An Odd Kind of Fame: Stories of Phineas Gage (review)

Malcolm Macmillan. An Odd Kind of Fame: Stories of Phineas Gage. Cambridge: MIT Press, 2000. xiii + 562 pp. Ill. $39.95 (0-262-13363-6).

It is perhaps appropriate that "the American crowbar case" is a misnomer, because there is little about most of its history that is fully accurate, including its popular name. We do know that a 3.6 ft. tamping iron (for setting blasting powder) shot upward through the left face and frontal lobe of one Phineas Gage (?1823-60) at a railroad construction site near Cavendish, Vermont, on 13 September 1848. His subsequent survival for eleven and a half years would be remarkable even in our own time, but the real interest in the case has always been its implications for our understanding of frontal lobe function. However, there are two basic problems. First, although Gage's skull was exhumed after he was buried, and it still resides in the Warren Museum at Harvard University, the brain was never examined. Second, the descriptions of his personality and behavior after the injury are simply inadequate. Of course, the latter difficulty has seldom stopped partisans of differing persuasions about cerebral localization from citing the case to their own advantage.

Until the publication of An Odd Kind of Fame, most of the scientific and historical literature about Gage has been scattered and fragmentary. Among a small number of well-done but limited studies, one of the best was published by Frederick Barker II a few years ago. ¹ Now, with the availability of this book, it seems unlikely that any more factual information about Gage will ever emerge. Malcolm Macmillan's ingenuity and industry in searching out potential sources bespeaks a genuine obsession with his subject, but his obsession is well leavened by his scholarly skepticism. In the end, he concludes that we have only one source of reliable information about Gage--namely, his treating physician, John Martyn Harlow (1819-1907), who published reports of the case in 1848 and 1868. Macmillan shows convincingly that all other reports either derive from Harlow, or are inaccurate to the extent that they do not. Unfortunately, even Harlow's extensive paper of 1868 does not contain sufficiently clear descriptions of Gage's later personality to support the many claims that have been made about it, partly because Gage tried to run away from Harlow--he got as far as Chile, and he died in San Francisco.

Chapters 2 through 6 and 15 contain the results of Macmillan's extensive searches for primary material about Gage, about Harlow, and about Harlow's treatment and reports. One of the most important points here is Harlow's repeated debridement of Gage's brain fungi and drainage of his brain abscess. Obviously, it is impossible to know exactly which parts of his brain Gage lost in this process; therefore, it is impossible to localize the extent of his frontal lobe damage by simply reconstructing the path of the tamping iron from the location of the skull defects. Macmillan states this conclusion clearly, but too modestly (pp. 84-87). It invalidates all retrospective attempts at the precise localization of Gage's brain-tissue loss, even with modern imaging applied to the skull.

In chapters 7 through 9, Macmillan reviews much of the history of cerebral localization in the nineteenth century, with an emphasis on frontal-lobe function. In chapters 10 through 12, he then uses this background to examine the many claims about Gage's role in the development of neurosurgery, psychosurgery, neurophysiology, and psychology. The connection to psychosurgery is practically nonexistent, but there is a definite link to neurosurgery and neurophysiology through David Ferrier (1843-1928), whose pioneering work on cerebral localization was pivotal to both fields. Indeed, Ferrier's interest in the case was probably a major factor in the celebrity that Gage acquired in the scientific world. In the first of his Gulstonian Lectures...