The Tale of the Dueling Neurosurgeons

by Sam Kean

  During his convalescence Penfield decided that God must have spared him for some higher purpose. Over the next decade he determined that that purpose was to illuminate the age-old mind-body problem—how a material brain produces an immaterial mind. The question had first tickled him at Oxford, in research labs where scientists had removed the upper brains of cats. These cats ate and slept and moved about just fine, but they’d become zombies—any sense of playfulness or personality vanished. Extrapolating, Penfield wondered where humankind’s highest faculties sat, and he decided to find out. For a junior surgeon to take on the mind-body problem when Aristotle, Descartes, Cajal, and other luminaries had failed wasn’t hubris, or at least not only hubris. New neurosurgical techniques were finally allowing scientists to work directly with the living brain—to prod it, palpate it, probe it with electricity. The prospect thrilled Penfield, and he spent the next few decades trying to glimpse the “ghost in the machine.”

  Such were the high-minded thoughts that had distracted Penfield for years. The news about Ruth brought him crashing back down to the stark medical realities of life and death. He’d accepted the job in Montreal only months before, and she arrived at his new house looking dazed and groping for handholds. Even before she ate breakfast, Penfield sat her down and shined a light into her eyes. Her optic nerve looked swollen, and he spotted little red hemorrhages on her retina, like cracks in a failing dam. He knew immediately, and had to steady himself on her shoulder. A tumor behind her sinuses was crushing her brain.

  Someone had to operate, soon. So after he sent Ruth to lie down, Penfield gathered three colleagues in his parlor and nominated himself. His aggressive approach would serve Ruth best, he argued: pussyfooting around, by leaving too much tissue behind, would only condemn her down the line. That said, Penfield knew that a sensible physician doesn’t treat loved ones—seeing them laid bare can make even the steadiest hands tremble—so he asked his colleagues for advice. They debated a long while, but permitted him to scrub in.

  On December 11, 1928, Ruth drank a high-protein shake for breakfast at the hospital. Nurses “Bic’d” her head down to the smooth scalp and sterilized her skin. Penfield then used a wax crayon to outline a horseshoe above her right eyebrow. He sawed around the horseshoe and flipped open a trapdoor of skull, exposing her brain. A nearby atomizer kept the surface glistening with puffs of saline.

  He paused here and asked Ruth how she felt. Fine, she answered.

  Because the brain’s surface cannot feel pain, Ruth could stay awake for the operation, with only novocaine to dull her scalp, similar to what you’d get at the dentist. Penfield in fact preferred that patients remain conscious during surgery* and chat with the nurses, because that way he knew their brains were still functioning. (The danger started when they fell silent.) Not long into this operation, though, hearing Ruth chitchat about her six children unnerved him. Just this once, he asked his patient to hush.

  After decades of growth, the tumor had consumed most of Ruth’s right frontal lobe: it looked like a gray octopus sucking on her brain, with plenty of fat blood vessels feeding it. And although it consisted only of glial cells, its sheer bulk was crushing nearby neurons, which then misfired and caused seizures. Penfield set about removing the mass piece by piece; it felt somewhat hard to the touch, like crusty dough. In all, he had to remove one-eighth of her brain because of collateral tissue damage, the largest excavation he’d ever undertaken. From above, the remainder of her brain looked like a lopped-off loaf of focaccia.

  And that wasn’t the worst of it. As Penfield prepared to sew his sister back up, he noticed that one stray root of the tumor had slithered off along the skull floor. His eyes followed it into a hidden recess. The assisting surgeon noticed Penfield’s interest and murmured, “Don’t chance it.” But Penfield had nominated himself for the surgery exactly because he was the type to chance it—why leave a malignancy behind? So in what he later called “a frenzy”—“I was rather reckless,” he admitted to Ruth’s husband—he decided to attack. He wrapped a loop of silk thread around the final arm, drew it shut like a noose, and tugged.

  The arm pinched off and came free. Unfortunately, a nearby blood vessel also tore loose, and Ruth’s skull flooded. Penfield snatched some cotton wads to stanch the flow and pressed down hard, but her brain was disappearing beneath a rising red sea. Many tense minutes passed, and Ruth lost consciousness; only after three blood transfusions did she stabilize. Just as he sopped up the last bits of blood, however, thinking he’d won his gamble, he saw that the tumor had burrowed still deeper. It actually extended into Ruth’s left hemisphere, beyond where he could reach. At this, he wilted. The operation was over; the tumor had won. Years later he would revisit this moment—or rather, it would revisit him.

  During the next few days Ruth suffered the expected post-op headaches and nausea, but her memory, sense of humor, and stamina returned quickly. Three weeks after going home, in February, she even sent Penfield a letter about a recent night out at the Rotary Club, dancing with her husband. She’d felt spry and sexy and just so alive in her blue hat and blue dress. She told her brother that he’d given her her life back.

  Still, those close to Ruth noticed problems. Most important, she lacked what neuroscientists call an “executive sense,” meaning that she now struggled to form plans and see them through. (Elliot, in our previous chapter, also suffered from this.) Penfield observed this deficit firsthand in early 1930 on a trip to California, when he visited Ruth for dinner one night, a simple affair for five. She’d had all day to prep, and it should have been patty-cake for an experienced homemaker like her. But Penfield arrived in the late afternoon to find her in tears—her children running wild, the table unset, the ingredients for the salad and sides strewn across the counters. The night didn’t turn out badly after all: Ruth could still follow directions and cook just fine, so after Penfield calmed her down and got the roast roasting, she cheered up. Penfield, though, could only sigh: Ruth was no longer Ruth.

  In the end, Penfield’s surgery merely bought Ruth time—time she and her family cherished, but too little of it. In May 1930 the seizures returned, and her eyes began bulging again. Unable to face another surgery, Penfield sent her to Harvey Cushing in Boston. When Cushing opened Ruth up, he saw that the octopus had grown back, as ugly and greedy as before. Cushing, a more cautious surgeon than Penfield, scraped out what he could, but more seizures erupted six months later. At this point Ruth declined further treatment (she’d recently converted to Christian Science), and in July 1931 a stroke finally killed her.

  Ruth’s death brought Penfield back to the dark hours after her first surgery. After showering up that day, he’d slumped down on a bench in the surgeons’ dressing room, wrapped in a towel and near tears. He was probably the world’s most gifted young neurosurgeon, and he’d been whipped. But he’d recently learned a new surgical technique while on sabbatical in Germany. It involved stimulating the cortex with electricity to find the origins of people’s seizures. From a surgical point of view, the idea seemed promising—a way to cut down on guesswork and pinpoint exactly what tissue to remove. But Penfield had the vision to see the technique’s broader potential. Sparking the brain in different places often induced hallucinations, stray sounds, or muscle spasms in the patient—sensations unrelated to the seizures but interesting in their own right. At the time scientists had only just started to explore the brain’s topography, and Penfield realized that electrical stimulation could help them map the cortex with far more precision. What’s more, the technique might even help him solve the mind-body problem, since he could probe patients’ minds while they were awake…

  Penfield woke up from this reverie in the dressing room half naked, with one sock on his foot, the other still in his hand. He had no idea how long he’d been muttering to himself, perhaps for hours. But after he snapped to, he vowed to do something he’d long been pondering: establish a new neurological institute, so he could study the conscious brain in detail. Ruth
’s death reminded him of this promise and finally spurred him. The institute opened within a decade, and over the next twenty years Penfield probably did more than any other scientist to explain how the brain works in real time. And while he never did resolve the big metaphysical questions that God had spared him to answer, he did find something almost as amazing—fragments, traces, glimpses of what we might call the scientific equivalent of the soul.

  For most of recorded history, human beings situated the mind—and by extension the soul—not within the brain but within the heart. When preparing mummies for the afterlife, for instance, ancient Egyptian priests* removed the heart in one piece and preserved it in a ceremonial jar; in contrast, they scraped out the brain through the nostrils with iron hooks, tossed it aside for animals, and filled the empty skull with sawdust or resin. (This wasn’t a snarky commentary on their politicians, either—they considered everyone’s brain useless.) Most Greek thinkers also elevated the heart to the body’s summa. Aristotle pointed out that the heart had thick vessels to shunt messages around, whereas the brain had wispy, effete wires. The heart furthermore sat in the body’s center, appropriate for a commander, while the brain sat in exile up top. The heart developed first in embryos, and it responded in sync with our emotions, pounding faster or slower, while the brain just sort of sat there. Ergo, the heart must house our highest faculties.

  Meanwhile, though, some physicians had always had a different perspective on where the mind came from. They’d simply seen too many patients get beaned in the head and lose some higher faculty to think it all a coincidence. Doctors therefore began to promote a braincentric view of human nature. And despite some heated debates over the centuries—especially about whether the brain had specialized regions or not—by the 1600s most learned men had enthroned the mind within the brain. A few brave scientists even began to search for that anatomical El Dorado: the exact seat of the soul within the brain.

  One such explorer was Swedish philosopher Emanuel Swedenborg, one of the oddest ducks to ever waddle across the stage of history. Swedenborg’s family had made a fortune in mining in the late 1600s, and although he was raised in a pious household—his father wrote hymns for his daily bread and later became a bishop—Swedenborg devoted his life to physics, astronomy, and geology. He was the first person to suggest that the solar system formed when a giant cloud of space dust collapsed in upon itself, and much like Leonardo he sketched out plans for airplanes, submarines, and machine guns in his diaries. Contemporaries called him “the Swedish Aristotle.”

  In the 1730s, just after turning forty, Swedenborg took up neuroanatomy. Instead of actually dissecting brains, though, he got himself a comfy armchair and began leafing through a mountain of books. Based solely on this inquiry, he developed some remarkably prescient ideas. His theory about the brain containing millions of small, independent bits connected by fibers anticipated the neuron doctrine; he correctly deduced that the corpus callosum allows the left and right hemispheres to communicate; and he determined that the pituitary gland serves as “a chymical laboratory.” In each case Swedenborg claimed that he’d merely drawn some obvious conclusions from other people’s research. In reality, he radically reinterpreted the neuroscience of the time, and most everyone he cited would have condemned him as a luna-and/or heretic.

  The history of neuroscience might look quite different if Swedenborg had pursued these studies. But in 1743 he began to fall into mystical trances. Faces and angels hovered before him in visions, thunder pealed in his ears; he even smelled hallucinatory odors and felt odd tactile sensations. In the midst of these trances he often fell down shuddering, and an innkeeper in London once found him wrapped in a velvet nightgown, frothing at the mouth and babbling in Latin about being crucified to save the Jews. Swedenborg woke up insisting he’d touched God, and at different times claimed to have conversed with Jesus, Aristotle, Abraham, and inhabitants of the five other planets. (Uranus and Neptune hadn’t been discovered yet, or he surely would have met Uranians and Neptunians, too.) Sometimes the visions revealed answers to scientific mysteries, such as how bodies eaten by worms will nevertheless be reconstituted on Judgment Day. Other trances were more casual, like the time he brunched with angels, and discovered that some angels hate butter. Yet another time God pulled a mean joke and turned Swedenborg’s hair into a Medusa’s nest of snakes. Compared to such intense visions the cerebral pleasures of science had no chance, and from 1744 onward he devoted his life to chronicling these revelations.

  Swedenborg died in 1772, and history has returned a split verdict on his legacy. His eclectic dream diaries charmed the likes of Coleridge, Blake, Goethe, and Yeats. Kant, meanwhile, dismissed Swedenborg as “the arch-fanatic of all fanatics.” Many other observers were similarly baffled. What could transform a gifted and reserved gentleman scientist into someone whom John Wesley called “one of the most ingenious, lively, entertaining madmen that ever set pen to paper”? The answer may be epilepsy.

  At its most basic level epilepsy involves neurons firing when they shouldn’t and stirring up storms of electrical activity inside the brain. Neurons can misfire for many reasons. Some misfit neurons were born with misshapen membrane channels and can’t regulate the flow of ions in and out. Other times, when axons suffer damage, neurons start discharging spontaneously, like frayed electrical wires. Sometimes these disturbances remain local, and just one location in the brain goes on the fritz, a so-called partial seizure. In other cases, the seizure short-circuits the entire brain and leads to either a grand mal or a petit mal seizure. Grand mals (now called tonic-clonic seizures) start with muscular rigidity and end with the stereotypical thrashing and foaming; they’re what most of us think of when we think of epilepsy. Petit mals avoid the thrashing but usually cause “absences,” in which the victim freezes up and her mind goes blank for a spell. (William McKinley’s wife, Ida, suffered from petit mals. During state dinners McKinley sometimes just draped a napkin over her face and blustered through the next few minutes to divert attention.)

  The triggers for epileptic fits can be bizarrely specific: noxious perfume, flashing lights, mah-jongg tiles, Rubik’s cubes, wind instruments, parasitic worms. Although potentially embarrassing, seizures don’t always compromise someone’s quality of life—and in rare cases, people benefit. Some first-time seizure victims find that they can suddenly draw much better or that they now appreciate poetry. Some folk (but only women so far—sorry, guys) orgasm during seizures. Specific triggers aside, seizures do erupt most commonly during times of stress or psychological turmoil. Probably the best example of this is Fyodor Dostoyevsky.

  Biographers disagree about whether Dostoyevsky suffered any seizures when young, but he himself said that his epilepsy emerged only after his near execution in Siberia. Dostoyevsky and some fellow radicals were arrested in April 1849 on charges of plotting to overthrow Czar Nicholas. That December soldiers dragged the lot of them to a snowy public square studded with three tall posts. Until that moment the comrades assumed they’d get off with breaking rocks for a spell. Then a priest arrived, as did a firing squad, and clerks handed the prisoners white smocks to change into—funeral shrouds. Dostoyevsky grew frantic, especially when a friend pointed to a cart filled with what looked like coffins. Soldiers meanwhile marched the crew’s ringleaders to the posts and covered their eyes with white hoods. The gunmen raised their rifles. A minute of agony passed. Suddenly the rifles dropped, and a messenger clattered up on horseback, carrying a pardon. In reality Nicholas had staged the entire scene to teach the punks a lesson, but the stress unhinged Dostoyevsky. And after he’d spent a few months in a labor camp (the czar didn’t let them off that easy), the abusive guards and harsh weather finally pushed him over the edge, and he had his first major fit—shrieking, foaming, convulsions, the whole production.

  That first seizure lowered the threshold inside Dostoyevsky’s brain, and after that, any mild stressor, mental or physical, could fell him. Guzzling champagne could trigger fits, as could sta
ying up all night to write or losing money at roulette. Even conversations could detonate him. During a philosophical bull session with a friend in 1863, Dostoyevsky began pacing back and forth, waving his arms and raving about some point. Suddenly he staggered. His face contorted and his pupils dilated, and when he opened his mouth a groan escaped: his chest muscles had contracted and forced the air out. The seizure that followed was intense. A similar incident occurred a few years later, when he collapsed onto the divan in his wife’s family’s living room and began howling. (This couldn’t have impressed the in-laws.) Dreams could set him off as well, after which he usually wet the bed. Dostoyevsky compared the seizures to demonic possession, and he often plumbed the agony of them in his writing, including epileptic characters in The Brothers Karamazov, The Insulted and Injured, and The Idiot.

  Dostoyevsky almost certainly had temporal lobe epilepsy. (As mentioned, the temporal lobes sit behind your temples and wrap laterally around the brain, somewhat like earmuffs.) Not all temporal lobe epileptics thrash and foam, but many of them do experience a distinctive aura. Auras are sights, sounds, smells, or tingles that appear during the onset of seizures—a portent of worse things to come. Most epileptics experience auras of some sort, and most non–temporal lobe epileptics find them unpleasant: some unlucky folk smell burning feces, feel ants crawling beneath their skin, or pass horrendous gas. But for some reason—perhaps because the nearby limbic structures get revved up—auras that originate in the temporal lobes feel emotionally richer and often supernaturally charged. Some victims even feel their “souls” uniting with the godhead. (No wonder ancient doctors called epilepsy the sacred disease.) For his part, Dostoyevsky’s seizures were preceded by a rare “ecstatic aura” in which he felt a bliss so intense it ached. As he told a friend, “Such joy would be inconceivable in ordinary life… complete harmony in myself and in the whole world.” Afterward he felt shattered: bruised, depressed, haunted by thoughts of evil and guilt (familiar motifs in his fiction). But Dostoyevsky insisted the hardship was worth it: “For a few seconds of such bliss I would give ten or more years of my life, even my whole life.”