This Man Survived A Mind-Boggling Brain Injury, And The Case Still Baffles Experts 172 Years On

The iron bar has passed through Phineas Gage’s head. It’s smashed through his cheek, gone clean through his brain and passed out to fly through the air for some tens of feet. It seems clear that Gage should have been killed by the accident. Yet not only is he alive, but he’s also able to talk to the doctor who rushes to attend him.

Before the accident, Gage had been a much-loved character. According to The Psychologist magazine, his doctor, John Martyn Harlow, would later describe him as having been “strong and active,” not just in his body but in his mind as well. By all accounts, he would’ve been a nice guy to be around: good-natured, easy to get along with, having what the doctor described as a “well-balanced mind.”

But the passage of the tamping iron through his brain changed all that. Those who’d known him before the accident were stunned by the man whom they encountered afterwards. The alteration was so “radical” that, according to Harlow, people described him as “no longer Gage.” And this transformation would bring Gage notoriety.

Yes, Gage’s misfortune has since led to him becoming very well known among neuroscientists. This is largely due to the story of Gage’s transformation being the earliest indication that a switch in personality might follow damage to the brain. Altogether, University of Melbourne don Malcolm Macmillan has estimated that Gage features in two out of three psychology 101 guides.

Over time, different teams of brain researchers have explored the story of Gage. These include Stanley Cobb, a neurologist who in the 1940s tried to figure out where precisely the iron had passed through Gage’s skull. And as technology improved, others did the same with new methods: CT scanning during the 1980s and 3-D modeling in the following decade.

But who was Gage? Well, we don’t have that many details, bar that he came from New Hampshire farming stock. He later found work in railway building, and at the time of the accident he was with the Rutland and Burlington Railroad Company. This firm had received a state charter in the 1840s and was laying tracks in Vermont.

Gage had grown into a hard-working, friendly man, at peace with the world and gentle of disposition. His employers found him, according to Harlow, “the most efficient and capable foreman” they had. As for the men in his gang, well, he was a “great favorite” of theirs, too. But all of that would change.

The jobs Gage had included getting rid of stone in order to make the terrain level enough to lay down tracks. He did this by putting gunpowder into apertures that’d been created in the rocks. Once this task had been completed, the fissure would be covered with sand, so that he could safely pack it down with an iron crowbar.

Gage oversaw the placement of the apertures and the amount of explosives to use. He also had the responsibility for pushing the gunpowder down into the hole, so there’d be a more contained detonation. To do that, he employed a tamping iron, which was a cylinder that tapered along its 3.5 feet or so.

But for some reason, on an afternoon in September 1848 Gage allowed something to break his focus. And he then started to pound on the gunpowder prior to the sand being added. His tool scraped the tone, producing a spark that set off the explosives. To Gage’s horror, the iron was fired towards him by the ensuing blast.

The spike of the iron plowed into Gage’s cheek near his left eye. It then carved through the bottom of his skull and, after shooting through his brain, exited from the tip of his head. The propulsion had been so fierce that the iron continued to travel 25 yards or so afterwards.

Unsurprisingly, Gage possibly passed out at this point. But if he did, he wasn’t out for long. He was taken by cart to his nearby residence, where Gage was able to leave the vehicle without assistance. Once he’d gotten comfortable in a seat, he regaled bystanders with his tale. And when a medic turned up, he quipped, “Doctor, here is business enough for you.”

It seems that Gage then made a decent recovery from his accident. So six months or so after the bar pierced his head, he was ready to go back to his job. But Gage had changed – so much so that his firm wasn’t interested in giving him back in his previous position.

Strangely, even though Gage had changed noticeably, nobody at the time made that much of it aside from his employer. His different psychology didn’t merit a mention from Harlow in the contemporary report of the accident. And a further account a couple years later also failed to reference it. Others only made passing note of a reduction in his mental capacities. It was as late as 1868, in fact, long after Gage had passed, that Harlow made a more substantial report that described the changes in psychology.

Perhaps the scientists of the day just didn’t think to question whether having a spike go through Gage’s head had caused his personality to change. After all, they knew very little about the brain, with scant idea of how it operates. They had notions about nerves governing physical motion, but even these were limited.

As far as the world of science was concerned, the brain remained an enigma for the most part. And they weren’t well informed about how personality is related to the brain, either. After all, this was the age of the phrenologist. Yes, the height of medical science was examining lumps on the head to figure out what your character was!

Nor did anyone have much to go on when theorizing about Gage. Harlow’s account of 1868 is the only good source of information, and even that remained little read. This meant stories spread about Gage that had relatively little basis in truth. And as we’ll see, even scientists helped amplify the myth.

Harlow was well placed to know about the changes that Gage had undergone, given that he was responsible for Gage’s post-accident treatment. “He is fitful, irreverent, indulging at times in the grossest profanity, which was not previously his custom,” Harlow wrote of Gage’s character following the incident. And that wasn’t all that Harlow had to say.

Once a model citizen, Gage had now apparently lost the balance of “intellectual faculties and animal propensities.” This was especially unfortunate, because he struck Harlow as a strong man but with the mind of a child. Gage would no longer listen to advice that didn’t suit his desires. Instead, he was “pertinaciously obstinate, capricious, and vacillating” when it came to making plans, which he’d readily abandon.

Harlow’s character study hadn’t run to more than a couple hundred words, but later observers would have far more to say. Gage ballooned into a gross braggart, often drunk, plagued with sexual problems. Lazy and unmotivated, he couldn’t hold down jobs and ended up a drifter, showing himself off in circuses as a curio.

But the descriptions that people indulged in aren’t wholly accurate. And some aspects are entirely made up. For instance, Harlow mentioned that Gage had toured some of New England’s bigger settlements and had been on show at a New York museum. But over time such modest travels had been exaggerated into the story of a feckless drifter.

The museum that Gage had appeared in had been owned by PT Barnum, who’s better known today for owning a circus than a museum. This has led to fanciful tales that he appeared in Barnum’s circus, which have obscured the fact that Gage actually exhibited himself in the American Museum. And from a circus, then of course it’s a small step to being part of a freak show.

On top of that, Gage spent at most 12 months in New York and New England, since by the start of 1851 he was in steady employment again. So far from the waster that he’s often painted as, in truth he worked at a stable in the U.S. for 18 months before decamping to Chile, where he was employed as a stagecoach operator.

After the accident, Gage had been in poor health, not even feeling strong enough to help out on the family farm. He journeyed as far as Boston in the winter of 1849, but even in 1850 he was still struggling physically. It’s certain that he wasn’t making a fortune as a circus freak, though, since he had legitimate work.

So what else might’ve been exaggerated? Well, Harlow had it from Gage’s mom that he invented tales of what he’d been doing to keep his nieces and nephews amused. These stories may later have been mixed in with accounts of people who’d had brain operations to create a picture of a lying boaster who was quick to anger.

Case studies of people who’d undergone lobotomies seem to be where ideas that Gage was feckless or lazy came from. Harlow didn’t write anything about alcohol consumption or Gage’s love life. But Gage somehow still became discussed as somebody lost in a haze of booze and obsessed with sex.

Harlow did certainly describe a man who’d changed, though, even if it wasn’t in the ways that people would later claim. Professor Malcolm Macmillan, who wrote a book about Gage, told NPR in 2017, “He was the first case where you could say fairly definitely that injury to the brain produced some kind of change in personality.”

Neurologist Allan Ropper, from Brigham & Women’s Hospital and Harvard Medical School, sees in Gage the birth of neuroscience. He told NPR, “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.” The reason, Ropper explained, was that, “It’s one region [of the brain], it’s really obvious, and the changes in personality were stunning.”

Even though Gage did recover to some extent, the accident remains the likely cause of the end of his life. In 1859 he returned from Chile a sick man and looked to recuperate with family in California. But it was to no avail: convulsions that resulted from epilepsy would carry him off in 1860.

After Gage’s demise, an autopsy wasn’t held. And it wouldn’t be until 1867 that his remains were dug up for examination. The following year, Harlow received his skull, and that’s the only remnant of Gage that science can examine today. It isn’t clear what exact damage was done to his brain, since of course its position at the time of the accident can’t be determined for certain.

During Gage’s lifetime, there’d been three attempts to find out what exact route the tamping iron had taken. But even those couldn’t reach a consensus. Harlow determined that it’d exited close to the bregma, in the midline of the skull. This would have caused severe damage to the brain’s middle-left and left-frontal lobes. The doctor believed that the right side of Gage’s brain had taken over as a result.

With the advent of CT scanning, scientists could gain a new view of the iron’s passage. Richard Tyler and his son Ken took scans at Boston City Hospital that gave a two-dimensional view of the skull. This led them to conclude that while the left side of the brain had indeed been harmed, there’d also been some damage on the right.

Hanna Damasio’s team didn’t agree a dozen years later, though. She recreated Gage’s skull in three dimensions using existing photos, measurements and X-rays of Gage. Damasio concluded that the harm was caused more on the right and to the front of the brain than had previously been thought.

Two years later, advancements in science led to a new view. Ion-Florin Talos and Peter Ratiu were able to deploy thin CT scans to look at Gage’s actual skull and reconstruct it. They found that the entry hole for the tamping iron was too narrow for it to have passed through. So the skull must have lifted off to allow passage and then come back together after it was through.

Because of the hinge mechanism that this involved, and the fracture that was left behind, Ratiu and Talos could pinpoint the exit spot. It was left of the central line of the skull. They concluded that the damage to the brain would’ve been to the frontal and left lobes. In other words, they agreed with Harlow. So after decades of scientific investigation, they’d returned to square one!

Gage has a lasting fame, then, and students still hear about him to this day. Neurology professor Jack van Horn told NPR that similar cases crop up constantly. “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,” he said. “So you do have these modern kind of Phineas Gage-like cases.”

Yet Gage’s unique story continues to fascinate. To this day, visitors to Harvard Medical School’s Warren Anatomical Museum seek out items that – despite their slightly grisly nature – help tell that tale. There you can find not just the man’s skull and a mask of his face, but also the very tool that caused his personality to change.

But as we’ve seen, and Macmillan confirmed to NPR, the alteration of Gage’s personality probably was far from permanent. Macmillan told the broadcaster, “That personality change, which undoubtedly occurred, did not last much longer than about two to three years.” So this is good news for those who suffer brain injury today. He added, “Even in cases of massive brain damage and massive incapacity, rehabilitation is always possible.”

The importance of Gage’s case today doesn’t lie in a description of his behavior. We still aren’t all that clear on exactly what he was like before and after the accident. And we still don’t know enough to say what piece of damage caused which change in personality. But what is important is that Gage adapted and learned to live with it.