The next article in our series is a case report written in 1848 by John M. Harlow, M.D.,1 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,2 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 MacMillan3 and Barker.4
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.5 In this report, Harlow described the following:
His contractors, who regarded him as the most efficient and capable foreman in their employ previous to his injury, considered the change in his mind so marked that they could not give him his place again. He is 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 operation, which are no sooner arranged than they are abandoned in turn for others appearing more feasible. In this regard, his mind was radically changed, so decidedly that his friends and acquaintances said he was "no longer Gage."
Dr. David Ferrier, who was an early champion for the theory of cerebral localization, discovered Harlow's second report and used it as the highlight of his famous 1878 Goulstonian lectures,6 which described in detail the focal mapping of the cerebral function. The frontal lobes were considered to be involved in higher executive function. Dr. Ferrier cited the Gage case as a primary example of how frontal lobe injury can result in changes of personality that are not demonstrable by sensory and motor exam. The Gage case is now one of the most frequently cited articles from nineteenth-century medical literature.
Phineas Gage died in San Francisco, apparently from complications of seizures, 12 years after his injury. Dr. Harlow obtained consent from Mr. Gage's family to obtain the skull and tamping iron, which are now in the collection of the Warren Anatomic Museum at Harvard University.