No Longer Gage? The Iron Bar, the Country Doctor and Neuroscience’s Most Famous Patient

At about half past four on the afternoon of September 13, 1848, a railroad foreman named Phineas Gage was packing a charge of blasting powder into a hole in a ledge of rock outside Cavendish, Vermont. Somebody behind him called out, or did something that caught his eye. He turned his head to look over his right shoulder. At that moment the iron rod in his hands struck a spark against the rock, the powder went off, and the rod left the hole like a javelin. It entered his face below the left cheekbone, passed behind his left eye, went up through the front of his brain, and came out of the top of his skull. It landed many yards behind him, slick with blood and brain.

Gage did not die. Within minutes he was talking. He rode sitting up in an oxcart to his hotel, climbed a flight of stairs with a little help, and told a doctor that the iron had gone through his head. Twenty years later his skull, with its ragged holes, went into a glass case at Harvard, where it became one of the most famous relics in the history of brain science. Two-thirds of introductory psychology textbooks mention him, according to the psychologist and historian Malcolm Macmillan. The lesson they usually draw is short and grim: the iron destroyed his frontal lobes, and with them the decent, hard-working man he had been.

The real story is stranger and kinder than that. Almost everything firsthand we know about Gage’s character after the accident comes from one country doctor, and fills only a few hundred words. Over the next century and a half those words were stretched into a legend of a drunken, brawling drifter who lived as a freak-show exhibit and died broke. Newer research, including a letter from a doctor who knew him in South America and two photographs found only in this century, points somewhere else: to a man who was badly changed for a while, and then, as far as anyone can tell, slowly learned how to live again.

“Here is business enough for you”

Gage was 25 that September, the eldest of five children of a family in Grafton County, New Hampshire. The physician who later made him famous, John Martyn Harlow, described him as “a perfectly healthy, strong and active young man,” five feet six inches tall and about 150 pounds, “possessing an iron will as well as an iron frame.” He was the foreman of a gang cutting a roadbed for the Rutland & Burlington Railroad through the rocky country near Cavendish, and his employers considered him “the most efficient and capable foreman in their employ.”

Blasting rock in 1848 was simple and dangerous. A crew drilled a deep hole into an outcrop, poured in powder and set a fuse, then covered the charge with sand or clay and packed it down hard with an iron rod, so the force of the explosion would go into the rock rather than back out of the hole. Gage had his own rod, made by a local blacksmith to suit him. It was not a crowbar. It was a smooth, round bar three feet seven inches long and an inch and a quarter thick, weighing thirteen and a quarter pounds, with one end tapering over about a foot to a point a quarter of an inch across.

Accounts differ on exactly what went wrong. In Harlow’s version, Gage was sitting on a shelf of rock above the hole, tamping the powder before his men poured in the sand, when his attention was drawn to the crew loading rock onto a car behind him. As he looked over his shoulder he dropped the iron onto the charge, it struck fire, and the explosion drove the bar “obliquely upwards” through his head. Other tellings have Gage’s assistant forgetting the sand, and Gage, turning back, ramming the bar down hard on bare powder. Either way, the iron went in point first just in front of the angle of his left jaw and came out near the top of his forehead, close to the midline.

The explosion threw him onto his back. He twitched a few times and then spoke. His men, with whom he was “a great favorite,” carried him to the road and propped him up in an oxcart for the three-quarter-mile ride into Cavendish. About half an hour after the accident, a physician named Edward H. Williams drove up to the hotel and found Gage sitting in a chair on the porch. “When I drove up he said, ‘Doctor, here is business enough for you,'” Williams recalled. Williams could see the pulsing of the brain through the wound in the top of the head before he got out of his carriage. At first he thought Gage must be mistaken about the bar going all the way through. Then Gage got up and vomited, and the effort pushed about half a teacupful of brain out of the hole in his skull onto the floor.

A country doctor and a coffin

Harlow, who had a practice in the village, arrived around six o’clock. “The picture presented was, to one unaccustomed to military surgery, truly terrific,” he later wrote, “but the patient bore his sufferings with the most heroic firmness.” Gage recognized him and said “he hoped he was not much hurt.” His bed, Harlow wrote, was “one gore of blood,” and Gage was swallowing so much of it that he threw it up every fifteen or twenty minutes.

With Williams helping, Harlow shaved the scalp, cleared away clotted blood and three small triangles of bone, and then did something that still makes readers wince: he pushed the index finger of his right hand into the hole in the top of the skull and the index finger of his left hand up through the hole in the cheek, feeling for fragments, until the fingers nearly met. He removed “an ounce or more” of protruding brain, pressed two large loose pieces of skull back into place, and left the cheek wound open so it could drain. That evening Gage told him he did “not care to see his friends, as he shall be at work in a few days.”

It was not that easy. Two days after the accident Gage became delirious. An infection set in, and what Harlow called “fungus” began pushing out of the wound in his head and from the corner of his swollen left eye. By the end of the second week he was in a coma. His friends and attendants, Harlow wrote, were “in hourly expectancy of his death, and have his coffin and clothes in readiness.” One of the attendants begged the doctor to stop treating him and let him die in peace. Harlow refused. “I said it is not water, but matter that is killing the man,” he wrote, and he cut away the fungus, treated it with caustic, and opened the skin between the head wound and the bridge of the nose. Eight ounces of foul pus poured out.

That drainage probably saved Gage’s life. Harlow had graduated from medical school only about four and a half years earlier, and historians have credited him with avoiding the mistakes of his era: he did not dig around for every bone chip, and he kept the wound open and the head raised so that the infection could drain down through the hole the iron had made in the base of the skull. By early October Gage was asking for his pants so he could go out. By mid-November he was walking in the streets of Cavendish, against orders, without a coat. On November 25, ten weeks after the accident, he was taken home to his mother’s house in Lebanon, New Hampshire, about thirty miles away. By New Year’s Day 1849 the hole in the top of his head had closed, though the pulse of his brain could still be felt beneath it. He was blind in his left eye, and the lid drooped closed. Harlow, borrowing from the 16th-century surgeon Ambroise Paré, summed up his own role modestly: “I dressed him, God healed him.”

“A Yankee invention”

Harlow’s first report on the case, in the Boston Medical and Surgical Journal in December 1848, was widely disbelieved. A man with a hole that size through his brain was supposed to be dead. Harlow later complained that the city doctors refused “to believe that the man had risen, until they had thrust their fingers into the hole of his head,” and that one “distinguished Professor of Surgery in a distant city” had dismissed the whole thing as a “Yankee invention.”

What settled the matter was Henry Jacob Bigelow, Harvard’s professor of surgery. In late 1849 he paid Gage’s way to Boston and kept him there for eight or nine weeks, examining him, showing him to the Boston Society for Medical Improvement, and having a plaster cast made of his face and head. Bigelow’s report, in the American Journal of the Medical Sciences in July 1850, admitted that “the leading feature of this case is its improbability” and that he had been “at first wholly skeptical.” He came away convinced. He also pronounced Gage “quite recovered in faculties of body and mind.”

That verdict says as much about the medicine of 1850 as about Gage. Doctors then tested a brain-injured patient mainly for paralysis, blindness, deafness and loss of speech. Gage could walk, talk, see out of one eye and hear, so by those standards his brain seemed fine. The prevailing view was that the front of the brain did very little, partly because people sometimes survived injuries to it. Bigelow’s interest was in the survival, and he treated Gage as a curiosity: the science writer Sam Kean notes that at one meeting he presented Gage alongside an oddly shaped stalagmite.

While he was in Boston, Gage gave his tamping iron to Harvard’s medical museum. Bigelow had it engraved: “This is the bar that was shot through the head of Mr Phinehas P. Gage at Cavendish Vermont Sept 14, 1848. He fully recovered from the injury & deposited this bar in the Museum of the Medical College of Harvard University.” The inscription, dated January 6, 1850, gets both the date of the accident and the spelling of Gage’s first name wrong. Gage later took the iron back. It was, Harlow wrote, his “constant companion during the remainder of his life.”

“No longer Gage”

Harlow saw something that Bigelow either missed or chose not to report. When Gage came back to Cavendish in April 1849 and asked for his old job, his contractors turned him down. They “considered the change in his mind so marked that they could not give him his place again.” Harlow’s description of that change, which he did not publish until 1868, became the most quoted paragraph in the case:

“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 capacity and manifestations, he has the animal passions of a strong man. … In this regard his mind was radically changed, so decidedly that his friends and acquaintances said he was ‘no longer Gage.'”

It is a vivid passage, and it is nearly all there is. Harlow added that Gage’s mother said he told his young nieces and nephews “the most fabulous recitals of his wonderful feats and hair-breadth escapes,” and that he became very fond of pets, children, horses and dogs. Harlow also stressed that Gage’s memory and general intelligence seemed intact once the early delirium passed, and that his mental state was “nothing like dementia.” “Despite there being no more than a couple hundred words attesting to how he changed,” Macmillan told Kean, “he came to dominate thinking about the function of the frontal lobes.”

Even those words are harder to read than they look. Harlow never says how long the changes lasted, or how often Gage swore, or what “animal passions” meant. He was also a believer in phrenology, the fashionable 19th-century idea that character could be read from bumps on the skull, and he described Gage’s pre-accident temperament in phrenology’s terms as “nervo-bilious.” Phrenologists seized on the case, because the iron had come out near the top of the head, where their charts placed the “organs” of Veneration and Benevolence. To them, a man who had lost his respect for others and started cursing was exactly what you would expect.

Barnum’s, a livery stable and a coach to Chile

What Gage did next is the part of the story that textbooks tend to skip. First he traveled. Harlow says he visited Boston, “most of the larger New England towns, and New York, remaining awhile in the latter place at Barnum’s, with his iron,” meaning P. T. Barnum’s American Museum on Broadway, not Barnum’s later traveling circus. A broadside discovered by a Cavendish doctor, Gene Bont, advertises a lecture and exhibition by Gage in Concord, New Hampshire, apparently arranged by Gage himself and backed by testimonial letters from doctors who had examined him. Bigelow later wrote that Gage was “a shrewd and intelligent man and quite disposed to do anything of that sort to turn an honest penny,” but that he gave up the shows after a short time.

In 1851 he went to work for Jonathan Currier, who ran a livery stable and coach service in Hanover, New Hampshire, and stayed about a year and a half “without any interruption from ill health.” Then he did something remarkable for a man supposedly incapable of keeping a plan. In August 1852, by Harlow’s account, he signed on with a man who was setting up a line of coaches at Valparaíso, Chile, and sailed for South America. (He was seasick most of the way, his mother later said.) An envelope found in Harvard’s collections, dated August 26, 1854 and apparently written by Gage to ask that his tamping iron be handed to a relative, suggests the exact timing may have been different, but the destination is not in doubt.

For about seven years Gage worked in Chile, caring for horses and, in Harlow’s words, “often driving a coach heavily laden and drawn by six horses” between the port of Valparaíso and the capital, Santiago. An 1860 advertisement for that route, found by Macmillan’s colleague Matthew Lena, describes a journey of about 13 hours and 110 miles that left at four in the morning, with a fare of ten dollars and a 50-pound luggage limit. Before a run the driver had to see the horses fed, groomed and harnessed, load the baggage, collect fares and make change, and then keep his passengers comfortable on bad mountain roads all day, in a country whose language and customs were new to him.

Macmillan says his own thinking about this changed while he was watching Prince Philip compete in carriage driving on television. A coachman handling a team holds each horse’s reins between different fingers, and turning a corner takes planning, timing and fine control. “To have someone with impulsive behavior, uncontrolled behavior, carrying out the highly skilled task of stagecoach driving,” Macmillan told Kean, “I knew there was a contradiction there.”

The doctor from Valparaíso

In 2010 Macmillan and Lena published a paper in the journal Neuropsychological Rehabilitation with the deliberately provocative title “Rehabilitating Phineas Gage.” Its key new piece of evidence was a remark recorded in 1860 by J. W. Hamilton, a professor at Starling Medical College in Columbus, Ohio, and an editor of the Ohio Medical and Surgical Journal. Hamilton wrote that during a discussion of the Gage case, a “Dr. Henry Trevitt, of Valparaiso, South America, who was present, at once replied to our remark that he knew Gage well; that he lived in Chili, where he was engaged in stage driving; and that he was in the enjoyment of good health, with no impairment whatever of his mental faculties.” Lena established that Trevitt had been in Valparaíso from about mid-1858 to mid-1859, so he was describing Gage roughly ten years after the accident.

Put that together with the rest of the record, Macmillan argues, and a different arc appears. Gage was back doing farm work within months of his injury. He organized his own public appearances. He held a steady job at a stable. A coach-line founder hired him in New England to drive for a new enterprise in a foreign country. He did that demanding job for years. Macmillan calls the result a “social recovery”: Gage may have been impulsive and erratic in the first months, but over time he seems to have relearned much of what he had lost.

Macmillan’s explanation is the structure of the work itself. People with frontal-lobe damage often do well on tests in a lab and badly in open-ended daily life, where they have to plan, choose and resist distractions. A stagecoach driver’s day was the opposite of open-ended: the same steps every morning, the same road, the same schedule. That resembles the rehabilitation methods developed by the Soviet neuropsychologist Alexander Luria for soldiers with frontal-lobe wounds in World War II, which leaned on rigid routines and external cues. Macmillan points to modern cases that fit the pattern, including a young woman with severe damage to both frontal lobes, described by researchers in 1990, who after years of uninhibited behavior learned to look after herself once a companion gave her a fixed written list of daily tasks to do in exactly the same order. “If even Phineas Gage bounced back,” Kean wrote, “that’s a powerful message of hope.”

The last months, and a grave reopened

Gage’s health began to fail in Chile in 1859, for reasons nobody recorded. He left for San Francisco, where his mother and sister had moved, and arrived “in a feeble condition.” Under their care he recovered enough to be “anxious to work,” and he found a job with a farmer in Santa Clara. In February 1860, the day after a hard day of plowing, he had a seizure at dinner. More followed. Only then, according to the account his family gave Harlow, did he start drifting from job to job, “always finding something which did not suit him in every place he tried.” On May 18 he went home to his mother. Two days later, at five in the morning, he had a severe convulsion. The family doctor bled him. The convulsions came again and again through the next day and night, and he died late on May 21, 1860, aged 36, almost certainly in what doctors now call status epilepticus. He was buried in San Francisco’s Lone Mountain Cemetery.

Harlow had lost track of his patient. Only in July 1866 did he find the family’s address and begin writing to Gage’s mother and his brother-in-law, a San Francisco merchant named D. D. Shattuck. (Working from their letters, Harlow put Gage’s death a year late, in 1861, an error that later researchers corrected and that some modern papers still repeat.) At Harlow’s request the family agreed to have the grave opened in 1867, with Shattuck, San Francisco’s mayor, Dr. Coon, and another physician, Dr. J. D. B. Stillman, overseeing the work. The skull and the tamping iron were then carried east and delivered to Harlow.

On June 3, 1868, Harlow stood before the Massachusetts Medical Society with both in front of him and presented “the history and sequel” of a case that, as far as he knew, “remains without parallel in the annals of surgery.” It was in this paper that he finally published his paragraph about “no longer Gage,” along with nearly everything known about the years in Chile. Then he gave the skull and the iron to Harvard’s Warren Anatomical Museum, where they have stayed ever since. In 1940, when San Francisco moved its old cemeteries out of the city, Gage’s headless remains were reburied at Cypress Lawn Memorial Park.

How a few hundred words became a legend

After Harlow, almost nobody went back to the original sources. Writers summarized summaries, and with each generation the story grew. Macmillan, who has tracked the retellings for decades, summed up the composite Gage of later books as “an unstable, impatient, foul-mouthed, work-shy drunken wastrel, who drifted around circuses and fairgrounds, unable to look after himself and dying penniless.” None of that appears in any account by someone who knew him. Some versions are flatly impossible. Kean lists a tale in which Gage sold the rights to his skeleton to one medical school after another and skipped town each time with the money, and another in which he lived for twenty years with the iron still stuck through his head.

Part of the problem is that Gage became evidence in other people’s arguments. In the 19th century, both sides of the debate over whether mental functions live in specific parts of the brain claimed him. As early as 1877 the British neurologist David Ferrier complained that he was “constantly being amazed at the inexactitude and distortion” of brain-injury reports written “by men who have some pet theory to support. The facts suffer so frightfully.” In the 20th century Gage was often linked to the rise of the lobotomy, sometimes even called the first one. Macmillan found no evidence that any surgeon designed an operation to copy Gage’s injury. What the case did show, he writes, was simply that a person could survive major damage to the brain, which made brain surgery for things like tumors seem less hopeless.

The most influential modern retelling came in 1994, when the neuroscientist Antonio Damasio opened his bestseller Descartes’ Error with Gage. Damasio used him to introduce a powerful idea, that emotions are not the enemy of reason but a necessary part of good decision-making, drawn largely from Damasio’s own patients with damage to the front of the brain. But his portrait of Gage leaned heavily on later embroidery, including Gage “drinking and brawling in questionable places,” and, as Kean notes, he even raised the possibility that “his soul was diminished, or that he had lost his soul.” The historian Zbigniew Kotowicz was blunt in response: “Harlow does not report a single act that Gage should have been ashamed of.”

Kean has a theory about why this particular myth has been so hard to kill. Most scientific legends inflate their heroes. Gage’s legend does the reverse: it turns a man into a cautionary tale, a good man ruined in an instant, and that makes a better story than a slow recovery does. “Phineas’ story is worth remembering,” Macmillan has written, “because it illustrates how easily a small stock of facts can be transformed into popular and scientific myth.”

Tracing the iron through the skull

Gage’s brain was never preserved, so modern scientists have had to work backward from the skull. In a study that made the cover of Science in May 1994, Hanna Damasio and colleagues reconstructed the path of the iron and concluded that it had damaged the front of the brain on both sides, the left and the right. Critics later pointed out that their model was built not from Gage’s own skull but from a different skull digitally reshaped to match its measurements, and that it tested only a handful of possible paths.

In 2004 a team led by Peter Ratiu at Brigham and Women’s Hospital in Boston used a thin-slice CT scan of the real skull. They concluded that the iron stayed on the left side and never crossed into the right hemisphere, as Harlow had believed from probing the wound with his fingers. They also found that the hole in the base of the skull was only about half as wide as the iron, and proposed that the skull had briefly hinged open as the bar went through and then sprung shut again. Because the iron did not break Gage’s lower jaw, Ratiu argued, his mouth must have been open at the moment of impact, as if he had been speaking.

In 2012, John Darrell Van Horn and colleagues at UCLA combined CT images of Gage’s skull with MRI and diffusion scans of the brains of healthy young men, to estimate not just which tissue the iron destroyed but which connections it cut. Testing a vast number of possible paths and discarding those that would have broken his jaw or worse, they agreed with Ratiu that the damage was on the left. They estimated that the iron destroyed about 4 percent of Gage’s cerebral cortex but about 11 percent of his white matter, the bundles of nerve fibers that wire brain regions together, and that the lost wiring affected networks well beyond the hole itself. A 2015 study led by Michel Thiebaut de Schotten reached a similar conclusion, comparing Gage with two other landmark patients, Paul Broca’s “Tan” and the amnesic patient H.M., and arguing that each case shows how behavior depends on connections between brain regions rather than on single spots.

All of these researchers have acknowledged that their models are educated guesses. Brains vary in size, shape and position from one person to the next, and the infection that nearly killed Gage, along with the bone fragments driven into his brain, destroyed tissue that no reconstruction can map. The iron’s path is now well understood. What it did to the man is still argued about.

The man in the daguerreotype

For about 160 years there was no known picture of Gage at all, except the plaster cast Bigelow had made of his head. Then a pair of Baltimore collectors, Jack and Beverly Wilgus, posted a scan of an old daguerreotype from their collection on Flickr in December 2007 under the title “One-Eyed Man with Harpoon.” They had owned it for decades and assumed it showed a whaler injured by a whale. A whaling enthusiast wrote to say the object was no harpoon. A year later a Montana database administrator, Michael Spurlock, saw the picture and thought of Gage at once.

Jack Wilgus, a retired photography professor, then noticed something the couple had never seen on the tiny image, which measures only about 2¾ by 3¼ inches: there was writing on the rod. Part of it seemed to read “through the head of Mr. Phi…” In March 2009 the Wilguses took the daguerreotype to Harvard and compared it with the tamping iron and the life cast. The inscription matched the one on the real iron, and the scars on the man’s face matched the cast. “Such a ‘wow’ moment,” said Jack Eckert, a librarian at Harvard’s Center for the History of Medicine. Like most daguerreotypes, the original is a mirror image, so published copies are usually flipped back to show Gage as he looked in life, with the injured left eye on his left.

A second portrait turned up in 2010, a copy handed down in two branches of the Gage family, showing him in a slightly different pose with the same iron. Neither picture shows a broken drifter. “Although just one picture,” Kean wrote of the first, “it exploded the common image of Gage as a dirty, disheveled misfit. This Phineas was proud, well-dressed, and disarmingly handsome.” Van Horn’s team put it more formally: “That he was any form of vagrant following his injury is belied by these remarkable images.”

Where Gage is now

Gage’s skull and iron remain among roughly 15,000 objects in the Warren Anatomical Museum, part of the Center for the History of Medicine at Harvard’s Countway Library of Medicine. For years they were the stars of a modest fifth-floor gallery that visitors could walk into for free. That gallery has since closed, and Atlas Obscura now lists the museum as permanently closed; the library’s catalog says that seeing items from the collection requires a request made in advance. The museum’s curator, Dominic Hall, has said that Gage is “an important part of Harvard Medical School’s identity,” and he has watched the meaning of the case shift over time. “In 1848, he was seen as a triumph of human survival,” Hall told the Harvard Gazette in 2015. “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.”

In Cavendish, a bronze plaque on a boulder beside Main Street marks “The Gage Accident.” It was dedicated on September 13, 1998, the 150th anniversary of the explosion, and it honors both Gage and the doctor who refused to let him die. A rock cut along the old railroad line south of the village is thought to be the spot, or close to it. A 3D scan of the skull is available through the National Institutes of Health’s 3D print exchange, so anyone with a printer can now hold a copy of the most famous wound in medicine.

Why Gage still matters

Strip away the legend and Gage still teaches something real. His case was one of the first to suggest that damage to a particular part of the brain could change a person’s character while leaving memory, speech and intelligence apparently intact, an idea that 19th-century medicine was not ready to accept and that modern neuroscience takes for granted. It is the same link between brain tissue and behavior that later drove experiments like José Delgado’s radio-controlled bull and today’s deep brain stimulation implants, and that researchers now probe with scanners, which come with their own traps, as the dead salmon in the fMRI machine famously showed.

The newer reading of Gage adds two more lessons. One is about the brain: even after a catastrophic injury, it may be able to relearn lost skills, slowly, given the right kind of structure. The other is about science itself. A famous case can become a mirror, reflecting whatever theory each generation brings to it, unless someone goes back and reads what the first witnesses actually wrote. Peter Ratiu has compared Gage to the guillotine in any telling of the French Revolution: whenever teachers need an anecdote about the frontal lobes, he told Kean, “you just take this ace out of your sleeve.” The ace is still worth playing. It is just a different card than the one most of us were dealt.

Further reading