Aug 21 2012

Phineas Gage Revisited

Phineas Gage

It is always amazing to see people survive and recover from massive brain trauma. The first medically described case of this is the now famous Phineas Gage(whose fame is probably at least partly due to the fact that his name is so memorable – very Dickensian). Gage was a railroad worker who was injured when he was tamping down explosives with an iron rod. A spark set off the explosives, sending the rod up and through his skull like a bullet. He somehow survived and remained conscious long enough to make it to help. He later was noted to have a significantly changed personality – disinhibited, profane, and restless with an inability to plan and control his behavior.  He suffered from seizures following the injury, probably an infection, and died about 12 years later.

Recently we have a similar case from Brazil – Eduardo Leite, a construction worker, was struck by a metal rod which fell from several stories up. The rod pierced his hard hat, went through the top of his skull on the right, and then exited between his eyes. Like Gage, Leite remained conscious, and was able to tell the emergency workers the story of what happened.

Eduardo Leite

Leite went through a five hour surgery to remove the rod, which had to be pulled through in the direction it pierced the skull. According to report Leite is doing well and will likely recover with few deficits.

The image is quite impressive, and it may seem amazing that anyone could survive such an injury to the brain, let alone with few deficits. However, a little knowledge of brain anatomy explains why this is possible.

From the images it appears that the rod went through the right frontal lobe. This is the most redundant part of the brain. Much of the function of the far frontal lobes is bilaterally redundant, meaning that either side (left or right) can function fine by itself. There are some lateralized functions there, like the frontal eye fields which control eye gaze – the right frontal eye fields will move the eyes to the left. But those structures could easily have been spared.

When neurosurgeons have to place an instrument through the brain, they generally do so through the right (non-dominant for most people) frontal lobe. When placing a ventricular shunt, for example, to drain fluid and reduce pressure build up inside the brain, they will place the tube through the right frontal lobe.

Leite’s injury, therefore, could not have been more perfectly placed in order to minimize neurological damage. From that point of view he was lucky – of course it’s not very lucky to have a metal rod fall through your head.

If you look at the Gage image you can see that the injury was more in the midline, and likely damaged both frontal lobes, hence the significant personality change.

Unlike Gage, Leite is also likely to do well long term. He may develop a seizure disorder from the injury, but this can be managed with anti-seizure medication. His recovery can be monitored with CT scans and MRI scans, and any rebleeding or complication can be treated. If he develops an infection that can be cleared up with antibiotics.

Of course, these cases are uncommon. Most people who have a metal rod shoot through their skull and brain either don’t survive or have significant deficits. The unlikely, however, will happen every now and then, given enough opportunity. It seems every few years a case like this crops up in the media, with impressive images of projectiles through the skull and amazing stories of how the victim survived with remarkably few deficits. With almost 7 billion people in the world, even very unlikely events will happen on a regular basis, and thanks to mass media and the internet you are likely to hear about it.

19 responses so far

19 thoughts on “Phineas Gage Revisited”

  1. HHC says:

    Unfortunately, Gage did not have the options provided by worker’s compensation laws. Most laws were enacted in the States after the 1917 Supreme Court case involving due process for employers. The test case concerned the New York Railway.

  2. Elias says:

    I’m wondering about the possibility of potential damage caused by using follow-up MRI’s. If any tiny flakes of steel rubbed off the rod during penetration, could MRI move them in an unpredictable and dangerous manner?

  3. Pavel says:

    Wouldn’t this be supportive of the camp that argues that the brain is quite well compartmentalized? I hear arguments that the “modular brain” paradigm is rather outdated and that the brain functions are much more distributed across the regions than we have assumed. The Leite case suggests not, but it’s hard to imagine that as much efficient as our brain is, it’ll be wasting so much cortical real estate on a few mundane functions.

  4. BillyJoe7 says:

    A good description of why miraculous happenings are not miraculous at all. It is possible to drive a thick rod through the brain and survive with almost no disability. It might be a million to one chance but, given a million chances, it’s going to happen. It’s just statistics.

  5. nybgrus says:

    I was reasonably certain that I had recalled the change in Gage’s personality to be from a kind, shrewd, professional man to a profane, angry, and disinhibited one… not increasing calm and apathy. But it has been a long time since my undergrad psych class so I looked it up. According to Harlow’s first hand accounts from 1868:

    [Gage was] fitful, irreverent, indulging at times in the grossest profanity (which was not previously his custom), manifesting but little deference for his fellows, impatient of restraint or advice when it conflicts with his desires, at times pertinaciously obstinate, yet capricious and vacillating, devising many plans of future operations, which are no sooner arranged than they are abandoned in turn for others appearing more feasible. A child in his intellectual capacity and manifestations, he has the animal passions of a strong man. Previous to his injury, although untrained in the schools, he possessed a well-balanced mind, and was looked upon by those who knew him as a shrewd, smart businessman, very energetic and persistent in executing all his plans of operation. In this regard his mind was radically changed, so decidedly that his friends and acquaintances said he was ‘no longer Gage’.

    I recall learning that point as a disinhibition of the frontal lobes’ governance of the limbic system – in this case by mechanical severance of the connections.

    A minor point, no doubt, but it jumped out at me as I read.

    And yes, as BJ said – people are significance junkies. Something that has a 1 in a billion chance of happening will still happen 7 times with how many people there are. That doesn’t mean anything significant, but people will marvel at the low likelihood and assume there must be a “reason” for it (usually religious in nature, of course).

  6. Jared Olsen says:

    the rod is obviously re-bar, but what is the orange stuff around the entry and exit? Brain tissue(!) or artifacts of the imaging process?

  7. BillyJoe7 says:

    I suspect that it is subcutaeous fat not completely “subtracted” from the image (which attempts to show only the rod and the skull bones). Other bits can be seen within the eye sockets and over the jaw.

  8. ConspicuousCarl says:

    nybgrus on 21 Aug 2012 at 6:21 pm
    Something that has a 1 in a billion chance of happening will still happen 7 times with how many people there are.

    Or as Penn Jillette likes to say in response to the “You’re one in a million” cliche… “There are EIGHT PEOPLE JUST LIKE ME in New York?”

  9. banyan says:

    I wish we could see more details of the damage that occurred to former Rep. Gabrielle Giffords. I remember hearing news reports of where she was shot and thinking that she could not possibly survive.

  10. nybgrus – thanks. There are two basic frontal lobe damage syndromes – apathetic and disinhibited. I remembered Gage as an apathetic syndrome, but it seems he was disinhibited by that description.

    I have checked out a few references and will make the appropriate corrections.

  11. daedalus2u says:

    Most rebar these days is coated with corrosion inhibitors, usually something like epoxy paint. That is the green color that most rebar you see in highway repair. Usually that is done at the rebar factory because it is cheaper and protects the rebar during shipping and storage. This happened at a construction site, so the rebar would be new, and even if it was not coated would very likely not have flakes of rust on it.

    Iron oxide comes in several forms. The usual red rust is Fe2O3 which is non-magnetic. Magnetite is Fe3O4 and is black, but usually doesn’t form via corrosion from elemental iron in air. Thick and flaky rust is usually due to electrolytic corrosion, where the surface is Fe2O3 but there can be lower oxides like FeO and Fe3O4 in layers that are protected from the air. Flaky rust takes a long time to form, and would be highly undesirable in rebar because then the bond between the rebar and the concrete would be limited to the bonding of the rust layer which is quite weak. Rebar that did have flaky rust on it would not be suitable for use in concrete. But then, maybe that is why someone threw it off the 5th floor.

    I think it is doubtful that there was iron oxide that could become detached on the rebar. If it did, the surgeons would really want to make sure they got it all. I think that any pieces big enough to be a problem for MRI would be big enough to see on x-ray and they would do many x-rays to make sure they got everything and that they fixed the vasculature. Probably lots of MRIs too. Probably lots of x-rays with IV contrast fluid to make sure that there was adequate perfusion of blood and CSF.

  12. Xplodyncow says:

    What are some good resources for someone with no medical training to learn more about the brain? I’m fascinated by this stuff, but when terms like “dorsolateral prefrontal cortex” or “up-regulation/down-regulation” or “ventral tegmental area” or “hypothalamus-pituitary-adrenal axis” or “anterior cingulate cortex” are tossed around without explanation, I get lost.

  13. ccbowers says:


    I had the very same reaction before I read your comments, and the later correction in the post. I then started to wonder if the Phineas Gage ‘story’, taught in many intro college classes that have to do with the brain, had a bit of added myth to make a better narrative.

    After looking into it a bit, it turns out the story I was taught (several times in different classes) was mostly accurate, but on at least one occasion I remember learning that he became an alcoholic, abusive, and unable to keep a job, but it turns out that there is little evidence for those things and they appear to be exaggerations at best.

  14. nybgrus says:

    @Dr. Novella – My pleasure

    @ccbowers – Especially with stories this old, one can be safe to assume there will be exaggerations and stories made up. However, the basic gist seems to be that he became rather disinhibited and angry… which I recall from my psychology course as part of the evidence that the frontal lobes acts as a higher level executive control over the more primitive parts of the brain. That was 18 years ago that I took that course, and I actually don’t recall revisiting it specifically later on so the details were fuzzy but the broad brush strokes of the Gage story still stayed embedded deep in my brain 😉

  15. ksadrieh says:

    The brain is amazing and fortunately has plasticity and redundancy. Nothing is more striking than seeing a post-hemispherectomy or post large lobectomy patient regain function (certainly not all do). In the case of patients that had a malformation, migrational defect, or lesional epilepsy, you can argue that the tissue removed wasn’t doing much in the first place. But seeing post-traumatic recovery gives a new appreciation of the flexibility of our nervous system.

  16. Natalia says:

    This image really scares, and by seeing it it doesn’t seems that there are any chances of survival. But really thanks to the team who has made it possible by removing that metal rod successfully & thus saves the worker. I have come across with few books based on neurology which does states the basis of Neurologic Diagnosis. This very problem do simply relates with one in that eBook. For more info, you can check out this.

  17. Calli Arcale says:

    It is important to note that there is actually very little first-hand information about how Phineas Gage behaved after his accident, and that there is reason to be a least a little skeptical of Dr Harlow’s 1868 account — notably, it was published twenty years after he last examined Gage (and eight years after Gage’s death), and apart from hearsay, his information is confined to the time immediately following the accident, when Gage suffered from seizures. The pain he was enduring could make anyone irritable, and of course he also had to learn how to cope with having only one eye and likely also some lost function in the brain. A physician who examined him a year later found nothing unusual in his behavior, and he was able to hold down jobs afterwards. The combination of the grotesque nature of the injury and the fact that he was subsequently exhibted by P. T. Barnum and others (with his tamping iron) was probably a major influence on the progressively more extreme versions of the story.

  18. neuronerd says:

    So the claim that Phineas Gage’s social skills were profoundly affected is mostly myth. See the recent article by Van Horn et al. here:

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