Abstract
One can only admire Malcolm Macmillan's huge scholarship; he approaches the story of Phineas Gage with an unrivalled depth of knowledge. This is, of course, the story of the survivor of ‘one of the most remarkable, if not the most remarkable, injuries to the brain in medical history’ (p.11). Mr Gage, on the 13th of September 1848, had been distracted by his workmates while tamping down an explosive charge in a hole drilled in a rockface. With his head averted, he continued working, but the tamping iron struck rock causing the charge to explode. The tamping iron, an inch and a quarter in diameter, and three feet eight inches in length, was propelled through his head, entering below the left zygomatic arch and exiting in the midline near the coronal suture. The case of Phineas Gage came to be perpetuated in the history of medicine because he survived his horrific injury, was conscious, walking, and talking in the minutes and hours that followed the accident, and because (but probably of secondary importance during the next half century or more) the only long-term change was an alteration of personality.
This remarkable case was to be reported (albeit in a rather modest manner) in an increasingly incredulous midnineteenth century press (Chapter 3). To underscore the rather low profile of the case at that time, Macmillan establishes that the ink used to print all of the articles on Gage would not be sufficient to print a single banner headline in the modern press. The case was even to surface in fiction, film and TV documentaries, and popular music of the late twentieth century (Chapter 13). (Perhaps the latter came about because the case is so often described in Psychology 101 texts!) The case was also to surface in the scientific and clinical literature (of the day and later) enveloping itself in a haze of academic mythology (see particularly Chapter 14: Scientific Stories).
Here, to my way of thinking, lies the central contribution of the book. Much has been written on the significance of the case of Phineas Gage. The nature of his personality change has been elaborated (possibly distorted) into a prototype par excellence of the frontal lobe syndrome. Yet the only link between us and the clinical reality of the postinjury Gage is a handful of scattered notes and recollections of one of the two attending physicians, John Harlow. In Macmillan's hands, this becomes a study of the mutations that creep into the historicoclinical record in medicine, and an exercise in ‘recovering the truth’, not only about Gage, but about Harlow as well. In an attempt to evaluate the validity of Harlow's account, Macmillan traces Gage's meanderings to South America, and wonders whether a man with extensive frontal damage could have undertaken such activities of daily living as driving a stagecoach over difficult terrain (fully documented in Chapter 6), as Gage is reputed to have done. Ultimately, the empirical status of Harlow's account is the issue that still needs to be resolved. After Macmillan's exhaustive account, however, one wonders if there is anything left to be uncovered.
The book is immensely detailed, locating the case of Phineas Gage within a rich historical, social, and scientific context. It is certainly a major document in the field of neuropsychology, and I think that time will tell that this is the definitive work on Phineas Gage.