Blood and Guts (31 page)

The practice of trepanning was in widespread use from around
10,000 BC, before the invention of reading or writing. The incredible
thing is that archaeologists have found skulls with holes drilled
in them all over the world. The evidence suggests that trepanning
was being practised by many different peoples in completely different
locations. These were communities that were segregated by
geography. They had no possible way of contacting each other or,
indeed, any knowledge of the others' existence. This implies that
either many groups developed trepanning separately, or that the
practice was passed down from our earliest human ancestors.

The big question is why? Why on earth would you want to drill
a hole in someone's head? There could be any number of reasons,
which historians can only guess at. In some civilizations, those who
were trepanned also show evidence of head injuries, suggesting that
trepanning was used as a treatment. It might also have been used to
cure headaches, epilepsy or insanity. Perhaps it allowed demons to
escape. There is speculation that it might even have given the recipient
magical powers – a window, perhaps, to the gods.
^*

^*
You might think you need trepanning like a hole in the head, but it is still practised today.
Surgeons have to use drills to access the brain, but there are also alternative therapy groups
that recommend trepanning for all sorts of mental health conditions. In 2000, for instance,
a British woman decided to do her own DIY brain surgery. Twenty-nine-year-old Heather
Perry from Gloucester injected herself with a local anaesthetic before drilling a one-inch hole
in her own skull. Unfortunately, the drill went in too far, damaging a membrane and requiring
emergency medical help. Despite the mishap, she told reporters she had no regrets about
the procedure.

Back in the nineteenth century there were three major challenges
facing budding brain surgeons: the risk of infection, the
danger of haemorrhage and the fact that they had very little idea
what each bit of the brain did. The issue of infection applied to any
major surgery, but infection from operations was gradually being
defeated as Lister's reforms were adopted. As for controlling blood
loss, this was still a significant problem. The brain has more than
four hundred miles of blood vessels and consumes nearly two pints
of blood every minute. The scalp, brain and bone are all extremely
bloody, so cutting into the skin, skull and membranes surrounding
the brain means there is a good chance of a patient bleeding to
death on the operating table.

As for understanding how the brain works and the functions of
its different areas, these are things that scientists are still grappling
with today. Phineas Gage gave surgeons an insight into the role of
the frontal lobes, but any sort of accurate map of the mind was still
a long way off. All this left surgeons powerless to help people with
brain injuries or tumours. Or to find a surgical cure for insanity.
Even so, despite limited knowledge and unrefined techniques, some
surgeons were still prepared to have a go.

Hospital for Epilepsy and Paralysis, London, 1884

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.