(Warning: this blog is not for the squeamish!)
An American railroad worker suffered a bizarre accident 170 years ago today, one that he was not only incredibly lucky to survive, but which contributed greatly to early understanding of how brain injury can bring about personality changes.
Phineas Gage was a strong, intelligent and competent worker, trusted by his employers who made him a construction foreman on the Rutland and Burlington Railroad, in Vermont. Experienced in the use of explosives, he was in charge of a work gang blasting rock to clear a path for the new railroad.
On September 18th, 1848, he was preparing an explosive charge when the accident happened. The job entailed boring a deep hole into the rock, adding blasting powder and a fuse, then using a ‘tamping iron’ to pack sand or clay into the hole above the powder. Like many explosives men, Gage had his own tamping iron, made to his specifications by a blacksmith.
As he was tamping down the charge, he was distracted by men working behind him. Looking over his right shoulder, he opened his mouth to speak when his tamping iron sparked against the rock and ignited the charge. The resulting explosion propelled Gage’s iron from the hole like a bullet from a gun. The top end, which was pointed, entered his left cheek, passing behind the left eye, through the frontal left lobe of the brain and out through the top of the skull.
The entire tamping iron – three feet seven inches long, an inch-and-a-quarter in diameter and weighing 13 pounds – passed through Gage’s head like a javelin, landing point-first some 80 feet away. Gage was thrown onto his back and gave some brief convulsions of his arms and legs. Rushing to his aid, his men expected to find him dead, but instead found him not only alive, but conscious.
Within a few minutes he was speaking and able to walk, with some help, to an oxcart, in which he sat upright for the three-quarter mile ride to his lodgings in the nearby town of Cavendish. A local doctor, Edward Williams, arrived to find his patient sitting in a chair outside the hotel. Gage greeted him with the words: “Doctor, here is business enough for you”, which Dr Williams later described as “one of the greatest understatements of medical history!”
Dr Williams wrote a vivid description of what he found: “I first noticed the wound upon the head before I alighted from my carriage, the pulsations of the brain being very distinct. The top of the head appeared somewhat like an inverted funnel, as if some wedge-shaped body had passed from below upward.
“Mr Gage, during the time I was examining this wound, was relating the manner in which he was injured to 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 Gage 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.”
Unsure of how best to proceed, Dr Williams sent for fellow physician Dr John Harlow, who had studied phrenology and took a keen interest in the human brain. Together they were able to clean Gage’s wounds, including removing protruding bone and brain matter, before dressing them. Neither man expected Gage to survive for long, not least due to his considerable blood loss, but Harlow commented that “the patient bore his sufferings with the most heroic firmness.”
Gage himself expected to be back at work within days, but his optimism proved unfounded. Instead his convalescence was long and difficult, at times taking him to the very brink of death. He veered from being conscious and alert to semi-comatose and delirious, and only Dr Harlow’s considerable skill saved him from death when his wound became horribly infected.
Incredibly, just 10 weeks after the accident Gage was well enough to go home to his parents’ farm in New Hampshire, where he continued to make a slow but steady recovery. By April the following year he was able to return to Cavendish, where Dr Harlow noted that, apart from losing the vision in his left eye and some facial paralysis on the left side, Gage was physically recovered from his ordeal.
He was also mentally sound, though his mother noted some memory loss and friends claimed his personality had altered considerably, some even suggesting he was “no longer Gage”. These changes greatly interested Dr Harlow, who would go on to study Gage’s mental recovery in depth and publish medical papers on his case. Debate continues over the nature and extent of his personality changes, which were likely sensationalised in contemporary accounts and seem to have diminished as his recovery continued.
After a period as something of a ‘medical celebrity’, speaking to large audiences about his injury and remarkable survival, Gage worked for several years as a long-distance stagecoach driver in Chile. Around 1859 his health began to fail, but he recovered under the care of his mother and sister, by then relocated to San Francisco where he continued to work.
In 1860 he began to suffer from epileptic seizures, which steadily increased in frequency and severity. It was during a particularly severe and sustained seizure that he died on May 21st, at the age of 36. Although buried in the local cemetery, his skull was later exhumed (with his family’s blessing) for further medical study.
It was eventually donated to the Warren Anatomical Museum at Harvard Medical School, where it remains on display, together with Gage’s inscribed tamping iron. It had been his “constant companion” throughout his life following the accident. The above photograph, originally from the collection of Jack and Beverly Wilgus and now in the Warren Anatomical Museum, shows a recovered Phineas Gage holding his tamping iron.