Adventures in Human Being

by Gavin Francis

  By the time I had scrubbed in and put on my gown, he was already at work. “Come in, come in,” he said, looking up from a heap of green cloth on a table. “You’re just in time for the fun part.” I was dressed as he was, draped in the same green cloth as lay on the table, a surgical mask over my face and nose. The surgical lights flashed in the professor’s spectacles. “We’re just cutting the window in the skull.” He turned back to his work, and resumed his conversation with the nurse opposite; they were discussing an American war movie. He began to cut into the skull with a saw. Smoke rose from the bone, together with a smell reminiscent of barbecued meat. The nurse sprayed water over the cutting surface, to catch the dust and keep the bone cool. She also held a suction tube to draw up the smoke that threatened to cloud the professor’s view.

  Seated to one side was the anesthetist, who wore blue pajamas instead of a green gown; he was doing a crossword, and occasionally would reach under the pile of drapes. There were a couple of other nurses, standing back from the table, whispering to one another with their hands held behind their backs. “Stand over there,” the professor said, and nodded to the space opposite. I jumped into position, and the nurse handed me the suction tube. I had already met the patient – let’s call her Claire – and knew that she suffered from severe intractable epilepsy. Here, unusually, was someone affected not by tumor or trauma, but by a delicate shift in the electrical balance of her tissues. Her brain was structurally normal but functionally fragile, forever teetering on the edge of seizures. If normal cerebral activity – thought, speech, imagination, sensation – moves through the brain with the rhythms of music, seizures might be likened to a deafening blast of static. Claire had been so injured, frightened and handicapped by these seizures that she was prepared to risk her life with this surgery in order to be free of them.

  “Suck,” the professor said. He changed the position of the tube in my hands so that it hovered over his saw blade, then began to cut through more bone. “The neurophysiologists tell me her seizures originate just under here.” He tapped the exposed skull with a pair of forceps; the noise was like a coin dropped on porcelain. “That’s where the seizures are coming from.”

  “So we’ll cut out the source of the seizures?”

  “Yes, but the source is very close to the area responsible for speech. She won’t thank us if we make her mute in the process.”

  Once he had sawn through the skull, the professor prised in little levers, similar to those used to take the tire from a bicycle wheel, and lifted up a medallion of bone. He handed it to the nurse. “Don’t lose that,” he said. The window was about five centimeters in diameter, and revealed the dura mater, the protective layer that lies beneath the skull, shiny and opalescent like the inside of a mussel shell. The professor removed that too, and I looked down on a disc of creamy pink matter, ribbed like sand at low tide, with blood vessels traced over its surface in filaments of purple and red. The brain itself was slowly pulsating, rising and falling with each beat of the patient’s heart.

  And so to the “fun” part, as the professor put it. The dose of anesthetic was slowly reduced, and Claire began to groan. Her eyes flickered and then opened. The drapes had been pulled back, and the steel pins fixed into her skull were now visible.

  A speech therapist had arranged her chair next to the operating table so that she was able to bend forward, close to Claire’s face. The therapist explained that Claire was in an operating room, that she couldn’t move her head, and that she would be shown a series of cards and should name each object and what could be done with it. Claire grunted, unable to nod, and they began. Her voice was drawling and disembodied – an effect of the sedatives. The cards showed images like the ones you’d find in a child’s storybook. “Clock,” she said, “you tell the time with it.” “Key,” she said, “you open doors with it.” The images of simple objects went on, drawing her back to her earliest linguistic memories. Her concentration was intense, eyebrows creased, forehead glistening with sweat.

  Meanwhile, the professor had swapped his saw and scalpel for a nerve stimulator. He began to dab at the surface of the brain delicately, at first holding his breath. There were no hints of bravado now, no jokes or chat: his entire attention was concentrated on two steel points separated by a couple of millimeters. The electrical effect was minimal – would barely be felt if applied to the skin – but on the sensitive surface of the brain its effect was overwhelming. The stimulator caused an electrical storm that obliterated normal function. The portion of the brain affected was small, but it was big enough to contain millions of nerve cells and their connections.

  “She carried on talking so that bit’s not ‘eloquent,’” he said. “So we can cut it.” He placed a numbered label, like a tiny stamp, over the place he had just touched with the stimulator. The number was carefully cataloged by one of the nurses, while he moved on to the next patch. The professor called this process “mapping”: the human brain was an uncharted country being opened to surgical discovery. He moved carefully over the surface, numbering and recording; it was methodical, patient work. I had heard stories of his standing at the operating table for sixteen hours straight, reluctant to abandon the patient even to go to the toilet or eat a snack.

  “Bus, you can tra … tra …”

  “Speech arrest,” the therapist said, looking up at us. “Shall we try that one again?” She showed another card. “Knife, youah, aah …”

  “There we are,” the professor said, pointing to the area he had just passed over with the electric current. “Eloquent brain.” He placed another label carefully over the area, and moved on.

  I studied the eloquent brain carefully, willing it to appear in some way different from the rest of the tissue around it. Her vocal cords and throat might make the sound, but here was the wellspring of her voice. It was the connections between neurons in that exact place, the patterns they made as they fired, that enabled speech, therefore defining it neurosurgically as “eloquent.” But there were no distinguishing features, no sign that this patch of cortex was the channel through which Claire spoke to the world.

  On one occasion at medical school a visiting neurosurgeon showed us slides of an operation to remove a brain tumor. Someone in the front row raised his hand and remarked that it didn’t look like a very delicate process. “People tend to think of brain surgeons as being very dextrous,” the neurosurgeon replied, “but it’s the plastic surgeons and microvascular surgeons who do that meticulous stuff.” He indicated the slide on the wall: a patient’s brain with an aerial array of steel rods, clamps and wires. “The rest of us just go gardening.”

  Once Claire was asleep again, the professor removed a chunk of her brain – the “epileptogenic” part – and dropped it into a bin. “What was that chunk responsible for?” I asked him. He shrugged. “No idea,” he said; “we just know it’s not eloquent.”

  “Will she notice any change?”

  “Probably not, the rest of the brain will adapt.”

  THERE WAS A SCAR on her brain like a lunar crater by the time we’d finished. With her brain and mind once more anesthetized, we cauterized the severed blood vessels, filled up the crater with fluid (so that she didn’t have any air bubbles moving around inside her head afterward), and then sutured up the dura with neat embroidery stitches. We reattached the disc of bone by inserting little screws through strips of titanium mesh.

  “Don’t drop them,” the professor said as he handed me each screw. “They cost about fifty quid each.”

  We unrolled Claire’s scalp, which had been held out of the way with clips, and stapled it back in place. I met her again a couple of days later and asked her how she was feeling. “No seizures yet,” she said. “You could have made a nicer job of the stapling, though.” Her mouth unfurled into a triumphant smile: “I look like Frankenstein’s monster.”

  2

  SEIZURES, SANCTITY & PSYCHIATRY

  Men ought to know that from nothing else but the

  b
rain come joys, delights, laughter and sports, and

  sorrows, griefs, despondency, and lamentations …

  All these things we endure from the brain.

  Hippocrates, On the Sacred Disease

  THE PSYCHIATRIC HOSPITAL in Edinburgh looks like a stately home, set in parkland on the outskirts of the city. It was built by the city authorities as a lunatic asylum two centuries before I studied there. The idea of building an asylum had formed in the late eighteenth century – the closing years of Edinburgh’s Enlightenment – as a response to the barbarity and squalor of the city center’s Bedlam madhouse.* A prominent young poet, Robert Fergusson, had died in the Bedlam in 1774, and a compassionate local doctor called Andrew Duncan had resolved to create a better institution. The new asylum was intended to be among the most compassionate and humane of its kind in Europe.

  The original Bedlam, or “Bethlehem,” asylum in London gave its name to many of the lunatic asylums that were established subsequently across the British Isles.

  By the late twentieth century, when I arrived, the core of the original asylum had been engulfed by incongruous modern architecture. There were no more lunatics (only “patients” and “clients”) but there were laminated maps, smoking shelters, link corridors and plastic signs: “Andrew Duncan Clinic,” “Mental Health Assessment Service,” “Rivers Center for Post-Traumatic Stress Disorder.”

  I was introduced to Dr. McKenzie, the psychiatrist responsible for teaching me – a smart woman in a blue tweed jacket and skirt. She showed me around one of the in-patient wards. I was encouraged to mix with the patients, sitting with them in the smoking room and asking them how they’d come to be there. There was a wild-eyed traveling salesman with a bald pate and a silken robe: he told me he’d been admitted after unscrewing all the doors in his house because they “blocked energy.” There was a woman who spent her time trembling in the ward’s laundry cupboard and muttering to herself – she even slept there. There was a librarian, brought in by the police, who wore a waistcoat and cravat and claimed he was an incarnation of Jesus. And there was Simon Edwards, a bony, elderly man with skin like papyrus, who before being admitted to the hospital had complained that his body was rotting from the inside.

  Many of the patients talked incessantly, given the opportunity, but Mr. Edwards did not. He spent his days sitting silently in his room, staring at the wall, immobilized by severe, psychotic depression. He wouldn’t eat, didn’t seem to sleep, and hardly even seemed to breathe – he gave the impression that he wanted to waste away to nothing. Dr. McKenzie told me that the usual antidepressant medications had failed. As Mr. Edwards was rapidly losing weight, he was to begin a course of electroconvulsive therapy. If I wanted, I could come down the next morning and watch.

  The following day I was hesitant outside the ECT department, unsure if I should enter. The door was ajar; inside I could see whitewashed walls, and a bleaching light shone in through the windows. The floor was covered in the sort of linoleum you see in operating rooms, cambered to rubber skirting boards so that dirt and germs have few places to hide. In the center of the room was an iron-framed bed stretched with a pressed white sheet. The door swung open, pulled wide by Dr. McKenzie. She had taken off her tweed jacket and was carefully rolling up the sleeves of her blouse.

  There was an anesthetist with his back to the bed; as I entered the room he turned to greet me. A medical monitor on a rolling stand stood next to the bed. There was a tray of anesthetic drugs, a defibrillator in case of cardiac arrest and a tank of oxygen attached to a mask. All this equipment was familiar from the emergency room over at the city’s main hospital, but it was startling to see it here in an environment more used to psychology, occupational therapy and pills. The ECT generator itself was a compact blue box with plugs, switches and a series of wires. It had a dashboard of ruby LEDs, like the timer on a Hollywood bomb.

  Mr. Edwards was wheeled in and helped onto the couch. His eyes were a coagulation of sorrow: rheumy and opaque. He said nothing, just looked blankly at the ceiling, and didn’t even flinch when the anesthetist slid a needle into his vein. He was incapable of giving consent to the ECT, and so was being treated under one of the sections of the Mental Health Act. Two drugs were injected into the needle: a short-acting anesthetic and a muscle-relaxing agent, otherwise the spasm provoked by an ECT seizure can cause injury to bones and muscles. Once paralyzed and anesthetized, the patient had a plastic tube inserted into his mouth to keep his tongue from slipping back. His breathing was maintained through the mask by the anesthetist.

  Dr. McKenzie placed a cylindrical metal electrode, shaped like a judge’s gavel, against each of Mr. Edwards’s temples. She pushed a button on the handle of each, and I thought I heard a low whine, like the sound of a mosquito in the ear. Mr. Edwards’s face quivered, his arms flexed, and his body began to twitch and shudder. “Why is he shuddering if he’s been paralyzed?” I asked, wondering if something was wrong.

  “These tonic-clonic movements are actually pretty minimal,” the anesthetist said. “If we hadn’t paralyzed him, they’d be far more intense.”

  After only twenty or thirty seconds Mr. Edwards’s arms dropped to the couch. The anesthetist rolled him onto his right side, and, after checking that all was well, pushed him on the gurney through to another room.

  Dr. McKenzie rolled down her sleeves and buttoned on her jacket. “There’s a lot of superstition around ECT,” she said as she reached the door, “but it’s one of the safest and, in some instances, the most effective therapies we have.”

  Mr. Edwards was put on a regime of two treatments a week. At first there was little improvement, but after a while his facial expression, having previously been blank, would alter when I or one of the nurses went into his room to speak to him. He seemed startled by life, like a Lazarus unconvinced that he’d been done a favor. After two weeks he began to talk.

  ELECTROCONVULSIVE THERAPY is one of psychiatry’s most controversial treatments – it’s used less now than in decades past, but is still recommended in some cases of severe depression. It triggers epileptic seizures by applying electricity to an unconscious patient’s temples – a dramatic and, to some, a frightening idea for a medical therapy. Seizures have long been considered an alarming transformation of the body – to the ancient Greeks they were even “The Sacred Disease”: evidence of direct communication between the human world and a spiritual realm. Fits appear to overwhelm the flesh, as if the spirit has been possessed, or has temporarily left the body. Following a seizure many people experience a period of quiet sedation, as the brain recovers to its pre-seizure state. That seizures were once considered “sacred” is understandable – the first time I saw someone collapse with a fit, convulse, then drift off to sleep, it was as if I’d watched a process of possession, catharsis and sanctification.

  Paracelsus, an alchemist-physician of the sixteenth century, called epilepsy “the Falling Sickness.” He agreed with the ancient Greeks: epilepsy was “a spiritual disease and not a material one,” but despite its spiritual basis he insisted that seizures could respond to physical treatment, recommending a mixture of camphor (an irritant oil made from the bark of laurel trees), metal ash and “extract of unicorn.” In the sixteenth century ingestion of camphor was known to cause seizures, so it was paradoxical of Paracelsus to recommend its use in epilepsy.

  A major problem of the day was how to sedate lunatics to stop them injuring themselves and others, and Paracelsus had noticed that epileptics seemed subdued following attacks. His genius was to connect the two: he wondered if by inducing seizures with camphor, he could sedate those caught up in an agitated frenzy – the first recorded instance of shock therapy. Paracelsus’s influence was still felt as late as the eighteenth century: several reports were published in the 1700s describing camphor-induced seizures in the treatment of both lunacy and mania.

  In the nineteenth century camphor fell out of fashion – it was too dangerous and unreliable – but the concept was resurrected in th
e 1930s by a Hungarian neurologist, Ladislas Meduna. Meduna had examined brains under the microscope and noticed that those of individuals who had suffered epilepsy were unusually dense with “glia” – the supporting cells that provide scaffolding in the brain. Glial cell proliferation represents a form of scarring (the brains of boxers also exhibit this “gliosis”). Others had reported that the brains of schizophrenics had a lower concentration of glial cells than normal, and Meduna wondered if the two observations were related. If he could induce scarring through the induction of repetitive seizures, he reasoned, maybe he could subdue madness. (The same reasoning might have led him to recommend that schizophrenics take up boxing.)

  He began in 1934 as Paracelsus had done four centuries earlier, using camphor. But instead of using it to quiet those patients caught up in a manic frenzy, he chose subjects whose psychosis was manifest through catatonia – an unresponsive stupor. After a few camphor-induced seizures some of his patients did indeed become more responsive; he claimed a 50 percent success rate in “shocking” his patients back into interaction with the world. Camphor was slow and unpleasant for the patient: sometimes the seizures wouldn’t come on for three hours after a painful intramuscular injection. Meduna switched to a drug called Cardiazol that works far more quickly but has horrible side effects for the patients – it initiates muscle spasms and generates strong feelings of panic. Despite this, the 1930s saw psychiatrists across Europe experimenting with Cardiazol-induced seizures in the treatment of their catatonic patients.

  The 1930s were a time of reckless experimentation with the brain: the first lobotomies were performed, and a division arose between “neurology” and “psychiatry” that mirrored the evolving distinction between disorders of the brain and the mind. There was a feeling among those working in psychiatry that something had to be done to put it on a par with the rest of “physical” medicine, where new treatments were being developed every year.