The earliest description of the frontal lobe syndrome in an Edgar Allan Poe tale

On Sept 13, 1848, a meter-long iron spike impaled the skull of railroad construction foreman Phineas Gage. Gage remarkably not only survived, but, after a period of recovery, was able to walk, move his hands, speak normally, and his cognition appears not to have been grossly affected. The mishap captured the public attention: it was reported in the Free Union Soil (Ludlow, VT) and in a medical journal by J. Harlow, one of Gage's physicians [1]. It had typically thought that Gage's personality was profoundly changed by the injury, and his case had become a paradigmatic example of localized function in the brain. However, recently McMillan [2] has shown that there is little if no information about a change in Gage's personality contemporaneous to the accident and its aftermath.

Some years ago it was noted [3] that the Edgar Allan Poe (1809-1849) story “The Business Man” published posthumously in 1850 might very well be a description of the frontal lobe syndrome predating Gage's accident, indeed incorporating features described in the 1990's of pediatric frontal lobe patients [4]. The unnamed protagonist of the story describes himself interestingly from the outset: “I am a businessman. I am a methodical man. Method is the thing, after all. But there are no people I more heartily despise than your eccentric fools who prate about method without understanding it; attending strictly to its letter, and violating its spirit.” He credits his sense of order with a formative childhood accident: “A good-hearted old Irish nurse (whom I shall not forget in my will) took me up one day by the heels, when I was making more noise than was necessary, and swinging me round two or three times … and then knocked my head into a cocked hat against the bedpost. This, I say, decided my fate, and made my fortune. A bump arose at once on my sinciput [forehead], and turned out to be as pretty an organ of order as one shall see on a summer's day.”

This businessman cannot even keep a job, lasting in most of the eight occupations listed in the story for a few months or less, typically quitting or being fired after a squabble with employers whom he feels do not appreciate his sense of order. The jobs are as flawed as the entrepreneur who perpetrates them; one is in the “Assault-and-Battery business,” and he is jailed once for his enterprising actions. Aspects of the frontal-lobe syndrome suffered by the businessman include his obsessive interest and devotion to order, flat affect, and poor functioning in society. Characteristics seen in patients with pediatric injuries such as antisocial behavior—e.g., violent occupations and incarceration—and no insight into the thinking processes of others, are also noted.

Recently we have noticed that not only was Poe's story “The Business Man” published during his life (Broadway Journal 1845 (August, 2); 2: 49–52), but an earlier version of the story entitled “Peter Pendulum, The Business Man” was published in February of 1840 [5]—a remarkable eight years before Gage's accident. The earlier version is six paragraphs shorter than the later one—the protagonist has and loses only four jobs. As well, the name of the protagonist is removed from the title and text in the later version. But the frontal lobe injury and the protagonist's “frontal lobe” personality and behavior (including violent occupations and incarceration) are all there in the original version.

Poe was a jack of many literary trades: master of prose, inspired poet and fearsome literary critic. Perhaps the greatest and most original American writer ever, Poe also pioneered the modern detective story and horror story. But Poe was also interested in science. For example, in his prose poem Eureka (1848), Poe made important points about resolving Olber's paradox in astrophysics about why the night sky is dark: Poe appreciated that a finite universe is needed for the night sky to be dark.

How could Poe have known about the frontal lobe syndrome, something that required the dramatic event of Gage's injury for trained physicians and scientists to appreciate, years before Gage's accident? Further, Poe also seems to understand the severity of the syndrome when it starts in childhood. Presumably, Poe must have used his keen observatory and deductive powers to link a frontal lobe injury to a change in behavior in someone he knew from childhood. The titular businessman mentions in his diatribe that, “In biography the truth is everything – and in autobiography, especially so …” But the question of who the inspiration is for the brain-injured nuisance of Poe's story is destined to remain buried within; like all great art, it also leaves us with nuances and questions evermore to ponder.

Poe's diagnostic coup remains. His 1840 piece is the earliest, and still one of the finest and most gripping descriptions of the frontal lobe syndrome put into print.

Declaration of Interest: Neither author has any financial or other conflicts.