Passage of an iron bar through the head: 50-year follow-up

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Most neurologists are familiar with the case of Phineas Gage and the consequences of the passage of an iron bar through his head in an accident sustained in 1848. The case may be said to be the one of the beginnings of cognitive neuropsychology [1, 2, 4, 6, 7]. However, only occasional cases of passage of an iron bar through the head with longterm follow-up have been published since Gage [3, 8]. We present the clinical and cognitive findings in a patient over 50 years after an accident in which an iron bar passed through his head. In 1954, at the age of eight, the patient and his friends were playing with iron rods found in a building yard, throwing them as spears. One throw accidentally pierced the patient’s head, passing from the right occipital to the right frontal region: he recalled a piece of brain sticking out on the iron rod in front of his eyes. Following surgical removal of the bar, and a second operation to re-explore the wound, the ‘‘miracle boy’’ (as described in the local press) went on to make an excellent recovery, although he was left with mild weakness and involuntary movements of the left (non-dominant) arm, because of which he attended a special school. However, subsequent social and occupational function was not impaired: he raised a family, learned to drive, and worked in paid employment for a public utility company for many years. Assessed at age 64, some 56 years after his injury, he was able to give a full account of the accident and of his subsequent life. On neurological examination, he had a mild left spastic hemiparesis with some dystonia in the arm. Assessing his cognitive function, his score on the Mini-Mental State Examination was 30/30 and on the Frontal Assessment Battery 15/18 (impaired inhibitory control and motor series). On the Mini-Mental Parkinson [5] he scored 29/32, losing three points for the visual registration test. On neuropsychological assessment Wechsler Adult Intelligence Scale III (WAIS III) showed intellectual function in the average range (full scale IQ 98) with no evidence of intellectual decline (Wechsler Test of Adult Reading predicted full scale IQ 97). Wechsler Adult Intelligence Scale III performance on tests of processing speed was borderline (fifth percentile). On the Wechsler Memory Scale (WMS III) he was borderline on both immediate and delayed memory. Language function was preserved on the Graded Naming Test. Copy of the Rey figure showed difficulties in planning and was slow (both copy and time Bfirst percentile). On the Delis–Kaplan Executive Function System he was impaired on measures of cognitive flexibility, abstract thinking and category formation. Brain imaging (CT) confirmed right occipital and frontal brain damage. Unlike Phineas Gage, our patient suffered no dramatic change in personality following his brain injury, and maintained normal social and occupational function throughout his adult life. On neuropsychological assessment he did show mild cognitive impairments, in processing speed, short-term memory and learning for verbal and visual material, visual spatial planning, and in some aspects of executive functions. Gage’s physician, Dr. Harlow, following his patient up in 1868, some 20 years after the accident, argued that the frontal lobe lesion had caused a loss of planning skills. The neurobehavioral changes, sometimes labelled B. M. Aji E. J. Ghadiali A. Jacob A. J. Larner (&) Cognitive Function Clinic, Walton Centre for Neurology and Neurosurgery, Lower Lane Fazakerley, Liverpool L9 7LJ, UK e-mail: a.larner@thewaltoncentre.nhs.uk