To survive was one-in-a-million, but to almost completely recover is incomprehensible. The side-effects, however, made him shunned by decent society

A moral man, Phineas Gage,
Tamping powder down holes for his wage,
Blew his special-made probe,
Through his left frontal lobe,
Now he drinks, swears, and flies in a rage.
(Anonymous limerick)

On September 13, 1848, an unbelievable medical marvel occurred.

A foreman named Phineas Gage was toiling at the head of a work-gang. They were blast­ing rock to pre­par­e the road­bed to lay railroad track on the under-construction Rut­land & Bur­ling­ton Rail­road in Ver­mont, USA.

A fit, strong man, sound of mind, temperament and morality, Gage was 25 at the time and his employers described him as “the most efficient and capable foreman in their employ”.

Setting a blast entailed boring a hole deep into an out­crop of rock; adding blast­ing pow­der and a fuse; then using the tamping iron to pack (‘tamp’) sand, clay, or other material into the hole above the powder in order to contain the blast’s energy and direct it into surrounding rock.

A freak instance of fate then shattered Gage’s life forever.

He stood over his tamping iron as he worked when one of his men drew his attention. Gage’s head was turned over his right shoulder and his mouth was open mid-speech. At that precise moment, his tamping iron sparked against the rock and ignited the explosive powder.

The iron bar, 1.25in (3.2 cm) thick, 3ft, 7in (1.1 m) long, and weighing 13.25lbs (6.0 kg)‍ shot out the hole like a cannonball and straight up into Gage’s cranium.

In a flash, the pointed, smooth, cylindrical bar skewered the foreman’s brain, entering the left side of Gage’s face in an upward direction, just forward of the angle of the lower jaw.

Continuing upward outside the upper jaw it possibly fractured the cheekbone, before passing behind the left eye, through the left side of the brain, then completely out the top of the skull through the frontal bone.​​

The tamping iron landed like a javelin point-first some 80 feet (25 m) away “smeared with blood and brain”.

Gage was thrown onto his back and convulsed violently for a few minutes. Instead of perishing, however, this incredibly robust fellow started to speak.

Within minutes and, with only little assistance, Gage walked over and sat upright on an oxcart for a ride back to town.

Within half an hour of the accident physician Edward Williams arrived to find Gage sitting outside his hotel and was greeted with perhaps the greatest understatement in medical history:

“When I drove up he said, “Doctor, here is business enough for you.” I first noticed the wound upon the head before I alighted from my carriage, the pulsations of the brain being very distinct… Mr. Gage, during the time I was examining this wound, was relating the manner in which he was injured to the bystanders.”

“I did not believe Mr. Gage’s statement at that time, but thought he was deceived. Mr. Gage persisted in saying that the bar went through his head. Mr. G. got up and vomited; the effort of vomiting pressed out about half a teacupful of the brain [through the exit hole at the top of the skull], which fell upon the floor.”

Another doctor by the name Harlow arrived later and related his shock at Gage’s injury:

“You will excuse me for remarking here, that the picture presented was, to one unaccustomed to military surgery, truly terrific; but the patient bore his sufferings with the most heroic firmness. He recognized me at once, and said he hoped he was not much hurt. He seemed to be perfectly conscious, but was getting exhausted from the hemorrhage. His person, and the bed on which he was laid, were literally one gore of blood.”

Convalescence and Recovery

Both physicians cleaned up the wound, bandaged it loosely for it to drain and applied a nightcap.

They also applied bandages to his arms which had been deeply burned by the blast, as had Gage’s face, and on that first evening on the long road of convalescence, Harlow noted: “Mind clear. Constant agitation of his legs, being alternately retracted and extended … Says he ‘does not care to see his friends, as he shall be at work in a few days.’”

Despite his own optimism, Gage’s convalescence was long, difficult, and uneven. Though recognizing his mother and uncle — summoned from Lebanon, New Hampshire, 30 miles (50 km) away‍ — ‌ on the morning after the accident, on the second day, he “lost control of his mind, and became decidedly delirious”

His condition ebbed and flowed over the coming days, and the fellow’s friends and family braced themselves for his inevitable passing with a coffin at the ready.

Yet, the moment never came.

One of the factors which saved Gage’s life was Dr Harlow’s experience with cerebral abscess, and the good doctor was compelled to drain eight ounces [250 ml] of excessively fetid, ill-conditioned pus and blood from the wound.

By the 24th day Gage “succeeded in raising himself up, and took one step to his chair”.

Despite all the odds, he was on the road to recovery.

After 10 weeks, Gage could return to his mother’s home, and by February the following year had recovered so extraordinarily, he could do light work around the farm.

In less than a year of an iron bar shooting through the man’s skull, he could do a good half-day’s work and his physical damage appeared restricted to mild memory loss and loss of use of his left eye.

“No Longer Gage”

Another factor to explain Gage’s survival was the fact the tamping bar skewered his Frontal Lobe and not more critical lobes of the brain. In simple terms, damage to the Frontal Lobe affects memory and planning, and psychological functions linked to morality and substance abuse, amongst others.

Out of all the parts of the brain to suffer a spiked bar fly through it, the Frontal Lobe is the best cerebral section to endure that injury.

Gage may have been the first case to prove that the brain determined personality based on his startling change of character as a result of his horrific accident.

Dr Harlow noted changes in Gage’s behaviour within three years of his accident, particularly in the first few months.

Although the man’s intelligence, and memory even, appeared fine his temperament and morality, in contrast, were completely scrambled.

Before the accident, Gage was known as hardworking, responsible, focused and popular with his men. Yet afterwards, Harlow noted: “He is fitful, irreverent, indulging at times in the grossest profanity (which was not pre­vi­ous­ly his custom)”

And Harlow went on to describe how he could be extremely obstinate one moment then capricious and vacillating at others.

He stated: “A child in his intel­lec­tu­al capacity and man­i­fes­ta­tions, he has the animal passions of a strong man.”

For a while, folks even came to avoid his company as he was described as “gross, coarse and vulgar to such a degree his [company] was intolerable to decent people.”

More salacious rumours that he became a wife-beating, psychopathic, degenerate layabout were gross exaggerations or outright lies, however. For starters, he wasn’t married.

Later Life

In November 1849, as the rumours and scepticism of his injury spread Gage was invited to Boston to present himself to the Boston Society for Medical Improvement, after Harvard University’s Professor of Surgery examined Gage’s cranium to establish that the unbelievable accident had actually happened.

Since he’d lost his old job, Gage toured around for three years exhibiting himself; appearing for example as one of ‘Two Wonders of the World’ at a Vermont exhibition alongside ‘General Washburn, the living dwarf skeleton’. But made a poor living from these exhibitions.

He managed to scrape enough money together to travel down to Chile in August ’52 to work as a long-distance stagecoach driver on the Valparaíso–Santiago route.

He took with him the tamping bar he reacquired as his constant companion.

During this time of employment Gage managed to recover the responsibility and decency he’s once been known for, and demonstrated full mental faculties for which the job of stagecoach demanded, including forward planning, care for the horses and courtesy with the passengers, etc.

Yet, by 1859 the hardships of the job caused his health to decline again and he returned to recuperate in San Francisco with his mother and sister.

Despite recovering enough to begin working again, by February 1860, Gage began to suffer severe epileptic seizures and succumbed to them four months later.

He was 36 at the time.

Phineas Gage’s impossible survival of his accident is down to the fact the bar transitioned through less critical cerebral tissue; his fitness; and prompt, skilled medical attention.

But his almost complete physical, mental and psychological recovery make this a tale to be remembered.

In 1866 Harlow, who was by then a prominent physician, busi­ness­man, and civic leader in Massachusetts ​​somehow learned that Gage had died and, at Harlow’s request, the Gage’s family had his skull exhumed and delivered it to Harlow themselves.