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Colourised image of Phineas Gage holding the iron rod

How did Phineas Gage survive an iron rod shooting through his brain?

Despite losing a considerable portion of his left frontal lobe in a catastrophic accident, Phineas Gage lived for twelve years after his mishap.

Image: Colourised studio portrait of Phineas Gage holding the iron rod CC BY-SA 3.0

Edward H. Williams rushed to the hotel in the town of Cavendish, Vermont. The physician and railroad executive had been told to come quickly to attend to a severely injured employee. When he arrived, he found the man, Phineas Gage, sitting in a chair outside the hotel. Gage had a large hole in his cheek and another in the top of his head. ‘Doctor,’ Gage said to Williams, ‘here is business enough for you.’ Shortly after, Gage rose from his chair and vomited a large quantity of blood. To Williams’ astonishment, a piece of the man’s brain fell out of the hole in his head and flopped on the floor. How on earth was he still alive?

A bizarre accident

Phineas Gage worked as a blasting foreman. His job was to pack holes with gunpowder and sand and then ignite it to blast rock out of the way of the advancing railway. To ensure the full force of a blast was directed at the rock, Gage used a four-foot-long iron rod shaped like a javelin to tamp the powder and sand down.

On the afternoon of 13th September 1848, Gage was tamping sand into a hole as he and his team prepared the roadway for the Rutland and Burlington Railroad. When he turned his head to talk to one of his men, the iron rod made contact with the rock and sparked, igniting the powder. The resulting explosion sent the rod shooting out of the hole, up through Gage’s left cheek and out through the top of his head, landing 80 feet away ‘smeared in blood and brain’.

As his horrified team looked on, Gage collapsed on his back, convulsed several times and then was still. Remarkably, when his men ran over to him, Gage wasn’t just still very much alive, but also well enough to walk unassisted to an oxcart that took him into town. The blood-soaked foreman was placed in a chair outside the hotel while one of his men went to fetch Williams.

An extraordinary survival

At first, Williams didn’t believe Gage’s story. It didn’t seem possible that a man could survive such a horrific injury. Cavendish’s resident doctor, John Harlow, arrived shortly afterwards. Harlow had known Gage before the accident and, like Williams, he was initially sceptical. The fact that Gage had not only survived having an iron rod shot through his head but was also talking to the two physicians defied logic.

Harlow and Williams set about treating his injury. They managed to seal up both holes in his head and then spent the next few days clearing away necrotic tissue and pus that leaked from the wounds. Neither physician expected Gage to live, especially once he lapsed into a semi-coma twelve days after sustaining his injury. Remarkably, not only did Gage survive, but 24 days after the accident, he was up and walking about. It seemed nothing short of a miracle.

Despite losing a considerable portion of his left frontal lobe, Gage lived for twelve years after his accident. Observers, among them Dr. Harlow, noted his personality changed considerably. Before the accident he had been an affable, likeable man; afterwards, he swore a lot, was impatient with his friends and colleagues, dismissive of authority and prone to violent mood swings. Those who knew him said he was ‘no longer Gage’. He was unable to keep his previous job, so went to work as a coach driver in Chile.

Furthering our knowledge of neuroscience

Gage was brought to the attention of the New York medical establishment. The change in Gage’s personality led neuroscientists to realise, for the first time, that severe trauma inflicted on the frontal lobes of the brain led to changes in the way a person acted and behaved. Gage continues to this day to be a case study for doctors studying neurology, psychology and neuroscience.

In later life, Gage developed severe epilepsy. He had moved back to the USA from Chile to work on a farm in California, but lost his job when the seizures became too frequent, rendering him incapable of working. He died of a seizure on 21st May 1860 at 36.

Phineas Gage’s skull

With the permission of his mother, Gage’s skull was exhumed and sent to Dr. Harlow for further study, along with the iron rod that Gage had later had inscribed with the details of his accident. Both now reside at the Warren Anatomical Museum at Harvard Medical School.

Gage’s skull is a remarkable object and is key to understanding how he managed to survive such a devastating injury. CT scans show that the hole created by the tamping iron as it passed through the sphenoidal sinus - which sits at the base of the cranium housing the brain - is half the diameter of the rod. This means that as the rod shot through Gage’s skull, it hinged open to accommodate it, resulting in a fracture down the front of the skull from the large exit wound to the left eye socket. This opening prevented a significant amount of further damage which, had it not occurred, would have probably killed Gage instantly.

The exit wound itself shows that the rod passed through the left frontal lobe of Gage’s brain. It is estimated that Gage lost a small amount of his cerebral cortex, which led to changes in his personality. The reason Gage did not die of his injury is because the fluid that would normally build up in a person’s skull after a severe brain injury, causing inflammation, infection and haemorrhage, was in Gage’s case able to drain away through the hole in his cheek, relieving the pressure.

Today, the skull and tamping iron of Phineas Gage are two of the Warren Anatomical Museum’s most popular exhibits. To those who see the huge hole in the top of the skull, it seems impossible that anyone could have survived such an injury. That Phineas Gage not only survived but lived to tell the tale is remarkable. His contribution to our understanding of how brain injuries change personality has been invaluable to the study of neuroscience.