Abstract
The survival of 25-year-old Phineas P. Gage after major bifrontal brain trauma in 1848 was miraculous. He regained full independence; however, significant personality/character alterations marked his 12½-year survival. We evaluated 10 men, 15–41 years of age, from 14 to 108 months after bifrontal brain injury. Neurologically, all could leave the hospital for independent home living. Formal neuropsychological testing and serial neurological assessments were obtained to define the patients' recovery. Initially, they returned to either their former school grade or their former employment level or completed vocational training and appeared to have a “good outcome.” Only one had significant cognitive testing defects. Subacute to chronic magnetic resonance images demonstrated bifrontal injury in all, with additional temporal injuries in four. Notably, anterograde history with self-assessment and “significant-other” interviews revealed varying degrees of personality change unrelated to cognitive impairment in these patients. Thus, more than 140 years after Phineas Gage's accident, postinjury personality assessment by clinical observation still remains the most sensitive indicator of bifrontal trauma dysfunction. The persistent observations will serve to direct the rehabilitation for these patients.