage's work provided him structure, positively contributing to his recovery and aiding in his rehabilitation.

How Did Phineas Gage's Personality Change?

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

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

Severity of Gage's Brain Damage

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

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

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

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

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

Why Is Phineas Gage Important to Psychology?

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

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

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

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

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

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

Bottom Line

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

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

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

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

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

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

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

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

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

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

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

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

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

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

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

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Phineas Gage's great legacy

O grande legado de phineas gage, ricardo vieira teles, filho.

1 Faculty of Medicine, Universidade Federal de Goiás – Goiânia, GO, Brazil.

The case of Phineas Gage is an integral part of medical folklore. His accident still causes astonishment and curiosity and can be considered as the case that most influenced and contributed to the nineteenth century's neuropsychiatric discussion on the mind-brain relationship and brain topography. It was perhaps the first case to suggest the role of brain areas in determining personality and which specific parts of the brain, when affected, can induce specific mental changes. In addition, his case contributed to the emergence of the scientific approaches that would later culminate in psychosurgery. Gage is a fixed element in the studies of neurology, psychology, and neuroscience, having been solidified as one of the greatest medical curiosities of all time, deserving its prominence.

O caso de Phineas Gage é parte integrante do folclore médico. Seu acidente ainda causa espanto e curiosidade, e pode ser considerado como o caso que mais influenciou e contribuiu para a discussão neuropsiquiátrica do século XIX sobre a relação mente-cérebro e topografia cerebral. Foi talvez o primeiro caso a sugerir o papel de áreas cerebrais na determinação da personalidade e que partes específicas do cérebro, quando afetadas, podem induzir mudanças mentais específicas. Além disso, seu caso contribuiu para o surgimento de abordagens cientificas que culminariam posteriormente na psicocirurgia. Gage é um elemento fixo nos estudos de neurologia, psicologia e neurociências, tendo sido solidificado como uma das grandes curiosidades médicas de todos os tempos que merece seu destaque.

THE ACCIDENT

Gage, a 25-year-old male, 1.70 m in height and weighing approximately 70 kg, was employed in railroad construction at the time of the accident. As the company's most capable employee, with a well-balanced mind and a sense of leadership, he was directing a rock-splitting workgroup while preparing the bed of the Rutland & Burlington Railroad south of Cavendish, Vermont, USA. At 4:30 PM on September 13, 1848, he and his group were blasting a rock, and Gage was assigned to put gunpowder in a deep hole inside it. 1

The moment he pressed the gunpowder into the hole with a bar, the friction caused sparks, and the powder exploded. The resulting blast projected the meter-long bar, which was 3.2 cm in diameter and weighed about 6 kg, through his skull at high speed. The bar entered his left cheek, destroyed his eye, passed through the left front of the brain, and finally completely left his head at the top of the skull on the right side. Gage was thrown on his back and had some brief convulsions, but he woke up and spoke in a few minutes, walked with a little help, and sat in an ox cart for the 1.2-km trip to his quarters. 1

In the city about 30 minutes after the accident, Doctor Edward H. Williams arrived to provide medical care. Gage had lost a lot of blood, and his following days were quite difficult. 1 The wound became infected, and Phineas was anemic and remained semicomatose for more than two weeks. He also developed a fungal infection in the exposed brain that needed to be surgically removed. His condition slowly improved after doses of calomel and beaver oil. By mid-November he was already walking around the city. 2

THE CONSEQUENCES

For three weeks after the accident, the wound was treated by doctors. During this time, he was assisted by Dr. John Harlow, who covered the head wound and then reported the case in the Boston Medical Surgery Journal. In November 1849, invited by the professor of surgery at Harvard Medical School, Henry Jacob Bigelow, Harlow took Gage to Boston and introduced him to a meeting of the Boston Society for Medical Improvement ( Figure 1 ). 3

In his reports, Harlow described that the physical injury profoundly altered Gage's personality. Although his memory, cognition and strength had not been altered, his once gentle personality slowly degraded. He became a man of bad and rude ways, disrespectful to colleagues, and unable to accept advice. His plans for the future were abandoned, and he proceeded without thinking about the consequences. 4 And here was the main point of this curious story: Gage became irritable, irreverent, rude and profane, aspects that were not part of his way of being. His mind had changed radically. His transformation was so great that everyone said that “Gage is no longer himself.” 5

As a result of this personality change, he was fired for indiscipline and could no longer hold a steady job. He became a circus attraction and even tried life in Chile, later returning to the United States. However, there is something still little known about Gage: his personality changes lasted for about four years, slowly reverting later. As a proof of this, he worked as a long-haul driver in Chile, a job that required considerable planning and focus skills. He died on May 21, 1861, 12 years after the accident, from an epileptic seizure that was almost certainly related to his brain injury. He was not submitted to an autopsy, but his mother, after exhumation of the body, donated his skull and iron rod at the request of Dr. Harlow, which, in turn, sometime later donated them to Harvard University ( Figure 2 ). 1

Gage's case is considered to be one of the first examples of scientific evidence indicating that damage to the frontal lobes may alter personality, emotions and social interaction. 6 Prior to this case, the frontal lobes were considered silent structures, without function and unrelated to human behavior. Scottish neurologist, David Ferrier, was motivated by this fact to investigate the role of frontal lobes in brain function. Ferrier removed the frontal lobes in monkeys and noted that there were no major physiological changes, but the character and behavior of the animals were altered. 7

Knowledge that the frontal lobe was involved with emotions continued to be studied. The surgeon Burkhardt in 1894 performed a series of surgeries in which he selectively destroyed the frontal lobes of several patients in whom he thought might control psychotic symptoms, being the modern prototype of what was later known through Egas Moniz as psychosurgery. 7 Today, it is well understood that the prefrontal cortex of the brain controls the organization of behavior, including emotions and inhibitions.

Folkloric as it may be, but nonetheless remarkable, the contribution of Phineas Gage's case should not be overlooked, as it provided scientists the baseline for the promotion of studies in neuropsychiatry, and a source of inspiration for world medicine. 8 In 2012, a team of neuroscientists used computed tomography of Gage's skull with typical brain MRI scans to show how the Gage brain connection could have been affected. 9 And it is not just the researchers who keep coming back to Gage. Medical and psychology students still learn about Gage from their history lessons. Neurosurgeons and neurologists still sometimes use Gage as a reference when evaluating certain cases. 10 The final chapter of his life also offers us a thought-provoking learning about cases of massive brain damage, showing us that rehabilitation may be possible. 11

Therefore, Gage — inadvertently — made a huge contribution to neurology in several areas, including the study of brain topography in behavioral disorders, the development of psychosurgery, and finally the study of brain rehabilitation. Also, Gage's case had a tremendous influence on early neuropsychiatry. The specific changes observed in his behavior pointed to theories about the localization of brain function and correlated with cognitive and behavioral sequelae, thereby acquainting us with the role of the frontal cortex in higher-order actions such as reasoning, behavior and social cognition. In those years, while neuropsychiatry was in its infancy, Gage's extraordinary story served as one of the first pillars of evidence that the frontal lobe is involved in personality, which helped solidify his remarkable legacy in world medical history.

This study was conducted at the Universidade Federal de Goiás, Goiânia, GO, Brazil.

Funding: none.

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Lessons of the brain: The Phineas Gage story

Harvard Correspondent

In 1848, an iron bar pierced his brain, his case providing new insights on both trauma and recovery

Imagine the modern-day reaction to a news story about a man surviving a three-foot, 7-inch, 13½-pound iron bar being blown through his skull — taking a chunk of his brain with it.

Then imagine that this happened in 1848, long before modern medicine and neuroscience. That was the case of Phineas Gage.

Whether the Vermont construction foreman, who was laying railroad track and using explosives at the time of the industrial accident, was lucky or unlucky is a judgment that Warren Anatomical Museum curator Dominic Hall puzzles over to this day.

“It is an impossible question, because he was extraordinarily unlucky to have an iron bar borne through his skull, but equally lucky to have survived, on such a low level of care,” said Hall. “We are lucky, to have him.”

Gage’s skull, along with the tamping iron that bore through it, are two of the approximately 15,000 artifacts and case objects conserved at the Warren, which is a part of the Center for the History of Medicine in Harvard’s Francis A. Countway Library of Medicine .

The resultant change in Gage’s personality — when he went from being well-liked and professionally successful to being “fitful, irreverent, and grossly profane, showing little deference for his fellows” and unable to keep his job — is widely cited in modern psychology as the textbook case for post-traumatic social disinhibition.

But as the years have gone by and we’ve learned more about his life, argued Hall, the teachings have changed.

“In 1848, he was seen as a triumph of human survival. Then, he becomes the textbook case for post-traumatic personality change. Recently, people interpret him as having found a form of independence and social recovery, which he didn’t get credit for 15 years ago.”

When Gage died 12 years after the accident, following epileptic seizures, his body was exhumed, while his skull and tamping iron were sent to the physician who had cared for him since the accident, John Harlow. Harlow later donated the items to the Warren, where they have remained for 160 years.

“In many ways, I see Gage similarly to how you would see a portrait of one of the famous professors hanging on the wall — he’s an important part of Harvard Medical School’s identity,” said Hall. “By continually reflecting on his case, it allows us to change how we reflect on the human brain and how we interact with our historical understanding of neuroscience.”

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How Phineas Gage’s Freak Accident Changed Brain Science

Vermont Historian Explains How A Railway Accident Paved The Way for Neurosurgery And More

Cavendish might look like any other small Vermont town. Nestled between rolling hills and the Black River, with one main street running through town, it’s a launching point for trout anglers, snowmobilers and skiers. But this rural town of just over a thousand people can claim a remarkable historical figure: Phineas Gage .

Gage was a young construction foreman who suffered a gruesome accident that changed the history of brain science.

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In 1848, while blasting through rock to build the new railroad, an explosion sent a 3-foot, 13-pound iron rod up through his cheekbone and out the top of his skull. The tamping rod landed 80 feet away, “ smeared with blood and brain .”

Remarkably, Gage lived for another 11 years. He lost one eye and had a permanent hole in his skull, covered by a thin layer of skin.

Gage was a medical marvel.

There had been a long-running debate in the 19th century on whether different regions in the brain govern different behaviors. Here was a case of severe damage to the left frontal lobe, followed by a dramatic personality shift. It seemed to prove the point once and for all.

“It laid the path for the first real brain surgery in 1885 ,” said Margo Caulfield, director of the Cavendish Historical Society, told “ To the Best of Our Knowledge .” “It opened up a whole new horizon. You can survive a brain injury, you can touch the brain, which means you can do surgery. It’s really, really huge.”

Gage himself was never the same after the accident.

He’d been well-liked by his co-workers and his employer, but later, his doctor reported that he became “ fitful, irreverent, indulging at times in the grossest profanity .”

A friend said, “ Gage is no longer Gage .”

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Gage was unable to work on the railroad, but he still needed a job.

For a while, he made money by exhibiting himself around New England as a curiosity, showing off the holes in his head and his famous tamping iron.

Then, he was offered a job as a long-distance stagecoach driver on the Val Paraiso-Santiago route in Chile. It was a 100-mile route, and 13 hours of handling a coach and six horses, plus passengers, over rough terrain.

Gage lived in Chile for seven years and then started having epileptic seizures.

He died in 1860 at the age of 36.

Over the years, scientists have interpreted Gage’s story in different ways.

At first, he was seen as a triumph of human survival. Then for decades he became a textbook case for post-traumatic personality change. More recently, Gage’s case has been interpreted as a story of resilience. For a man who was supposedly anti-social and volatile, Gage’s ability to hold onto a challenging job in Chile suggests he’d regained his independence and social adaptability.

Perhaps Gage’s story is a textbook case of another sort, showing the brain’s capacity for rewiring after trauma. This gift of neuroplasticity is why we’re able to handle so much that life throws at us.

“I am fascinated by what he overcame to survive for as long as he did,” Caulfield said. “The resiliency piece of his story fascinates me … I think resiliency is just hard-wired into our DNA.”

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41 Phineas Gage: A Neuropsychological Perspective of a Historical Case Study

Alan G. Lewandowski, Clinical Neuropsychologist, Neuropsychology Associates

Joshua D. Weirick, Post-Doctoral Research Fellow, Department of Speech, Language and Hearing Sciences, Purdue University

Caroline A. Lewandowski, Private Practice

Jack Spector, Clinical Neuropsychologist, Independent Practice

• Published: 07 May 2020
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The case of Phineas Gage is one of the most frequently cited cases from 19th century medical literature and represents the first of a series of famous cases involving the brain and behavior. While many reiterations of Gage’s case have been published, it remains important to modern neuroscience due to its unique historical significance, ongoing clinical relevance, and the insights it offers neuropsychology into the functional effects of brain injury on thinking, emotions, and behavior. This chapter revisits the critical aspects of this landmark case from a contemporary clinical perspective and discusses the implications of injury to the prefrontal cortex and pathways.

Introduction

On Wednesday, September 13, 1848, a construction crew working for the Rutland and Burlington Railroad near Duttonsville, Vermont, was excavating rock to prepare the ground for track that was soon to be laid. In charge of the crew was a 25-year-old foreman named Phineas Gage, who was using an iron bar to pack black powder into a hole that had been drilled into the rock. For an unknown reason, a spark ignited the black powder and the ensuing explosion propelled the metal rod through the left side of Gage’s face, entering at a slight angle below his zygomatic arch. It passed behind his left eye, through the left frontal lobe, and exited the skull anterior to the juncture of the sagittal and coronal sutures, landing about one hundred feet behind him. Incredibly, Gage endured the injuries and lived another eleven and a half years. Due to his survival of an accident of this magnitude, he entered into the annals of scientific and historical literature as a frequently cited example of a frontal cortical injury.

One week after the accident, on September 21, 1848, the Free Soil Union newspaper in Ludlow, Vermont, published the following account:

Horrible Accident—As Phineas P. Gage, a foreman on the railroad in Cavendish, was yesterday engaged in tamkin [sic] for a blast, the powder exploded, carrying an iron instrument through his head an inch and a fourth in circumference, and three feet and eight inches in length, which he was using at the time. The iron entered on the side of his face, shattering the upper jaw, and passing back of the left eye, and out at the top of his head. The most singular circumstance connected with this melancholy affair is, that he was alive at two o’clock this afternoon, and in full possession of his reason, and free from pain. (Macmillan, 2000a , p. 12)

A review of the medical notes kept by the John Harlow, the physician who treated Gage immediately after his injury are not fully consistent with this newspaper account, especially with regard to the patient having been “free from pain.” Interestingly, 161 years later in July 2009, the Los Angeles Times published an article titled “A piercing image of Phineas Gage” (Maugh, 2009 ), which described the discovery of “the only known image of legendary brain-injury patient Phineas Gage” in a daguerreotype image. The LA Times account claims that “it [the bar] was successfully removed” and “contemporary accounts suggest that Gage’s personality was dramatically altered because he was disfigured in the accident” (Maugh, 2009 ). Unfortunately, but perhaps not surprisingly, more than a century and a half later the complexities of the case continue to pose challenges.

Phineas Gage, his treating physicians, the witnesses to the accident, and Cavendish, Vermont: the characters and setting of this story are, individually, unremarkable. Yet united by the circumstances of a remarkable event, they have contributed uniquely to the development of neuropsychology and continue to be relevant to modern psychological practice. Gage’s case is a story of the right projectile, at the right speed and the right distance, passing through the right area of the brain, of the right patient, who was treated by the right doctor, at the right time in history (Lewandowski, 2003 ). The result is that his injury, treatment, and long-term recovery continue to lend interest and relevance to contemporary neuroscientists across a broad range of medical and psychological disciplines.

Although birth documentation for Gage is lacking, he was probably born on September 9, 1823, in Lebanon, New Hampshire, and was named after his paternal grandfather. Genealogy records confirm that his father was Jesse Gage and his mother was Hannah Swetland, who married on April 27, 1823. He was the oldest of five children: his siblings Laura and Roswell were born in 1826, Dexter was born in 1831, and Phoebe was born in 1832 (Macmillan, 1986 ).

At the time of the injury Gage was 25 years old, and was described as “a perfectly healthy, strong and active young man” prior to the accident, standing “five feet six inches in height” with an “average weight one hundred and fifty pounds.” He possessed “an iron frame” and a “muscular system unusually well developed,” thus indicating that he was in excellent physical health (Harlow, 1868 , p. 330).

Gage’s premorbid psychological and cognitive status is also portrayed in very positive terms. He was reportedly of “well balanced mind,” and “was looked upon by those who knew him as a shrewd, smart businessman, very energetic and persistent in executing all his plans of operation.” In addition, he was of “considerable energy of character” (Harlow, 1868 , p. 340), and was regarded by his employers as “the most efficient and capable in their employ” (Harlow, 1868 , p. 399). Harlow observed that Gage possessed “an iron will” and a “nervo bilious temperament” (Harlow, 1868 , p. 330). His use of the term “nervo bilious” is a subtle indicator of phrenology’s influence on Harlow, as bilious (fibrous) and nervous are two of the four phrenological temperaments (Combe, 1830 , pp. 42–34).

Interestingly, Gage is described as having been “untrained in the schools” (Harlow, 1868 , p. 340); however, considering he could read and write (which may have assisted him in securing employment in a supervisory position as a railroad foreman), Macmillan ( 2000a ) suggests that this description refers to a lack of secondary education.

Cavendish past and present

Gage’s accident occurred outside Duttonsville, Vermont, which was a small village in the township of Cavendish, incorporated in 1761 (at present, however, “Cavendish” is the name of both the township and village). It is located east of the Green Mountains range of the Appalachians in Windsor County, approximately 25 miles southeast of Killington, Vermont (Cavendish Connects, n.d.) . As shown in Figure 41.1 , if one were to compare a historical map of Cavendish to a current topographical map, little change would be noted (Chase, 1856 ). The railroad bed that Gage and his construction crew were preparing is located approximately ¾ of a mile south of Main Street and to the east of Depot Street (Macmillan, 2000c ).

To fully appreciate the circumstances leading to Gage’s accident, it behooves one to have some familiarization with the state of transportation in the United States at that time in history. Prior to the development of railways in the early 1800s, the only available methods of travel or transporting goods in the northeast was limited to walking or using horses or pack animals attached to carriages or wagons when roads were available or the terrain permitted. Whereas transportation by steamer, canal boat, or barge offered an alternative, movement was restricted by the location and direction of the river or waterway and still required some land travel at the point of disembarking. As a result, the movement of people and their possessions across land remained very slow, inefficient, and cumbersome until John Stevens, the father of American railroads, sought to improve the speed and efficiency of transportation by proposing a rail line between New York and Lake Erie in 1815 (Winchester, 2014 ), generally following the Erie Canal. Stevens built a steam locomotive that he demonstrated at his New Jersey estate in an attempt to secure funding from local legislators. While he never lived to see this project completed, his efforts proved the viability of railway transportation such that, by the first half of the 1800’s, railroad construction exploded. The meager 20 miles of railroad track that had existed in 1828, expanded to almost 3000 miles by 1836 (Winchester, 2014 ).

Initially railroads were designed to connect major ports and their surrounding communities, but by 1870 rapid expansion resulted in the railroad industry becoming the nation’s second largest employer of men organized by innumerable work crews responsible for preparing the ground and laying track (Winchester, 2014 ). Over time railways developed to connect cities and therefore the ground required preparation by either excavation or filling in low areas. This drive to expand railway transportation to increase the efficiency of commerce is ultimately why Gage and his crew were engaged in the foothills outside of Duttonsville in 1848.

Gage was employed by the Rutland and Burlington railroad as a foreman of a construction crew. At the time of the accident he and his crew were excavating rock approximately ¾ mile southeast of Duttonsville in order to prepare the ground for track. This task, on its surface, seems relatively simple: Gage and his crew drilled holes in the to-be-excavated rock and filled those holes with gunpowder. The charges were then detonated, and the fragmented rock could be removed or placed in low-lying areas to level the grade. However, with the inherent risks in excavating rock by using explosives and the rudimentary equipment available, the danger and complexity of this type of work should not be underestimated. In order to fully grasp the planning, organization, and complexity required of Gage to execute these tasks, a cursory understanding of drilling and blasting with 19th century technology is necessary.

In the 1800s the method for drilling blasting holes in solid rock involved the use of a team of men working in close proximity and in concert to strike an iron drill bit with sledge hammers. One member of the gang was assigned the position of holding a drill bit, while one or two other members of the crew struck the head of the bit with a hammer. The force of the blow drove the bit into the rock, and the worker holding the bit turned it with each blow. The accrued rock dust was then removed by pouring small amounts of water into the hole to create a mud that stuck to the bit and was periodically removed by tapping the bit against a rock or wiping it clean with the worker’s hand. The bit was then replaced in the hole and the process continued, substituting bits of greater length as the hole deepened.

One can only speculate as to the skill and precision required of Gage and his crew as his men alternated hammer blows in a rhythmic manner, while one turned the bit with one or both hands. Holes approximately 2 yards deep could be bored into granite in about 5 to 6 hours, and several holes would be “drilled” across the area of rock to be excavated. Once the rock was loosened by the blast, a derrick crane and boom were used to load the rock onto animal- drawn carts for removal or placement into low-lying areas to level the ground for the rails (Lynch & Rowland, 2005 ).

After drilling, holes were packed with explosive powder. While some Gage citations have suggested the use of dynamite or blasting powder, the process of removing rock in the early 1800s involved the use of black powder. Dynamite was not yet invented and would not be available until Alfred Nobel introduced it to the United States in 1868 (Schuck & Sohlman, 1929 , p. 101).

Blasting powder uses detonation from the Latin word “de-tonare,” meaning to (expend) thunder, and therefore creates a supersonic combustion through shock compression that splits rock. In contrast, black powder, more commonly known as gunpowder, occurs through deflagration from the Latin word “de-flagrare,” meaning to burn down. The combination of heat and gas result in an effective propellant, as was the case in Gage’s tamping iron. As a result, black powder creates a subsonic combustion that occurs through thermal conductivity that heaves rock (Lynch, 2002 , p. 168).

Black powder is an inherently unstable chemical that combines proportionate measures of sulphur, potassium nitrate (saltpeter) and charcoal. While sulphur and charcoal act as the fuel, saltpeter acts as an oxidizer (Lynch, 2002 ). Its advantage (and danger) lies in the fact that it is relatively easy to ignite. A small spark is sufficient to set it off, as can be seen in the use of muzzle-loading weapons that use either flint or a percussion cap to ignite the powder packed into a breech. The force of the blast depends on a number of variables that include the amount of powder, the size of the grains, and the pressure under which the blast is initiated. Pressure and combustion are obtained by the ratio of fuel to the oxidizing agent and how tightly the powder is packed into a receptacle such as the breech of a gun, or in this case, the hole that Gage was drilling into solid rock (Krehl, 2009 ).

Blasting rock is done by placing black powder into a deep hole of fairly narrow diameter with a fuse positioned to the same depth. The fuse is then trailed onto the ground and of sufficient length to allow the person who ignites the fuse time to move a safe distance away. Layered in the hole on top of the black powder is a collection of aggregate such as sand or soft clay. Sand was commonly used because it is a readily available, easily obtainable, inexpensive, and can be compacted tightly to fill up the small spaces in a hole. As a result, pressure is created by trapping expanding gases, thus leading to combustion sufficient to heave rock (Ihlseng & Wilson, 1907 ). The process of drilling and tamping is demonstrated in Figure 41.2 .

Drilling blasting holes

Another variable that added to the danger of Gage’s work was the fuse. In the early 1800s fuses were known as “coils” or “quills” and were hand made by filling quills or straw with black powder, by covering lengths of hemp of varying thickness with tar and black powder, or by wrapping hemp around a core of powder-filled straw and coating the resulting fuse in tar to protect it from moisture (U.S. Department of the Army, 1984 ). Because of variability in their individual manufacture, fuses lacked uniformity and it was difficult to estimate their burn rate. Safety fuses were not introduced to civil engineering until 1831 when William Bickford introduced a half-inch “coil” to the British mining industry. Safety fused were probably uncommon among railroad workers in America at the time of Gage’s accident (Smith, 1909 , pp. 112–117).

Given the instability of black powder combined with the unreliable fuses, it is easy to see the inherent danger in Gage’s work during a period when explosives technology was in its infancy. At the time of Gage’s accident, railroading in general was a very dangerous profession. Although railroad worker fatalities were not reliably documented until the late 1800s, Aldrich ( 2006 ) found that nearly 4000 workers were killed in 1845 as a result of various railroad construction accidents, although the actual deaths were likely to have been higher than recorded.

The missile that caused the injury was an iron bar measuring 3 feet 7 inches long and weighing 13 ¼ pounds (shown in Figure 41.3 ). It is described as a “tamping iron,” named for its purpose. A tamper is a device used to compact or flatten aggregate to increase compression. Gage’s iron was used to “tamp” or pack down the loose sand that was placed on top of black powder during the process of blasting rock.

The terms “tamper” and “tamping” are derived from the Middle English “tampion,” which is a type of plug placed in a gun or cannon muzzle in order to protect it from dirt or moisture in the environment. “Tampion” itself may be a borrowing from Old French “tapon,” which referred to a piece of cloth used for plugging a hole (Tamp, n.d.) .

Tamping refers to the use of a “tamper” or, as in Gage’s work, a tool designed to compress aggregate. Typically, sand is placed over explosive powder and packed tightly in order to increase compression of gases to render a more powerful blast. In his 1850 publication, Bigelow describes that the iron was “forged by a neighboring blacksmith” and that it was “unlike any other having been made to please the fancy of the owner” (p. 14), indicating that Gage probably had his tamping iron custom made.

Gage’s tamping iron

An inspection of the tamping iron reveals that it is about 1¼ inch in diameter and roughly speaking the width of a common broom or mop handle. The texture is smooth and one end of the bar is gradually shaped to a point (Lewandowski, 2001 ). This is this end that was propelled into Gage’s lower left face and through his head.

It may be questioned as to why the bar was designed to be pointed at one end, when its primary purpose was packing aggregate. Tools, and particularly farm implements, are most often designed to serve multiple purposes. Consider a hammer that is designed to drive as well as remove nails, or a wrench with both open and closed ends). It is not unreasonable to assume that Gage instructed the blacksmith who forged the tamping iron to shape the end to a gradual point, as was common among miners, who often referred to this type of tool as a “needle” (Lewandowski, 2003 ). The tapered shape allowed for the tool to be used for holes of different diameters, for shaping a hole, or as a wedge or lever that could be used for dislodging split rock (Ihlseng & Wilson, 1907 ).

The Accident Site

Navigating to the accident site from the center of modern-day Cavendish would involve traveling down Main Street until Depot Street is reached, and then following Depot Street to the south. A set of railroad tracks will be encountered. The accident occurred east of this area near the first bend of the track heading to the south (Lewandowski, 1998 ; Macmillan, 2000c ; Pate, 1999 ).

More important than the exact site of the accident, which is not precisely known, is the topography of the immediate area (Lewandowski, 2001 ). The railroad bed where Gage was injured is nested in a corridor between two vertical walls of rock of about 30 feet in height and of considerable length (as shown in Figure 41.4 ).

Railroad track and rock near the accident site

The Accident

Gage’s accident occurred on September 13, 1848 at approximately 4:30 in the afternoon. The account is well documented by John Harlow, the local physician who treated Gage, and to whom it can be assumed Gage provided details during his period of recovery. Harlow ( 1868 ) recounts the accident as follows:

He was engaged in charging a hole drilled in the rock, for the purpose of blasting, sitting at the time upon a shelf of rock above the hole. His men were engaged in the pit, a few feet behind him, loading rock upon a platform car, with a derrick. The powder and fuse had been adjusted in the hole, and he was in the act of ‘tamping it in,’ as it was called, previous to pouring the sand. While doing this, his attention was attracted by his men in the pit behind him. Averting his head and looking over his right shoulder, at the same instant dropping the iron upon the charge, it struck fire upon the rock, and the explosion followed, which projected the iron obliquely upwards, in a line of its axis, passing completely through his head, and high into the air, falling to the ground several rods behind him, where it was afterwards picked up by his men, smeared with blood and brain. The missile entered by is pointed end, the left side of the face, immediately anterior to the angle of the lower jaw and passing obliquely upwards, and obliquely backwards, emerged in the median line, at the back part of the frontal bone, near the coronal suture. (Harlow, 1868 , p. 331)

After the accident Gage reportedly suffered “a few convulsive motions of the extremities,” but was soon conscious and able to speak (p. 331). Astonishingly there are no reports of Gage having lost consciousness or experiencing post-traumatic amnesia. His men carried him approximately 10 yards to the road where he was placed in a sitting position in a cart and transported about ¾ of a mile to Adams’s Inn. Gage left the cart with only a little assistance from bystanders and made his way to a chair on the porch where he awaited medical assistance from the local physician. During this time documents support that he remained alert and oriented.

Eyewitness Accounts

One of the first witnesses to Gage’s condition after the accident was Joseph Adams, the proprietor of the local tavern where some of the railway workers boarded. This is the hotel to which witnesses refer and where Gage was taken after the injury. In addition to being the local tavern owner, Adams was also the local Justice of the Peace who provided an affidavit for Harlow at the request of Henry Bigelow who also examined Gage months after the accident (Bigelow, 1850 ).

It is understandable that many did not believe that a person could survive such a devastating injury and therefore his public position and testimony lent credibility in the subsequent documentation. The notification of a local cabinet maker named Winslow who owned a shop about four buildings down from the tavern provides a good example. Winslow was told of the accident and subsequently measured Gage in order to begin work on a coffin for his anticipated death (Macmillan, 2000a ).

In his affidavit Adams testifies as follows:

This is to certify that P.P. Gage had boarded in my house for several weeks previous to his being injured upon the railroad, and that I saw him and conversed with him soon after the accident, and am of opinion that he was perfectly conscious of what was passing around him. He rode to the house, three-quarters of a mile, sitting in a cart, and walked from the cart into the piazza, and thence upstairs, with but little assistance. I noticed the state of the left eye, and know, from experiment, that he could see with it for several days though not distinctly. In regard to the elevated appearance of the wound, and the introduction of the finger into it, I can fully confirm the certificate of my nephew, Washington Adams, and others, and would add that I repeatedly saw him eject matter from the mouth similar in appearance to that discharged from the head. (Bigelow, 1850 , p. 14)

Adams, along with others, presented a compelling picture of Gage’s physical condition immediately after the injury. In addition, he must have recognized the importance of the tool, as he went searching for the bar the following day:

The morning subsequent to the accident I went in quest of the bar, and found it at a smith’s shop, near the pit in which he was engaged. The men in his pit asserted that ‘they found the iron, covered with blood and brains,’ several rods behind where Mr. Gage stood, and that they washed it in the brook, and returned it with the other tools; which representation was fully corroborated by the greasy feel and look of the iron, and the fragments of the brain which I saw upon the rock where it fell (Bigelow, 1850 , pp. 14–15).

A second and equally important witness was a local Protestant minister who observed Gage as he was taken out of the cart and assisted onto a porch chair. Reverend Joseph Freeman spoke with Gage, discussed the incident with some of his crew, and inspected the accident site and the tamping tool that was taken to the blacksmith’s shop. Because of his position in the community, Reverend Freeman also provided an affidavit and further verified the facts of the incident. On December 14, 1849 he testified as follows:

I was home on the day Mr. Gage was hurt; and seeing an Irishman ride rapidly up to your door, I stepped over to ascertain the cause, and then went immediately to meet those who I was informed were bringing him to our village. I found him in a cart, sitting up without aid, with his back against the fore board. When we reached his quarters, he rose to his feet without aid, and walked quick, though with an unsteady step, to the hind end of the cart, when two of his men came forward and aided him out, and walked with him, supporting him to the house. I then asked his men how he came to be hurt? The reply was, ‘The blast went off when he was tamping it, and the tamping-iron passed through his head.’ I said, ‘That is impossible.’ Soon after this, I went to the place where the accident happened. As I came up to them, they pointed me to the iron, which has since attracted so much attention, standing outside the shop-door. They said they found it covered with brains and dirt, and had washed it in the brook. The appearance of the iron corresponded with this story. It had a greasy appearance, and was so to the touch. (Bigelow, 1850 , p. 15)

Dr. Edward Williams, who spoke with Gage and collaborated with Harlow immediately after Gage’s injury, also provided an affidavit. In a letter dated December 4, 1849, from his home in Northfield, Vermont he wrote:

Dr. Bigelow: Dear Sir—Dr. Harlow having requested me to transmit to you a description of the appearance of Mr. Gage at the time I first saw him after the accident, which happened to him in September 1848, I now hasten to do so with pleasure. Dr. Harlow being absent at the time of the accident, I was sent for, and was the first physician who saw Mr. G., some twenty-five or thirty minutes after he received the injury; he at that time was sitting in a chair upon the piazza of Mr. Adams’s hotel, in Cavendish. (Bigelow, 1850 , pp. 14–16)

Williams’s contribution was in detailing Gage’s appearance and his examination findings.

First Responder

Dr. John Harlow, the physician best known for his treatment of Gage, was not immediately available when Gage was brought to Adams’s Inn. As a result, Dr. Edward Higginson Williams, another local physician, was summoned in his stead, and it was Williams who was the first to evaluate Gage’s injury and render immediate assistance. In a sense, he was ex post facto the emergency physician who first attended Gage, and the portico of the Adams’s Inn was his de facto emergency and trauma bay where he began his assessment.

Williams was a twenty-four-year-old graduate of Vermont Medical School when he attended to Gage. His obituary in the New York Times , appearing in December 1899, notes that he practiced as a physician for only a short period of time before he left medicine to work in the railroad industry, eventually securing part ownership of the Baldwin Locomotive Works (New York Times, 1899 ). Although a young physician at the time he treated Gage, he had sufficient medical experience to begin addressing the penetrating head wound, verify the presenting history and mechanism by which the injury occurred, confirm the symptoms, and do what he could to stabilize the patient until Harlow arrived.

Most students of psychology, neuroscience, and medicine are very familiar with the quotation attributed to Gage’s family and friends that, “He was no longer Gage” (Harlow, 1868 ); however, Williams provides a quote from Gage himself that, while lesser-known, is equally compelling. Consider the circumstances under which he and Gage were introduced: the patient had just suffered a horrific injury that should have killed him. He was then transported back to town on an oxcart three quarters of a mile to a local tavern where he sat in a chair on a veranda waiting for half an hour for a physician to arrive. When Dr. Williams arrived in his carriage, Gage addressed him. Williams recalled, “When I drove up he said, ‘ Doctor, here is business enough for you .’ ” This simple statement by Gage confirms his self-reliant character and offers marvelous insight into his personality.

Dr. Williams’ comments about Gage’s injuries suggest that he was in disbelief of the circumstances of the injury. He was decisively convinced following a personal examination in addition to the confirmatory comments of the railroad crew members who were present at the time of the accident (Figure 41.5 ):

I first noticed the wound upon the head before I alighted from my carriage the pulsations of the brain being very distinct; there was also an appearance which before I examined the head, I could not account for: the top of the head appeared somewhat like an inverted funnel; this was owing, I discovered, to the bone being fractured about the opening for a distance of about two inches in every direction. I ought to have mentioned above that the opening through the skull and integuments was not far from one and a half inch in diameter; the edges of this opening were everted and the whole wound appeared as if some wedge-shaped body had passed from below upward. (Bigelow, 1850 , p. 16)

Williams’ initial observations of Gage’s behavior may be of interest to neurological clinicians. Recall that his examination took place within an hour of the traumatic brain injury. Gage was probably in shock, but had not yet succumbed to infection, hence delirium had not yet set in. Retrospectively, Williams’s interactions with Gage provide behavioral observations that could be considered a rudimentary mental status examination. He was able to establish that Gage was oriented to person, place, time, and purpose. In addition, Williams’s observations of visual, verbal, and motor responding, which are supported by affidavits, establish that Gage’s eyes were open, he conversed normally, and he obeyed commands. By today’s emergency and trauma standards for head injury evaluation, one could speculate that Gage demonstrated a normal Glasgow Coma Scale score of 15 (Teasdale & Jennett, 1974 ), which would lend some support to a positive outcome from his traumatic brain injury.

Gage’s skull

Williams continues:

At the time I was examining this wound, he was relating the manner in which he was injured to the bystanders; he talked so rationally and was so willing to answer questions, that I directed my inquiries to him in preference to the men who were with him at the time of the accident and who were standing about at this time. Mr. G. then related to me some of the circumstances as he has since done; and I can safely say that neither at that time nor any subsequent occasion, save once, did I consider him to be other than perfectly rational. The one time to which I allude was about a fortnight after the accident, and then he persisted in calling me John Kirwin; yet he answered all my questions correctly.

Despite being the first physician to directly assess Gage’s injury, Williams nonetheless remained skeptical. In an affidavit to Bigelow he reported:

I did not believe Mr. Gage’s statement at that time, but thought he was deceived; I asked him where the bar entered, and he pointed to the wound on his cheek, which I had not before discovered; this was a slit running from the angle of the jaw forward about one and a half inch; it was very much stretched laterally, and was discolored by powder and iron rust, or at least appeared so. Mr. Gage persisted in saying that the bar went through his head.

The Treating Physician

Dr. John Martyn Harlow arrived at Adams’s Inn at approximately 6 p.m., and was clearly taken by Gage’s presentation: “the picture presented was, to one unaccustomed to military surgery, truly terrific; but the patient bore his sufferings with the most heroic firmness.” At that point both physicians combined their medical skill to stabilize Gage’s condition. He walked up a flight of stairs to an upper bedroom “with a little assistance” (Harlow, 1848 , p. 390) and was placed in a bed so that Harlow could begin a more detailed examination. In this sense, Harlow actions were similar to those of a modern-day trauma surgeon.

Harlow found Gage’s wound so significant and complete that he “passed in the index finger its whole length without the least resistance, in the direction of the wound in the cheek, which received the other finger in like manner” (Harlow, 1848 , p. 390). Although this procedure may seem alarming by modern standards, it should be recalled that at the time, an understanding of pathogens and infectious disease (germ theory) was not yet commonplace in American medicine. In fact, many physicians educated in the 19th century continued to debate the Miasma theory of disease transmission (Halliday, 2001 ; Last, 2007 ). Consider that Lister’s use of phenol in aseptic surgical techniques would not be introduced until 1867 and not widely accepted into clinical practice until the late 1800s (Greenwood, 1998 ; Lister, 1867 , 1868 ).

While Harlow and Williams dressed the wound, Gage’s behavior was compliant and cooperative, and he was “perfectly conscious, answering all questions, and calling his friends by name as they came into the room.” At the same time, however, he was observed to be losing a significant amount of blood “both externally and internally,” vomited several times, and began to fatigue. Gage’s pulse was weak at 60, but Harlow does not report where he palpated his patient. Harlow reports that “he was getting exhausted from the hemorrhage, which was very perfuse both exterally [sic] and internally, the blood finding its way into the stomach, which rejected it as often as every 15 or 20 minutes.” The blood loss was clearly significant, as Harlow reports that, “His person, and the bed on which he was laid, were literally one gore of blood” (p. 390). Given this description, it seems likely that the effects of hypovolemic shock were occurring as Gage’s hemoglobin was decreasing.

Williams and Harlow then shaved Gage’s head, removed the dried blood and a very small sharp piece of bone, and resected “a portion of the brain which hung by a pedicle” (p. 390). Larger pieces of the frontal bone were replaced as close to their original position as possible, the scalp was closed with “adhesive straps,” and a compression dressing was applied, over which they placed a night cap. This concluded the initial resuscitation and stabilization of the patient, and, in a cursory sense, it was not too dissimilar to that of contemporary protocols exercised by emergency room physicians and trauma surgeons.

Historically, injuries to the brain were more often than not fatal due to the trauma itself, intracerebral infection, and herniation from increased intracranial pressure, blood loss, etc. (Bollet, 2002 ; Cronyn, 1871 ; Karger, Sudhues, & Brinkmann, 2001 ). It was not until Percivall Pott’s publication of Observations on the nature and consequences of those injuries to which the head is liable from external violence in 1768 that physicians would be offered clear guidance on the medical management of acceleration and deceleration head injuries, not just injury to the skull, but to the treatment of the brain (Pott, 1768 ). Pott addressed cerebral contusions, skull fractures, concussions, and the management of pus (McCrory, 2001 ), and his writings were recognized in the 19th century as revolutionary in the treatment of head wounds (Butler, 1851 , p. 99). Thus, his medical treatises would have been well known to Harlow’s professors at Jefferson Medical College.

Interestingly, in his report, Harlow is somewhat defensive when he addresses the issue of “probing” the brain, noting that he had later been questioned as to why he did not do so. He presents his rationale as follows: “I think no surgeon of discretion would have upheld me in the trial of such a foolhardy experiment, in the risk of disturbing lacerated vessels from which the hemorrhage was near being staunched [sic], and thereby rupturing the attenuated thread, by which the sufferer still held life” (Bigelow, 1850 , p. 17; Harlow, 1848 , p. 390).

Probes in the 19th century were essentially long stiff metal wires with porcelain tips used to extract skull and bone fragments from the brain after penetrating head injuries. Such an instrument was used by US Surgeon General Dr. Joseph Barnes, who attended to President Lincoln after his assassination. Accompanying Barnes were Lincoln’s personal civilian physician, Dr. Robert Stone, and other US Army physicians who included Dr. Anderson Abbott, the first African-Canadian doctor, and Dr. Charles Crane, Assistant Surgeon General. As the ranking officer, Barnes directed the trauma treatment and, with the assistance of U.S. Army surgeon Dr. Charles Leale, probed Lincoln’s brain first with his (nonsterile) fingers and then with a Nelaton probe. Given the absence of modern neuroimaging, the use of a probe was judged necessary to discern the location and trajectory of the bullet (Trunkey & Farjah, 2005 , pp. 977–978). This porcelain tipped medical instrument was used to explore the wound and break blood clots, which likely increased the loss of blood and in doing so may have expedited Lincoln’s death (Bollet, 2002 ; Trunkey and Farjah, 2005 ). (An excellent example of this type of probe can be found on display at the Armed Forces Institute of Pathology museum in Washington, D.C., which displays the actual probe Barnes and Leale used, alongside fragments of the President’s skull and the 41 caliber lead ball fired from Booth’s derringer.)

Harlow’s treatment of Gage was guided by having been taught to avoid probing a brain (Harlow, 1848 , p. 390). In his medical education at Jefferson Medical College in Philadelphia (now Thomas Jefferson University) he had the benefit of being trained by several famous faculty members who historically have been referred to as the “faculty of ‘41” (Aptowicz, 2014 , p. 83; Elliot, 1911 ; Macmillan, 2001 ).

One of Harlow’s professors was Thomas Dent Mutter, a pioneer of reconstructive surgery, who was known for advocating for antiseptic techniques, replacing bone fragments, allowing for wound drainage, treating with purgatives and cathartics, and never probing. His influence is clearly seen in Harlow’s detailed description of his treatment of Gage (Harris, 1994 ). Further medical insight pertinent to this particular type of injury came from Professor Joseph Pancoast. Pancoast is still well known to surgeons today, and, like Mutter, he pioneered a number of procedures particularly with early reconstructive techniques. He authored A Treatise on Operative Surgery (Pancoast, 1844 ) in which he addresses the treatment of intracerebral pus, and chaired both the Departments of Surgery and Anatomy (Radbill, 1986 ). Lastly, Professor Robley Dunglison was Thomas Jefferson’s private physician who immigrated from England to establish the medical school at the University of Virginia (Gemmill, 1972 ). He published books on health, hygiene, morals, and intellect (Dunglison, 1835 ); human physiology and the history of medicine; and the medicinal use of marijuana (Dunglison, 1846 , p. 153). Known as the father of American Physiology (The National Cyclopaedia of American Biography, 1909, p. 270) Dunglison chaired Jefferson Medical College’s Department of Medicine and was best known for his publication Human Physiology , in which he addressed human temperament and idiosyncrasies, individual and cultural differences, and phrenology (Dunglison, 1832 , pp. 445–479). In addition to these accomplishments, perhaps equally important to Gage’s survival were his extensive prescriptions for multiple medical conditions (Dunglison, 1846 , 1833 ).

Harlow’s Physical Medicine and Rehabilitation

From the time of his arrival at bedside about 6 p.m. on Wednesday, September 13 until Saturday, November 18, 1848, Harlow made detailed observations of his treatment (Bigelow, 1850 , 1900 ; Harlow, 1848 , 1868 ). A review of his medical record indicates that he managed Gage’s medical trauma in a manner commensurate with prevailing medical practice and is rightfully credited with Gage’s stabilization and ultimate recovery. In addition, however, the circumstances of Gage’s wound and his preinjury status may have contributed to his survival. As the noted neurologist Charles Symonds declared, “It is not only the kind of injury that matters, but the kind of head” (Richardson, 2013 , p. 168).

Both Bigelow and Harlow report in some detail about Gage’s pre-injury status (Bigelow, 1850 , 1900 ; Harlow, 1848 , 1868 ), as this was pertinent in their discussion of his subsequent survival and later changes in demeanor. Recall that Gage was described by those who knew him as healthy, strong, active, muscular, physically well developed, shrewd, and intelligent. One can assume, then, that Gage’s premorbid physical and mental condition was not complicated by any significant known or documented premorbid disease, insults, or injuries. This is entirely consistent with Harlow’s ( 1868 ) report that Gage “had scarcely a day’s illness from his childhood to the date of this injury (p. 330). As a result, Gage’s state of health at the time the accident likely contributed positively to his chances of recovery.

A second variable that has not been previously discussed is the effects of the skull fracture that occurred as the tamping iron exited Gage’s cranium. It is very likely that Harlow’s efforts to stabilize his patient were inadvertently aided by the shattering of his skull resulting in a de facto decompressive craniectomy.

A decompressive craniectomy is a neurosurgical procedure sometimes employed in cases of severe brain trauma to allow for brain expansion where swelling occurs as the result of increased intracranial pressure within the skull vault. If left untreated, the interruption of the autoregulation of normal cerebral blood flow can result in increased cerebral perfusion pressure causing marked intracranial edema and ultimately leading to herniation and death (Aarabi et al., 2006 ; Reitan & Wolfson, 1986 ). The energy expended from the acceleration force drove the iron under Gage’s zygomatic arch, through the brain and dura, and exited the calvarium, resulting in bone loss that in turn, allowed for a natural expansion of the brain. Although Harlow and Williams replaced the pieces of bone available, all of the fragments were not recovered and part of the exit wound remained uncovered. This is apparent when examining any photograph or drawing of the skull or when viewing Gage’s life mask. Harlow ( 1868 ) observed that, “The fragments of bone being lifted up, the brain protruding from the opening and hanging in shreds upon the hair, it was evident that the opening in the skull was occasioned by some force acting from below.” He specifically describes how the frontal bone “was extensively fractured, leaving an irregular oblong opening in the skull of two by three and one-half inches” and goes on to report that “the pulsations of the brain were distinctly seen and felt” (p. 332).

After dressing the wound with Williams, Harlow stayed with Gage until 10 p.m., noting that “sensorial powers remain as yet unimpaired” (p. 391). Gage remained fully oriented as evidenced by his ability to name his friends and their residences. His unfaltering and committed character is reflected in his statement to Harlow that he expected to return to work in one or two days, even though he continued to hemorrhage for the next 48 hours.

The next morning Gage’s face became quite swollen and, although in pain, he was able to speak and was noted to be rational. Day two post injury (the 15th) his hemorrhaging stopped, but he began to show signs of delirium and was observed to be “disconnected and incoherent.” At this point Harlow recorded a prescription of “vin. Colchicum ℥ 3 ss every six hours until it purges him” (p. 391). Following the Apothecaries’ system of pharmacy common to 19th century United States at that time (Hasegawa, 2006 ), Harlow administered one half dram, or about 2 ml of colchicine, which in high doses is a toxic alkaloid derived from the corms of the autumn crocus (Colchicum autumnale). This flower extract was frequently used by physicians at that time for its pain-relieving, sedative, and anti-inflammatory properties. In small to moderate doses it produces gastrointestinal side effects that can be used as a sedative, cathartic, diuretic, and emetic (Kyle, et al., 1997 ; Rodnan & Benedek, 1970 ). Because its side effects include gastrointestinal movement, Harlow used it to induce bowel evacuation.

Day three post injury Harlow ( 1848 ) reported a discharge of foul smelling and thin watery pus intermixed with brain material and a fungus at the outside corner where the upper and lower eyelids of the left (injured) eye meet. Gage described the feeling of the left side of his head as “banked up” (p. 391) and had not yet had a bowel movement. Harlow applied ice water to Gage’s eye and head to address the inflammation and prescribed “sulph. magnesia ℥, repeated every four hours until it operates” (p. 391), hence an ounce of magnesium sulfate that was used as a laxative to initiate bowel motility.

Day four post injury, Harlow ( 1848 ) recorded the success of the laxative, noting that Gage “purged freely,” experienced some remission from his delirium, and that he was “rational and knows his friends.” While his facial wounds were healing, Gage’s abscess increased in volume, became foul smelling, and was described by Harlow as “very foetid and sanous” (p. 391).

Day five post injury Harlow ( 1848 ) observed that Gage slept throughout the night and showed preference for lying on his right side, probably because of pain and discomfort. His tongue was described as “red and dry” and his breath as “foetid,” suggesting probable dehydration. Harlow’s interventions that day included probing the skull at its base “without giving pain,” prescribing a cathartic “which operated freely,” and applying cold to the wound. While Gage remained psychologically optimistic and reported to Harlow that “he shall recover,” he continued to experience delirium marked by periods of coherence (p. 391).

Day six through day eight post injury, Gage’s mental and physical condition remained compromised but stable. Harlow ( 1848 ) recorded symptoms of restlessness, dry hot skin, red tongue, and excessive thirst over these three days, as well as impaired mental status marked by “talking incoherently with himself, and directing his men” (p. 391). By this description, Gage clearly continued to suffer from acute confusion, ongoing infection, and dehydration.

Gage’s impaired mental status continued through the morning of the 9th day post injury when he reported “he shall not live long.” His physical agitation and behavioral noncompliance now complicated the clinical picture as evidenced by Harlow’s ( 1848 ) description that his patient “Throws his hands and feet about, and tries to get out of bed.” Harlow described fever (“head hot”) and prescribed “a cathartic of calomel and rhubarb, to be followed by castor oil, if it does not operate in six hours” (p. 391).

Harlow’s use of medications to regularly purge Gage was consistent with 19th century “heroic medicine.” This philosophy advocated alleviating nerve and blood overstimulation that were assumed to cause all disease. Common treatments to restore health included blistering, bloodletting, vomiting, and purging (Duffy, 1990 ; Stavrakis, 1997 ). Harlow’s choice of Calomel is understandable as it was a commonly prescribed therapeutic in the 1800s. In its pharmaceutical form, it is an odorless powder that was commonly prescribed for internal use to treat multiple medical conditions such as constipation, infectious disease, fever, cholera, pleurisy, dropsy, gout, worms, and eclampsia (Weatherall, 2006 ). Externally its use was intended as a disinfectant to treat smallpox sores, syphilitic ulcers, and warts (Risse, 1973 ). Calomel is mercury chloride and therefore is no longer used as a therapeutic agent. Consistent with standards of practice at that time, Harlow used it with Gage in small does as a stool softener and laxative, and in larger does as a purgative.

For the next 11 days (Saturday September 23 through Tuesday October 3) Harlow’s records indicate that Gage remained semi-comatose, “seldom speaking unless spoken to, and then answering only in monosyllables” and that he lost vision in his injured eye (p. 392). Harlow treated the fungal brain and orbit abscess with cold compresses to the head and silver nitrate. Prior to the advent of modern antibiotics, silver nitrate was used medicinally as an antimicrobial. It can be assumed that Harlow applied the antiseptic to Gage’s wounds to treat the infection and prevent sepsis and further tissue decomposition. Gage’s dressings were changed every 8 hours and laxatives were administered regularly. Nevertheless, during this time an infection occurred in the occipitofrontalis muscle that Harlow punctured to drain about 8 ounces of pus.

Twenty-two through 24 days post injury Harlow observed wound discharge, which he referred to as “laudable pus” (p. 392), which, at the time, was thought to be associated with healing (Alexander, 1985 ). Gage’s improvement was also evidence by his ability to raise his head. During this time Harlow also prescribed that Gage sit up at bedside for five minutes at a time before returning to bed, a practice not dissimilar from modern rehabilitation methods used on intensive care units.

Twenty-eight days post injury Harlow recorded Gage’s responses to that which constituted brief mental status questions. While he had already documented that Gage was oriented to person, he was now able to establish orientation to place, time, and purpose. That is, when asked about the date of injury, Gage confirmed accurately that the accident occurred “four weeks this afternoon at 4 ½ o’clock” (p. 392). Given the severity of the brain trauma, the contemporary neuropsychologist or physician might assume significant anterograde and retrograde amnesia. Surprisingly, this was not the case, as Gage was able to recall how the accident took place and his transport to Adam’s Inn. In addition, he kept an accurate account of the day and recognized most of his visitors. In fact, Harlow described Gage’s memory as being “perfect as ever.” However, Gage is also described as being unable to perform some simple activities of daily living, which included estimating “size or money” or “exchanging $1000 for a few pebbles” (p. 392), suggesting limitations to executive reasoning. In contrast, his physical condition showed progressive improvement as the abscess in the posterior part of his mouth continued to diminish with the topical use of silver nitrate.

At thirty-seven days post injury Gage was able to get out of bed independently and sit up at bedside for 30 minutes at a time; however, he was noted to be “very childish” and asked Harlow to allow him to return to his home in New Hampshire. Considering his physical condition, his request probably reflected an early indication of his lack of insight. Two months after the injury on November 8, Gage was no longer confined to his bed. Harlow kept him on a “low diet” and noted normal appetite, sleep, digestive, and bowel patterns. Gage’s increased physical activity included sitting up “most of the time during the day,” ambulating about the stairs and porch of Adams’s Inn, and walking in the street. Given his apparent stable mental and physical status, Harlow left for a week and instructed his patient “to avoid excitement and exposure” (p. 392).

In spite of his directives, when Harlow returned a week later he was told that Gage was reportedly “in the street every day except Sunday” and that “his desire to be out and to go home to Lebanon has been uncontrollable by his friends, and he has been making arrangements to that effect” (p. 392). At one point, Gage walked half a mile to a store in the cold wet weather without benefit of a coat or proper footwear. When Harlow checked on him, Gage was in bed and described as “depressed and very irritable” with “hot and dry skin,” thirsty, constipated, and complained of stabbing pain on the left side of his face. Harlow’s use of the term “rigors” suggests that Gage’s symptoms included high fever, cold, sweating, and shivering. His treatment included a cold compress to treat the fever and prescribing a “black dose” every six hours. This historical pharmaceutical was compounded by combining elixir of senna (black figs), currants, coriander, and cream of tartar every six hours as a remedy for constipation (Beringer & Griffith, 1921 ). Of equal interest to Harlow was a needle-like piece of bone in the back of Gage’s mouth that he ejected “within a few days” (Harlow, 1848 , p. 393).

The following day, Gage’s physical condition had not improved much. As a result, Harlow appears to have become more aggressive in his treatment, bleeding him about 16 ounces and prescribing 650 mg of calomel, 130 mg of ipecac, and a dose of castor oil. He notes that Gage responded to this intervention and in the evening added 195 mg of “r. Antim. Et potassa tart” (tartar emetic) and 180 ml of simple syrup administered every four hours, likely to address the fever.

Over the next two days, between November 17 and 18, Gage reported “feeling better in every respect.” He was now nine weeks and two days’ post injury, without head pain, and able to ambulate. As a result, Harlow perceived him medically stable, although he clearly had reservations regarding Gage’s psychological condition, as evidenced by his final entry into the medical record that Gage “appears to be in a way of recovering if he can be controlled ” (emphasis added; Harlow, 1848 , p. 393). Harlow provided additional behavioral observations on Gage’s change in mental status in his republication of the case in 1868. However, of particular interest to neuropsychologists is that he signed off in the medical record by noting, “I think the case presents one fact of great interest to the practical surgeon, and, taken as a whole, is exceedingly interesting to the enlightened physiologist and intellectual philosopher ” (emphasis added; Harlow, 1848 , p. 393).

Status Post Discharge

Harlow ( 1868 ) ended his acute care on November 18, which was two months and ten days’ post injury. His last entry into the medical record suggests that his patient was sufficiently physically recovered. Having been released from Harlow’s care, Gage returned to his home in Lebanon, New Hampshire on November 25.

The following week, Harlow traveled the 30 miles for a home visit to Gage and “found him going on well” (p. 338). He also notes a recheck on January 1, now almost 16 weeks after the injury from which Harlow concluded further healing, noting “the opening in the top of his head was entirely closed, and the brain shut out from view, though every pulsation could be distinctly seen and felt” (Harlow, 1868 , p. 338).

Gage remained at home in New Hampshire over the next 12 weeks and continued to recover throughout the winter months. Harlow ( 1868 ) documents that in the spring, he returned to Cavendish and applied for his previous position as a foreman but was not afforded reemployment due to the significant change in his behavior and comportment. Given the convenience of his return, Harlow took the opportunity to reexamine his patient.

Harlow’s Reexamination

Upon his return to Cavendish, Gage was about seven months into his recovery. Harlow’s assessment included observations of Gage’s appearance, physical findings, and behavior, with inferences about his psychological functioning that retrospectively constitute a fairly thorough examination of his physical, behavioral, and psychological status.

Harlow described Gage’s physical status as generally normal, noting the following:

General appearance good; stands quite erect, with his head inclined slightly towards the right side; his gait in walking is steady; his movements rapid, and easily executed. The left side of the face is wider than the right side, the left malar bone being more prominent than its fellow. There is a linear cicatrix near the angle of the lower jaw, an inch in length. Ptosis of the left eyelid; the globe considerably more prominent than its fellow, but not as large as when I last saw him. Can adduct and depress the globe, but cannot move it in other directions; vision lost. A linear cicatrix, length two and one-half inches, from the nasal protuberance to the anterior considerably more prominent than its fellow, but not as large as when I last saw him. Can adduct and depress the globe, but cannot move it in other directions; vision lost. A linear cicatrix, lengths two and one-half inches, from the nasal protuberance to the anterior edge of the raised fragment of the frontal bone, is quite unsightly. Upon the top of the head, and covered with hair, is a large unequal depression and elevation-a quadrangular fragment of bone, which was entirely detached from the frontal and extending low down upon the forehead, being still raised and quite prominent. Behind this is a deep depression, two inches by one and one-half inches wide, beneath which the pulsations of the brain can be perceived. Partial paralysis of the left side of face. His physical health is good, and I am inclined to say that he has recovered.

Harlow’s remarks suggest that Gage’s overall appearance was generally unremarkable, the exception being the ptosis of his left eyelid which can clearly be seen in the daguerreotype discovered in 2009. Harlow also documented apparent changes in Gage’s personality:

Has no pain in the head, but says it has a queer feeling which he is not able to describe. Applied for his situation as foreman, but is undecided whether to work or travel. 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 place again. The equilibrium or balance, so to speak, between his intellectual faculties and animal propensities seems to have been destroyed. He is fitful, irreverent, indulging at times in the grossest profanity (which was not previously his custom), manifesting but little deference for his fellows, impatient of restraint or advice when it conflicts with his desires, at times pertinaciously obstinate, yet capricious and vacillating, devising many plans of future operation, which are no sooner arranged than they are abandoned in turn for others appearing more feasible. A child in his intellectual passions of a strong man. Previous to his injury, though untrained in the schools, he possessed a well-balanced mind, and was looked upon by those who knew him as a shrewd, smart business man, very energetic and persistent in executing all his plans of operation. In this regard his mind was radically changed, so decidedly that his friends and acquaintances said he was ‘no longer Gage.’ (Harlow, 1868 , pp. 338–340)

After Harlow published his initial report in December 1848, he was contacted by Dr. Henry Bigelow, a prominent Boston surgeon and Harvard professor. Bigelow ( 1850 ) acknowledged having been verbally informed of the accident but was highly skeptical as to the facts of the case. Using Harlow as an intermediary, he provided funds for Gage to travel to Boston for an examination. Given Harlow’s determination that his patient was now “quite well” (p. 330), Gage accepted Bigelow’s offer.

Dr. Henry Bigelow: A Second Opinion

Henry Bigelow, M.D. is perhaps one of the most interesting individuals with whom Gage interacted. Bigelow was a prominent surgeon at Massachusetts General Hospital and a professor of surgery at Harvard University who was instrumental in bringing Gage’s accident to medical prominence. To fully appreciate how his involvement was necessary in validating Gage’s injuries and treatment to the skeptical medical community at that time, one must understand Bigelow’s social background and medical training that allowed him to lend gravitas to Harlow’s report (Schatzki, 1994 ).

Bigelow was the eldest son of an affluent Massachusetts family whose father was a renowned surgeon and Harvard Medical School professor who was socially well connected in Boston society. He entered Harvard at age 15 intent on following his father’s medical career. His memoirs suggest an egotistical individual, self-described as having “personal magnetism,” being a “brilliant operator,” and to those who observed his surgical technique “was to recognize a master” (Bigelow, 1894 , pp. 37–38).

In spite of these self-described laudable attributes, Bigelow’s actual behavior was in many circumstances otherwise. While at Harvard, he was reprimanded for noise violations after disturbing the college with a trumpet he made from a tin coffee pot. He also made nitrous oxide for the Rumford student chemistry club and compromised his health from multiple binges. Perhaps as an early indication of his fascination with anesthesia, he rationalized his abuse of the inhalant as being one of his “most important investigations.” While these pranks were tolerated by Harvard’s administration, he was eventually expelled in 1834 along with five freshmen and the entire sophomore class for taking part in a three-month student rebellion. Although he dismissed damages from the uprising by describing it as a “stirring incident,” the revolt included burning a classroom, exploding a device in Holden Chapel, assaulting two watchmen, and using gunpowder to burn the Harvard’s president, Quincy, in effigy (McCaughey, 1970 ). Compounding the group’s vandalism, Bigelow was personally sanctioned for having three muskets in his dorm room at Hollis Hall that he discharged multiple times into a wooden post (pp. 10–12) and for nearly wounding a fellow student named James Elliot Cabot “by the accidental discharge of a gun” (Bigelow, 1894 , pp. 9–13).

After his expulsion he studied anatomy and physiology at Dartmouth College with Oliver Wendell Holmes, visited Cuba for a period of months to remedy his respiratory difficulties (allegedly from his nitrous abuse), spent time in Italy, Egypt, Paris, and London, where he studied with Longet and reportedly “mastered” auscultation with the stethoscope under Sir James Paget. He finally returned to the Boston, where he eventually he received his medical degree from Harvard in 1841 (Bigelow, 1894 pp. 24–25).

Historically Bigelow is best known for being the first physician to publish on the surgical application of ether, having first watched Morton and Warren demonstrate its use with two cases. in October 1846 (Morton & Woodbury, 1895 ). He used the inhalant on one of his own cases a month later and published his account, thereby circumventing publication by the actual pioneers of the discovery. In doing so was given credit for establishing its medical importance, which contributed to his surgical appointment that same year at Massachusetts General Hospital. Interestingly, he also addressed the anesthetic properties of kerosene after experimenting with self-inhalation of its vapor (Bigelow, 1846 , 1894 ).

Having established his medical credentials, it is not surprising that Bigelow was highly skeptical of the occurrence of Gage’s accident and his survival. The injury as described with the limited loss of function was so inconceivable that many in the medical community were highly doubtful and thought that the facts were misunderstood. In Bigelow’s published remarks, he noted that “A physician who holds in his hand a crowbar, three feet and a half long, and more than thirteen pounds in weight, will not readily believe that it has been driven with a crash through the brain of a man who is still able to walk off, talking with composure and equanimity of the hole in his head” (Bigelow, 1850 , p. 19).

In January 1850, Bigelow secured Gage’s presence and exhibited him to Boston’s medical community for a number of weeks during which Gage was subject to multiple examinations that confirmed the case facts as described by Harlow. Having presented him as a case study in medical rounds, Bigelow reported, “I have been able to satisfy myself as well of the occurrence and extent of the injury as of the manner of its infliction” (Bigelow, 1850 , p. 13). Bigelow demonstrated the injury to colleagues by recreating the path of the tamping iron through an anatomical (cadaver) skull and in doing so verified how the bar could enter, pass through, and exit the cranium without inflicting a fatal lesion. As a result, he wrote, “This is the sort of accident which happens in the pantomime at the theatre, but not elsewhere. Yet there is every reason for supposing it in this case literally true. Being at first wholly skeptical, I have been personally convinced; and this has been the experience of many medical gentlemen who, having first heard of the circumstances, have had a subsequent opportunity to examine the evidence” (Bigelow, 1850 , p. 13).

Bigelow’s importance in Gage’s case lies in his establishing a second opinion and, given his position of prominence in Boston medical society and his reputation, to corroborate Harlow’s findings. In addition, his recapitulation of Harlow’s treatment provided an additional source of documentation in a highly-respected medical publication, The American Journal of the Medical Sciences . In doing so, he afforded the case broader public exposure to the medical community of the northeast United States, which other physicians then began to cite (Butler, 1851 ). Of equal importance to Bigelow’s gravitas was his successful obtainment of a collection of affidavits by those who either witnessed the accident or saw Gage afterwards. Through letters to Harlow, he collected critical documents that formally affirmed the facts of the case, and included these accounts in his 1850 publication. By doing so, he resolved the doubts or reservations held by his medical colleagues who subsequently supported his opinion. “This is no fancy picture drawn to task credulity, but a well authenticated fact” (Butler, 1851 , p. 99).

Gage’s Change in Mental Status: Frontal Cortical Injury

Gage is often cited as an example of a frontal cortical injury with subsequent changes in personality or comportment (Mesulam, 1985 ; Prigatano, 1992 ; Suchy, 2016 ). It has been suggested that there are three principal frontal-subcortical circuits involved in cognitive, emotional, and behavioral processes: dorsolateral, ventromedial, and orbitofrontal, each corresponding to areas of the prefrontal cerebral cortex.

The dorsolateral frontal cortex mainly projects to the dorsolateral head of the caudate nucleus and has been linked to executive functions, such as those measured on tests of mental flexibility, planning, abstraction, and deductive reasoning. It was this link between dorsolateral structures and executive reasoning that led to early conclusions that the frontal lobes were the seat of executive reasoning, so much so that such tasks were described as tests of “frontal lobe functioning.”

The ventromedial circuit projects from the anterior cingulate gyrus to the nucleus accumbens in the basal forebrain. Ventromedial lesions are associated with apathy, amotivational states, social withdrawal, reduced initiation, and motor slowing (Herman, et al., 1992 ; Herman & Cullinan, 1997 ).

It has been proposed that the anterior cingulate cortex (ACC) can be further sectioned into anatomically and functionally distinct subdivisions, based upon its connections to other frontal lobe regions, notably a supracallosal region of the ACC. This area projects to dorsolateral frontal areas and subcallosal portions of the ACC, which then connect to the posterior orbitofrontal regions. While supracallosal ACC lesions are associated with executive impairment and related cognitive inefficiencies, subcallosal ACC lesions are associated with control of respiration, blood pressure, and other autonomic functions (Herman & Cullinan, 1997 ).

The orbitofrontal cortex projects to the ventromedial caudate nucleus and is linked to socially inappropriate behaviors, such as disinhibition, impulsivity, and anti-social behaviors, behavioral inconsistency, and unreliability (Cullinan, et al., 1995 ). These are the behaviors described by Harlow ( 1868 ) in the aftermath of Gage’s injury.

Advances in neuroimaging and modeling technology have led to refined hypotheses as to the likely path of the tamping iron that produced Gage’s brain injury. Based upon magnetic resonance imaging (MRI) data and three dimensional modeling, Damasio and associates (1994) concluded that Gage’s brain lesion involved the anterior half of the left orbital-frontal context, the polar and anterior mesial frontal cortices, and the anterior-most portions of the anterior cingulate gyrus. That is, his lesion affected the ventromedial region of both frontal lobes while sparing the dorsolateral regions. They further concluded that “Gage … fits a neuroanatomical pattern we have identified within a group of individuals with frontal damage. Their ability to make rational decisions in personal and social matters is invariably compromised and so is their processing of emotion.”

More recently, Van Horn and associates (2012) employed diffusion weighted imagery (DWI) and MRI modeling and determined that considerable cortical and subcortical damage to white matter tracts was localized to the left frontal lobe. In their modeling, it was estimated that the tamping iron damaged approximately 11% of the white matter in the frontal lobe and approximately 4% of the cerebral cortex. They hypothesized that damage occurred to the superior longitudinal fasciculus, which connects all lobes in both hemispheres, and the uncinated fasciculus, which links the limbic system to parts of the frontal lobe. As such, some brain structures affected were quite remote from the site of impact, but nonetheless contributed to Gage’s changes in behavior and comportment in the aftermath of his brain injury.

According to Bigelow ( 1850 ), these mental status changes were fairly marked. He described Gage as “fitful” and “irreverent”; he demonstrates “but little deference for his fellows” (a far cry from the Gage who was a “great favorite” of his men) and is “at times pertinaciously obstinate, yet capricious and vacillating”; he employs “the grossest profanity,” which was not typical pre-injury. Harlow also seems to imply that Gage had an unwillingness to carry out his plans, writing that they were “no sooner arranged than they are abandoned in turn for others appearing more feasible” (p. 340). This characterization seems to contrast sharply with Harlow’s descriptions of Gage’s pre-injury mental status, when he was “persistent in executing all his plans of operation” (p. 340) and possessed “an iron will” (p. 330). The Rutland and Burlington railroad company, who previously employed Gage and regarded him as highly capable and dependable, now “considered the change in his mind so marked that they could not give him his place again” (p. 339).

Long-Term Recovery

Harlow ( 1868 ) provided an account of Gage’s long-term recovery, as relayed by Gage’s mother. According to Harlow, sometime after his examination in 1850, Gage traveled throughout New England, including to Boston and New York. While in New York, that Gage spent some time “at Barnum’s,” apparently in reference to P. T. Barnum’s famous New York museum (Bigelow, 1894 , pp. 119–123).

Barnum’s autobiography (Barnum, 1855 ) contains no mention of Gage (an observation also noted by Macmillan, 2000a ), and a review of the Barnum’s Museum Illustrated Guide from 1850 similarly does not mention him (The Lost Museum Archive, n.d.) ; however, there is also some evidence to support Harlow’s assertion that Gage participated in public exhibition. Macmillan and Lena ( 2010 ) describe first a letter by Henry Bigelow which also states that Gage appeared at Barnum’s museum. Second, they describe two advertisements for appearances by Gage, one for an appearance in Concord, New Hampshire, and another for Montpelier, Vermont. While it is unclear if Gage’s stay at Barnum’s was extended or quite brief, he clearly seems to have appeared at the museum for a time and also participated in other public appearances, possibly independent of the museum and possibly under his own management (Macmillan & Lena, 2010 ).

Harlow reports that Gage took a job in the livery stable of Jonathan Currier in 1851, apparently abandoning exhibition due to lack of public interest (Macmillan & Lena, 2010 ). After working in Currier’s stable for “nearly a year and a half” (Harlow, 1868 , p. 340), Gage travelled to Valparaiso, Chile, with an acquaintance who planned to establish a horse drawn coach business to transport passengers from the coastal region to Santiago.

At this point there is evidence that the dates in Harlow’s report become somewhat less accurate; for example, while he ends by stating that Gage died in 1861, records list his burial date as May 23, 1860, making Harlow’s history inaccurate by a year in this regard. Gage likely remained in Chili until 1859, at which time he travelled to San Francisco, home to his mother and sister, reportedly due to failing health. Gage briefly worked on a farm in Santa Clara although “did not remain there long,” and approximately three months before his death suffered seizures, described as “a fit,” followed by “two or three fits in succession” (p. 341). He then suffered a “severe convulsion” the day before his death, followed by repeated convulsions until his time of death at approximately 10 p.m. the following day.

Gage’s Final Resting Place

Gage was first interred at Lone Mountain Cemetery (renamed Laurel Hill in 1864) on May 23, 1860; however, he would not finally lie undisturbed until nearly eight decades later. Gage’s body was exhumed in 1867 at the request of John Harlow. Because no autopsy of Gage was performed upon his death, Harlow requested that Gage’s mother give him possession of the skull and tamping iron for the benefit of the historical record (Harlow, 1868 ). The skull and tamping iron were retrieved and sent to Harlow, who subsequently donated them to the Museum of the Medical Department of Harvard University (now the Warren Anatomical Museum), where they are still on display in the Countway Library of Medicine. The remainder of Gage’s body was reinterred and would remain at Laurel Hill. But unstoppable urban progress prompted San Francisco supervisors to prohibit new burials in the city and eventually declare the city’s old cemeteries a public nuisance. Heated debate over what do with the cemeteries’ tens of thousands of occupants, as well as the many ornate and expensive monuments, prevented any action from being taken for a number of years. By the early 1900s Laurel Hill was in a lamentable state of disrepair:

At Laurel Hill Cemetery high weeds obstructed the once stylish paths and avenues. Statues were overturned and carried off. Scavengers methodically pillaged vaults. Coffins were hacked open and bones strewn about. Entire skeletons were stolen (Svanevik & Burgett, 1992 , p. 28).

Fortunately, Gage was not among the many dead who had their final resting place desecrated by vandals. In 1937 the city of San Francisco ordered the transfer of remains from Laurel Hill to Cypress Lawn in Colma, California (Svanevik & Burgett, 1992 ). Gage’s transfer slip (Figure 41.6 ) indicates his remains were transferred from Laurel Hill on May 17, 1940, and interned in vault 962 of the Pioneer Monument, located in Cypress Lawn Memorial Park (H. Lopez, personal communication, May 21, 1996).

Why Study Gage?

What contemporary significance does the case study of Gage’s injury hold for neuropsychology? The detailed descriptions of his injury and meticulous notes recording his changes in physical and cognitive status during and after recovery lend the case a uniqueness that is unparalleled by most medical case studies of the period. In this sense, Gage’s case provides at least four compelling reasons for ongoing study by clinicians interested in brain-behavior relationships. First, it is of historical importance to neuropsychology. Second, it remains clinically relevant to students, psychologists, physicians, and scientists in the fields of neuroscience, physical medicine, and rehabilitation, particularly for those interested in brain injuries, localization, and the frontal lobes (Macmillan, 1994 ). In addition, most reiterations in texts and scholarly articles contain errors, and lastly, the mechanism of injury and accompanying historical facts continue to maintain a high level of interest that is referenced by multiple medical and scientific disciplines.

Gage’s transfer slip

Historical Importance

The historical importance of Gage’s case can be found in the influence it had on 19th century thinking about the brain and behavior. It was one of the first in a series of single-case medical studies published in the 1800s and early 1900s that provided a foundation for understanding the brain’s function and mental status changes following disease, insult, or injury to the central nervous system.

Following publication of Gage’s injury, Paul Broca ( 1861 ) published his famous case of the patient Leborgne, known as “Tan,” who experienced language deficits associated with a left frontal lesion as the result of syphilis (Lazar & Mohr, 2011 ). In 1880 Josef Breuer presented Bertha Pappenheim, “Anna O.,” to the medical community as an example of psychogenic paralysis of vision and speech, hence an early example of conversion disorder (Breuer & Freud, 2000 ). Sigmund Freud ( 1909 ) published his famous case of severe anxiety of horses of Herbert Graf or “Little Hans,” titled “Analysis of a Phobia in a Five-year-old Boy.” Lastly, in the 1920s Alexander Luria presented his synesthesia case of the journalist Solomon Shereshevsky to describe how stimulation of one sensory pathway leads to automatic, involuntary experiences in a second sensory or cognitive pathway (Luria, 1966 ).

Clinical Relevance

Gage’s injury is significant to neuroscience and neuropsychology, in particular, because his attending doctor, John Harlow, conducted the first detailed documentation of frontal cortical damage altering emotional regulation and behavior. Not surprisingly, many who learned of the accident doubted the mechanism of injury, assuming that survival from a traumatic impalement of the brain of this magnitude was inconceivable. Even the Reverend Joseph Freeman, who saw Gage immediately after the accident, responded with disbelief upon being told that the tamping iron passed through his head, simply stating “That is impossible” (Bigelow, 1850 , p. 15).

Though many are commonly met with skepticism or disbelief, there are a number of historical references to the treatment of traumatic brain injuries (Chaucer, 2005 , p. 770; Cronyn, 1871 ; Karger, 2001 ; Leny, 1793 ). Most describe military surgical interventions following impalement by projectiles such as spears, javelins, lances, and arrows (Bollet, 2002 ). One of the oldest examples is the ancient Egyptian medical text known as the Edwin Smith Papyrus (1600 bce ), which categorized trauma by organ, including brain injuries classified by scalp lacerations, penetration of the skull, and injury to the brain (Nunn, 1996 ; Reitan & Wolfson, 2000 ; Wilkins, 1992 ).

It is understandable that a lack of knowledge about brain functioning led to a simplistic approach to the treatment of brain trauma. For example, in his medical writings Hippocrates addressed head injuries by focusing on consequences of insults to the skull (Wilkins, 1972 ), whereas Galen concentrated on the ventricles and their association with psychic pneuma and the rational soul to explain changes in consciousness (Finger, 1994 ). Ganz ( 2013 ) writes that this approach continued until the 1700s, when French, English, Irish, and Scottish surgeons began to more accurately identify alterations in mental status subsequent to traumatic brain injury to the cerebral cortex. Specifically, he identifies Henri-Francois Le Dran, Percival Pott, James Hill, Sylvester O’Halloran, William Dease, and John Abernethy as being seminal figures in the development of surgical interventions of the brain.

One of the most famous historical examples similar to Gage’s injury is that of Henry V who, as a prince, was wounded in 1403 on the battlefield in Cheshire, England. After a massive barrage of arrows was launched, the future king was struck in the face by an arrow that entered below his eye and to the left side of his nose, penetrating six inches into his skull (Strickland & Hardy, 2011 ). He survived the injury and was treated at Kenilworth castle by John Bradmore, who described in detail his removal of the arrowhead with a mechanical extraction device and the use of resin, wax, herbs, and honey, which served as crude antiseptics, noted to be “good for chilled nerves and sinews” (Cole & Lang, 2003 , p. 97).

Even in the 1800s Gage’s case was not the first to document personality change as a result of frontal lobe injury. Benson and Blumer ( 1975 ) report on a 16-year-old male who suffered a self-inflicted gunshot wound with a black powder pistol which extensively damaged the medial-orbital frontal lobe (de Nobele, 1835 ). Prior to the injury, the adolescent was said to exhibit withdrawn, depressed behavior. Post-injury, his personality seemed markedly changed; he was described as being “happy, vivacious, and jocular” (Stuss & Benson, 1984 , p. 19), despite suffering blindness as a result of the injury. As exemplified here, while Gage’s injury may be the most widely known, frontal lobe injuries due to war, riding or draft animals, hunting, farming, and work accidents were documented long before Gage (Harris, 1847 ; Heustis, 1829 ; Leny, 1793 ) and after his injury (Bird, 1865 ; Cronyn, 1871 ; Fitch, 1852 ; Folsom, 1868 ; Noyes, 1882 ).

Gage’s case however, is unique from other historical examples of traumatic brain injury because of its contribution to our understanding of the role of the frontal lobes. Previously, it had been thought that the frontal lobes had little influence on behavior and cognition, until the absence of executive functioning became apparent following their impairment (Suchy, 2016 ). David Ferrier cited Gage as a primary example of how a frontal lobe injury can alter personality without sensory or motor findings (Neylan, 1999 ) and used Gage’s injury to explain inhibitory and attentional changes in primates and humans. He associated attention with higher cortical functioning and described “its relation to the anatomical substrata of the prefrontal lobes” (Ferrier, 1878 , p. 447). Although he later changed his position, in his first edition of The Functions of the Brain , Ferrier ( 1876 ) proposed a frontal-inhibitory-motor function of the brain and also advocated for cerebral localization using Harlow’s clinical observations to support focal mapping of cerebral functions (Ferrier, 1878 ). Damasio, Grabowski, Frank, Galaburda, and Damasio ( 1994 ) stated that Gage’s case perhaps should have signaled the beginning of the study of the biological basis of behavior, placing Harlow’s observations on par with those of Broca and Wernicke. It is no wonder that most students of neuroscience, medicine, and psychology have been taught about Gage’s change in behavior following cortical damage and the subsequent implication for personality change.

Most Reiterations Contain Errors

It is difficult to find a reiteration of Gage’s case in scholarly articles or texts without finding errors. This is particularly evident in introductory psychology textbooks that discuss Gage’s post-accident recovery and mental status changes (Macmillan, 2000b ); Griggs, 2015 ). Was the instrument of destruction a crowbar or tamping iron (Barker, 1995 )? Did the bar pass through his head or did his physician remove it (Maugh, 2009 )? Did he recover his “faculties of body and mind” (Bigelow, 1850 , p. 14) and retain “in a perfect degree his mental powers” such that “at no time during his recovery was his mind seriously affected” (Butler, 1851 , p. 99) or did he in fact not fully recover his mental faculties, as the American Phrenological Journal claimed after the injury (“Remarkable case of injury,” 1851)? Could he only “briefly sustain work as a stable hand” (Lyketsos, Rosenblatt, & Rabins, 2004 , p. 250) or did he maintain consistent employment after his recovery? After the injury was he rational? Did he demonstrate a lack of foresight (Harlow, 1868 ) or was his disfigurement so traumatic that it altered his personality (Kotowicz, 2007 )? Did Gage’s injury inspire the development of 19th century neurosurgical interventions for brain lesions or the frontal lobotomy procedure (Macmillan, 2000a; Starr, 1848)? The point to be made is that even though the original documents are now easily accessible to researchers and a comprehensive analysis of the case exists (Macmillan, 2000a ), even academic researchers continue to perpetuate errors and get the facts of this case wrong.

In his work, An Odd Kind of Fame: Stories of Phineas Gage , Malcolm Macmillan ( 2000a ) presents what is likely to be the most extensive research of Gage’s injury ever written. Macmillan hypothesized that errors or misrepresentations present in summaries of Gage’s injury, recovery, and subsequent behavioral changes could be the result of later authors’ ignoring some or all of Harlow’s description of Gage’s recovery and life post-injury. This is likely to lead to largely accurate descriptions of the basic facts of the case (date, time, and nature of the accident; the physical properties of the tamping iron; etc.) but vague, incomplete, inaccurate, or exaggerated descriptions of Gage’s behavioral changes and employment—the story becoming less clear as it moves away from its climax. Macmillan suggests that further exaggerations of Gage’s altered behavior may be the result of generalizations or the over-simplification of damage to the frontal lobe from other, similar case studies that may have been projected onto Gage’s history after the fact.

Numerous examples can be found in the literature that inaccurately cite the Gage case to illustrate a particular character trait such as wantonness, virulence, and immorality following damage to this area of the cortex. Inconsistent with Harlow’s behavioral observations, which were also supported by Bigelow’s affidavits collected from eyewitnesses, Biever and Karinch ( 2012 ) describe Gage as having become “sexually promiscuous and hostile” and “totally disinhibited,” and therefore conclude that “Phineas Gage’s limbic brain was apparently destroyed, but his cognitive brain survived intact” (p. 42). To paraphrase what Macmillan has said on a number of occasions (e.g., Kean, 2014 ; Lewandowski, 1998 ; Macmillan, 2000a , p. 333), the initial reports by Harlow and Bigelow come closest to accurately capturing the facts surrounding Gage’s accident, treatment, and recovery, and they should be treated as the primary sources for facts.

Uniqueness and Interest

Lastly, Gage’s injury and his recovery are very interesting. The patient and his attending doctor were very unremarkable people who were brought into the annals of science and history by this one remarkable event (Lewandowski, 2018 ). The mechanism of injury is a source of fascination that has somewhat of a carnival side-show quality. Gage is one of the most frequently cited cases from 19th century medical literature. Harlow himself said in his 1868 publication that Gage was “the man for the case,” that the iron’s smoothness reduced damage to concussion/compression, and that the area of the brain compromised “was the best fitted of any part of the cerebral substance to sustain the injury” (p. 344). As a result, the case of Phineas Gage continues to lend great interest and contemporary relevance to neuroscientists across a broad range of psychological and medical specialties.

Phineas Gage’s improbable survival from the blast that caused a tamping iron to pass through his head occurred during a time when survival from catastrophic brain injury was quite rare. The unique circumstances of the case—including the advantageous size, shape, and texture of Gage’s tamping iron, the limited concussive/compressive damage secondary to the force of impact, and the sequence of techniques employed by Harlow during Gage’s acute treatment—contributed to his survival and the implications of the case for the medical science of the time. Moreover, it occurred at a time when the particular functions associated with the cerebral cortex were for the most part unknown and thought to be unknowable. Because those very few individuals who suffered penetrating brain injuries and sustained pre-frontal trauma survived, it was assumed that these portions of the brain were behaviorally silent.

The Gage case was the first to extensively document that changes in such complex and seemingly inherent qualities such as judgment, impulse control, demeanor, and temperament were not only associated with the brain, but with particular regions within it. It challenged the medical community to begin to question if temperament could be subject to external influences and therefore amenable to scientific principles such as modification, prediction, and clinical treatment.

Gage’s injury occurred at a time when surgical advances and the treatment of infection had progressed to the point where at least some severely traumatically injured patients could survive long enough to be clinically observed and where individuals so injured would be triaged in a manner that would permit them access to heroic care. This would not have occurred if mediums for the exchange of medical information had not reached a tipping point, such that case reports, procedures, and findings previously occurring in isolation could be posted, compared, and aggregated in recently established medical journals. Consider also that while Harlow did not have the resources of hospitals, medical schools, medical meetings, and apothecaries that his physician colleagues had in urban areas, he was prepared through clinical training by a group of renowned medical professors for this very complex traumatic brain injury that even he equated with a military injury.

Gage is among the first well-documented cases of brain-injury where the roles of the patient and the treating physician evolved into intertwined and extended friendships or stewardships, such that long-term follow-up was possible and the changing nature of brain injuries over time could be detailed and explicated. There are echoes of the relationship between Gage and Harlow in the cases of “S.” (Luria), “Tan” (Broca), and Lelong (Wernicke), through to that between Corkin and the amnest, “H.M.” Gage was the first case of which we are aware that offered rich and compelling descriptions of the effects of brain injury over time. In fact, the copious notes taken by Harlow immediately after the accident and throughout Gage’s treatment and recovery have largely (but not completely) precluded the case from accusations of exaggeration and frank invention that haunt mid-19th century medical scholarship.

This, then, may be the reason that the case of Phineas Gage continues to have an enduring influence on contemporary neuropsychology. Many of us were first drawn to neuropsychology because of our interest in the human consequences of brain injuries, in the ways in which the complex activities of normal people could be dramatically damaged by injuries to their brains, and the ways in which that knowledge could be used to help them adapt or recover. This may be the lasting legacy of the case of Phineas Gage: the degree to which the facts and mythology of this case have captured the imagination of generations of future neuropsychologists.

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Phineas Gage

The wonders of day to day brain functions are not to be taken lightly. Amongst other functions, daily brain function includes prioritizing information from the five senses, managing autonomic systems , and maintaining working memory. While this is already impressive, the brain is also capable of healing itself and undergoing significant functional and structural change (Kolb & Whishaw, 1998). While incidents such as traumatic brain injuries (TBIs) are life-altering, the case of Phineas Gage illustrates how the brain can continue to function despite a severe injury.

Despite his physical recovery, friends, family and Harlow noted several changes in Gage’s behavior. Harlow described changes in his personality such as “fitful, irreverent, indulging at times in the grossest profanities (which was not previously his custom), manifesting little deference for his fellows, impatient of restraint or advice when it conflicts with his desires” (Harlow, 1868). This is paired with the oft-quoted observation, he had become “no longer Gage” (Harlow, 1868). Though no psychological assessments of Gage exist, experts propose, “Harlow argued that the behavioral changes in Gage’s personality were the direct result of the damage to the left frontal lobe” and experts propose these changes “[result] from deficits in rational decision-making and emotion processing” ( Thiebaut de Schotten et al., 2015). How radical these changes were has been debated as this is based on individual reports and is not independently documented (Macmillian, 2009; Kendra, 2019). Later in life, Gage was also said to make a partial psychosocial recovery, working in both Chile and America, and touring with the story of his survival (Macmillian & Lena, 2010). Gage’s health only truly began to fail in 1859, growing ill and dying in 1860 (Macmillian & Lena, 2010).

Early explanations of Gage’s changed behavior rely on single-process explanations, parts of the brain relating to a single type of function (Macmillian & Lena, 2010). This varies from the modern conception of the brain as a series of interconnected systems  (Macmillian & Lena, 2010).

Two other interesting cases are that of Henry Gustav Molaison and Louis Victor Lebornge. Henry Gustav Molaison was an American man who after a bilateral medial temporal lobectomy could no longer form new memories (Thiebaut de Schotten et al., 2015). This procedure cured his epilepsy, but “ Molaison was able to maintain information online for about [thirty seconds], but his ability to convert short-term memories into long-term memories was lost” (Thiebaut de Schotten et al., 2015). Pierre Paul Broca, for whom the Broca’s area is named, worked with two patients who lost their ability to speak following damage to the frontal lobe. One of the two, Louis Victor Leborgne was thirty years old at the time of his admittance and had lost the ability to speak except for the word “tan” (Thiebaut de Schotten et al., 2015). He spent twenty one years at Bicêtre Hospital, but “eventually deteriorated,” becoming both paralyzed and bedridden for the final seven years of his life (Thiebaut de Schotten et al., 2015).

These cases were seminal to our current understanding of the brain. While our understanding of both plasticity and functional systems has advanced, there are still many points of further research such as the effects of sleep or stem cell therapy on brain healing (Wong, 2008). You can support HBSF’s  research on the brain and neurodegenerative disease by donating here .

Written by Senia Hardwick

Kolb, B., & Whishaw, I. Q. (1998). Brain plasticity and behavior. Annual Review of Psychology , 49 (1), 43–64. https://doi.org/10.1146/annurev.psych.49.1.43

Harlow J . 1868 . Recovery from the passage of an iron bar through the head . Publ Mass Med Soc . 2:327–347.

Kendra, C. (2019). The famous case of phineas gage’s astonishing brain injury . Verywell Mind. https://www.verywellmind.com/phineas-gage-2795244

Macmillan, M. (2009, July). More about phineas gage . http://brightbytes.com/phineasgage/more.html

Macmillan, M., & Lena, M. L. (2010). Rehabilitating phineas gage. Neuropsychological Rehabilitation , 20 (5), 641–658. https://doi.org/10.1080/09602011003760527

Thiebaut de Schotten, M., Dell’Acqua, F., Ratiu, P., Leslie, A., Howells, H., Cabanis, E., Iba-Zizen, M. T., Plaisant, O., Simmons, A., Dronkers, N. F., Corkin, S., & Catani, M. (2015). From phineas gage and monsieur leborgne to h. M.: Revisiting disconnection syndromes. Cerebral Cortex , 25 (12), 4812–4827. https://doi.org/10.1093/cercor/bhv173

Wong, K. (2008). Helping the brain heal itself. Cell Stem Cell , 3 .

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Why Brain Scientists Are Still Obsessed With The Curious Case Of Phineas Gage

Jon Hamilton

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

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

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

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

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

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

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

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

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

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

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

One Account Of Gage's Personality Shift

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

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

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

For example:

• In the 1940s, a famous neurologist named Stanley Cobb diagrammed the skull in an effort to determine the exact path of the tamping iron.
• In the 1980s, scientists repeated the exercise using CT scans.
• In the 1990s, researchers applied 3-D computer modeling to the problem.

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

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

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

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

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

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

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

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

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

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

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

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

• Brain research
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Phineas Gage: Neuroscience’s Most Famous Patient

An accident with a tamping iron made Phineas Gage history’s most famous brain-injury survivor

Steve Twomey

Jack and Beverly Wilgus, collectors of vintage photographs, no longer recall how they came by the 19th-century daguerreotype of a disfigured yet still-handsome man. It was at least 30 years ago. The photograph offered no clues as to where or precisely when it had been taken, who the man was or why he was holding a tapered rod. But the Wilguses speculated that the rod might be a harpoon, and the man’s closed eye and scarred brow the result of an encounter with a whale.

So over the years, as the picture rested in a display case in the couple’s Baltimore home, they thought of the man in the daguerreotype as the battered whaler.

In December 2007, Beverly posted a scan of the image on Flickr, the photo-sharing Web site, and titled it “One-Eyed Man with Harpoon.” Soon, a whaling enthusiast e-mailed her a dissent: that is no harpoon, which suggested that the man was no whaler. Months later, another correspondent told her that the man might be Phineas Gage and, if so, this would be the first known image of him.

Beverly, who had never heard of Gage, went online and found an astonishing tale.

In 1848, Gage, 25, was the foreman of a crew cutting a railroad bed in Cavendish, Vermont. On September 13, as he was using a tamping iron to pack explosive powder into a hole, the powder detonated. The tamping iron—43 inches long, 1.25 inches in diameter and weighing 13.25 pounds—shot skyward, penetrated Gage’s left cheek, ripped into his brain and exited through his skull, landing several dozen feet away. Though blinded in his left eye, he might not even have lost consciousness, and he remained savvy enough to tell a doctor that day, “Here is business enough for you.”

Gage’s initial survival would have ensured him a measure of celebrity, but his name was etched into history by observations made by John Martyn Harlow, the doctor who treated him for a few months afterward. Gage’s friends found him“no longer Gage,” Harlow wrote. The balance between his “intellectual faculties and animal propensities” seemed gone. He could not stick to plans, uttered “the grossest profanity” and showed “little deference for his fellows.” The railroad-construction company that employed him, which had thought him a model foreman, refused to take him back. So Gage went to work at a stable in New Hampshire, drove coaches in Chile and eventually joined relatives in San Francisco, where he died in May 1860, at age 36, after a series of seizures.

In time, Gage became the most famous patient in the annals of neuroscience, because his case was the first to suggest a link between brain trauma and personality change. In his book An Odd Kind of Fame: Stories of Phineas Gage , the University of Melbourne’s Malcolm Macmillan writes that two-thirds of introductory psychology textbooks mention Gage. Even today, his skull, the tamping iron and a mask of his face made while he was alive are the most sought-out items at the Warren Anatomical Museum on the Harvard Medical School campus.

Michael Spurlock, a database administrator in Missoula, Montana, happened upon the Wilgus daguerreotype on Flickr in December 2008. As soon as he saw the object the one-eyed man held, Spurlock knew it was not a harpoon. Too short. No wooden shaft. It looked more like a tamping iron, he thought. Instantly, a name popped into his head: Phineas Gage. Spurlock knew the Gage story well enough to know that any photograph of him would be the first to come to light. He knew enough, too, to be intrigued by Gage’s appearance, if it was Gage. Over the years, accounts of his changed character had gone far beyond Harlow’s observations, Macmillan says, turning him into an ill-tempered, shiftless drunk. But the man in the Flickr photogragh seemed well-dressed and confident.

It was Spurlock who told the Wilguses that the man in their daguerreotype might be Gage. After Beverly finished her online research, she and Jack concluded that the man probably was. She e-mailed a scan of the photograph to the Warren museum. Eventually it reached Jack Eckert, the public-services librarian at Harvard’s Center for the History of Medicine. “Such a ‘wow’ moment,” Eckert recalls. It had to be Gage, he determined. How many mid-19th-century men with a mangled eye and scarred forehead had their portrait taken holding a metal tool? A tool with an inscription on it?

The Wilguses had never noticed the inscription; after all, the daguerreotype measures only 2.75 inches by 3.25 inches. But a few days after receiving Spurlock’s tip, Jack, a retired photography professor, was focusing a camera to take a picture of his photograph. “There’s writing on that rod!” Jack said. He couldn’t read it all, but part of it seemed to say, “through the head of Mr. Phi...”

In March 2009, Jack and Beverly went to Harvard to compare their picture with Gage’s mask and the tamping iron, which had been inscribed in Gage’s lifetime: “This is the bar that was shot through the head of Mr. Phinehas P. Gage,” it reads, misspelling the name.

Harvard has not officially declared that the daguerreotype is of Gage, but Macmillan, whom the Wilguses contacted next, is quite certain. He has also learned of another photograph, he says, kept by a descendant of Gage’s.

As for Spurlock, when he got word that his hunch was apparently correct, “I threw open the hallway door and told my wife, ‘I played a part in a historical discovery!’ ”

Steve Twomey is based in New Jersey. He wrote about map and document thieves for the April 2008 issue of Smithsonian .

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• The Disappearing Spoon

The Disappearing Spoon podcast

Everything you know about phineas gage is wrong.

What can a railroad construction foreman’s devastating skull injury teach us about the brain’s ability to heal?

Despite what you’ve heard, neuroscience’s most famous patient did not turn into a lying, drunken psychopath. He’s actually an amazing example of resiliency and overcoming trauma.

About The Disappearing Spoon

The Science History Institute has teamed up with  New York Times best-selling author Sam Kean to bring a second history of science podcast to our listeners. The Disappearing Spoon tells little-known stories from our scientific past—from the shocking way the smallpox vaccine was transported around the world to why we don’t have a birth control pill for men . These topsy-turvy science tales, some of which have never made it into history books, are surprisingly powerful and insightful.

Host: Sam Kean Senior Producer: Mariel Carr Producer: Rigoberto Hernandez Audio Engineer: Jonathan Pfeffer

It was a lovely September day in 1848. A construction foreman named Phineas Gage was helping lay track for a railroad company in Vermont. Some boulders were blocking the railroad’s path, so the company hired a gang of rowdy Irishmen to blast their way through.

As foreman, Gage supervised the Irishmen. He also helped drill holes into the boulders and fill them with gunpowder. Gage then packed the gunpowder down into the hole with an iron rod. The rod looked like a short javelin. It was 1¼ inches thick, stretched 3 ½ feet long, and weighed 13 pounds. 

Around 4:30pm, the Irishmen were loading some busted rock onto a cart. It was near quitting time, so perhaps they were a-whooping and a-hollering. Gage had just finished pouring gunpowder into a hole, and turned his head. 

Accounts differ about what happened next. Some say that Gage was packing the gunpowder down with the iron rod, and scraped it against the side of the hole, creating a spark. Regardless, a spark shot out somewhere inside the hole and ignited the gunpowder. At which point the iron rod reversed thrusters.

The iron rod blasted upward, and entered Gage’s skull below his left cheekbone. It destroyed a molar, pierced his left eye, and plowed into his brain’s left frontal lobe. The rod then exited on top, and landed twenty-five yards distant. One report claimed it whistled as it flew, and was streaked with blood.

The rod’s momentum threw Gage backward. He landed hard. Amazingly, though, he never lost consciousness. He twitched a few times on the ground, but was talking within minutes. He even walked under his own power to a nearby cart, and sat upright on the trip back to town.

At his hotel, Gage waited in a chair on the porch and chatted with passersby—who were, uh, startled to see a volcano of bone jutting out of his scalp.

Thus began perhaps the most famous case in medical history. Every neuroscience textbook in existence has a section on Phineas Gage. Incredibly, though, nearly every textbook gets the story wrong. 

You might have heard that, after his injury, Gage became a criminal, a drunk, a psychopath. None of that’s true.

Instead, there’s good evidence that, far from turning toward the dark side, Gage recovered after his accident—and perhaps resumed something like a normal life. It’s a possibility that, if true, could transform our understanding of the brain’s ability to heal.

When the first doctor arrived, Phineas Gage greeted him by angling his head and saying, “Here’s business enough for you.” Finally, around 6pm, the first doctor turned the case over to Dr. John Harlow. It’s not clear why. Harlow was a country doctor. He mostly treated people who’d fallen off horses. Not neurological cases. 

Harlow didn’t believe Gage’s story at first. Surely, the rod hadn’t passed through his skull? But it had: Gage had a flap in his cheek and everything. Harlow then watched Gage lumber upstairs to his hotel room and lie on the bed. Which ruined the linens, since his upper body was one big bloody mess. 

In the room, Harlow shaved Gage’s scalp and peeled off the dried blood and brains. Harlow then extracted skull fragments from the wound. Throughout this all, Gage vomited every twenty minutes. But otherwise, he remained calm and lucid. He betrayed no discomfort or pain. 

Over the next few days, an infection set in and Gage’s brain swelled dangerously. Things were touch and go for a week, and Gage lapsed into a coma. A local cabinetmaker measured him for a coffin. 

But Harlow’s diligent care allowed Gage to pull through. Gage soon returned to his family farm on Potato Road to recover. Gage did lose his left eye, but his memory, language, and motor skills remained intact. All in all, he seemed almost normal.

Almost. Harlow had kept Gage alive, but Gage’s family swore that he’d changed. The man who returned home was not the same man they knew and loved. His memory, language, and motor skills remained intact. But his personality changed. 

Before the accident, Gage was known for making plans and sticking to them. Afterward, he changed his mind willy-nilly and rarely stuck things through. Before, Gage was also indifferent to animals. Afterward, Gage adored critters of all kinds. And while the original Gage was courteous and polite in company, the new Gage was coarse and foul-mouthed. 

Most strikingly, Gage lost all money sense and developed irrationally strong attachments to certain objects. Harlow once tested Gage by offering him money for some random pebbles that Gage had picked out of a stream. Gage refused to part with them even for $1,000. Gage also carried with him at all times the iron rod that had brained him.

Harlow summed up Gage’s new personality by saying that, quote, the “balance … between his intellectual faculties and his animal propensities seems to have been destroyed.” More pithily, friends said that Gage “was no longer Gage.”

Despite his stellar work record before, the railroad refused to reinstate Gage as foreman. He took to working odd jobs on farms instead. He also indulged his newfound love of horses and became a carriage driver in New Hampshire. At one point, Gage even exhibited himself at P.T. Barnum’s freakshow museum in New York, staring back at the audience with his one good eye. For an extra dime skeptics could part his hair and watch his brain pulsate through a flap of skin over the exit wound in his skull.

After his stint at the museum, Gage’s life gets murky for a few years. Facts are hard to come by. But that hasn’t stopped scientists from filling that vacuum of facts with rumors and unfounded speculation.

One rumor claimed that Gage developed a drinking problem and started getting into brawls at taverns. Another claimed that he became a scam artist. He supposedly went to a medical school and sold them the exclusive rights to keep and study his skull after he died. Then he went to another medical school—and sold the same rights. And then another school, and another, skipping town and pocketing the cash each time. One ridiculous source even claimed that Gage lived for a dozen years with the iron rod still impaled in his noggin.

Other rumors in modern textbooks contradict each other. Some sources describe Gage as sexually indifferent, while others call him promiscuous. Some sources say he was hot-tempered, while others call him emotionally void, as if lobotomized. One neuroscientist even claimed that Gage “had lost his soul.”

To be clear, there’s zero historical evidence for any of those rumors of Gage’s mental or physical decline. In fact, in the only known picture of Gage, he looks nothing like a wastrel or someone whose life is spiraling out of control. He’s proud, well-dressed, even handsome.

To be clear, Harlow’s reports make it clear that Gage’s personality changed somehow. It’s about the only hard fact we have, neurologically speaking. But his other comments about Gage’s mental state are ambiguous. 

Take the comment about Gage’s life being taken over by “animal propensities.” That sounds dramatic, but what does that mean—“animal propensities”? Did he eat too much? Demand sex? Howl at the moon? We have no idea.

Or consider this. In addition to loving animals after his accident, Gage also felt drawn to children suddenly. And on his visits home, Gage would reportedly spin wild tales for his nieces and nephews. Made-up stories about his supposed adventures on the road. 

Some neuroscientists have interpreted Gage’s storytelling as evidence of confabulation. It’s a neurological symptom that involves chronic lying. It usually arises after frontal lobe damage. Then again, who hasn’t made up a tall tale to make little kids laugh? They love that stuff. It’s a pretty weak case for brain damage.

Similarly, we know that Gage had trouble sticking to plans after his accident. That’s another sign of frontal-lobe damage, because the frontal lobe controls mental skills like reasoning, planning, and self-control. In addition, Gage seemed to lose the impulse control that prevents most people from swearing in public. But it’s a far cry from someone saying saucy words like “hell” and “damn” to claiming that Gage was a drunken, brawling criminal.

In all, Gage’s life story, as appears in textbooks, has become as much legend as fact—a mélange of scientific prejudice, artistic license, and outright fabrication. Most people who learn about Gage in classes or textbooks have no idea how weak the case is for Gage becoming a villain. 

Moreover, some modern historians have argued, forcefully, that Gage seems to have recovered some of his faculties in the decade after his accident. He never became the Phineas Gage of old. But some of his negative traits either diminished or disappeared, possibly because his brain proved plastic enough to heal and recover some lost functions.

In 1852, Phineas Gage’s life took a dramatic turn. He left the New England of his youth and followed a gold rush down to Chile in South America. He was seasick the whole voyage. Once ashore, he found work driving a horse carriage. His job involved shuttling passengers along the rugged, mountainous trails between Valparaiso and Santiago. 

Gage held this job for seven years. Which is staggering, considering both his brain damage, and the complexity of the work. Gage likely drove a team of six horses. And horse reins at the time were complicated because you had to control each horse separately. 

For instance, consider rounding a bend. To do so without tipping the coach over, you had to slow down the inner three horses a touch more than the outer three horses, simply by tugging on their reins with varying amounts of pressure. That would have taken a lot of dexterity. I mean, imagine driving a car while steering all four wheels independently. This could not have been easy for someone with brain damage. 

Especially because the trails in Chile were quite crowded. This would have forced Gage to make quick stops and dodge other carriages. And because he probably drove at night sometimes, he would have had to memorize the trail’s twists and turns and fatal drop-offs. Plus keep an eye out for bandits. 

Gage also likely cared for his horses by grooming and feeding them—a significant responsibility. And, contradicting the claim that he lacked all money sense, Gage probably collected passenger fares. Not to mention that he presumably picked up some conversational Spanish while in Chile—no mean feat for any adult.

You wonder how many of Gage’s passengers would have climbed aboard had they known about their one-eyed driver’s little accident a few years earlier. But all in all, Gage seems to have handled himself fine.

It probably helped Gage that he followed a similar routine each day. He likely arose before dawn to prepare his horses and carriage. Then he spent the next thirteen hours driving the same road back and forth from Valparaiso to Santiago.

Now, the fact that Gage seemingly carved out a life for himself in Chile doesn’t mean that his brain recovered fully. But scientists now know that the brain’s neural circuits can recover somewhat after damage, partly by rewiring themselves. And perhaps Gage retained enough of his frontal lobes to retain some basic planning skills. At the very least, Gage didn’t deteriorate into the drunken sociopath that many modern textbooks claim. 

In truth, those claims about Gage are probably influenced by modern cases of brain damage. Cases where people did turn into sociopaths. You can hear more in a bonus episode at patreon.com/disappearingspoon. People who gambled money wildly, abandoning their family, and suddenly become pedophiles. That’s patreon.com/disappearingspoon.

Sadly, despite building a life for himself in Chile, Gage couldn’t outrun his brain damage entirely. And when it did catch up to him, the end was swift. 

Poor health forced Gage to leave Chile in 1859. He caught a steamer up to San Francisco, where his family had moved. After a few months of rest in California, Gage found work on a farm and seemed to be doing better. 

Unfortunately, a punishing day of plowing in early 1860 wiped him out. He had a seizure the next night over dinner. More seizures followed.

Gamely, Gage tried to keep working during this spell of trouble. But after years of steady work in South America, the seizures made him restless and capricious again. He began drifting from farm to farm, quitting each job for unknown reasons. 

Finally, on May 20th, 1860, while resting at his mother’s home, he had several violent seizures in a row. He died the next day at age thirty-six, having survived his accident by almost a dozen years. 

Gage’s skull was later exhumed by doctors. It remains on display at Harvard University today, along with the iron rod that remodeled his brain. Oddly, his skull has become something of a pilgrimage spot for people with an interest in macabre history.

I’ve spent a lot of time in this podcast bemoaning the lack of hard facts about Gage’s life. But in truth, that dearth of details probably secured Gage’s fame. That lack left infinite room for interpretation, and allowed each generation of scientists to reinterpret his case anew. Everyone from legendary neurosurgeons to phrenologists reading head bumps have invoked Gage to support their pet theories. Overall, Gage has become a Rorschach blot for neuroscientists. What we think of him changes from era to era, as the obsessions and preoccupations of each era change. 

Including our era. Nowadays scientists cite Gage in support of theories about multiple intelligences; emotional intelligence; the social nature of the self; brain connectivity; every modern neuro-obsession. 

And what Phineas Gage means now will probably change in the future, too. In fact, Gage’s story will probably always be with us. In part because it’s a hell of a story!  Once upon a time, a man with a funny name really did survive having an iron rod explode through his skull. It’s tragic, gruesome, bewildering—and even comes with a science lesson.

But the deeper reason that Gage will always be with us is this. Despite all that remains murky and obscure, his life can teach us something important—that the brain and mind are one. After all, about the only hard fact we know is that his personality did change. And that’s no small thing.

As one neuroscientist has written, “beneath the tall tales and fish stories, a basic truth embedded in Gage’s story has played a tremendous role in shaping modern neuroscience: that the brain is the physical manifestation of the personality and sense of self.” That’s a profound idea, and it was Phineas Gage who first pointed us toward that truth.

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Phineas Gage – Unravelling the myth

Malcolm Macmillan updates a familiar tale, 160 years after its inception.

03 September 2008

Could you survive a small crowbar passing completely through your head? Most psychologists would answer 'Yes': almost all of them learned that Phineas Gage did. Although Phineas' accident occurred 160 years ago this month, its consequences are still discussed in most introductory textbooks of psychology, neuropsychology, and physiology. You might therefore think much has been learned since 1848, when the accident happened, and the publication 20 years later, in 1868, of a significant account of its psychological consequences. But in fact little has been added. Moreover, much of what has been written is completely wrong. So, why should Phineas still be of interest?

Phineas and the accident

At 25 years of age Phineas Gage was the foreman of a railway construction gang building the bed for the Rutland and Burlington Railroad in central Vermont in the USA. He and his gang were blasting a cutting through a large rocky outcrop about three quarters of a mile south of the town of Cavendish. It was Gage who decided where holes would be drilled in the rock, and how much powder with which to charge them. To focus the explosive force, the powder and fuse would be gently 'tamped' down before sand was added and a more vigorous tamping applied. Only then would the fuse be lit. For tamping, Phineas used the larger end of a special crowbar-like tool called a tamping-iron. Three feet seven inches long, it weighed thirteen and a half pounds. It was a one-and-a-quarter inch cylinder, tapered to a point of about one quarter of an inch at one end. At 4:30pm on Wednesday 13 September 1848 Phineas, apparently distracted, began tamping before the sand had been poured. The tamping iron struck the rock causing a spark to light the powder. The resultant explosion propelled the tamping iron out of the hole and completely through his head. It entered point first, under the left cheekbone, or zygomatic arch and next penetrated the base of the skull, just behind the bony socket of the left eye. Finally it emerged at the top of the skull, probably slightly in front and to the left of the bregma (the junction of the coronal and sagittal sutures), and landed about 20 to 25 yards behind him. For a short time Phineas may have been unconscious. His gang carried him to a nearby ox-cart where, sitting against its head board, he was driven to the Cavendish inn where he lived. He alighted unaided. Then from a chair on the 'piazza' (New England=verandah) he told his story to the bystanders. He greeted Edward Higginson Williams, the first medical practitioner to arrive, with 'Doctor, here is business enough for you'. Dr John Martyn Harlow arrived about an hour later and he and Williams managed to stem the profuse haemorrhage. That action and Harlow's subsequent management of a severe infection undoubtedly saved Phineas' life. Three months later, Phineas was well enough to return to his parents' farm. After probably spending most of 1849 regaining his strength, he travelled to Boston in the November to be examined by Henry Jacob Bigelow, the Professor of Surgery at Harvard, and was presented to the medical students there (Bigelow, 1850; Boston Society for Medical Improvement, 1849; Harlow, 1848, 1868).

The post–accident history

After the accident Phineas was unable to regain his job as a foreman. Probably some time in 1850 he became an attraction at Barnum's American Museum in New York, and visited the major cities in New England to lecture and exhibit himself. He worked for some 18 months for Jonathan Currier who ran a livery stable and coach-line service from his Dartmouth Inn, in Hanover, NH. Then Gage went to Chile with a man who planned to set up a stagecoach line in Valparaiso (Harlow, 1868). After many years driving stagecoaches, Phineas decided in June 1859 to return to his family, now living in San Francisco. He had had some kind of illness and arrived in a weakened condition. Several months elapsed before he was strong enough to work on farms south of the city. Not long after, in February 1860, and after ploughing the day before, 'while sitting at dinner, he fell in a fit'. 'Unquestionably epileptic', his seizures gradually increased in severity and on 18 May he returned to his mother's house where he suffered a successive series of them. By 21 May 1860 the seizures had killed him. He had survived for eleven and a half years (Harlow, 1868; Macmillan, 2000, pp.106–109). How had Phineas survived the injury and lived for so long? Harlow adduced four factors: -    His 'physique, will, and capacity of endurance, could scarcely be excelled'; -    The shape of the tamping iron left behind no 'prolonged concussion or compression'; -    The entry of the tamping iron created an opening for draining the infection, without which 'recovery would have been impossible'; and -    The portion of the brain traversed by the iron 'was, for several reasons, the best fitted…to sustain the injury.' Here Harlow modestly disguised his own very considerable medical skill by saying only that, in Ambroise Paré's famous words, 'I dressed him, God healed him' (Harlow, 1868).

The psychological aftermath

The damage to Phineas' brain had profound psychological consequences. In 1868, in fewer than 200 words, Harlow summarised why Phineas' contractors would not re-employ him. That summary, together with a few words from his 1848 report, tell us practically everything we know about Phineas. Harlow said 'the balance between his intellectual faculties and animal propensities seems to have been destroyed'. Phineas became: -    'Fitful', 'irreverent', grossly profane, and showed 'but little deference for his fellows'; -    'Impatient of restraint or advice' that conflicted with his desires; -    'Pertinaciously obstinate, capricious, and vacillating' about his plans for the future – 'no sooner arranged than they are abandoned'; and -    'A child intellectually' with 'the animal passions of a strong man'. Previously he had been: -    'Strong and active' with 'an iron will' and of 'nervo-bilious temperament'; -    Of 'temperate habits' and 'possessed of considerable energy of character'; -    A 'great favorite' with his men; -    'The most efficient and capable foreman' employed by his contractors; -    In possession of 'a well–balanced mind'; and -    Regarded as a 'shrewd, smart business man, very energetic in executing all his plans'. So 'radical' was the change, his friends and acquaintances said he was 'no longer Gage' (Harlow, 1848, 1849, 1868). Phineas' mother told Harlow that Phineas entertained 'his little nephews and nieces with the most fabulous recitals' of his adventures that had no 'foundation except in his fancy'. He 'conceived a great fondness for pets, and souvenirs, especially for children, horses and dogs – exceeded only by his attachment to his tamping iron, which was his constant companion during the remainder of his life'. After his first seizure she said he often changed his employment, always finding 'something that did not suit him'.

Which parts of the brain were damaged?

There was no autopsy when Phineas died. His body was exhumed, probably late in 1867, and his skull given to Harlow in early 1868. Nothing was left of his brain. Phineas' skull is all we have as a guide to the damage. Concussion, pieces of bone, haemorrhage, and infection would have destroyed additional tissue beyond that in the immediate path of the tamping iron, even if we knew exactly what that was. And the precise position of Gage's brain within his skull cannot be known. For those reasons, and because the areas in which various functions are localised varies somewhat among individuals, there will always be uncertainty about which of them were destroyed (Macmillan, 2000, pp.84–86). Three studies were made on the living Phineas to determine the path of the tamping iron. They disagreed about the exit area in relation to the bregma and whether it was right or left of the midline. Harlow (1868) made the first of the attempts using the skull. The entry from under the left cheekbone to the rear of the eye socket posed little problem. Where the tamping iron had emerged at the top of the skull was less certain. Opting for the exit being 'near' the bregma and 'in' the median line, Harlow concluded that the left frontal and middle left lobes had been destroyed. His attribution of Gage's 'partial' recovery to their functions having been taken over by the 'intact' right hemisphere meant that he did not think the right was significantly damaged. Between 1982 and the present, three CT–based methods have been used to reconstruct the passage of the tamping iron through Phineas' brain. They produced somewhat varying pictures of its travel (Macmillan, 2000, Chapter 5, especially Tables 5.1 and 5.2; Ratiu et al., 2004). In 1982 Rick and Ken Tyler of Boston used coronal and sagittal CT-scans of Gage's skull to determine the limits of the bony damage. From those images, which were two-dimensional and static, they concluded the brain damage was mostly to the left hemisphere but that the right must also have suffered (Macmillan, 2000, pp.77–79 and Appendix E). After making X-rays, photographs, and measurements of Gage's skull, Hanna Damasio and her colleagues linearly deformed a 3-D reconstruction of a human skull from a cadaver until it matched those measurements. From their collection of brains of about the right size they then placed a 3-D reconstruction of the one that best fitted into this Gage–like skull. Damasio et al. then modelled the passage of the tamping iron through this Gage-like brain inside the Gage-like skull. They had the tamping iron emerging from under the semi-detached but otherwise undamaged right flap of frontal bone so that the brain damage was more frontal and right of the midline than had been suggested previously (Damasio et al., 1994). Real light arrived when Ratiu et al. (2004) and Ratiu and Talos (2004) used thin CT-scans to build a three-dimensional representation of Phineas' skull itself, rather than an image of what it might have been like. How well they succeeded is immediately obvious in an illustration from the second of their papers (shown on this cover of The Psychologist) (Ratiu & Talos, 2004). They were the first to see that the diameter of the entry area being smaller than that of the tamping iron required the skull to have hinged open for the iron to pass through it. They connected that fact with the continuous line of fracture beginning under the cheekbone and running to the left parietal bone well beyond the rear of the hole at the bregma. After the tamping iron passed through, the hinge must have been closed by the action of the soft tissues. From the video clips Ratiu and Talos included in their paper, it can be seen that the line of fracture and the hinging action place the exit left of the median line and slightly in front of the bregma. On their reconstruction, the brain damage was left-frontal – almost exactly as Harlow said.

The implications and the context

It was a long time before Phineas' psychological changes became known. None were specifically mentioned by Harlow in 1848; nor did Bigelow report any in 1850. Some memory impairment was recorded privately by Jackson (1849), and an anonymous report the same year very briefly noted a great impairment of his mental powers (Standing Committee on Surgery, 1850). Some detail first appeared in an 1851 phrenological journal's reply to Bigelow ('A most remarkable case', 1851). However, not until Harlow's little-known 1868 report was any real notice taken of the psychological changes, and even in comments on it they were frequently ignored (Macmillan, pp.113–116, 197–199). Some of this neglect is explicable by the lack of knowledge in the early 1800s about the functions of the brain. Apart from Franz Josef Gall's organology (phrenology), there was no theory before 1848 of what the brain did. That nerves transmitted sensations and controlled movement was known, but it was not even generally accepted that damage to one side of the brain affected movement or sensation on the other. Early descriptions like Bigelow's of Gage being unimpaired probably meant merely that his muscles and sense organs functioned normally. Johannes Müller and Alexander Bain had argued that willing and moral behaviour depended on an inhibitory function localised vaguely in some 'higher' part of the nervous system or even in the brain, but could advance no supporting empirical evidence (Macmillan, 2000, pp.158–170). But functions like language and personality had not been shown to depend on the way the brain worked. The context began to change about the mid-1860s; that is, by the time of Harlow's 1868 report. Paul Broca's clinical observations suggested that language functions were localised in the left frontal lobe. A little later, David Ferrier's monkey experiments demonstrated that prefrontal damage caused profound personality changes (Ferrier, 1873). It was Ferrier who rescued Gage from the obscurity of the journal in which Harlow's 1868 report was buried (Ferrier, 1876, 1877–1879, 1878), but 10 years elapsed before Harlow's findings gained acceptance. A theory of frontal functioning was even further away. Gage was literally ahead of his time.

Facts vs. the common picture

There are just four primary sources of information about Gage: Harlow (1848), Bigelow (1850), then Harlow again (1868) – the only physicians to have examined him and published their observations – and finally J.B.S. Jackson (1870), who added a few facts of his own to what Gage's family and others had told him. Anything not from these sources, or similarly documented, is not a fact about Phineas Gage. This is not to say these primary sources are entirely reliable. Harlow, for example, writing in 1868 while in contact with Phineas' mother, reported that Phineas died in 1861, whereas funeral parlour records prove conclusively that he died in 1860. (In this article and elsewhere I have silently corrected other dates dependent on this one.) Similarly, a curious relic recently found by Dominic Hall, Curator of Harvard's Warren Anatomical Museum, suggests that Phineas went to Chile in 1854 and not in 1852 as reported by Harlow. First the facts. Harlow's picture of Phineas is at total variance with most later portrayals. A fair composite of today's accounts would have a pre-accident Gage who was reliable, industrious, mild-mannered, temperate, genial, friendly, affable, the favourite of his peers and elders, showing considerable promise – a peaceful, happy and tranquil man. The composite of modern writers has the accident transforming this Phineas into a restless, moody, unpredictable, untrustworthy, depraved, slovenly, violently quarrelsome, aggressive and boastful dissipated drunken bully, displaying fits of temper, and with impaired sexuality. He is a waster: unwilling to work and unable to settle down. He spends most of the rest of his life in travelling circuses or drifting around fairgrounds to exhibit himself as a human freak, and dies penniless. The facts about the real Phineas may have a slight resemblance to the modern pre-accident representation, but he can hardly be recognised in the post–accident picture. Second, interpretations. Many interpretations of Phineas' behaviour have been made to support particular theories. Thus Vincent and others matched his allegedly changed sexuality – not mentioned in the sources – to that of some post-lobotomy patients; others, like Damasio and colleagues, portrayed Gage's damage and behaviour such that they matched those of a selection of their own modern patients (Macmillan, 2000, pp.329–330). Distortions like these were great enough to justify devoting some 50 pages of my book to analysing them, and for MIT Press to allow me to include facsimiles of the primary sources (Macmillan, 2000, Figure 15.2 and Appendix A). Third, long-term effects. Every scientific and popular picture of Phineas I know of has him impulsive and unreliable until his death. Yet his year and a half working for Currier, and the demanding motor and cognitive skills required of a stagecoach driver are inconsistent with this long-term outcome (Macmillan, 2000, pp.104–106).

A social recovery?

Could Phineas have made some kind of 'social recovery'? There are a few reports of people with brain damage similar to his who recovered without formal treatment. In each instance, someone or something gave enough structure to their lives for them to relearn lost social and personal skills. Here we may speculate about Phineas' daily routine. Some detail may be inferred from a recently discovered contemporary account of stagecoach driving on what seems to be the very route Phineas drove. He would have had to rise early each driving day, prepare himself, feed and groom the horses, harness them to the coach, and be at the departure point by 4am. There he would have had to deal politely with the passengers, load their luggage (up to 50 pounds each), and collect fares, and so on, before beginning a 13-hour journey over 100 miles of poor roads, often in times of political instability or frank revolution. All this – in a land to whose language and customs Phineas arrived an utter stranger – militates as much against permanent disinhibition as do the extremely complex sensory-motor and cognitive skills required of a coach driver (Macmillan, 2000, p.104–106). As I understand it, relearning in a structured environment is the basis of many brain-damage rehabilitation programmes (such as that at the Oliver Zangwill Centre at Ely in Cambridgeshire). If Phineas Gage did recover, could his employment have provided a similar structure? Only by filling out the post-accident record can this be determined. I have found a poster advertising one of Phineas' lectures. Matthew L. Lena, my Boston colleague, and I hope to find some eyewitness report of it. Matthew has also found a physician who said he saw a quite well Phineas in Chile around 1858. There would be practical and theoretical consequences of a discovery that Gage so recovered. It would add to current evidence that rehabilitation can be effective even in difficult and long-standing cases. But it would also mean that theoreticians of frontal lobe functioning would have to consider whether the lobes themselves and their functions were much more plastic than we now think. Recognition of that kind would, of course, match the now accumulating evidence about the recovery of biological systems in general.

Why bother?

We will never know with certainty what the pre- and post-accident Phineas Gages were really like; nor will we ever know exactly the parts of his brain that were damaged in the flash that transformed the one into the other. So, why bother? First, it is always worthwhile correcting the historical record, though the degree of rigor mortis, especially in textbooks, seems too far advanced for even a Dr Frankenstein to re-enliven poor Phineas. Second, Phineas' story is worth remembering because it illustrates how easily a small stock of facts can be transformed into popular and scientific myth. I was much struck by David Ferrier's remark in an 1877 letter about Phineas to Henry Pickering Bowditch in Boston. He asked Bowditch for the facts about Phineas as they were originally reported because he was 'amazed at the inexactitude and distortion to which they are subject by men who have some pet theory to support'. And as we have seen, scientific myths about Phineas continue to be used to support particular theoretical positions. The factual record is small, and the most important element of it – Harlow's 1868 report – not readily available, and most who have written about Phineas have been too lazy or slipshod to check it. Paradoxically, the very slightness of reliable fact which allows myths about Phineas to flourish also makes disentangling those myths a conceptually easy, if tedious, task. Phineas' primary importance is as a historical marker. We can see how his skull was damaged, but we will only ever have estimates of his brain damage. We also know too little about him before and after the accident to draw detailed conclusions about its effects. Phineas has to be remembered for being the first reported case in which brain damage caused alterations to personality. But we may yet learn the extent of his recovery and what brought it about.

Box: Gage outside science

The story of Phineas Gage has entered popular culture, leading to plays, films, TV programmes and YouTube skits, poems and stories, sculptures, bands and songs, and even a team of lawyers who apply behavioural science to legal education. My favourites (partly because I was consulted on them!) are the plays 'That Elusive Spark' by Janet Munsil and 'The Ballad of Phineas P. Gage' by Crystal Skillman, and the song 'Phineas Gage' by Dan Linder.

Box: Questions about Gage

Matthew Lena and I are interested in the following topics and I would be pleased to supply more specific information to readers who may be able to help. -    The fate of Dr John Martyn Harlow's case notes and correspondence about Gage. -    Anything at all relating to Phineas in New England (to about 1854), Chile (to about 1859) and San Francisco, Santa Clara, or Alameda Counties, California (died, 1860). -    Identity of the 'distinguished Professor of Surgery in a distant city' whom Harlow said had termed Gage a 'Yankee invention' (some time before 1868). -    Harlow and his wife, Frances Kimball Harlow, especially when living in Stillwater, Minnesota (ca. 1857–1860). -    Departure/arrival/passenger lists for ships travelling among New York/New England, Panama/Valparaiso, and San Francisco (1850–1868). -    In Valparaiso and Santiago, Chile, 1850–1860:     Livery or transportation businesses (particularly an 'American' or '(James) McGill & Co.' coach line);     Dr William Trevitt (American consul) or his nephew Henry;     the hospital for American seamen; and activities and publications of physicians or of English-speaking persons. -    Dr Henry Trevitt and Dr William Trevitt in Wilton, Connecticut and Franklin Co., Ohio (resp.) approximately 1861 forward. -    A Dr William J. Lo– – – – (full surname unknown) residing in Brooklyn Township (now Oakland, Alameda Co.) California in 1860, possibly a teacher of the deaf, or his wife Cordelia (both originally of Maine). -    Dr Jacob Davis Babcock Stillman and Dr Henry Perrin Coon of San Francisco (esp. personal papers ca. 1867). -    The Starling Medical College in Columbus, Ohio, and faculty member J. W. Hamilton (ca. 1860). - Malcolm Macmillan is Professorial Fellow in the Department of Psychology at the University of Melbourne. He is much indebted to his partner, Edith Bavin, of Latrobe University Melbourne, to Matthew L. Lena of Boston, and to Peter Ratiu of Arad Romania for valuable cooperation, many important findings, and helpful suggestions. [email protected]

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

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

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

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

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

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

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

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

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

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

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

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

For example:

• In the 1940s, a famous neurologist named Stanley Cobb diagrammed the skull in an effort to determine the exact path of the tamping iron.
• In the 1980s, scientists repeated the exercise using CT scans.
• In the 1990s, researchers applied 3-D computer modeling to the problem.

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

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

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

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

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

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

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

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

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

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

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Phineas Gage, Neuroscience’s Most Famous Patient

Each generation revises his myth. here’s the true story., from a virtuous foreman to a sociopathic drifter.

On Sept. 13, 1848, at around 4:30 p.m., the time of day when the mind might start wandering, a railroad foreman named Phineas Gage filled a drill hole with gunpowder and turned his head to check on his men. It was the last normal moment of his life.

Other victims in the annals of medicine are almost always referred to by initials or pseudonyms. Not Gage: His is the most famous name in neuroscience. How ironic, then, that we know so little else about the man—and that much of what we think we know, especially about his life unraveling after his accident, is probably bunk.

Image via J.B.S. Jackson/A Descriptive Catalog of the Warren Anatomical Museum

The Rutland and Burlington Railroad had hired Gage’s crew that fall to clear away some tough black rock near Cavendish, Vermont, and it considered Gage the best foreman around. Among other tasks, a foreman sprinkled gunpowder into blasting holes, and then tamped the powder down, gently, with an iron rod. This completed, an assistant poured in sand or clay, which got tamped down hard to confine the bang to a tiny space. Gage had specially commissioned his tamping iron from a blacksmith. Sleek like a javelin, it weighed 13¼ pounds and stretched 3 feet 7 inches long. (Gage stood 5-foot-6.) At its widest, the rod had a diameter of 1¼ inches, although the last foot—the part Gage held near his head when tamping—tapered to a point.

Gage’s crew members were loading some busted rock onto a cart, and they apparently distracted him. Accounts differ about what happened after Gage turned his head. One says Gage tried to tamp the gunpowder down with his head still turned, and scraped his iron against the side of the hole, creating a spark. Another says Gage’s assistant (perhaps also distracted) failed to pour the sand in, and when Gage turned back, he smashed the rod down hard, thinking he was packing inert material. Regardless, a spark shot out somewhere in the dark cavity, igniting the gunpowder, and the tamping iron rocketed upward.

The iron entered Gage’s head point-first, striking below the left cheekbone. It destroyed an upper molar, passed behind his left eye, and tore into the underbelly of his brain’s left frontal lobe. It then plowed through the top of his skull, exiting near the midline, just behind where his hairline started. After parabola-ing upward—one report claimed it whistled as it flew—the rod landed 25 yards away and stuck upright in the dirt, mumblety-peg-style. Witnesses described it as streaked with red and greasy to the touch, from fatty brain tissue.

Image courtesy EEng/Creative Commons

The rod’s momentum threw Gage backward, and he landed hard. Amazingly, he claimed he never lost consciousness. He merely twitched a few times on the ground, and was talking and walking again within minutes. He felt steady enough to climb into an oxcart, and, after someone grabbed the reins and giddy-upped, he sat upright for the entire mile-long trip into Cavendish. At the hotel where he was lodging, he settled into a chair on the porch and chatted with passersby. The first doctor to arrive could see, even from his carriage, a volcano of upturned bone jutting out of Gage’s scalp. Gage greeted the doctor by angling his head and deadpanning, “Here’s business enough for you.” He had no idea how prophetic those words would be. The messy business of Gage continues to this day, 166 years later.

Most of us first encountered Gage in a neuroscience or psychology course, and the lesson of his story was both straightforward and stark: The frontal lobes house our highest faculties; they’re the essence of our humanity, the physical incarnation of our highest cognitive powers. So when Gage’s frontal lobes got pulped, he transformed from a clean-cut, virtuous foreman into a dirty, scary, sociopathic drifter. Simple as that. This story has had a huge influence on the scientific and popular understanding of the brain. Most uncomfortably, it implies that whenever people suffer grave damage to the frontal lobes—as soldiers might, or victims of strokes or Alzheimer’s disease—something essentially human can vanish.

Recent historical work, however, suggests that much of the canonical Gage story is hogwash, a mélange of scientific prejudice, artistic license, and outright fabrication. In truth each generation seems to remake Gage in its own image, and we know very few hard facts about his post-accident life and behavior. Some scientists now even argue that, far from turning toward the dark side, Gage recovered after his accident and resumed something like a normal life—a possibility that, if true, could transform our understanding of the brain’s ability to heal itself.

Gage “was no longer Gage”

The first story that appeared about Gage contained a mistake. The day after his accident, a local newspaper misstated the diameter of the rod. A small error, but an omen of much worse to come.

Psychologist and historian Malcolm Macmillan, currently at the University of Melbourne, has been chronicling mistakes about Gage for 40 years. He has had a peripatetic career: Among other topics, he has studied disabled children, Scientology, hypnosis, and fascism. In the 1970s, he got interested in Gage and decided to track down original material about the case. He turned up alarmingly little, and realized just how rickety the evidence was for most of the science about Gage.

Macmillan has been sifting fact from fiction ever since, and he eventually published a scholarly book about Gage’s story and its afterlife, An Odd Kind of Fame . Although slowed by a faulty hip replacement—he has trouble reaching books on the bottom shelves at libraries now—Macmillan continues to fight for Gage’s reputation, and he has gotten so involved with his subject that he now refers to him, familiarly, as Phineas. Above all, Macmillan stresses the mismatch between what we actually know about Gage and the popular understanding of him: “Despite there being no more than a couple hundred words attesting to how he changed, he came to dominate thinking about the function of the frontal lobes.”

The most important firsthand information comes from John Harlow, a self-described “obscure country physician” who was the second doctor to reach Gage the day of the accident, arriving around 6 p.m. Harlow watched Gage lumber upstairs to his hotel room and lie down on the bed—which pretty much ruined the linens, since Gage’s body was one big bloody mess. As for what happened next, readers with queasy stomachs should probably skip to the next paragraph. Harlow shaved Gage’s scalp and peeled off the dried blood and brains. He then extracted skull fragments from the wound by sticking his fingers in from both ends, Chinese-finger-trap-style. Throughout this all, Gage was retching every 20 minutes, because blood and greasy bits of brain reportedly kept slipping down the back of his throat and gagging him. Incredibly, Gage never got ruffled, remaining conscious and rational throughout. He even claimed he’d be back blasting rocks in two days.

Photo courtesy Creative Commons

The bleeding stopped around 11 p.m., and Gage rested that night. The next morning his head was heavily bandaged and his left eyeball was still protruding a good half-inch, but Harlow allowed him visitors, and Gage recognized his mother and uncle, a good sign. Within a few days, however, his health deteriorated. His face puffed up, his brain swelled, and he started raving, at one point demanding that someone find his pants so he could go outside. His brain developed a fungal infection and he lapsed into a coma. A local cabinet-maker measured him for a coffin.

Fourteen days into the crisis, Harlow performed emergency surgery, puncturing the tissue inside Gage’s nose to drain the wound. Things were touch-and-go for weeks, and Gage did lose sight in his left eye, which remained sewn shut the rest of his life. But he eventually stabilized, and in late November he returned home to Lebanon, New Hampshire—along with his tamping iron, which he started carrying around with him everywhere. In his case report, Harlow modestly downplayed his role in the recovery: “I dressed him,” he wrote, “God healed him.”

During his convalescence, stories about Gage started circulating in newspapers, with varying degrees of accuracy. Most gave Gage the tabloid treatment, emphasizing the sheer improbability of his survival. Doctors gabbed about the case, too—albeit with a dose of skepticism. One physician dismissed Gage as “a Yankee invention,” and Harlow said that others, like St. Thomas with Jesus, “refused to believe that the man had risen until they had thrust their fingers into the hole of his head.”

Dr. Henry Bigelow brought Gage to Harvard Medical School for a formal evaluation in 1849. Although Bigelow treated Gage like a curiosity—he once presented Gage at a meeting along with a stalagmite “remarkable for its singular resemblance to a petrified penis”—the visit resulted in the only other detailed, firsthand account of Gage and his accident besides Harlow’s. Surprisingly, Bigelow’s report pronounced Gage “quite recovered in his faculties of body and mind.” However, as was common in neurological exams then, Bigelow probably only tested Gage for sensory and motor deficits. And because Gage could still walk, talk, see, and hear, Bigelow concluded that his brain must be fine.

Photo courtesy Harvard Art Museum/Fogg Museum

Bigelow’s assessment meshed well with the medical consensus at the time, which held that the frontal lobes didn’t do much—in part because people could suffer grave injuries to them and walk away. Scientists now know that parts of the frontal lobes contribute to nearly every activity inside the brain. The forefront of the lobes, called the prefrontal area, plays an especially important role in impulse control and planning.

But even today scientists have only a vague idea of how the prefrontal lobes exercise that control. And victims of prefrontal injuries can still pass most neurological exams with flying colors. Pretty much anything you can measure in the lab—memory, language, motor skills, reasoning, intelligence—seems intact in these people. It’s only outside the lab that problems emerge. In particular, personalities might change, and people with prefrontal damage often betray a lack of ambition, foresight, empathy, and other ineffable traits. These aren’t the kind of deficits a stranger would notice in a short conversation. But family and friends are acutely aware that something is off.

Frustratingly, Harlow limited his discussion of Gage’s mental status to a few hundred words, but he does make it clear that Gage changed—somehow. Although resolute before the accident, Harlow says Gage was now capricious, and no sooner made a plan than dropped it for another scheme. Although deferential to people’s wishes before, Gage now chafed at any restraint on his desires. Although a “smart, shrewd businessman” before, Gage now lacked money sense. And although courteous and reverent before, Gage was now “fitful [and] irreverent, indulging at times in the grossest profanity.” Harlow summed up Gage’s personality changes by saying, “the equilibrium … between his intellectual faculties and his animal propensities seems to have been destroyed.” More pithily, friends said that Gage “was no longer Gage.”

As a result of this change, the railroad refused to reinstate Gage as foreman. He began traveling around New England instead, displaying himself and his tamping iron for money. This included a stint in P.T. Barnum’s museum in New York— not Barnum’s traveling circus, as some sources claim. For an extra dime, skeptical viewers could “part Gage’s hair and see his brain … pulsating” beneath his scalp. Gage finally found steady work driving a horse coach in New Hampshire.

Beyond that sketch of his activities, there’s no record of what Gage did in the months after the accident—and we know even less about what his conduct was like. Harlow’s case report fails to include any sort of timeline explaining when Gage’s psychological symptoms emerged and whether any of them got better or worse over time. Even the specific details of Gage’s behavior seem, on a closer reading, ambiguous, even cryptic. For instance, Harlow mentions Gage’s sudden “animal propensities” and, later, “animal passions.” Sounds impressive, but what does that mean? An excessive appetite, strong sexual urges, howling at the moon? Harlow says that Gage cursed “at times,” but how often is that? And was this a saucy “hell” or “damn” here and there, or something more dastardly? Harlow notes that Gage started telling his nieces and nephews wild stories about his supposed adventures. Was he confabulating here, a symptom of frontal lobe damage, or simply indulging a love of tall tales? Even the conclusion that Gage “was no longer Gage” could mean almost anything.

Indeed, it has come to mean almost anything. One reason it’s hard to diagnose frontal lobe damage is that people vary quite a bit in their baseline behavior: Some of us are rude, crude, cruel, flighty, or whatever naturally. To judge whether a person changed after an accident, you have to have known him beforehand. Unfortunately, no one who knew Gage intimately left any sort of statement. And with so few hard facts to constrain people’s imaginations in later years, rumors began to swirl about Gage’s life, until a wholly new Phineas emerged.

Macmillan summarizes this caricature of Gage as “an unstable, impatient, foul-mouthed, work-shy drunken wastrel, who drifted around circuses and fairgrounds, unable to look after himself and dying penniless.” Sometimes his new traits contradicted one another: Some sources describe Gage as sexually apathetic, others as promiscuous; some as hot-tempered, others as emotionally void, as if lobotomized. And some anecdotes seem like outright fabrications. In one, Gage sold the exclusive, posthumous rights to his skeleton to a certain medical school—then sold the same rights to another school, and another, skipping town and pocketing the cash each time. In another tale, a real howler, Gage lived for 20 years with the iron rod still impaled in his skull.

Phyllis Gage Hartley/Creative Commons

More uncomfortably, some scientists have questioned Gage’s humanity. Descartes’ Error , a popular book from 1994, trotted out many familiar tropes: that women couldn’t stand to be in Gage’s presence, that he started “drinking and brawling in questionable places,” that he was a braggart and a liar and a sociopath. The neuroscientist author then got metaphysical. He speculated that Gage’s free will had been compromised, and raised the possibility that “his soul was diminished, or that he had lost his soul.”

People butcher history all the time, of course, for various reasons. But something distinct seems to have happened with Gage. Macmillan calls it “scientific license.” “When you look at the stories told about Phineas,” he says, “you get the impression that [scientists] are indulging in something like poetic license—to make the story more vivid, to make it fit in with their preconceptions.” Science historian Douglas Allchin has noted the power of preconceptions as well: “While the stories [in science] are all about history—events that happened,” Allchin writes, “they sometimes drift into stories of what ‘should’ have happened.”

With Gage, what scientists think “should” have happened is colored by their knowledge of modern patients. Prefrontal lobe damage is associated with a subsequent slightly higher rate of criminal and antisocial behavior. Even if people don’t sink that low, many do change in unnerving ways: They urinate in public now, blow stop signs, mock people’s deformities to their faces, or abandon a baby to watch television. It’s probably inevitable, Macmillan says, that such powerful anecdotes influence how scientists view Gage in retrospect: “They do see a patient and say, ‘Ah, he’s like what Phineas Gage was supposed to be like.’ ” To be clear, Harlow never reports anything criminal or blatantly unhinged about Gage’s conduct. But if you’re an expert on brain damage, scientific license might tempt you to read between the lines and extrapolate from “gross profanity” and “animal passions” to seedier behavior.

If repeated often enough, such stories acquire an air of truthiness. “And once you have a myth of any kind, scientific or otherwise,” Macmillan says, “it’s damn near impossible to get it destroyed.” Macmillan especially bemoans “the degree of rigor mortis in textbooks,” which reach a large, impressionable audience and repeat the same anecdotes about Gage in edition after edition. “Textbook writers are a lazy lot,” he says.

Historians have also noticed, not surprisingly, that myths have more staying power when they’re good stories—and Gage’s is truly sensational. Once upon a time, a man with a funny name really did survive having an iron rod explode through his skull. It’s tragic, macabre, bewildering—and even comes with the imprimatur of a science lesson. In contrast to other scientific fables, Gage’s has an intriguing twist as well. Most other scientific myths depart from reality by inflating the heroes (usually scientists) into godlike creatures, wholly pure and wholly virtuous. Gage, meanwhile, gets demonized. He’s Lucifer, fallen. Gage’s myth has proved so tenacious in part because it’s fascinating to watch someone break bad.

The journey of the tamping iron

With the development of new scanning and computer technologies, a new chapter in Gage studies has opened in the past quarter century. Unfortunately, no one preserved Gage’s brain when he died, so scientists are left examining the few remaining relics from his life instead, especially his skull and tamping iron, which are on display at the Warren Anatomical Museum at Harvard Medical School.

In six years as museum curator, Dominic Hall has become an expert on Gageanalia. He often shows the skull and tamping iron to student groups, and he finds that people don’t mind hearing even graphic details about Gage’s injury. “There’s just something about him,” Hall says.

People’s Cyclopedia of Universal Knowledge

Gage’s skull and tamping iron are basically the only reason the Warren Museum still exists, says Hall, although calling it a “museum” seems generous. It’s really just two rows of 8-foot-tall wooden cabinets; one sits on either side of an atrium on the fifth floor of Harvard’s medical library. Surrounding the Gage artifacts are head sculptures with phrenology labels, a life mask of Samuel Taylor Coleridge, and stillborn Siamese twins, among other curios.

The left eye socket of Gage’s skull, near the entry wound, looks jagged. The exit wound on top consists of two irregular holes with a patch of bone stuck between them, like a flattened wad of white gum. The tamping iron rests one shelf below the skull. Hall describes the rod as heavy, but struggles beyond that. “It’s not like a baseball bat or shovel,” he says, “because the weight is distributed throughout.” He finally just says, “it feels real .” The tip of the iron looks blunted, like a slightly used crayon, and the shaft contains an inscription, in white calligraphic script, explaining Gage’s case. Phineas is misspelled twice.

The skull’s obvious entry and exit wounds have tempted several scientists to digitally recreate the journey of the tamping iron. They hope to determine what parts of the brain were destroyed, which might make Gage’s deficits clearer. The sophisticated computer modeling helps scientists study normal brain function as well, but there’s something undeniably splashy about recreating the most famous accident in medical history.

The best-known recreation of the accident was done by the husband-and-wife team of Antonio and Hanna Damasio, neuroscientists now at the University of Southern California. Antonio Damasio developed a famous theory of how emotions work, especially how they supplement and enhance our reasoning skills. To do so, he drew on a number of his own patients with frontal-lobe deficits. But he also drew on Gage. (Damasio, the author of Descartes’ Error , is the scientist who described Gage as a vagrant sociopath.) The Damasios modeled Gage’s accident in part to search for evidence that he suffered damage to both his left and right hemispheres, which would make any personality changes more drastic. They found what they were looking for, and the study graced the cover of Science in 1994.

The Damasios still stand behind their paper. But two later studies, which took advantage of higher-horsepower computers to create more accurate models of Gage’s skull, have since questioned their results. In 2004, a team led by Peter Ratiu, who was then teaching neuroanatomy at Harvard and now works as an emergency doctor in Bucharest, Romania, concluded that the rod could not have crossed over the midline and damaged Gage’s right hemisphere. What’s more, Ratiu determined that, based on the angle of entry and lack of a broken jawbone, Gage must have had his mouth open and been speaking at the moment of impact. Ratiu’s renderings of this moment—with the iron rod piercing a gaping mouth—have an unnerving quality, reminiscent of Francis Bacon’s paintings of screaming popes.

In 2012, neuroimaging expert Jack Van Horn led another study on Gage’s skull. In contrast to Macmillan, Van Horn refers to Phineas as “Mr. Gage.” He first delved into the case while living in New Hampshire, near the old Gage farmstead on Potato Road. Van Horn now works at USC in the same department as the Damasios.

Van Horn’s study sifted through millions of possible trajectories for the iron rod, he says, and ruled out all but a few “that didn’t break his jaw, didn’t blow his head off, and didn’t do a bunch of other things.” (For comparison, the Damasio study scrutinized a half-dozen trajectories.) Overall, Van Horn’s work supported Ratiu’s: The rod, he argues, never crossed over to the right hemisphere.

Van Horn did introduce a new wrinkle, however. He studies brain connectivity, the emerging awareness that, while neurons are important to brain function, the connections between neurons are equally vital. Specifically, the patches of neurons that compute things in the brain (grey matter) reach their full potential only when networked together, via axon cables (white matter), to other centers of neural computation. And while Gage suffered damage to 4 percent of his grey matter, Van Horn concluded, 11 percent of his white matter suffered damage, including cables that led into both hemispheres. Overall, the injury “was much more profound than even we thought,” he says.

Image courtesy Van Horn JD, Irimia A, Torgerson CM, Chambers MC, Kikinis R, et al.

How that damage affected Mr. Gage’s behavior, though, is tough to predict. Van Horn has read Macmillan’s work closely, and he says it scared him away from undue speculation. “I didn’t want to piss [Macmillan] off,” he jokes. Van Horn nevertheless did compare the destruction of Gage’s white matter to the damage wrought by neurodegenerative diseases like Alzheimer’s. Gage might even have displayed classic symptoms of Alzheimer’s, he argues, such as moodiness and an inability to complete tasks. John Harlow’s original case report did state that Gage’s changes were “nothing like dementia,” Van Horn acknowledges. But Harlow examined Gage shortly after his accident, Van Horn says, not months or years later, when such symptoms might have emerged.

Despite different interpretations, Damasio, Ratiu, and Van Horn all agree about one thing: Their models are basically sophisticated guesswork. Clearly, the tamping iron destroyed some brain tissue. But the flying bone shrapnel and the fungal infection would have destroyed still more tissue—and that destruction is impossible to quantify. Perhaps even more important, both the position of the brain within the skull, and the location of various structures within the brain itself, actually vary a lot from person to person—brains differ as much as faces do. When cataloguing brain destruction, then, millimeters matter. And no one knows which exact millimeters of tissue got destroyed in Gage.

That ignorance hasn’t slowed down the speculation. Phineas Gage is reborn every generation, but as a different man: Each generation reinterprets his symptoms and deficits anew. In the mid-1800s, for example, phrenologists explained Gage’s profanity by noting that his “organ of veneration” had been blown to bits. Nowadays scientists cite Gage in support of theories about multiple intelligences, emotional intelligence, the social nature of the self, brain plasticity, brain connectivity—every modern neuro-obsession. Even Macmillan, after studying the end of Gage’s life, has edged beyond merely debunking other people’s stories, and started presenting his own theory about Phineas Gage’s redemption.

“I knew there was a contradiction there”

Incredibly, after working 18 months in the horse stable in New Hampshire, Gage struck out for South America in 1852. He was seasick the whole voyage. He’d been recruited by an entrepreneur hoping to take advantage of a gold rush in Chile, and once ashore, Gage resumed driving coaches, this time along the rugged, mountainous trails between Valparaiso and Santiago. You wonder how many passengers would have climbed aboard had they known about their one-eyed driver’s little accident, but he did the job for seven years.

Poor health forced Gage to quit Chile, and in 1859 he caught a steamer to San Francisco, near where his family had moved. After a few months of rest, he found work as a farm laborer and seemed to be doing better, until a punishing day of plowing in early 1860 wiped him out. He had a seizure the next night over dinner. More followed, and after one particularly intense fit, he died on May 21, age 36, having survived his accident by almost a dozen years. His family buried him two days later, possibly with his beloved tamping iron.

J.D. Van Horn, A. Irimia, C.M. Torgerson, M.C. Chambers, R. Kikinis, et al./Warren Anatomical Museum at Harvard Medical School

Gage’s story might have ended there—an obscure small-town tragedy, little more—if not for Dr. Harlow. He had lost track of Gage years before, but he learned the address of Gage’s family in 1866 (through some unspecified “good fortune”) and wrote to California for news. After milking the family for details, Harlow prevailed upon Gage’s sister, Phebe, to open the grave and salvage Gage’s skull in 1867. The exhumation sounded like quite a to-do, with Phebe, her husband, their family doctor, the city mortician, and even San Francisco’s mayor, one Dr. Coon, all present to peek inside the coffin. Gage’s family then hand-delivered the skull and tamping iron to Harlow in New York a few months later. At this point Harlow finally wrote up a full case report, which included virtually everything we know about Gage’s mental status and sojourn to South America.

Most accounts of Gage’s life omit all mention of Chile. Even Macmillan didn’t know what to make of it for decades. But in the past few years, he has become convinced that Chile holds the key to understanding Gage.

The epiphany came while, of all things, watching Queen Elizabeth’s husband, Prince Philip, race coaches on television one night. Philip, an old-fashioned sportsman, drives horse coaches similar to the ones Gage did, and the intricacy of the rein-work and difficulty of the maneuvering struck Macmillan as significant. The driver controls each of his horses’ reins with a different finger, for example, so even rounding a bend takes incredible dexterity. (Imagine driving a car while steering each wheel independently.) Moreover, the trails Gage drove were crowded, forcing him to make quick stops and dodges, and because he probably drove at night sometimes, he would have had to memorize their twists and drop-offs, plus watch for bandits. He also presumably cared for the horses and collected fares. Not to mention that he likely picked up a soupçon of Español in Chile. “To have someone with impulsive behavior, uncontrolled behavior, carrying out the highly skilled task of stagecoach driving,” Macmillan says, “I knew there was a contradiction there.”

He pursued his hunch, and after parsing and reparsing the vague chronology in Harlow’s case report, Macmillan now believes that Gage’s behavioral troubles were temporary and that Gage eventually recovered some of his lost mental functions. Independent evidence also supports this idea. In 2010 a computer scientist and intellectual property consultant who sometimes collaborates with Macmillan, Matthew Lena, turned up a statement from a 19 th -century doctor who lived in “Chili” and knew Gage well: “He was in the enjoyment of good health,” the doctor reported, “with no impairment whatever of his mental faculties.” * To be sure, Macmillan does not believe that Gage magically recovered everything and “became Gage” again. But maybe Gage resumed something like a normal life.

Modern neuroscientific knowledge makes the idea of Gage’s recovery all the more plausible. Neuroscientists once believed that brain lesions caused permanent deficits: Once lost, a faculty never returned. More and more, though, they recognize that the adult brain can relearn lost skills. This ability to change, called brain plasticity, remains somewhat mysterious, and it happens achingly slowly. But the bottom line is that the brain can recover lost functions in certain circumstances.

In particular, Macmillan suggests that Gage’s highly regimented life in Chile aided his recovery. People with frontal-lobe damage often have trouble completing tasks, especially open-ended tasks, because they get distracted easily and have trouble planning. But in Chile Gage never had to plan his day: Prepping the coach involved the same steps every morning, and once he hit the road, he simply had to keep driving forward until it was time to turn around. This routine would have introduced structure into his life and kept him focused.

A similar regime could, in theory, help other victims of Gage-like brain damage. One gruesome paper from 1999 (“Transcranial Brain Injuries Caused by Metal Rods or Pipes over the Past 150 Years”) chronicles a dozen such cases, including a drunken game of “William Tell.” Another case occurred on a construction site in Brazil in 2012, when a metal bar fell five stories, pierced the back of a man’s hardhat, and exited between his eyes. More commonly, people suffer brain damage on the battlefield or in car accidents. And according to a traditional reading of Gage, their prognosis was bleak. But according to Macmillan’s reading, maybe not. Because if even Phineas Gage bounced back—that’s a powerful message of hope.

Proud, well-dressed, disarmingly handsome

Phineas Gage has probably never been more popular. Several musicians have written tributes. Someone started a blog called The Phineas Gage Fan Club, and another fan crocheted Mr. Gage’s skull. YouTube contains thousands of Gage videos, including several re-enactments of the accident. (One involves Barbie dolls, another Legos. Beneath one, somebody commented, inevitably, “ mind=blown .”) What’s more, his skull has become the modern equivalent of a medieval saint’s relic: The log book at the Harvard museum has recorded pilgrims from Syria, India, Brazil, Korea, Chile, Turkey, and Australia within the past year. Comments in the book include, “An odd treat,” and “Phineas Gage was on my bucket list.”

Photo courtesy the Collection of Jack and Beverly Wilgus

More importantly, new material about Gage continues to emerge. In 2008, the first-known image of Gage turned up, a sepia daguerreotype of him holding his tamping iron. (A second photo has since appeared.) The picture’s owners, the collectors Jack and Beverly Wilgus, originally labeled it “the whaler,” speculating that, somewhat like Ahab, the young man in it had lost his left eye to “an angry whale.” But after they posted the picture on Flickr , whaling enthusiasts protested that the smooth tamping iron looked nothing like a harpoon. One commenter finally suggested it might be Gage. To check this possibility, the Wilguses compared their image to a life mask of Gage made in 1849 and found that the features lined up perfectly, including a scar on Gage’s forehead. Although just one picture, it exploded the common image of Gage as a dirty, disheveled misfit. This Phineas was proud, well-dressed, and disarmingly handsome.

Scientifically, Gage’s legacy remains more ambiguous. His story certainly captures people’s imaginations and kindles their interest in neuroscience. (Whenever I’m in mixed company and mention that I’ve written a book about the most fascinating injuries in neuroscience history , someone always blurts out, “Oh, like Phineas Gage!”) But his story also misleads people, at least in its traditional form. Based on interviews and citations, Macmillan’s revised history does seem to be gaining traction. But it’s an uphill climb. “It has occurred to me [to ask] from time to time,” Macmillan sighs, “what the hell I am doing working on this?”

As for the latest research on Gage—especially the brain connectivity and brain plasticity work—it seems sound. But that’s really for posterity to judge. Perhaps each new theory about Gage is indeed inching us closer to the truth. On the other hand, perhaps Gage is doomed to remain a historical Rorschach blot, revealing little but the passions and obsessions of each passing era.

Because of all the uncertainty, Ratiu, the Bucharest doctor, recommends that neuroscientists stop teaching Gage. “Leave this damn guy alone,” he says. (Like Gage himself, people seem to indulge in “gross profanity” when discussing his case.) But this seems unlikely. Whenever teachers need an anecdote about the frontal lobes, “you just take this ace out of your sleeve,” Ratiu says. “It’s just like whenever you talk about the French Revolution you talk about the guillotine, because it’s so cool.”

If nothing else, Macmillan says, “Phineas’s story is worth remembering because it illustrates how easily a small stock of facts can be transformed into popular and scientific myth.” Indeed, the myth-making continues today. “Several people have approached me with a view to develop film scripts or plays,” he says. One involved Gage falling in love with a Chilean prostitute who rescues him from a life of dissolution. Another involved Gage returning to the United States, befriending and freeing a slave, then banding together with Abraham Lincoln to win the Civil War.

Another, deeper reason Gage will probably always be with us is that, despite all that remains murky and obscure, his life did hint at something important: The brain and mind are one. As one neuroscientist writes, “beneath the tall tales and fish stories, a basic truth embedded in Gage’s story has played a tremendous role in shaping modern neuroscience: that the brain is the physical manifestation of the personality and sense of self.” That’s a profound idea, and it was Phineas Gage who pointed us toward that truth.

Update, May 7, 2014: The top image of Phineas Gage is a daguerreotype, which shows the mirror-image reflection of what is photographed. The image has been flipped to show the life-like orientation. Another daguerreotype of Gage that appears later in the piece is also flipped.

Correction, May 15, 2014: This piece originally misstated that Matthew Lena is a neuroscientist. He is a computer scientist and intellectual property consultant. ( Return .)

A UC Berkeley linguist explores what Kamala Harris’s voice and speech reveal about her identity

"When we talk about Kamala Harris as a modern candidate, she is in some ways embodying all of the ways the country has moved on from the idea that you can only be one thing at once."

By Jason Pohl

Lawrence Cooper/Sipa USA via AP

August 6, 2024

Every now and then, a scholar’s niche expertise lines up with a cultural or political moment and finds an audience hungry for the details. Nicole Holliday is having one of those moments. 

Holliday is an acting associate professor of linguistics at UC Berkeley who studies what politicians say, how they speak and what their speech reveals about their identity. Perhaps more than any other scholar, Holliday has spent years examining the speaking style of a politician who is also having a moment: Kamala Harris.

What does Harris’s enunciation of vowels say about her California roots? How do a few choice words on the debate stage speak to her background as a Black woman? And how does that all change when she’s working a crowd in Georgia or delivering a policy statement in Washington? 

“I’m really interested in what happens with the voice, with the body, to inhabit these different parts of a person’s style,” said Holliday, who has also researched Barack Obama’s speaking style. “Politicians are the best people to study this on because you know what their motivations are — they’re all trying to get elected, or they’re trying to get money, or they’re trying to get voters.”

Journalists and the general public have become increasingly interested in Holliday’s work ever since President Joe Biden dropped his reelection bid and Harris soared to the top of the ticket as the Democratic presidential nominee. Holliday’s TikTok videos describing the science of Harris’s tone, style and word choice have gone viral, as have her explanations on why linguistically it’s problematic when people intentionally mispronounce her name. (It’s “comma-la.”) 

Individuals shifting how they speak based on their goals isn’t reserved for politicians, and it shouldn’t be viewed as inauthentic, Holliday said. Regular people vary their tone and word choice from their workplaces to their homes. Those variations fascinate Holliday.

“Most of the stuff that I’m talking about happens way below the level of consciousness,” Holliday said, “It would be really hard to control, even if you were trying.”

Berkeley News asked her what her research on Harris says about Harris’s culture and identity, why it matters that some people — including Donald Trump — continue to mispronounce her name, and what language can teach us about the current political moment. 

Berkeley News : Can you give me the 30,000-foot assessment of what your research has found especially interesting or special about the way Kamala Harris speaks? 

Nicole Holliday: She has a really unique style that reflects her biography. She sounds like an African American woman. She sounds like she’s from Northern California. She sounds like a charismatic political figure. But these are different identities that one person would have to inhabit all at once, and they’re traditionally seen as in conflict.

Our stereotype of a persuasive politician is not a Black and Indian woman. If you ask somebody to draw a picture of an American politician, they’re not drawing Kamala Harris. So she’s got to be a politician and, at the same time, sound like herself: a woman and Black and Indian American. And rep her hometown because she is a hometown girl, which can be a little bit of a liability for her now on a national stage because of the way that California is painted. 

But damn, she is so California.

Gage Skidmore via Wikimedia Commons

Say more. As a linguist, what do you hear in her speech that signals her California roots? 

When people describe the features that are geographically unique to California in the linguistic literature, they focus on a few things. There is this thing called the California vowel shift , where the back vowels move forward, and this is something that we see Harris do. 

@mixedlinguist VP Harris is sociolinguistally awesome, and fortunately I already wrote a paper about that! #linguisttok My website with all my research: https://nicolerholliday.wordpress.com ♬ original sound – Nicole Holliday

She doesn’t say “cool.” She says “kewl.” She doesn’t say goat. She says “gewt,” with the tongue far forward in the mouth. This is also a change that’s been in progress across America, so a lot of young people, even in the Midwest, will pronounce their back vowels far forward like this. But it started in California. It would be very strange if she had those vowels and she was her age and she was from New York. This is not something that they do over there. 

Another example: She has this interesting thing going on with what we call the low back vowels. Her low back vowels are distinct, which is not the case for most Californians, but they’re both kind of shifted up.

What that means is that words that are like “cot” and “caught,” those for me, a person from Ohio, are the same. But for her, they’re slightly distinct, but higher than we would expect. That’s a really interesting interplay, because I think that has to do with her being a Black woman from California. 

If she were a white woman, or if she were a Black man, we might not see this exact pattern.

You also say she’s embodying what’s called African American English. What do you mean?

I looked at her debate speech from when she was running as a primary candidate for the 2020 nomination. And when she talks about things that have to do with her biography, specifically about race or about immigration — these things that she can speak on from personal experience —  she uses a set of tones that is more what we would characterize as an African American charismatic style. So she kinda sounds more like Obama. 

When she talks about things like the economy or gun control or the climate, she uses a more typical, average white politician style, in terms of her tone. It is very interesting. And in this situation, it’s not a function of talking to different audiences, because she’s just in the same debate. It’s really what she’s talking about.

Lastly, she has this very occasional strategic use of casual features that are, for white Americans, just seen as really casual, but can also be what we call “camouflaged features of African American English.” This is my favorite thing. African American English is stigmatized. People call it “bad English.” They say it’s “improper.” All of this kind of stuff. But as a result, middle class and upper middle class Black people have found a way to kind of index their Blackness — highlight this part of their identities — without getting chastised for using “bad grammar.” 

And she does this even in the super formal debate speech.

She uses “gotta” and “gonna” in these particular ways. And of course, yes, white people say “gotta” and “gonna.” Everybody in America says “gotta” and “gonna.” But in a debate context, that is a little bit surprising, given how formal the rest of her style is. 

Is there an example of her doing this that comes to mind?

My favorite quote from her is from Oct. 15th, 2019, in the fourth primary debate. She said, “This is a crisis of Donald Trump’s making, and it is on a long list of crises of Donald Trump’s making. And that’s why dude gotta go.” 

When she has these strong zingers, particularly against Trump, they tend to go viral. Nicole Holliday, UC Berkeley

“Dude. Gotta. Go.” Not “Dude’s gotta go.” No. For a while, her primary campaign was selling T-shirts that said, “Dude gotta go.” It became a catchphrase. When I say that she’s doing this as part of a stylistic performance, that’s what I mean. Maybe it wasn’t premeditated. She didn’t think about it ahead of time. But that became a zinger, a one-liner. And when she has these strong zingers, particularly against Trump, they tend to go viral.

The last one is with “I’ma,” which is actually the most distinctively African American of these features. She says, “Cause I’ma tell you as a prosecutor” and “I’ma tell you what I saw.” 

We hear her do it now, too, once in a while. This is her being able to be like, “Look, look, look. I have these fancy degrees and I’m a prosecutor. And yes, I’m the vice president of the United States. But don’t forget that I’m from Oakland, and I’m Black.”

How much of this is conscious? And how much of this is just the deeply ingrained way we speak that’s been honed from decades of talking? 

@mixedlinguist Is Kamala Harris code-switching? What do we even mean by that? #linguistTok #kamala My website: https://nicolerholliday.wordpress.com ♬ original sound – Nicole Holliday

Political figures have debate coaches, speech coaches, things like that. But my sense is that the stuff that she’s doing in this case would be really hard to control. Maybe you can make a little argument about the “I’ma” and the “gotta.”

But the vowels? I’m a professional linguist, and if someone was like, “Make your vowels more California,” I don’t think I could do that. Especially not when I’m trying to, like, deliver a policy position. The cognitive load is too high. 

That holds even more for what I’m saying about the stuff that she does with her tone. It’s not really possible to do this at the level of consciousness. We choose our words, for sure, but even those in a debate kind of context are a little bit difficult. Those are the things you prep. 

But your speech coach is never gonna be like, “All right, so you need to raise the pitch by exactly 50Hz on the first syllable of prosecutor.” It doesn’t happen. It may be that she has a style in mind, but controlling the specific features that are attached to it is not really possible, 

I could see some people with a cynical reading of all of this being like, “Nothing is real, everything is prepared, they’re all politicians, and they’re all trying to manipulate us.” It sounds like you’re saying, “Yeah, maybe.” But also that it’s unlikely because of the more technical parts of speech that linguists spend their careers studying.

I would actually maybe turn that on its head and say, “Yeah, that’s every human.” We notice them doing it because we know that they’re selling something to us.

And this isn’t just her. This is Trump. This is J.D. Vance. This is Pete Buttigieg. It’s everybody who has that job, because selling the brand is part of the job. That’s how they keep their jobs.

Do you think that highlighting your New York-ness if you call the New York DMV is going to get you further than if you sound like you’re from California? Sure it is. And nobody had to tell you that. It’s not a conscious process. But arguably, we all do it. 

It’s just that with the politicians, because we know what they want, it’s clearer that they’re doing it. And the line between a politician doing something as a cynical ploy and doing something that really is part of their biography that I actually connect with as a voter is very fine.

As a linguist, what do you make of the deliberate mispronunciations of “Kamala” that have continued, despite her being a prominent national politician for many years now?

The right way to say anyone’s name — anyone’s name — is how they tell you to say their name. Period. That’s the first point. 

@mixedlinguist What’s up with the differences in how people say “Kamala”? Her name has become a shibboleth that tells us about the speaker’s alignment! #linguistTok #kamala ♬ original sound – Nicole Holliday

I know a guy named Christopher. People call him Chris. He doesn’t want to go by Chris. It’s disrespectful. The third time that he tells you, “My name is not Chris,” and you keep doing it, unless you have some kind of really good excuse, it’s disrespectful. 

For years, Kamala Harris has been putting out videos saying, “My name is Kamala,” and the stress is on the first syllable.

Yes, there are many reasons that regular people can get it wrong in conversation, especially if you’re a person that hasn’t heard her name very much, you’ve only read it. Some people have trouble hearing stress differences. If English isn’t your first language, that might be interfering with your ability to hear the way that she’s pronouncing her name with the stress. I’m not at all saying that your pronunciation of her name as an everyday person is an indication of your politics. I’m not making that claim.  

What I am saying is, if you’re the former president of the United States, or a U.S. Senator, or a media personality with extensive training who’s had to say her name thousands of times in your life and you’ve never bothered to try to say it the way that she says it, that’s on purpose.

You’ve also studied Maya Rudolph’s portrayal of Kamala Harris on Saturday Night Live. What makes that parody so good?

My first published Kamala Harris paper was about Maya Rudolph. She takes literally the exact phrases and the tone of those phrases that Kamala Harris uses, and then she dials them up to 11. I’m sure that Maya Rudolph doesn’t actually know how to do this the way that I would coach her as a linguist. She’s not looking at the waveform and the pitch up and down and being like, “All right, well, I need to raise myself by 50Hz here.” We don’t do that. But it’s like she really hears what Kamala Harris is doing. She internalizes it. And then when she goes to put on the Kamala Harris costume, it’s like a caricature. 

This is why parody is funny. Everybody that plays a politician on SNL does this to varying levels of effectiveness. But I would argue that Maya Rudolph is just a really skilled comedian anyway. I’m so glad that they just announced that she’s going to play Kamala Harris for the next year. I was really worried that we wouldn’t get more Maya Rudolph. 

But now I have to write another paper.

There are going to be a lot of speeches in the months ahead. There are going to be a lot of campaign stops. What’s next on your list of things to study?

What I didn’t have in the earlier analysis was her in different situations. Now, I hear her being different in Atlanta than in Philadelphia than in Los Angeles. And I want to know: Where is the California-ness? Where is the Black woman-ness? Where is the politician? I think she’s doing all of these things all the time. But I’m also interested in how people respond to her.  

What’s your sense of that response, so far? 

Speaker Mike Johnson said to members of Congress that they should not leverage racist and sexist attacks against her, that it would not help their cause. And they cannot seem to stop doing it.  

I’m interested in how she responds… She’s got a really fine line to walk.  Nicole Holliday, UC Berkeley

So if she gets portrayed as inauthentic by her opponents, I’m interested in how she responds. Does she shift something about her language in that response, or does she not? Maybe she shouldn’t. Maybe the way is to just let this roll off. I’m not a political consultant. But I do think she’s got a really fine line to walk. 

And there’s something really challenging for her, too. With Barack Obama, he did get the criticism that he wasn’t really Black. But in his case, the only other option was that he was white, and that didn’t work. His opponents were not going to go around saying he was white.

For her, because she has all of these identities at the same time — she is Indian American, she is Black American, she’s Jamaican American — there can be a little bit of a whack-a-mole where everyone will always accuse her of not being X enough.

This is disconcerting because it comes from a cultural and linguistic assumption that people can only ever be one thing. But that’s not the world we live in. So when we talk about Kamala Harris as a modern candidate, she is in some ways — with her biography, her ethnicity, her gender — embodying all of the ways the country has moved on from the idea that you can only be one thing at once. 

So I’m very interested to see how she manages to stay true to herself to respond to those never-ending critiques, and what she does with different audiences.