Henderson's problems started in about 1880. The Scottish farmer was working in Canada when a piece of timber fell from a house and struck him on the head. The impact knocked him unconscious, but he recovered well and, apart from the occasional headache, returned to health. A year or so later he found that the left side of his mouth had developed a twitch. There was a similar sensation on the left side of his tongue. Within a few months, he was experiencing fits. They began with a 'peculiar feeling in the left side of his face and tongue' before spreading down the left side of his body. They culminated in convulsions and eventually loss of consciousness.
Henderson told the doctors that his symptoms had gradually worsened. He explained how he started to experience the twitching sensation on the left side of his face on a daily basis. The seizures increased in frequency until he was blacking out at least once a month. The twitching spread to his left hand and arm. The limb had weakened until he could no longer move it at all. By August he was unable to use his tools and was forced to give up work. By the autumn the paralysis had spread to his leg. He walked with a noticeable limp. Henderson was admitted to hospital on 3 November, but his condition was deteriorating by the day.
When physician A. Hughes Bennett examined Henderson, the case notes made depressing reading. Bennett had little doubt that a 'fatal termination was not far distant'. Henderson was keeping the rest of the ward awake with his screams; terrible cries from the violent, stabbing pains in his head. The headaches lasted for up to twelve hours at a time. He experienced seizures, attacks of sporadic twitching, violent tremors and uncontrollable vomiting. Bennett prescribed morphine for the pain, but no amount of ice packs or drugs seemed to give poor Henderson any relief. The situation was desperate; a 'fatal termination' seemed inevitable. But Bennett had one final trick up his sleeve.
There was no outward sign on Henderson's skull where the problem might be. Nevertheless, Bennett had studied localization and, without the aid of imaging equipment (no one had yet invented any), the physician diagnosed that Henderson was suffering from a brain tumour. What's more, he was confident he knew where it was: on the right side of the Scotsman's brain – the part that doctors believed controlled movement in the left side of the body.
Bennett decided that the tumour had to be removed, but as he wasn't a surgeon himself he enlisted the help of Rickman Godlee. A nephew of Lister, Godlee was well versed in the latest antiseptic operating techniques. Together he and Bennett planned the first operation to remove a tumour from a living human brain. The procedure would take place on 25 November 1884.
The operating theatre was prepared in the strictest accordance with Lister's methods. The instruments were soaked in carbolic; so too were the bandages and the surgeon's hands. Henderson was carried from the ward and laid out on the operating table, his head propped up on a wooden block. When everyone was ready, a gauze containing chloroform was placed over the patient's face. He was instructed to take deep breaths and gradually slipped into unconsciousness. An assistant started up the carbolic pump and soon a fine mist of antiseptic acid engulfed the area around the patient. They were ready to start.
To work out where to cut, Bennett had drawn a series of lines across Henderson's scalp. It was similar to using triangulation to obtain the position of a location on a map. He had tried to estimate where in his patient's brain the tumour was most likely to be. There were four lines in total and X marked the spot. Bennett indicated to Godlee where to make the first hole.
The drill squeals as Godlee cranks the handle and the bit grinds through the skull, becoming clogged with skin and fragments of bone. He makes sure to apply enough pressure to create the hole, but not too much in case the tool suddenly plunges inwards and gouges the brain. Godlee carefully removes an inch-wide circle of scalp and peers into the hole. An assistant holds an oil lamp over Henderson's head so that they can all get a better look. So far, so good. The outer membranes covering the brain – the meninges – look normal, but when Godlee sticks his knife through them, the brain pulsating beneath appears to bulge.
The doctors decide to proceed with the next hole. Godlee pushes the drill against the skull so that it is slightly overlapping the first hole, and begins to turn the handle. When he has finished drilling, he takes a hammer and chisel and starts to chip away at the jagged corner between the two holes. They can see more of the brain, but, after a quick discussion, they decide to make a third hole. Once Godlee has finished it off with the chisel, they are left with a triangular aperture in the man's head.
Working slowly, Godlee starts to slice through the first layer of the membrane – the dura. He is careful to avoid a large blood vessel. When he lifts the surface of the membrane he can clearly see a transparent solid globule of tissue underneath. He has found the tumour – exactly where Bennett had predicted. Pulling apart the membrane a little further, he is able to wedge a narrow steel spatula between the tumour and the surrounding brain tissue. He slips his finger underneath to try to pull the mass free. He pulls too hard because the upper part of the tumour breaks open.
The operation is getting messy. Blood is oozing out over everything. As soon as Godlee mops it up with a sponge, the triangular opening in Henderson's head wells up again. Struggling to see what he is doing, the surgeon dips in a spoon and begins to scrape away at the remains of the tumour, trying as hard as possible not to remove too much healthy brain in the process. Removing the tumour leaves a hole around one and a half inches deep or, as Bennett puts it, 'a size into which a pigeon's egg would fit'. Later, when they have cleaned it up, they will find the tumour to be 'about the size of a walnut'.
Hands covered in blood, everything else now totally soaked in stinging carbolic from the spray, Godlee starts to close the wound. To do this he employs another recent surgical innovation (a variation of which is still used today): an electrocautery. This is an advance on the old-fashioned cauterizing iron, which has done so much damage during amputations (see Chapter 1). Godlee inserts an electrode into the wound and holds it against the bloody tissue as his assistant throws a switch. The flesh sizzles and the bleeding slows. Satisfied, Godlee stitches together the dura, slipping in a rubber tube to drain any excess fluid, and dresses the wound in gauze. A mixture of blood and spinal fluid drizzles from the tube.
The whole operation has taken two hours. Henderson has remained unconscious throughout, but when he awakes he seems to have suffered no ill effects. Better still, the pain in his head, the convulsions and the twitches have all disappeared. His left side is still partially paralysed, but this is only to be expected. It looks as if Bennett and Godlee have done it. Henderson is cured.
Unfortunately, Henderson did not live long enough to appreciate this remarkable new surgical treatment. Despite Godlee's best efforts, the wound somehow became infected. Bennett speculated that this might have been as a result of the cauterizing apparatus or the sponges (or it could have been because the surgeons had not worn masks or gloves), but once the infection had taken hold, there was little the doctors could do. One month after the operation Henderson, like so many experimental patients in the history of surgery, was dead.
Whether an operation that ultimately leads to the patient's death can be described as successful is debatable. Bennett and Godlee's achievement was nevertheless considerable. They had done everything they could think of to prevent infection, and the technology they used – from the chloroform anaesthetic to the carbolic spray and electrocautery – was Victorian state-of-the-art. Bennett had accurately diagnosed a brain tumour, had identified exactly where it would be, and Godlee had managed to remove it successfully without the patient dying on the operating table. Given that without the operation Henderson would certainly have died in terrible pain, Bennett and Godlee were probably right, on balance, to go ahead and deserved the acclaim they received.* They had made a major advance in neurosurgery, proving that it was possible to open the sealed casket of the skull and operate on the brain. Now it seemed that every other surgeon wanted to have
a go.
* Of course, as it turned out, Henderson did die in terrible pain, only it was from meningitis rather than a brain tumour.
Over the next twenty years, thousands of operations were carried out on the brain. In the United States alone more than five hundred surgeons attempted brain surgery between 1886 and 1896. These were all general surgeons who applied the same techniques to excising a brain tumour as they might to removing a diseased appendix. Like Bennett and Godlee, they would categorize operations as successes even though their patients subsequently died. The surgeons consoled themselves with the knowledge that their patients would have died anyway; but this didn't stop them pocketing a healthy fee for the operation.
In 1889 the German surgeon Ernst von Bergmann compiled a review of the mortality rates from brain operations. His study made depressing reading. On average, half the patients undergoing brain surgery died. Some bled to death on the operating table after surgeons accidentally severed a major blood vessel, sending a shower of blood spurting from the wound. Other surgeons managed to remove tumours successfully only to find that they couldn't shove the brain back in again. Lobes of brain tissue would bulge accusingly through the hole in the patient's head. Struggling to force it back in, they would find they could no longer draw together the flaps of dura or get the skull back on. It was like trying to close the lid of an overfilled suitcase, and would almost have appeared comical had it not invariably ended with the patient's death.
If the surgical procedures themselves left a lot to be desired, so did the diagnosis and aftercare. Bennett had got the position of Henderson's tumour absolutely spot on, but other surgeons were not so lucky. The anatomy of the brain was only broadly understood. Surgeons would anaesthetize the patient, drill into their skull and cut into the membranes only to find a perfectly healthy brain underneath – thereby incurring all the risks of surgery without any hope of success.
One of the greatest killers, however, was infection – a problem that had been overcome in most general surgery. Time and again surgeons would operate, remove a tumour and successfully close the wound, only to have the patient die from infection a few weeks later. Even those who, like Bennett and Godlee, employed the very latest antiseptic techniques still seemed to come unstuck at this final hurdle. Soon even the most gung-ho surgeons decided that brain surgery was more trouble than it was worth and gave up neurosurgery altogether. The mortality rate was doing nothing for their reputation. Brain surgery remained in the Dark Ages. It desperately needed someone to make it safe.
THE MAN WITH ONE THOUSAND BRAINS
Peter Bent Brigham Hospital, Boston, 1931
* * *
Harvey Cushing was a god among surgeons. And he would often behave like one. Worshipped and feared in equal measure, his patients adored him while his assistants were terrified of him. Cushing was cold to his family and a bully to his friends, but a model of care and tenderness with his patients. Colleagues described him as hard and selfish. He was so focused on his work that when he was told his son had died in a car accident, he carried on with a scheduled operation anyway. When it came to brain surgery, Cushing was a miracle worker – the first true neurosurgeon.
A Cushing operation was an intense affair that could last for anything up to eight hours. He sometimes had another surgeon perform the opening of the skull and the closure at the end, but there was no doubt as to who was in charge. Cushing sat on a stool beside the operating table so that he was level with the patient's head. He worked slowly, methodically, pedantically. Every blood vessel was clamped off until the hole in the patient's scalp was surrounded by dozens of scissor-like clamps. He inserted smaller wire clips and painstakingly cut, scraped and cauterized as he removed tumours. In some cases these growths were massive – a witness reported one to be as 'big as an orange'.
Cushing was a tyrant in the operating theatre. He cursed his assistants if they failed to second-guess his every move, and barked at nurses if the right instrument wasn't placed in his gloved hand. He ordered surgeons out of the room if he thought they were being clumsy, and belittled his colleagues – usually in their presence. He demanded the same high standards from his staff that he expected from himself. But his results were exceptional. Only around one in ten of his patients died. Given that many were seriously ill and that antibiotics had not yet been invented, it was an impressive record.
On 15 April 1931 Cushing carried out his two thousandth tumour operation. His patient was thirty-one-year-old Ida Herskowitz. She had been suffering from debilitating headaches and was rapidly losing her sight. It wasn't a particularly complex operation (in relative terms), and the surgeon managed to remove a tumour successfully and restore Herskowitz's vision.*
* Ida Herskowitz was still alive thirty years later. Even though Cushing sometimes treated his staff abysmally, they were immensely loyal, and on completion of this landmark operation they presented him with a silver cigarette case and an elaborate celebratory cake.
Cushing had first become interested in operating on the brain when he was qualifying as a surgeon in the late 1890s. Despite the terrifying mortality rates associated with brain surgery, he decided that neurosurgery was going to be the next great surgical revolution, and he wanted to be part of it. Indeed, not only part of it – he wanted to lead it. With single-minded determination, he achieved his goal within a few years, and by the 1930s was at the height of his powers. Most of his innovations were relatively small, but together they made brain surgery effective and a good deal safer.
One of Bennett and Godlee's biggest problems had been the amount of blood that sloshed around as they were working. Cushing's first goal was to work out a way of stemming blood flow during an operation. He wanted to see what he was doing while preventing his patients from bleeding to death. His answer was to make small clips from pieces of household wire and clamp them across arteries and veins. He also adapted a pneumatic cuff, originally designed for measuring blood pressure, to act as a tourniquet and reduce blood flow to the scalp.
Cushing was quick to adopt new technology. He was one of the first surgeons to use X-rays for diagnosis, and pioneered the use of an 'electric scalpel'. This device was an advance on the primitive electrocautery probe used by Godlee and Bennett, and allowed the surgeon to cut and seal tissue at the same time. Unfortunately, the electric scalpel could also burn and shock – both the staff and patient – and in one case sent a patient jumping, in the words of a witness 'like a frog', almost off the operating table. Still, when it worked the electric scalpel was a major improvement for controlling bleeding, and particularly useful for excising tumours.
The risk of infection remained a major concern for surgeons, and Cushing operated in conditions of the strictest cleanliness. Everyone in the theatre wore masks and the surgeon operated with gloves. He also appreciated the importance of aftercare. Following operations, patients were nursed around the clock by staff specially trained in dealing with neurosurgery cases. Sometimes patients were even kept in the operating theatre to keep the risk of infection to a minimum. This post-operative treatment was the forerunner of the intensive care units found in modern hospitals.
If Cushing gave every appearance of remaining emotionally detached from his family and colleagues, quite the opposite was true when it came to his patients. It is said the only time he talked of his son's death with any emotion was when he was comforting the parents of a dead child. There is a picture of him holding the hand of a man suffering from acromegaly, a condition caused by an overproduction of growth hormone from the pituitary gland, which results in an abnormal increase in height. Another touching photograph shows him holding a cuddly toy at the bedside of a poorly child whose head is swathed in bandages.
Cushing could not bear to let a patient die, and would do anything he could to help them. Patients spoke of how gentle and kind he was, and told of his sympathy and understanding. Unlike some of the other god-like surgeons around at the time (and since), he was not above helping to clean a patient or deal w
ith their bedpan. And in return for this great care and his undoubted surgical skills, his patients bequeathed him their brains.
The Cushing Tumour Registry comprises a unique collection of photographs, notes, hospital records and brains. Lots and lots of brains. There are around one thousand of them in the Yale archives, collected over more than thirty years. They are arranged on shelves like jars of sweets. Each jar, labelled with details of the case, contains the disembodied brain of one of Cushing's patients. Each one is preserved in fluid, its folds and ridges helping to form a unique record of brain disease.
Cushing's legacy is represented by these jars, but is preserved by the techniques he developed – techniques that are still being used today. He helped train a new generation of neurosurgeons and his work led to future advances in neurosurgery. More than anyone, Cushing made modern brain surgery possible. Now surgeons could operate on brains with every confidence that their patients would survive.
Unfortunately, while Cushing was pushing forward the barriers of modern medicine, others seemed hell-bent on returning it to the Dark Ages.
WALTER FREEMAN, LOBOTOMIST
Washington DC, 1936
* * *
There were many reasons why Walter Freeman did what he did. The reasons were lying in the squalid wards of the mental hospitals, staring at the walls, screaming or moaning. The reasons were shouting at invisible demons or lying curled up in the corner of a rubber-walled cell. The patients of mental hospitals were Freeman's reasons; people with no hope.
In 1924, when Walter Freeman was first appointed as laboratory director at St Elizabeths Hospital in Washington DC, he was shocked by what he saw. When he strode through the overcrowded wards of the vast institution he felt a mixture of fear, disgust and shame. Fear of the patients who crowded around him, disgust at the excrement smeared on the walls, and shame that the doctors were powerless to do anything to help these poor people.
Blood and Guts Page 23