The historical setting of the book illuminates why it was so extraordinary for Phineas Gage to survive in 1848 and why the case became so significant. At the time, physicians were making great strides in modernizing surgery. With the introduction of anesthesia, surgeons could operate on patients without them experiencing pain. However, they had few of the scientific tools and knowledge of later generations. In particular, most physicians didn’t recognize that bacteria caused disease. Surgical gloves, sterilized equipment, and hand-washing practices weren’t commonplace. Even if a patient survived the trauma of a major operation, they were often likely to die due to post-operative infection or related complications.

At the time of Gage’s accident, many subscribed to phrenology, which is no longer considered valid. German physician Johann Christoph Spurzheim coined the term, which means “science of the mind.” Spurzheim believed that examining the skull could illuminate a person’s vulnerabilities and assets and therefore “lead to personal improvement for everyone, including the laboring classes” (Greenblatt, S. H. “Phrenology in the Science and Culture of the 19th Century.” Neurosurgery, vol. 37, no. 4, 1995, pp. 790-804). Phrenologists argued that the brain consists of muscles and that these appear as bumps throughout the skull. They claimed that if the brain doesn’t use these muscles, they would be small or not visible.

During Gage’s time, there was also considerable debate regarding how the brain works. Physicians and scientists knew that the brain is involved in all aspects of life; however, they disagreed as to whether the brain functions as separate modules, with each module corresponding to a specific mental function, or if the brain functions as a single unit. Physicians used Gage’s injury to support their positions on thought, behavior, and personality. As Fleischman notes, Gage’s story entered the scientific literature not as an established fact but as part of an ongoing discussion.

Gage’s story reflects the transitional nature of the medical profession. Through his account, Fleischman illuminates how limitations in medical knowledge and conflicting ideas within the scientific community influenced Gage’s treatment and the study of his case.