On 13 September, 1848, Phineas Gage, a fit 25-year-old railway-worker from Vermont was packing an explosive charge into a blasting hole. The tamping iron he was using to compress the charge struck rock instead of sand and it ignited the explosive. The resulting explosion drove the iron bar, weighing over 6kg, and 3 ft 7in in length, through Gage’s skull. The bar entered his skull under the left zygomatic arch, passing through the sphenoidal bone, entering the cranium, before passing out through the top of his head (Harlow, 1848). Computerised reassessment of his injuries would suggest that the bar damaged the medial and lateral orbito-frontal, and dorsolateral prefrontal regions of the left frontal lobe (Ratiu, Talos, Haker, et al, 2004). The only observable physical injury that Gage was left with was the loss of his sight in his left eye.
Prior to the injury, Gage was described as having a “well balanced mind . . . a shrewd, smart businessman, very energetic and persistent in executing all his plans of operation”. Twenty years after the accident, in 1868, the local GP John Harlow that attended to his injury previously described Gage’s personality as “radically changed, so decidedly that his friends and acquaintances said ‘he was no longer Gage’” (Harlow, 1868). Gage lived for another 12 years after the accident, and whilst some of the reports about his excess drinking, slovenliness, and disinhibited behaviour are probably over exaggerations and untruths inspired by 20th Century reports of lobotomy patients (Macmillan, 2000), Gage’s post-injury level of functioning was almost definitely reduced. In 1852 Gage went to South America, driving coaches and tending to horses in Chile until 1860. As his health failed he returned to the USA, living in San Francisco, but he never regained his health and after a series of fits, he died on 21 May 1861 (Harlow, 1868).
Interestingly, despite the relative infamy of Phineas Gage’s injury today, there is little evidence to suggest that it influenced any of the early practitioners of psychosurgery (MacMillan, 2002). Gage was not mentioned by Egas Moniz or Walter Freeman during their early presentations and there is nothing to suggest that Gage’s story influenced neurosurgical technique or prompted greater understanding of neuroanatomy. Early neurosurgeons would have been acutely aware of reports of frontal lobe injury or removal due to tumours, and the frontal lobe syndrome was largely described by Brickner (1936), Feuchtwanger (1923), and others. Freeman and Watts, in their 1942 book Psychosurgery, did mention Gage’s injury in some detail but made no suggestion that it was influential, merely of interest (Freeman & Watts, 1942, p. 43-45). The second edition of the book did not contain reference to Gage, suggesting that his influence had dimmed.
Perhaps the significance of Gage lies in his importance to those who were determined to forward the cause of cerebral localisation towards the end of the 19th Century. David Ferrier, a proponent of localisation, used the case in his 1878 lectures on the subject (Neylan, 1999). The story of Gage also illustrated the relationship between damage to the frontal areas of the brain and personality changes. His injury continues to be discussed in the medical literature to this day (For example: Mataro, Jurado, Garcia-Sanchez, et al, 2001; Neylan, 1999; Ratiu, Talos, Haker, et al, 2004).
Brickner, R. M. (1936) Bilateral frontal lobectomy: follow-up report of a case. Archives of Neurology and Psychiatry, 41, 580-585.
Feuchtwanger, E. (1923) Die Funktion des Stirnhirns: Ihre Pathologie und Psychologie. Berlin: Springer.
Freeman, W. & Watts, J. (1942) Psychosurgery. Springfield, IL: Charles C. Thomas.
Harlow, J. M. (1848) Passage of an iron rod through the head. Boston Medical and Surgical Journal, 39, 389-393.
---- (1868) Recovery after severe injury to the head. Publications of the Massachusetts Medical Society, 2, 327-347.
Macmillan, M. (2000) Restoring Phineas Gage: A 150th Retrospective. Journal of the History of the Neurosciences, 9, 46-66.
MacMillan, M. (2002) Gage and Surgery for the Psyche. In An Odd Kind of Fame: Stories of Phineas Gage, pp. 229-253. Cambridge, MA: The MIT Press.
Mataro, M., Jurado, M. A., Garcia-Sanchez, C., et al (2001) Long-term effects of bilateral frontal brain lesion: 60 years after injury with an iron bar. Archives of Neurology, 58, 1139-1142.
Neylan, T. C. (1999) Frontal Lobe Function: Mr. Phineas Gage’s Famous Injury. Journal of Neuropsychiaty and Clinical Neurosciences, 11, 281-283.
Ratiu, P., Talos, I. F., Haker, S., et al (2004) The tale of Phineas Gage, digitally remastered. Journal of Neurotrauma, 21, 637-643.