It isn’t available online, but I have a review of Markus Heilig’s “The Thirteenth Step” in the current TLS.
It isn’t available online, but I have a review of Markus Heilig’s “The Thirteenth Step” in the current TLS.
This piece is no longer actively on nthposition. Fortunately I had previously preserved a copy on a precursor of this blog, with an entertaining typo in the heading.
I ended up having some correspondence with Macmillan subsequently – specifically about the lyrics to the Slackdaddy song (although I don’t think he like the word “primly”) His book is availble here. I think this book marked a point where I began to exhibit a certain reserve and scepticism about similarly pat, anecdotal stories.
I find that Jackson Beatty’s book seems to be rather obscure – one of the textbooks from my medical education that was perhaps less directly helpful in getting me through exams but did help provide a good quote illustrating the Official Version of Gage’s story.
At 4.30pm on 13 September 1848, the foreman of a group of railway construction workers in Cavendish, Vermont, suffered a horrendous accident that secured his later role as one of the most famous patients in the history of medicine. Virtually all humanity – famous, unknown and infamous – were, are or will be patients at some stage, but Phineas Gage is among the select few whose fame rests entirely on their status as patients. Some of Freud’s cases – “Rat Man”, Judge Schreber, Anna O – are perhaps Gage’s main rivals of this score. But while Freud and all his works have been closely examined and hotly contested over the years, Malcolm Macmillan, Adjunct Professor in the School of Psychology at Deakin University in Australia, found in 1983 that while various stories of Gage’s accident were widely known, little detail was. As the blurb puts it “almost nothing is known about him, and most of what is written is seriously in error.”
For the reader who has never heard of Phineas Gage, and may well be rather sceptical about his fame, I give a typical extract from a modern textbook, in this case the 1996 edition of Principles of Behavioural Neuroscience by Jackson Beatty:
The importance of the cerebral hemispheres for emotion, and in particular the frontal lobes, was made strikingly clear over a century ago by the case of Phineas Gage, the foreman of a railroad crew who suffered a remarkable injury. An accidental explosion drove an iron rod into Gage’s cheek and out through the top of his skull. Miraculously he survived the injury but suffered a massive lesion of the frontal lobes. Before the accident, Gage was a model citizen and employee, but the frontal damage transformed his very character. Gage’s physician described the change as follows:
“The equilibrium or balance, so to speak, between his intellectual faculty and animal propensities, seems to have been destroyed. He is fitful, irreverent, indulging at times in the grossest profanity (which was not previously his custom), manifesting but little deference for his fellows, impatient of restraint or advice when it conflicts with his desires, at times pertinaciously obstinate, yet capricious and vacillating, devising many plans of future operation, which are no sooner arranged that they are abandoned in turn for others- His mind was radically changed, so decidedly that his friends and acquaintances said that he was ‘no longer Gage'”
That’s the textbook version in neurology books, and such a striking story has naturally entered a wider consciousness. Macmillan gives many examples of the story’s use in documentaries, novels and other unexpected places. For example, in Roger Kimball’s The Long March: How the Cultural Revolution of the 1960s Changed America, the very first figure we encounter is Phineas Gage; based on a 1994 New York Times report, Kimball writes that “pondering the sad state of contemporary American cultural life, I have often recalled the sad story of Phineas Gage. Like him, our culture seems to have suffered some ghastly accident that has left it afloat but rudderless: physical intact, its ‘moral centre’ is a shambles.” On the morning of 13 September 1848, Gage would hardly have suspected he would be drafted into the culture wars of a century and a half later.
Macmillan even uncovers two rock bands called “Phineas Gage” and “Finneus Gauge”, and a song by Slackdaddy called “What’s the matter with Phineas Gage?”, of which he writes primly “although no one I know who has listened to the song has been able to understand more than a few words, the group neither seems to sing anything of significance about Gage nor to answer the question posed in the title of the song.”
There is no doubt that Gage suffered the accident, and that it had a dramatic effect on his life. Nevertheless, Macmillan shows, the account that has entered both scientific and popular discourse is flawed. Firstly, we know very little about Gage’s personality and habits before the accident, and secondly the after effects were not, contemporaneously, reported as being quite so dramatic.
Within twenty-four hours of the accident, a first report was (anonymously) printed in the Ludlow, Vermont Free Soil Union. Having described the accident, the paper reports that “the most singular circumstance connected with this melancholy affair is, that he was alive at two o’clock this afternoon, and in full possession of his reason, and free from pain.”
“Gage’s physician”, as cited (second-hand) by Beatty above, was Dr John Martyn Harlow. Harlow mentioned very few psychological changes in his initial report of 1848. Henry Bigelow, Professor of Surgery at Harvard, wrote in 1850 that Gage was “quite recovered in faculties of body and mind.” It was Harlow’s account of 1868 that began to introduce the changes; the passage Beatty cites is taken from this source. Later writers began to embellish even more, adding drunkenness, braggadocio, a vainglorious tendency to show off his wound as part of Barnum’s Traveling Exhibition and an utter lack of foresight where these were unmentioned by Harlow.
In 1848, Macmillan writes, there was strong resistance to the idea that function could be localised to any particular are in the brain. Bigelow’s verdict was a victory for advocates of localisation, implying that the frontal lobes served no particular purpose. By 1868 however localisation was beginning to hold sway, with Paul Broca’s work on localising language function to the left hemisphere. Macmillan shows how differing psychological and neurological theories shaped the presentation of Gage’s story.
Macmillan explicitly states that this is not intended as a work of postmodernist relativism. Rather he is simply arguing that the subsequent stories of Gage bore little relation to the original facts that were known about him. Harlow’s account is pretty much all we know about Gage, and it is important to separate it from the subsequent encrustation of myth.
Quite aside from the pressures of neurological debate, a number of other stories have clung to Gage. The various accounts of him showing off his wound in a tent on Boston Common and in Barnum’s circus seem to derived from a passing reference in Harlow’s 1869 report to Gage’s stay in New York at “Barnum’s, with his iron”, which Macmillan presumes must mean Barnum’s American Museum, and there is no evidence Gage toured with a circus.
As Macmillan writes, the textbook accounts of Gage are not wildly wrong. “If we divide the story into seven elements – rarely did a single account contain major errors in more than three of these elements”, and he finds that the more inaccurate textbooks seem to have depended on paraphrasing subsequent writers rather than Harlow’s report. This can be seen as a warning to authors in all disciplines to be wary of citing secondary sources routinely.
The story of Phineas Gage, as represented in the textbooks, is not a lie or a myth, but simply an exaggeration. Macmillan’s conclusion puts it best:
Vivid though Harlow’s description of Gage is, it is far from providing the detail we need for a full analysis of Phineas’ behaviour before and after the accident. That lack, together with the slightness of our knowledge of the specific locale and extent of the damage to his brain, provides too meagre a foundation on which to base hypotheses of the relation between the frontal lobes and their psychological functions- What has to be remembered is that his was the first case to point to a relation between brain an personality functions. That is its lasting importance.
Macmillan is exceedingly thorough and fair-minded in his approach. Some may even find the attention to detail excessive, with modern CT images of Gage’s skull, biographical chapters on Harlow, genealogical tables showing the lineage of Gage and Harlow. Macmillan, however, writes in a lively and accessible style. A book perhaps of interest only to a few, but nevertheless a fascinating example of how a medical case history “got legs”.
Apologies for the hiatus. This is my submitted copy rather than the review as it appeared in the TLS. I re read most of Rupert Wright’s book a few years ago. This was the first time I came across the concept of water charges, which seemed to strike everyone else in Ireland as something completely out of this world in late 2013. I greatly preferred Wright to Morris and found his debunking of the “the world’s next war will be over” idea (I nearly typed meme!) convincing.
Take me to the source: In search of water. Rupert Wright
The Blue Death: Disease, Disaster and the Water We Drink. Dr Robert D Morris
Thales of Miletus, the earliest identifiable philosopher and scientist (in a fairly loose sense of both terms) held that “everything is water.” That this is the first philosophical and first scientific statement is no accident; water is central to human existence. In the West, however, the words of Jake Gittes in “Chinatown” are apt – “I turned on the faucet, it came out hot and cold, I didn’t think there was a thing to it. “Rupert Wright, who has previously written books about life in the Languedoc region, begins his discursive, digressive, suitably elusive book with the sudden cessation of water supply in his French home. When he bought the place, the fact that it came with its own water supply was another romantic touch. Only when it stopped did he realise that there was indeed “a thing to it.”
Wright has written an entertaining tour of the world of water, if such a tautology is possible in a world that is mainly water. From the gigantic excavation of a third water supply tunnel for New York, happening almost invisibly to passers-by in Midtown Manhattan, to asommelier instructing bored Parisians in the appreciation of spring and mineral water, to the hunger-striking Bishop of Barra in Brazil trying to stop the damming of the São Francisco River, humanity’s relationship with water is by turns inspiring, absurd, and tragic.
Water policy is steadfastly unsexy. All over the world, Wright notices, oil ministers are Harvard-educated, Rolex-wearing, Armani-clad; water ministers wear cheap suits and use their mobile phones to tell the time. Wright is no reflex contrarian, but his scepticism about some of the received wisdom about water and water policy is bracing. One truism of bien pensant opinion he seems wearied by is the wars of the coming century will be a fought over water, a notion he imagines Flaubert consigning to a contemporary Dictionnaire des Idées Reçues. Only one war, he writes, has ever definitively been fought over water – “more have been fought over salt.” Water has been a tool of war rather than a cause of war, and the need for water drives co-operation as much as competition (Europe’s oldest law court the Tribunal de las Aguas de la Vega de Valencia, consists of eight magistrates who have convened every Thursday at midday since the Tenth Century to ensure the fair distribution of Turia River water.)
Wright is much more interested in how writers and artists have described and depicted water. Poetry flows throughout. He is particularly enraptured by the single flowing sentence that is Bloom’s reflection on water in Ulysses. That dry systemiser Stephen Dedalus disliked bathing and suspects ‘aquacities of thought and language’; hydrophilic Bloom boils the kettle and embarks on an epic sentence of reverie and connection about water. Three other texts especially inspire Wright – John Cheever’s “The Swimmer”, Roger Deakin’s “Waterlog” and Charles Sprawson’s “Haunts of the Black Masseur: The Swimmer as Hero” and he has something of the ruminative charm of Deakin and the digressive erudition of Sprawson.
No mention of Ulysses in Dr Robert D. Morris’ “The Blue Death” (Morris, incidentally, uses his professional title on the book’s cover.) While Rupert Wright does not gloss over the lethality of water-borne infections and the mass misery and death that can be caused by consuming water, Morris, a public health physician and water researcher, focuses exclusively on water-borne threats. Water, as a substance itself, is not centre stage – indeed is hardly mentioned. An aside that “safe water is not an end, but a process, an ongoing struggle in which improvement is always possible and often necessary. Purity, it turns out, is fleeting” is the closest we come to the philosophical reflections of Wright.
He begins with the tale of John Snow and the Broad Street pump. Snow is to epidemiologists what Indiana Jones is to archaeologists, and Morris lays of the suspense a little thick: “Snow felt he was finally closing in on the proof that might muffle his critics. The ground itself would need to shake to divert his attention from the task at hand. He would soon discover that an epidemiological earthquake like no other had its epicenter on the north side of the Thames.” We move on to the battles over cholera of Robert Koch and Louis Pasteur (“like seasoned gunfighters, they would meet in the streets of Alexandria with test tubes blazing until only one man was standing.”)
The tone shifts suddenly halfway through. Morris is no longer describing the heroic age of epidemiology and public health, but is centre stage. A meta-analysis he performs linking long-term consumption of chlorinated water with cancer earns him the suspicion of the water treatment industry and, it seems from his own account, the Environmental Protection Agency. Again we are reminded that water is “unsexy” – public attention, for Big Water, means bad news. Outbreaks of cryptosporidium in Milwaukee in 1993 and E. coli 0157:H7 in Canada in 2000 illustrate the weaknesses of water processing systems that have changed little in a hundred years. Morris is no neutral in these matters, and closes the book with an eight point plan for ensuring safe water (step 7, by the way, involves the universal use of point-of-use filtration for drinking water.)
Wright writes ruminatively, philosophically, sub specie aeternis,, while Morris is the researcher in the arena of current controversy and impatient with the slow pace of change. Wright is amusedly tolerant of bottled water and its attendant absurdities; Morris is angered by a fad whereby more water is used to produce the bottle than goes inside. Both aim to reveal the truth about the ubiquitous and invisible substance that we are learning not to take quite so much for granted – water is everywhere, water is eternal, water is indestructible, and water is scarce, fleeting, and fragile.