Popular Science Monthly/Volume 74/June 1909/Suggestions from Two Cases of Cerebral Surgery Without Anesthetics
| SUGGESTIONS FROM TWO CASES OF CEREBRAL SURGERY WITHOUT ANESTHETICS |
By Professor GEORGE TRUMBULL LADD
YALE UNIVERSITY
FOR the first time, so far as I am aware, there have been placed on record two cases of cerebral surgery, accompanied by somewhat extensive explorations of the brain-substance, without the use of anesthetics. The suggestions afforded, and the problems further opened, by these cases are so interesting from the psychological point of view that it seems to be desirable at least to call to them the attention of this association. Only one of these cases has as yet been reported in print;[1] for some of the facts connected with the other case I am indebted to correspondence with the operating surgeon, Dr. Harvey Cushing, of Johns Hopkins University.
Briefly described, the case of which we have the fullest report was as follows. The patient, R. C, was 32 years of age, unmarried, a farmer and teacher, a man quite up to the average of his class in intelligence, and of excellent moral habits. Previous to the beginning of his present trouble he had been in excellent health. When nine years of age he received a slight blow on the head; later, he received a blow from a baseball bat which fractured his nose. No other causes of possible cerebral injury were discoverable. About the year 1895 he began "to suffer from curious nervous attacks, which came on without cause." These consisted of strange sensations in the head, and twitchings of the left calf. But there was no loss of consciousness and the seizures lasted only a few minutes. With these symptoms there subsequently became associated tingling sensations, which sometimes spread up the left leg even to the thorax and the left arm, and more extensive twitching of the muscles, spreading itself in the same direction. These seizures were followed by numbness in the parts involved; but until July, 1900, there were no fits with complete loss of consciousness; and at the time of the first operation loss of consciousness had occurred only six times, although during the ten years previous there had been several hundred seizures.
The patient had, however, been subject to headaches from childhood, and these became more and more severe after the nervous attacks already described. For three months early in the year 1903, the headaches were particularly intense, and this period of intense pain in the head ushered in a period of definite occular symptoms, consisting of momentary attacks of blindness, followed by diplopia for two or three days. The headaches suddenly disappeared, but there was permanent loss of visual acuity, weakness of the left leg, and general nervousness.
At the time the patient entered the hospital, careful examination of the nervous condition gave the following results: The optic nerves seemed atrophied and there was some constriction of the visual fields. There was distinct hemiplegic limp on the left side, a slight weakness in the dorsal flexion of the left ankle, and possibly also in the flexion of the knee and hip. The reflexes of the left leg were also somewhat exaggerated. On the contrary, sensation seemed to be normal over the arm and hand. The deep reflexes in the arms and right leg were normal. The sensibility of the right leg and foot were without discoverable abnormality.
The conclusion of the diagnosis made at this time affirms: "It was evident that the patient was suffering from an organic lesion situated in the upper part of the Rolandic region, involving the cortex itself or lying just below it."
Four different operations were performed for relief of this patient, between the dates of November 22, 1906 and March 21, 1907. These were all unsuccessful and did not even reveal the cause of the malady, and this unfavorable result was chiefly due to the fact that the patient bore anesthetics—both chloroform and ether—so badly and the cyanosis was so profound and threatening as to compel the surgeons to abandon their attempts at further exploration of the brain, lest it might lead to a fatal result. Moreover these operations served to show that the exposed surface of the brain was entirely normal in appearance; and when this part of the cortex was faradized, there was no abnormality of motor response. "Clean-cut movements were elicited in the toes, lower leg and thigh." In the same way movements were also obtained in the thoracic muscles, in the lateral abdominal muscles and in the muscles of the shoulder; and from still lower centers were obtained flexion of the elbow and flexion of the wrist. Posterior to the central fissures no motor responses could be elicited.
Following the third operation, or on and after December 23, 1906, the seizures increased in severity. Aggravated by the weakness following an attack of bronchial pneumonia in January, 1907, the nervous symptoms increased to one or more daily, consisting of severe epileptiform fits which involved the entire body, and always with loss of consciousness.
The constant and urgent request of the patient for relief, at all risks, from his distressing condition, induced the doctors to attempt the fourth operation; and when this was unsuccessful even to the extent of revealing the abnormal conditions, to the fifth operation, which was without anesthetics and which is the one chiefly interesting from the psychological point of view.
This fifth operation was performed March 26, 1907. The bone flap was for the fifth time reflected; the dura was incised some distance outside the largest previous incision; an incision was made into the gyrus centralis posterior, which appeared somewhat flattened and yellowish in color; and about one centimeter below the surface the top of a thin-walled cyst came into view. By enlarging the incision until it measured 5 centimeters this cyst was removed; but below it a still larger cyst was disclosed, which was "in turn shelled out of its bed by pushing the brain away from it, and was in this way removed unruptured." The entire procedure lasted about three hours.
But what about the mental condition of the patient during this long-continued and extensive exploration and cutting and pulling of the brain and its integuments? We are informed that he was "interested," asking questions and conversing with the doctors most of the time. Although perfectly conscious, he "experienced no sensory impressions whatever, even when the dura was incised." The only discomfort, not to say pain, given to him by these extensive explorations of his brain, was when the edge of the incision of the dura was caught in a clamp and the membrane dragged upon. The patient himself called the attention of the surgeons to an otherwise unnoticed phenomenon which consisted of a slight twitching of the muscles of the left side and shoulder.
In his report Dr. Cushing expresses his regret that this rare opportunity was not seized in order to test the effects of stimulating the posterior and post-central convolutions upon the experience of conscious sensation. In a subsequent case of cerebral surgery without anesthetics, however, these convolutions were stimulated and distinct impressions of sensations were obtained which were localized by the subject in the extremities and not at all in the cortex itself.[2] No such sensory impressions were obtained by stimulating the pre-central area, or "motor strip," although the customary motor results were obtained. Further details of the second case were not at my disposal at the time of writing this paper.
The following remarks upon these surgical results as viewed from the psychological point of standing are intended as suggestions rather than as definitely established conclusions.
And, first, it would seem that the cerebral hemispheres, including their integuments, are largely or completely devoid of the capacity of self-feeling. It has been known for some time that the substance of the brain is insensitive to pain; but it has hitherto been held that the dura is a highly sensitive tissue. This belief was strengthened by the knowledge that this membrane receives its innervation from the trigeminal nerve, and by the experience that in trephining the lower animals, when the dura is reached, struggling, and rise in blood-pressure are common. But here was a fully conscious subject, able intelligently to describe his sensations, who felt no pain while the membranes over that part of the brain which is allotted to sensory impressions were incised and manipulated. This experience, therefore, throws back upon us the problem: What is it that causes intracranial pain, especially in the form of those intense headaches which follow upon disturbances of the cerebral blood-supply, or in cases of cerebral lesion like that now under discussion? May we not find that the causes of the pains which we locate in the cerebral hemispheres invariably lie outside of those hemispheres? Certainly, it is not strange that the localization in such cases should be even more indefinite than in the case of an aching tooth or some form of abdominal distress. Indeed, cerebral pains and other forms of discomfort, with their accompanying mental disturbances, may be so severe as to result in insanity, and yet the location of the irritating causes, whether nearby or remote from the brain, remain undiscovered.
Second, there is both additional light and increased confusion contributed by these cases of cerebral surgery without anesthetics to the problem of the functions of the post-central and so-called sensory convolutions. In both these cases stimulation of the motor strip called out motor responses; stimulation of the post-central area failed to call out motor responses. More important still by far is the fact that, in the second case, stimulation of the post-central convolutions was followed by distinct sensory impressions—not mere signs of such impressions, but conscious sensations, testified to in language by their subject; and these sensory impressions were located in the extremities and not at all in the cortex itself. This is definite and fairly conclusive evidence to the functional value of the post-central convolutions. But now, on the other hand, we have the fact that, although the incision was made in the middle of the field supposed to be especially if not exclusively sensory, no subjective sensations whatever were called forth in this way; and the yet more startling fact—T quote the words of Dr. H. M. Thomas, clinical professor of neurology in Johns Hopkins University—that.
All this accords with the evidence upon which our whole localization theory is based. This evidence tends to show: (1) that the different forms of mental functioning are not absolutely dependent upon definitely circumscribed and permanently fixed portions of the cerebral hemispheres; and (2) that by mental development a relative independence of the particular areas originally connected with the different forms of mental functioning may be attained. From the physiological point of view the cerebral substance appears as plastic and educable to a degree until recently unsuspected. And any dislocation or interruption of the proper connections becomes more dangerous than even a considerable loss of the brain-substance. From another point of view the same conclusion was reached in a paper entitled "A Suggestive Case of Nerve-Anastomosis," which I read before the Psychological Association at its meeting in 1904. I take this opportunity to call attention to the fact that Dr. Gushing by a purposeful division of the facial nerve and its anastomosis with the spino-facial, has more recently succeeded in restoring to the patient a considerable degree of normal emotional control of the expressive muscles of the face. I leave to expert physiologists to conjecture what new adjustments in their related forms of functioning this required from the cerebral hemispheres.
Third, these cases of cerebral surgery without anesthesia would seem further to confirm what has for some time been held to be true —namely, that slow abnormal developments, even when they finally involve much more serious destruction of the cerebral areas, and interruptions of the normal connections, are tolerated much more easily than sudden and rapid lesions or other abnormalities. Nor does it appear wholly out of place to say that while this education of the cerebral hemispheres to unwonted functions requires time, the emotions and will of the conscious agent are factors of the greatest importance in securing the results of this education.
Finally, there is one thought which I bring forward, not as a matter of argument, much less of proof; but, the rather, as a personal impression amounting almost to a conviction. In stating this impression I will take the liberty to employ the language of an "old-fashioned" but by no means altogether discredited psychology. Here is an intelligent human soul; he remains perfectly conscious, free from pain, and taking a lively interest in a surgical operation which explores, incises, pulls about, and otherwise manipulates, and finally drags two large abnormal growths out from, what is known to be the most important part, for the life of conscious sensation and voluntary motion, of his own brain. From the anatomical and physiological points of view, this picture is sufficiently startling. But when I take the more purely psychological point of view, I am impressed with the conviction that we are here dealing with the reality of a soul, as a spiritual agent, which while it is confessedly dependent for its development upon the development and normal functioning of the nervous centers, is, nevertheless, capable of attaining in the exercise of its higher and more complex forms of self-consciousness, a relative independence of those nervous centers. And if we ask ourselves whether this independence may perchance become absolute, after the destructive forces of nature have completely disintegrated the cerebral substance, we can not, indeed, answer "Yes," with the certainty of positive science. But upon my mind the impression made by such experiences as these is favorable to the affirmative answer. And so far as positive science can answer the inquiry at all, or even throw much light upon it, I prefer to follow along the lines of the seen and tangible and universally verifiable, rather than take the leap involved in a premature interpretation of doubtful phenomena by hypotheses touching the wholly unseen and intangible. Here, at any rate, is this conscious soul, manifesting itself as a partially "disembodied spirit." Its voice I can hear and interpret as one of my own kind. This manifestation appeals to me at present, and in accordance with scientific methods, much more strongly than any alleged communications from wholly disembodied spirits. Perhaps, however, at sometime in the future of the physical and psychological sciences, the two voices may speak with one accord.
- ↑ "Removal of a Subcortical Cystic Tumor at a Second-stage Operation without Anesthesia" (reprinted from the Journal of the American Medical Association, March 14, 1908, Vol. I., pp. 47-856).
- ↑ Still more recently, as I have learned in conversation, in a third case of cerebral surgery without anesthetics, the same operator obtained similar results of conscious sensations by faradizing the same region of the cerebral surface.