The Tale of the Dueling Neurosurgeons: The History of the Human Brain as Revealed by True Stories of Trauma, Madness, and Recovery

by Sam Kean

  When Wiens awoke, he felt his new, swollen face pressing down hard, like a lead mask. He could breathe only through a tube in his trachea. But all the discomfort seemed worth it a few days later. In a moment so mundane it’s poignant, he found he could finally smell food again. Lasagna. Touch sensation returned not long after, and he felt, really felt, his daughter’s kiss for the first time in years. Wiens even began dreaming of himself with his new face. These were moments the World War I masks, even the most artistic, could never replicate.

  As with hand transplants, doctors found that the more patients used their transplanted faces—shaving, smiling, applying makeup, smooching, getting smooched—the more they accepted the new faces as theirs, regardless of what they looked like. Humans do rely on vision to an extraordinary degree, and our visual circuits occupy far more brain territory than other sensory circuits. It’s no surprise that looks are so tied up with our sense of self. Ultimately, though, one important truth of neuroscience is that the brain constructs our sense of self from more than mere looks. As we’ll see later, our sense of self also draws on our emotional core and our memories and our personal narratives of our lives. The earliest face transplants took place in 2005, so their long-term medical viability remains unknown. But psychologically, at least, they’ve succeeded: the brain will indeed accept a new mien in the mirror—in part because it’s only a mien, a covering. As one observer noted, “If a face transplant demonstrates anything about what it means to be human, it may be that we are less superficial than we imagine.”

  PART III

  BODY AND BRAIN

  CHAPTER FIVE

  The Brain’s Motor

  Now that we’ve learned about some internal brain structures, it’s time to explore how the brain interacts with the outside world. It does so primarily through movement, which involves transmitting messages to the body via nerves.

  George Dedlow. The dimes and quarters and silver dollars trickling into Philadelphia’s “Stump Hospital” often came with notes of sympathy for George Dedlow. Every man crowding around the hospital’s front door wanted to tip his hat to, and every woman blow a kiss at, George Dedlow. The hospital superintendent pleaded ignorance, but well-wishers never tired of asking about Captain George Dedlow.

  The cover story of the July 1866 issue of The Atlantic Monthly was “The Case of George Dedlow,” one of the saddest of the Civil War’s many sad tales. In the introduction Dedlow claimed that he’d originally tried to publish his report in a proper medical journal, and after a number of rejections had transformed the piece into a personal narrative. The action began with Dedlow joining the 10th Indiana Volunteers as assistant surgeon in 1861, despite having completed just half of medical school. The U.S. military was so desperate for surgeons then—it had just 113, a small fraction of the 11,000 that both armies would require during the war—that most units snatched up even tyros like him.

  One night in 1862, Dedlow writes, while stationed near a malaria-ridden marshland south of Nashville, he received orders to sneak through twenty miles of enemy lines and secure some quinine. Seventeen miles in, he stumbled into an ambush and got shot in both arms—in his left biceps and right shoulder—and passed out. He woke to find the rebels, like centurions at the cross, drawing lots for his hat, watch, and boots. They eventually dumped him into a medical cart, which rattled him 250 miles south to an Atlanta hospital. His right arm throbbed the whole journey, burning as if it were being held near flames; he found relief only by dousing it with water. The burning continued for six weeks, and the pain became so acute that when his doctor suggested amputating the arm, Dedlow agreed despite the lack of ether.

  After recovering, Dedlow was exchanged for a Southern captive. Rather than return home, the one-armed doctor took just thirty days of furlough and rejoined his unit. The Indiana boys ended up in Tennessee again, and once again Tennessee did not treat them well. During one of the bloodiest battles in U.S. history, near Chickamauga Creek, Dedlow’s unit got caught in intense crossfire while scampering up a hill. Clouds of gun smoke enveloped them, punctured by red lightning and rifle thunder. This time Dedlow got shot through both legs, one of the battle’s 30,000 casualties.

  He awoke beneath a tree, in shock, with two shattered femurs. Orderlies gave him brandy and cut away his pantaloons while two surgeons—wearing navy-blue uniforms with green sashes about the waist—bent to examine him. They grimaced and walked away, damning him by triage. Sometime later, though, Dedlow felt a towel against his nose, then inhaled the fruity chemical pinch of chloroform. Two other surgeons had returned, and although Dedlow didn’t realize it, they’d decided to amputate both legs right there in the field.

  Confederate surgeons usually performed “circular” amputations. They made a 360-degree cut through the skin, then scrunched it up like a shirt cuff. After sawing through the muscle and bone, they inched the skin back down to wrap the stump. This method led to less scarring and infection. Union surgeons preferred “flap” amputations: doctors left two flaps of flesh hanging beside the wound to fold over after they’d sawed through. This method was quicker and provided a more comfortable stump for prosthetics. Altogether, surgeons lopped off 60,000 fingers, toes, hands, feet, and limbs during the war. (In Louisa May Alcott’s Hospital Sketches, one Union soldier proclaims, “Lord!, what a scramble there’ll be for arms and legs, when we old boys come out of our graves on the Judgment Day.”) A typical amputation lasted maybe four minutes, and on the worst days a surgeon might do a hundred—some in fields, some in barns, stables, or churches, some on nothing but a plank suspended between two barrels. In borderline cases surgeons erred on the side of amputating, since the mortality rate for compound fractures was abysmal. Not that the mortality rate for amputations was good. Sixty-two percent of double thigh amputees died.

  To his later sorrow, Dedlow woke up after his double thigh amputation. But it was at this very moment—in his fog, before he realized what had happened—that Dedlow’s tale swerved and began to transcend a typical soldier’s sob story. For despite the operation, Dedlow awoke with cramps in both calves.

  He hailed a hospital attendant, gasping, “Rub my left calf.”

  “Calf? You ain’t none,” the attendant answered. “It’s took off.”

  “I know better. I have pain in both legs.”

  “Wall, I never. You ain’t got nary leg.” With this, Dedlow recalled, “he threw off the covers and, to my horror, showed me…”

  Faintly, Dedlow dismissed him. He lay back, ill, probably wondering if he’d gone mad. But damn it, he’d felt the cramps in both legs. They’d felt intact.

  Soon another tragedy befell him. Dedlow’s left arm had never quite healed right after the ambush near Nashville and continued to weep pus. Now, in the dirty recovery ward, the arm contracted “hospital gangrene,” an aggressive disease that could eat away flesh at rates of a half inch per hour. Almost half of all victims died in their beds, and against his better judgment, Dedlow let his doctors save his life by amputating his last remaining limb. He awoke to find himself, he later sighed, a diminished thing, more “larval” than human.

  In 1864, Dedlow was transferred to Philadelphia’s South Street Hospital—nicknamed “Stump Hospital” for all the amputees limping through its corridors. But even within Stump, Dedlow’s helplessness set him apart: orderlies had to dress him every morning, had to drag him to the toilet at all hours, had to blow his nose and scratch his every itch. Virtually sedentary—orderlies had to carry him everywhere in a chair—he needed almost no sleep, and his heart beat just forty-five times per minute. With so little body to nourish, he could barely finish the meals that orderlies had to feed him bite by bite.

  Yet he could somehow still feel that missing four-fifths of himself—still feel pain in his invisible fingers, still feel his invisible toes twitching. “Often at night I would try with one lost hand to grope for the other,” he recalled, but the ghosts always eluded him. Out of curiosity he interviewed other Stump inmates and discovered t
hat they felt similar sensations—stabbing, cramping, itching—in their missing limbs. Indeed, the ungodly aches in their ghost arms and ghost legs often made their missing limbs more insistent and intrusive than their real ones.

  Dedlow didn’t know what to make of this phenomenon until, a few depressing months later, he met a fellow invalid, a sergeant with washed-out blue eyes and sandy whiskers. They struck up a conversation about spiritualism and communicating with departed souls. Dedlow scoffed, but the sergeant talked him into attending a séance the next day. There, after some preliminary mumbo jumbo, the mediums started summoning up people’s dead children and late spouses—a trick that often reduced the participants to hysterics. The mediums also relayed messages from the beyond, Ouija board–style, by pointing to letters on an alphabet card. They then listened for a confirmatory knock (spirits can knock, apparently) upon reaching the correct letter. Eventually a wan medium with bright red lips named Sister Euphemia approached Dedlow. She asked him to silently summon to mind whomever he wanted to see. All at once, Dedlow says, he got a “wild idea.” A moment later, when Euphemia asked if Dedlow’s guests were present, two knocks sounded. When Euphemia asked their names, they tapped out, cryptically, “United States Army Medical Museum, Nos. 3486, 3487.”

  Euphemia frowned, but Dedlow, a war surgeon, understood. As reported by Walt Whitman (and many others who couldn’t shake the image from their minds), hospitals routinely piled all their amputated limbs outside their doors, forming cairns of legs, arms, and hands. Rather than bury them, though, the army packed the flesh into barrels of whiskey and shipped them to the Army Medical Museum, which catalogued them for future study. Dedlow’s legs were apparently numbers 3486 and 3487, and per his wish, Euphemia had summoned them to the séance.

  At this point the story swerved again. Dedlow suddenly cried out, then began to rise in his chair. He reported feeling his ghost legs beneath him, reattaching themselves to his femurs. A moment later his torso rose, and he began staggering forward. He felt unsteady at first—after all, he noted, his legs had been soaking in booze. But he crossed half the room before they dematerialized, at which point he collapsed.

  Here Dedlow ended his story abruptly. Rather than cheer him, the brush with the other side only reminded him of what he’d lost, and he felt even more diminished. As he told the orderly transcribing his story, for any man “to lose any part [of himself] must lessen… his own existence.” He concluded, “I am not a happy fraction of a man.”

  Although rejected by medical journals, “The Case of George Dedlow” panged people—pierced them in a way that an academic paper never could have. The Civil War had maimed and disfigured hundreds of thousands of men. Nearly everyone had a brother or uncle or cousin whose wounds had never set right. Moreover, as the first well-photographed war, the Civil War branded the country’s psyche with indelible images, of stumps and naked wounds and holes where there shouldn’t be holes. These macabre photographs, in museums, in magazines, were in some ways the heir to Vesalius’s Fabrica. Except they didn’t celebrate the human form so much as catalogue its destruction.

  And yet for all their power, these images of broken men remained silent—until George Dedlow gave them voice. His story spoke for every misshapen soldier in every village square, for every sobbing wreck in every parish pew, for every amputee whose ghostly limb made him scream out in the night.

  So from far and wide that summer of 1866, donations arrived in Philadelphia for Captain Dedlow. Crowds even gathered around Stump’s front door, pleading to meet their hero—and were stunned to hear that Dedlow didn’t exist. With much regret, the hospital superintendent told the throngs that there was no George Dedlow among his patients. Nor could he find any George Dedlow in the hospital archives. For that matter, the military had searched its records and could find no cases, anywhere, of any quadruple amputees. The tale in The Atlantic Monthly, the superintendent explained, was fiction. The only authentic thing about it was Dedlow’s disorder, a disorder medicine had never taken seriously before. The only real detail was, paradoxically, the phantom limbs.

  For as long as human beings have waged wars, surgeons have lopped off limbs—although until recently soldiers rarely lived to speak of the experience. Similar to his reforms with treating gunshot wounds, Ambroise Paré convinced surgeons in the 1500s not to cauterize fresh stumps by dunking them in boiling oil or sulfuric acid. Instead Paré promoted ligation, which involved tying off the severed ends of arteries and sewing the stump shut. This greatly reduced blood loss and infection (not to mention agony), and meant that amputees finally had a decent chance of surviving. Paré became so confident of their survival, in fact, that he started designing fake limbs for them, some of which, thanks to gears and springs, actually moved. (His line of substitute ears, noses, and penises remained immobile, however.)

  Not surprisingly, the first stray references to phantom limbs appeared in Paré’s writing, and they quickly became an object of fascination for philosophers. René Descartes dabbled in neuroscience at times—he famously declared the pineal gland,

  * a pea-sized nugget of flesh just north of the spinal cord, the earthly vessel of the human soul—but he also ruminated on the implications of phantom limbs. One story, about a girl who lost her hand to gangrene but woke up moaning about the pain there, especially shook him. This and related stories “destroyed the faith I had in my senses,” he wrote—to the point that he stopped trusting the senses as a sure route to knowledge. From there it was but a small step to cogito ergo sum, a declaration that he had faith only in his powers of reasoning.

  British naval hero Horatio Nelson also leapt from phantom limbs to metaphysics. During the biggest blunder of his career—an attack on Tenerife, in the Canary Islands, in 1797—a musket ball shredded his right shoulder, and a surgeon had to hack it off in the dim hold of a rolling ship. For years afterward Nelson felt his phantom fingers digging into his phantom palm, causing excruciating pain. He actually took succor from this, citing it as “direct proof” that the soul existed. For if the spirit of an arm can survive annihilation, why not the rest of a man, too?

  The physician Erasmus Darwin (grandfather of Charles), philosopher Moses Mendelssohn (grandfather of Felix), and writer Herman Melville (in Moby-Dick) all touched on phantoms as well. But the first clear clinical account of phantom limbs—he even coined the term—came from Civil War doctor Silas Weir Mitchell.

  Neurologist Silas Weir Mitchell.

  Weir Mitchell—he hated the name Silas—grew up a dreamy lad in Philadelphia. He suffered from phantasmagoric nightmares after hearing about the “holy ghost” in church, and he dabbled in both poetry and science. He especially loved the bright, pretty concoctions his father, a doctor, would conjure up in his private chemical laboratory. Mitchell eventually decided to enter medical school—over the objections of his old man, who thought he wouldn’t stick it out. Mitchell did, and even did rigorous medical research on snake venom before settling into private practice in Philadelphia in the 1850s.

  Despite hating slavery, Mitchell didn’t take the outbreak of the Civil War that seriously. Like many Americans, north and south, he assumed his side would whip the other in short order, and that would be that. He soon realized his mistake and became a contract military doctor. After a few months of making rounds to different military hospitals, Mitchell discovered he had a knack for neurological cases, cases most doctors loathed, even feared. So as the bodies kept piling up—Philadelphia’s patient population reached 25,000 during the war—he helped found a neurological research center, Turner’s Lane Hospital, on a dirt road outside Philadelphia in 1863.

  One patient called Turner’s Lane “a hell of pain”—a fair assessment, although this was partly by design. The military arranged for most cases of neurological trauma to end up there, and Mitchell preferred to trade away “easy” cases to other hospitals for more challenging ones, swapping convalescents with simple stomach wounds for thrashing epileptics and howling infantrymen with shattered
skulls. Turner’s, then, became the hospital of last resort, and although many of his patients never recovered, Mitchell found the work rewarding. He became an expert on nerve damage and especially on phantom limbs, since the Civil War produced amputees on an unprecedented scale.

  A few months after Turner’s Lane opened, Mitchell rushed over to the Battle of Gettysburg, where he saw for himself why the Civil War left so many limbless. Before the 1860s most soldiers used muskets. Muskets loaded from the front and they loaded quickly, since the bullets had smaller diameters than the barrels. This gap between bullet and barrel, however, produced swirling air currents that spun the bullet chaotically as it zipped down the barrel’s length. As a result, the bullet curved when it emerged from the muzzle, like a doctored baseball. This made aiming all but pointless: as one Revolutionary War veteran sighed, “[when] firing… at two hundred yards with a common musket, you might as well just fire at the moon.”

  The other common type of military gun, the rifle, had the opposite problem: it was accurate—soldiers could plug a turkey’s wattle at several hundred yards—but slow. The key to the rifle’s dead aim was the inner barrel, which had tight, spiraling grooves running along its length; these grooves spun a bullet aerodynamically, like a football. For the grooves to work, however, the bullet and barrel had to be in close contact. This required bullets and barrels of basically the same diameter—which made them a bitch to load. Soldiers had to ram the bullets down the barrels inch by inch with rods, a laborious process that led to lots of jamming and swearing.

  A few enterprising soldiers finally combined the best of rifles and muskets in the 1800s. An Englishman stationed in India noticed that warriors often tied hollow lotus seeds to their blow darts. When fired with a puff, the seeds ballooned outward and hugged the peashooters’ barrels as they moved forward, much like a rifle. Inspired, the Englishman invented a metal bullet that had a hollow cavity, and in 1847 a Frenchman named Claude-Étienne Minié (min-YAY) greatly improved the design. Minié’s bullets were smaller than a rifle’s barrel, so they loaded quickly. At the same time, like the lotus seeds, they expanded when fired (from a punch of hot gas) and hugged the barrel’s grooves as they hurtled forward—making the guns uncannily accurate. Worse, because the bullets had to expand, Minié made them out of soft, pliable lead. This meant that, unlike those hard Russian bullets forty years later, Minié bullets deformed upon impact, widening into blobs and shredding tissue instead of passing clean through. The result was an awesome killing machine. Based on its accuracy, its rate of fire, and the likelihood of a gaping wound, historians later rated the Minié bullet/rifle combination as three times deadlier than any gun that had ever existed. And those soldiers who didn’t die had their limbs shattered beyond repair.