Frontal lobe function: Mr. Phineas Gage's famous injury.

T next article in our series is a case report written in 1848 by John M. Harlow, M.D., describing his care of Mr. Phineas Gage, who suffered an extreme injury to the frontal cortex. Mr. Gage was employed as a railroad worker in Vermont and fell victim to a freak accident that involved a long metal rod called a tamping iron. This rod was used to pack sand over an explosive charge, which was used to excavate rock for the building of railroad lines. In this instance the charge exploded unexpectedly and propelled the 3-foot-long rod through Mr. Gage’s head. The 13-pound rod entered the left cheek and exited the midline of the skull anterior to the bregma, resulting in severe injury to his left and, in all probability, his right prefrontal cortex. The Gage case, one of the most famous and influential in neuropsychiatry, played a crucial role in the discovery of behavioral syndromes resulting from frontal lobe dysfunction. Readers interested in detailed accounts of the case and its historical context can find excellent reviews by MacMillan and Barker. The case report was initially met with disbelief because it was thought to be impossible for a human to survive a brain injury of such magnitude. Beyond the astonishing fact of Mr. Gage’s survival was the description of his ability to walk immediately after the event, communicate sensibly, and remain lucid though most of the period following the injury. This fact attracted the attention of P. T. Barnum, who employed Mr. Gage for a short period following his recovery. Dr. Henry J. Bigelow, a prominent professor of surgery at Harvard Medical School, examined Mr. Gage after Harlow’s report and failed to note the changes in Gage’s behavior. He proclaimed that Gage had no demonstrable sequelae of the injury. Dr. Bigelow and others used the Gage case as a persuasive argument against the field of phrenology, which was the only prominent discipline at the time that considered the possibility of localization of brain function. Yet, as the reader will note, there are several suggestions in the original report that Mr. Gage’s behavior had changed. Dr. Harlow promised to report the mental manifestations of the injury in a subsequent communication. He did not produce this report until 20 years later, when he described a pervasive change in personality and character in the Journal of the Massachusetts Medical Society, a periodical with very limited circulation. In this report, Harlow described the following: