Malcolm Macmillan’s history of the case of Phineas Gage is an impressive
achievement. He has succeeded in writing the definitive history of one
of the most widely discussed cases in the history of neuroscience and psychology.

Phineas Gage was a railroad foreman who, in 1848, survived a very dramatic
brain injury. While Gage was packing down a charge of explosive powder
in preparation for a blast, the powder accidentally exploded and sent a
tamping iron through Gage’s head. The iron (3’7″ long, 13 1/4 lbs., 1 1/4″
inches in diameter through most of its length, and tapering to 1/4″ inch
at one end) entered Gage’s head just under his left eye, passed through
his left frontal lobe, emerged through the top of his head (a bit left
of center), and landed more than twenty meters behind him.

Not only did Gage miraculously survive the initial blast, but he never
lost consciousness and was able to walk to the nearest road, climb into
an oxcart and support himself while being driven into town. When the first
physician found Gage sitting in a chair in front of a tavern, a thoroughly
lucid Gage famously said to him, “Doctor, here is business enough for you.”
The most striking thing about Gage’s injury is that he remained completely
rational in the hours immediately following the accident and was able to
explain to the doctors exactly how the accident occurred. The case is also
interesting because of the changes in Gage’s personality that resulted.
Before the accident, Gage was described as a shrewd and capable foreman,
well-liked by the men he supervised. After the accident Gage became fitful,
capricious, impatient, vulgar, and unable to perform his former duties.
Although he lived for more than eleven years after the accident and was
able to hold down a job for most of that time, his friends said he was
“no longer Gage.”

An Odd Kind of Fame is the first and only comprehensive study
of Gage’s injury and its influence on the history of medicine, neuroscience
and psychology. Macmillan’s history begins with a careful analysis of the
published reports and case notes written by the physicians who treated
Gage immediately after the accident. Macmillan meticulously sifts through
the reports to distill the only accounts of Gage’s condition that are supported
by solid evidence. It turns out that very few of the important details
are known. There were no comprehensive psychological assessments (it was,
after all, 1848) and even the physical descriptions of the entry and exit
holes in Gage’s head are vague and far less informative that we would like.
Although defenders of a wide variety of incompatible theories see in Gage’s
supposed personality changes proof for their theories, Macmillan’s careful
study of the available documents reveals that “The lack of reasonably detailed
knowledge about which parts of Phineas’s brain were injured and about how
his mental processes were changed means that we cannot draw other than
the most general conclusions about brain-behavior relations from his case”
(p. 3). In other words, any time you see a researcher citing Gage as evidence
in support of some pet theory, be skeptical.

Since the actual medical notes of Gage’s physicians contain very little
information, most of Macmillan’s book is taken up with the history of discussion
about Gage. The amount and precision of historical detail included in these
sections is astounding. Macmillan examines all of the early reports of
the case in newspapers and medical journals and describes in detail the
medical treatment Gage received at the hands of John Martyn Harlow. Macmillan
cites every nineteenth- and early twentieth-century mention of Gage by
neuroscientists and psychologists and assesses the role (if any) Gage played
in the localization of brain functions, brain surgery and psychosurgery
(e.g., lobotomy). Macmillan also carefully reviews what can be known about
the precise trajectory of the tamping iron through Gage’s head, including
recent attempts at explanation based upon CT scans of Gage’s skull.

Macmillan’s history serves the much needed function of setting the record
straight. Macmillan shows that the majority of mentions of Gage in both
the popular and scientific press during the last 150 years get the historical
facts wrong and very often draw conclusions about the case that are not
warranted by the available evidence. Macmillan finds that most accounts
of the Gage case err because they are based upon hearsay and legend rather
than the first-hand reports of Harlow, Gage’s attending physician. The
amount of misinformation Macmillan unearths is unsettling-some scientific
papers report that Gage lived for twenty years with the tamping iron still
stuck in his head. Macmillan shows that even some widely respected contemporary
scholars, such as Hanna and Antonio Damasio, are not above using the Gage
case in ways that are not warranted by the evidence.

Macmillan’s research ranges far beyond the purely medical or scientific
aspects of the case. For example, he delves into details of nineteenth-century
New England labor practices in order illuminate the nature of Gage’s employment
and even traces the family histories of both Gage and John Martyn Harlow.
Macmillan’s zealous quest for the truth about Gage carries him to lengths
that are at times rather humorous. He surveys many works of fiction that
have been inspired by Gage and in each case argues for which medical sources
the fiction writer relied upon. He even tries (somewhat unsuccessfully)
to decipher the lyrics to recent rock songs in which Gage’s name appears.
Leaving no stone unturned, Macmillan also argues against claims made on
the 1998 website of descendants of Edward Higginson Williams, the first
physician to attend Gage. The family has long claimed that Williams administered
all of the medical treatment to Gage but that Dr. Harlow, the second physician
who attended Gage, unfairly lied about his role in an attempt to steal
the credit.

Macmillan covers all of the potentially relevant considerations surrounding
the Gage case with indefatigable determination. If the 380 pages of text
do not adequately slake your historical thirst about the case, there are
120 pages of appendices full of pictures and photocopies of historical
documents related to the case and 40 pages of references.

An Odd Kind of Fame is not light reading. It is a remarkable
piece of historical research. I do not recommend the book to anyone who
would like a simple overview of the Gage case. Such readers would be better
served by reading Macmillan’s brief account of the case in “Phineas Gage:
A Case for All Reasons” (In C. Code, C.-W. Wallesch, A.-R. Lecours, and
Y. Joanette, eds.,
Classic Cases in Neuropsychology (pp. 243-262),
1996, London: Erlbaum). However, the book is well-suited for anyone doing
research on the history of the localization of brain function or the history
of the neurosciences generally. The book will also prove very useful to
anyone wishing to argue against any interlocutor who uses Gage as evidence
for some theory. Chances are that the case will provide no evidence whatsoever
for the interlocutor’s position.

Macmillan’s book is more like a reference work than its cover suggests.
Although there are very few people who would benefit from sitting down
and reading An Odd Kind of Fame straight through, works such as
this play a very important role in any branch of scholarship. Macmillan
has cleared up much misinformation and has issued the definitive statement
on the case. It will be recognized as an authoritative and valuable resource
for many years to come.

© 2001 James Beebe

James Beebe is currently a doctoral
candidate at Saint Louis University and am working on issues in naturalized
epistemology and cognitive science. He will begin teaching at Louisiana
State University this fall.

Categories: General, Philosophical