Despite a very widely held belief to the contrary, the contribution of the Phineas Gage case to the development of psychosurgery, especially to the operations developed in the 1930s by Egas Moniz in Portugal, and Walter Freeman and James Watts in the United States, was very slight.  Some variants of this belief also link Gage to the surgical procedures that Burckhardt and Puusepp used on psychiatric patients in the late 1800s and early 1900s, but, however phrased, the belief is completely erroneous.  There is simply no evidence that any of these operations were deliberately designed to produce the kinds of changes in Gage that were caused by his accident, nor that knowledge of Gage's fate formed part of the rationale for them.  The story is a rather complicated one and these brief remarks are best considered against the references given below, and especially with the more detailed treatment of this specific issue in my An Odd Kind of Fame: Stories of Phineas Gage.

Surgery for what was then known as insanity came into existence shortly after the first operations on the brain for the removal of tumours. The earliest were conducted for relatively circumscribed symptoms, for example, visual hallucinations caused by a piece of fractured skull bone pressing into the brain. The Swiss psychiatrist Burckhardt went further and tried to cure or at least moderate the symptoms of severely disturbed patients whom we would today probably diagnose as cases of one or other of the schizophrenias. All six of Burckhardt's operations were based on trying to prevent the patients' hallucinatory sensations causing violent and aggressive movements. He tried to do this by cutting a 'trench' into the brain between its sensory and motor parts. Despite this simple-minded view, Burckhardt's rationale was based on his very considerable knowledge of the localisation of different sensory and motor functions in different parts of the brain.

However, only one of Burckhardt's six operations involved the frontal lobes.  In his words, "I looked for the point of attack not between the central [motor] and sensory convolutions but between them and the forebrain because dementia paralytica brings with it a whole number of psychic symptoms that should, in my opinion be localised in the forebrain."  But, Burckhardt did not mention Gage in his reasons for selecting that particular point of attack.  Nor did he draw on his case elsewhere.

Neither is there any reference to Gage in the rationale that Moniz set out for the operation he called leucotomy and which Freeman and Watts renamed lobotomy.  Gage does not seem to be discussed in any of Freeman's many works on brain surgery before he and Watts mentioned Gage in passing in the introduction to the first edition of their 1942 work on psychosurgery.  That reference is only to Gage as the most famous case in which injury to the frontal lobes caused 'mental symptoms.' However, those symptoms are not described and even this slight and passing mention is absent from the second edition of 1950.

Freeman did bring Gage into a press conference on 21st. November 1936, a few hours before he presented the paper on the results of the first lobotomies that he and Watts had conducted.  His unpublished account of the conference shows clearly that he did so solely to play for time and avoid giving one of the journalists the details he had already given another.  As he said, "with diversion and delaying tactics I escaped."  How irrelevant Gage was, even then, is shown by the fact that not one of the five stories that emerged from that conference, or slightly later, mentioned Gage (see Chapter 11 of An Odd Kind of Fame).

We know that one of the facts that led Moniz to consider operating in the frontal areas was what he considered the minimal effects of a related operation on Joe A, a patient of Brickner's.  Joe A. was almost certainly going to die from a massive tumour of both frontal lobes, and virtually the whole of both his frontal lobes were removed.  Moniz was much influenced by Brickner's saying that although Joe A.'s behaviour was less restrained after the operation, his mental processes were affected only quantitatively, and not qualitatively.

At the symposium at which he heard about Joe A., Moniz also heard of the incidental effect that bilateral frontal lobectomy had had on the toleration of frustration by the two chimpanzees used in some learning experiments conducted by Fulton and Jacobsen.  After the operation, the extreme frustration of one of the two chimpanzee subjects disappeared.  The observation prompted Moniz to ask if similar operations might relieve anxiety states in humans.  Although he tended to play down the importance of this influence relative to that of Joe A., Moniz's first operations were conducted within months of the symposium.  Once again, Gage did not figure in the discussions of his question at the symposium.

At the 1930 meeting of the Association for Research in Nervous and Mental Disease the effects of radical brain surgery on a number of patients, including Joe A., was first discussed.  Only one questioner raised the relevance of Gage to the kinds of changes seen after frontal lobe removal, and he was told very promptly that no comparison was possible.  Fifteen years later, at the 1947 meeting when all those who had been present in 1930 again attended, Gage was not mentioned by anyone.

Further reading:

Pressman, J. D. (1998). Last Resort: Psychosurgery and the Limits of Medicine. Cambridge: Cambridge University Press.

Valenstein, E. S. (1986). Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness. New York: Basic Books.