Review - An Odd Kind of Fame
Stories of Phineas Gage
by Malcolm Macmillan
MIT Press, 2000
Review by James R. Beebe
Aug 7th 2001 (Volume 5, Issue 32)

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