Authors: Richard Hollingham
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.
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.
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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 with 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.
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.
Psychiatric hospitals were known as snake pits. They were ware-houses
where society dumped the mentally ill; locked people away –
often for years, sometimes for a lifetime. They were places of horror
and hopelessness. Wards were packed with beds, with hardly any
space to move between them. The sheets would be soiled, many of
the patients ignored. There were too few staff, and many of those
acted more like prison warders than hospital carers.
As he walked through the wards, past the padded cells and
through the heavy steel doors, Freeman saw things that would
make a lasting impression on anyone. There were young men
squirming on the floor, their hands tied so that they could no
longer claw at their skin. He saw patients being force-fed, their jaws
clamped open by burly orderlies. Some patients would suddenly
become violent and abusive, only to be dragged off to a cell. Others
would be sitting, just sitting, staring into nothingness, as if their
brain had simply shut down.
Although St Elizabeths was one of America's largest mental
institutions, it was typical of others around the world. Admissions to
psychiatric hospitals were growing by some 80 per cent each year,
but the worst thing was that they could offer little in the way of treatment.
For the most part, the best the staff could do was keep the
patients alive. Those who attempted suicide were restrained or
constantly monitored. The only hope was that the mentally ill would
recover spontaneously after their period of 'rest' in the hospital. For
most patients the stay in hospital had the opposite effect and their
condition simply deteriorated.
By the 1940s what treatments there were relied on shocking the
brain back to health – sometimes quite literally. Doctors would overdose
their schizophrenic patients with injections of insulin to
induce convulsions. Others preferred to use a drug called Metrazol
to induce seizures. Metrazol convulsions were so violent that
patients were contorted in agony, and many suffered fractures to
their spine. Patients begged doctors not to put them through this
torture but, as some doctors reported that the seizures were resulting
in dramatic cures, their pleas usually fell on deaf ears.
The most controversial of all the shock therapies was ECT –
electroconvulsive shock therapy. Invented by an Italian who had
seen electric shocks used to stun pigs prior to slaughter, it appealed
to psychiatrists because it was quick, cheap and easy to use, and was
much more controllable than Metrazol. The other advantage of
ECT was that it could be used to control the behaviour of patients.
There is plenty of good evidence that ECT is effective at treating
mental illness, and it is still used today under controlled conditions
and with the full consent of the patient. However, in the 1940s, as
ECT spread to hospitals across the world, it was quickly adopted as
a way of keeping patients subdued.
The procedure was simple enough. Patients would be held
down on a bed while electrodes were placed on either side of their
head. Some ECT machines employed a Y-shaped electrode, like a
catapult, that could be held by the doctor. When the current was
turned on the electricity induced a seizure, leaving the victim
passive and quiet. Aggressive patients could be given several shocks
a day to keep them under control. Patients would be threatened
with ECT if they did not behave.
This is the world Dr Walter Freeman was working in – a world
he was determined to change. The theory of localization was now
widely accepted and Freeman was convinced that mental illness was
a result of a physical defect in the brain. It was a view backed by the
apparent effectiveness of shock therapies. But rather than fire jolts
of electricity through the brain, he wanted to change the whole way
it was wired up.
Freeman was determined to get to the root cause of mental
illness. In his laboratory he worked tirelessly, examining thousands
of brains – slicing them, dissecting them. Day and night he measured
the brains of dead mental patients and compared them with
'healthy' brains. Freeman was becoming an expert in brain
anatomy, but however much he sliced, diced, measured and
dissected, he could find nothing to distinguish the brain of a
severely mentally ill patient from the brain of anyone else. It seemed
like he had reached a dead end. He had wasted years of his life in
pursuit of a physical defect that didn't exist. Then he came across
the work of Portuguese surgeon Egas Moniz.
In 1935 Moniz had carried out a radical new operation. He
called it a leucotomy. The procedure involved drilling several holes
in the front of the patient's skull above the frontal lobes of the
brain. Moniz then inserted an instrument he had devised, known as
a leucotome. The device acted like an apple corer. When the
surgeon pressed down on a plunger and rotated the leucotome,
he could extract a brain core one centimetre wide. Usually, he
would take about four cores of brain during an operation. Moniz
could claim, with some justification, that around one-third of his
operations were successful. He never came up with a scientific
explanation for why leucotomies worked, but said they made his
patients calmer and less agitated; they removed many of the
symptoms of anxiety and psychosis. He believed the procedure had
no effect on the intelligence of the patients and that it enabled
them to lead normal lives once again.
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