"Phineas Gage had a hole in his head, and ev'ryone knew that he oughta be dead. Was it fate or blind luck, though it never came clear, kept keepin' on year after year"

PHINEAS GAGE (1823-1860) is one of the earliest documented cases of severe brain injury. Gage is the index case of an individual who suffered major personality changes after brain trauma. As such, he is a legend in the annals of neurology, which is largely based on the study of brain-damaged patients.

Gage was foreman of a crew of railroad construction workers who were excavating rocks to make way for the railroad track. This involved drilling holes deep into the rock and filling them with dynamite. A fuse was then inserted, and the entrance to the hole plugged with sand, so that the force of the explosion would be directed into the boulder. This was done with a crow bar-like tool called a tamping iron.

On 13th September, 1848, 25-year-old Gage and his crew were working on the Rutland and Burlington Railroad near Cavendish in Vermont. Gage was preparing for an explosion by compacting a bore with explosive powder using a tamping iron. While he was doing this, a spark from the tamping iron ignited the powder, causing the iron to be propelled at high speed straight through his skull. It entered under the left cheek bone and exited through the top of the head, and was later recovered some 30 yards from the site of the accident.

John Martin Harlow, the doctor who attended to him, later noted that the tamping iron was found "several rods [1 rod= 5.02m] behind him, where it was afterward picked up by his men smeared with blood and brain". The tamping iron was 3 ft. 8 inches in length and 1.25 inches in diameter at one end, not 1.25 inches in circumference, as reported in the newspaper report on the left. It tapered at one end, over a distance of about 1 ft., to a blunt end 0.25 inches in diameter, and weighed more than 6 kg.3



Whether or not Gage lost consciousness is not known, but, remarkably, he was conscious and able to walk within minutes of the accident. He was then seated in an oxcart, on which he was transported three-quarters of a mile to the boarding house where he was staying. Here, he was attended to by Harlow, the local physician. At the boarding house, Harlow cleaned Gage's wounds by removing small fragments of bone, and replaced some of the larger skull fragments that remained attached but had been displaced by the tamping iron. He then closed the larger wound at the top of Gauge's head with adhesive straps, and covered the opening with a wet compress. Gage's wounds were not treated surgically, but were instead left open to drain into the dressings.

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