academic books – A Medical Education

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.

Review of “An Odd KinD of Fame: Stories of Phineas Gage” by Malcolm Macmillan

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”.

Ancient medicine – Vivian Nutton

Think “ancient medicine”, and for most, Hippocrates comes to mind. The famous oath, which Hippocrates himself almost certainly had nothing to do with, has preserved the name into the age of mass pop culture; one recalls Homer Simpson begging Dr Hibbert to “remember your hippopotamus oath.” Perhaps some have dimly heard of Galen or other medical figures of classical antiquity, but Hippocrates is undoubtedly number one. Many would have also some awareness of the theory of the four humours, the four fluids which ancient doctors felt went “out of balance” in illness.

Professor Vivian Nutton, in his magisterial study that is, apparently, “the first large-scale history of ancient medicine in a single volume for almost 100 years”, looks beyond the Hippocratic method and tradition to the other medical practices of the Ancient Greeks and Romans. He acknowledges that much, and in particular much of the folk tradition and the role of female healers and midwives, is out of our reach because of the nature of the sources that have survived, and avoids making the book a dry account of the famous names and competing theories.

The history of medicine, Nutton writes, is the history of “men and women striving to come to terms with illness, whether as sufferer or as healer.” Hippocrates and the Hippocratics are dealt with fully, but Nutton is keen to bring us the full range of ancient medical thought. He pays especial attention to Galen of Pergamum, a figure much of his academic work has been concerned with and one whom he evidently feels a special affinity. But Galen tended to present himself as a lone fighter for truth amidst ignorance; Nutton introduces other schools of thought, less of whose works have survived (almost three million of Galen’s words are with us still), such as the Methodists, Pneumatists and the various groups of Hippocratics.

Medical thinking inevitably informs and is informed by the wider culture. The detailed description of wounds and their treatment in the Iliad lead some fanciful commentators to postulate that Homer was a medical officer attached to the Argives during the Trojan War. And Thucydides’ famously dispassionate description of the plague that befell Athens during the Peloponnesian War bears the influence of the Hippocratic method and has also inspired speculation that the author has had medical training.

Nutton discusses the interplay between medicine and religion. It comes as a surprise to discover how pliable the Ancient Greek Pantheon was. The cult of Ascelpius, god of healing, only emerged in the fifth century BC. Nutton suggests that there was not competition between medical and magical models of healing in the Greece of this time. It is easy to write of where ancient doctors got things wrong; certainly the four humours (blood, phlegm, bile and black bile) do not feature much in contemporary biology. However, their major insight, that illness was not necessarily a supernatural judgement from above, but something that could be understood and alleviated, was perhaps the most significant breakthrough in thinking about disease in history.

Most commentators have tended to be rather dismissive of Roman medicine. At least some of this is due to an equation of Roman with Latin and a more limited, insular culture than the Greeks; as Nutton writes, this was certainly true of the Republic but not of the multilingual Empire. Galen was a man of the second century AD. The book is strong on the medicine of the later Empire, with the rise of Christianity occasionally clashing with medical thinking but on the whole complementing it. The new religion, with its emphasis on the New Testament injunction to love one’s neighbour, oversaw the creation of the modern hospital in the early fourth century AD.

Nutton’s main focus is an attempt to reconstruct the individual lives of patients and doctors. He writes that he wants to “give a sense of ancient medicine, what it must have been like to have seen Hippocrates at the bedside of a patient, Erasistratus experimenting, Asclepiades or Thessalus holding forth, or Galen dissecting a pig.” Ancient doctors were independent spirits, and Nutton’s attempt to reconstruction the contention of different ideas of healing and illness is entirely admirable. The traditional, heroic account of ancient medicine as the gradual accumulation of skills and knowledge from early Greece to Galen is not abandoned, but balanced.

For a scholarly work, Ancient Medicine is a readable story of the ordinary lives of history. Nutton is a patient, fair-minded and wise guide to the array of medical practices of the classical past. The book acts as a corrective to misconceptions about the classical past, without indulging in revisionism for the sake of it.