THOUGHTS OF A BRAIN SURGEON

She was a lovely little girl, six years old, exceptionally pretty, bright, happy.  But our studies showed a large tumor in her brain.  Operating, I found the hemisphere markedly enlarged by giant cyst associated with the tumor.  I started in after the fluid—filled mass and. Disaster!  Suddenly the hemisphere collapsed and the large vessels on its surface ruptured, flooding my operating field with blood.

My colleagues and I struggled to stem the torrential flow, but we were losing the battle.  Gloom settled on us.  With my fingers, I held little pads of cotton tight against the hemorrhaging vessels, striving desperately to control the bleeding.  At last I succeeded.  I dared not to release my fingers; all I could do was pray while the child was transfused.

As I waited, I felt terribly inadequate, humble.  Who was I to be engaged in such awesome work, to think it was my responsibility, and mine alone, to remove this ugly growth from this little girl’s brain—the tissue substrate of her highest functions, her wonderful personality, her intelligence, memory, emotions, free will?  This area where we were operating, that was where she was, it was who she was.

Half an hour passed.  The operating room was alive with a terribly quiet tension.  No one, including me, believed I could lift my fingers from the pressure points without releasing another river of blood.  I kept applying digital pressure and preying, praying to God to will the necessary strength into my hands.

And then, quite suddenly, I felt relaxed.  I knew I had done all was in my power to do, and I was full of comfortable certainty that I could proceed.  Somehow God was in the room with us.  Carefully, slowly, I released my pressure on the vessels, one finger at a time.  There was no bleeding until all my fingers were free.  Then one vessel began to bleed, but it was easily controlled.

It took 4 ½ hours to remove the tumor.  I stayed close to the little girl’s bed for the next week.  Her wounds healed well; no re-hemorrhaging, no neurological deflect, no brain damage.  The result was all that had been hoped for, and the girl today is normal, happy teen-ager.

In 1974 I operated on a young boy who had suffered two massive brain hemorrhages—the result, studies showed, of a small tumor at the very center of his brain.  The hemorrhaged areas were badly infected.  The lad became comatose; he was dying.  We placed tubes into both sides of the brain and literally washed out the brain cavity with cold antibiotic solutions—a revolutionary new technique of our own devising.  Later we placed the boy on a respirator, a breathing machine, and reduced his body temperature.

For weeks the fight for life continued.  I kept praying, not only for the boy and his parents but also for the strength to sustain the entire medical team in the sad and exhausting case.  Then, almost imperceptibly and for reasons not yet clear, the boy began to improve.  After a fortnight we removed the cooling blanket.  Another two weeks and we were able to remove him from respirator, then to remove the drainage tubing from the brain.  Now, in my daily meetings with the distraught parents, I began suggesting the possibility that their son might survive, even if incapable of anything resembling a normal life.  Yet, unaccountably, he continued to improve.  By the time we discharged him, I was able to describe him as a spastic with severe mental retardation—far better than we had dared hope.

Several months later, the parents brought the boy back to me for an examination.  I am still astounded at what I found: he was in all respects completely, utterly normal—happy, active child.  The tumor is still there, in the center of his brain—we continue to keep a close watch on it—but it has caused no further trouble nor has grown.

If I seem to be saying that I have witnessed miracles that is not what I believe.  To be sure, I have been in many extremely dangerous operating-room situations—several of them apparently hopeless—in which to my amazement the patient has survived and prospered.  But I see nothing “miraculous” about these successes.  I don’t think they would have occurred without the combined hest efforts of all the medical professionals in that, I believe; it would not have been achieved without Divine help in making the decisions and in the actual technical performance.

Many research scientists seem to lose faith as their knowledge increases.  For me, the opposite has occurred.  My experiences with my patients, and in my neurological research trying to unravel the mysteries of the brain, have put me more than ever I awe of the brain.  And I am left with no choice but to acknowledge the existence of a Superior Intellect, responsible for the design and development of the incredible brain-mind relationship—something far beyond man’s capacity to understand.

Just think about this wondrous organ, the human brain.  The most sophisticated computer man will ever build will not match the complexity, efficiency and performance of this gelatinous mass of tissue weighing approximately three pounds.  With its topography of small hills and narrow valleys crisscrossed with red and blue streams, one-brain looks much laid any other.  But somewhere in there is what makes each of us unique.  For the brain contains the mind, the relationship between the container and its contains, science knows very little.

I am convinced that the brain is the repository of the human spirit, the soul.  Therefore, to me the brain is a holy place.  Still, it is subject to injury and illness, and sometimes it is necessary for us to enter and search its depths for tumors, hemorrhages, and infections.  To work in this area strikes me as an almost religious undertaking, and one demanding the highest of human skills.  I need a very solid set of beliefs to sustain me in such work.

I recall a lovely, long-ago spring day when I was called to a veteran’s hospital for consultation in the case of a man in his early 30s who had a malignant brain tumor.  His room was full of colorful, homemade get-well cards, several with pictures on them of a beautiful little dark-haired girl, and her repetitive plea; “Get well soon, Daddy”; “Come home soon”; “I miss you so much” But as I studied the young man’s records and examined him, I knew he would not be going home again.

My depression was profound.  I would mot want to try to weather such moments without the realization that understanding is beyond me, without faith that the patient and all involved with him are moving ahead, that they happen now to be center stage in a grand drama of time and space in which each of us figures significantly.

For me, the practice of medicine and religious faith are inextricably interwoven.  I prey a great deal, especially before and after surgery.  I find prayer satisfying.  I feel there are immense resources behind me, resources I need and want.

I knew great and good men among my colleagues who seem able satisfactorily to explain things to themselves in terms of mathematics and chemical formulas, and are comfortable in assuming that what is not explainable today will come clear as science continues to progress.  Yet the notion that human life is nothing more than a chance confluence of complex molecular biology and electrical activity strikes me as a defiance of logic.

From purely scientific standpoint, it seems to me the human brain-mind is so far beyond anything science have ever developed that a Superior Intellect-Creator is demanded to explain the uniqueness and individually of the human being.  No matter how much we learn about brain, we can never expect to explain the mind completely.  And I have to believe all this had an intelligent beginning that someone made it happen.  I can’t accept the proposition that at random points in time such substantial entities as intelligence, personality, memory and the human body just sort of fell together.

I also find it unreasonable to suppose that the brain death those powerful entities of intelligence, personality and memory simply cease to exist.  Far more reasonable to believe that the essence of us escapes from a container, the brain, which no longer is capable of supporting us, and finds support in a new dimension.

As to what becomes of the essence of us at brain death, I can’t presume even to speculate.  I can only say that logic leads me inescapably to faith—faith that the uniqueness, the individuality, of the human being lives on in this concept we call the soul.

THE RIGHT ARM OF EDDY KNOWLES

Everett “Eddy” Knowles, Jr., a merry, freckled, red-haired boy of 123, stood just off the roadbed and watched the Boston & Marine gravel train grinding slowly past Gilman Square in Somerville, Massachusetts, a suburb of Boston.  It was about 2:20 p.m. May 23, 1962.  Eddy was on his way home from Northeastern Junior High School, and had decided to have a fling at forbidden fruit—hooking a ride on freight.

As a gravel-laden gondola car moved slowly past him.  Eddy pulled himself to the steel step and grasped the handrail.  He hung there in triumph, all five feet and 90 pounds of him.  The spring breeze eddied through his jacket and cotton shirt as the freight groaned eastward.

A few seconds later the world went black for Eddy.  His leaning body slammed full force into a stone abutment supporting the Medford Street overpass.  His right arm cracked, and he dropped into the roadbed, crushing his thumb and the first two fingers of the left hand.  For a minute he laid there, a small-bewildered heap, until the train passed.

He was sure he had broken his right arm, the arm that had so far earned him a 3—1 winning record as a Littler League pitcher.  A smear of blood spread on his shirt just below the shoulder where the jacket had been torn.  Supporting his right arm with his mangled left hand, he struggled to his feet, climbed a steep bank and started home. 

As Eddy shuffled past the back loading platform of the Handy Card & Paper Co., Norman Woodside, the foreman saw the bloody, bedraggled figure and shouted to Richard Williams, a press operator, ‘Grab him!’ Williams laid Eddy on the wooden platform while Woodside phoned the Somerville police.  Woodside returned with Mrs. Alice Chmielewski, a clerk, who tried to put a rag tourniquet on Eddy’s arm.  Suddenly, she felt faint.  At the place she sought to apply the tourniquet, there was nothing but space.  Eddy Knowles had walked more than 100 yards, mostly uphill, clutching an arm that had been severed from his body.

Mrs. Chmielewski pushed some rags against the shoulder stump in an effort to stanch the bleeding.  “I got to get out of here,” moaned Eddy.  She held him gently and wiped the sweat from his forehead.  Eddy didn’t cry.  Indeed, he was not to shed a tear for the entire day of his ordeal.

A police squad car arrived in two minutes, and by 2:40p.m Everett Knowles, Jr.,had the good fortune to be wheeled into Massachusetts General Hospital, one of the finest in the United States.

As emergency ward administrator Ferdinand Strauss and his assistant, Michael Hooley, wheeled Eddy toward the emergency operating room, Hooley, asked Eddy his name, address, phone number, religion.  The boy replied clearly.  Hooley now put a complex system into operation.  One call went to the Knowles home; another to the patient-index center in the basement where 1,500,000 names are filed, luckily, Eddy had been a patient there before.  Within five minutes his medical record with his blood type reached the operating room.  Eddy already was receiving 250 cubic centimeters of plasma through a ‘cut down’ in his leg.  Now, the first of the six pints of whole blood he would receive flowed into him through the transfusion tube.  “My arm hurts.” Eddy told the doctors.  “Is it going to come off?”

Nurses Mary Brambilla and Francis Brahms lifted Eddy from his litter to the operating table.  Nurse Brahams cut away Eddy’s clothes with scissors.  Then, they all saw it: Eddy’s right arm lay three or four inches from the shoulder stump.  Not a single thread of skin bridged the gap.  “Will my arm be all right?”  Can you save it?”  Asked Eddy.  Dr. S.B.Litwin, a duty surgeon, nodded.  “Yes, son,” he said.  But at that moment nobody knew.

Dr. L.Henry Edmunds, Jr., the duty surgeon in charge now gave brisk, routine orders: tetanus shot, atropine, injections of penicillin and streptomycin, a sedative shot, pulse taking, blood pressure.  Eddy’s pressure was low, his pulse 120, and he was cold, sweaty—all indications of shock.  Hank Edmunds noticed on encouraging detail.  Eddy’s right-arm artery protruded almost an inch from his damaged flesh and, with each pulse, it throbbed and dilated—but no blood emerged.  It is one of nature’s miracles, this self-sealing quality of a severed artery.  In a young person especially, the vessel’s elasticity is so great that it closes within few seconds of rupture.

Dr. John M. Head, staff surgeon, and Dr. John F. Bruke consulted with Edmonds.  They all noticed that the lone arm, while bruised and damaged, was fairly clean.  Edmunds ordered Nurse Brambilla: “Put that arm on ice.”  Mary Brambilla filled two basins with crushed ice from the ward kitchen’s ice-making machine and placed the arm on them, then packed ice-filled bags around it.

At Edmond’s side now were a number of doctors, including 30-year-old Dr Ronald A. Malt, the resident in surgery and perhaps the most important man Eddy Knowles was to see that day.  These physicians conferred in the corridor.  Never in medical literature had they read of a case of a major limb successfully reattached to the body.  But Eddy and his severed arm appeared ideal for am attempt.  Each step that would be necessary—rejoining veins, arteries, bone, muscle, skin—had been performed routinely for years.  Could they all be done atones?

As the doctors talked, Father L. Chanel Cyr, duty chaplain at the hospital, administered extreme unction to Eddy.  Then Eddy’s father, a meatpacking employee, who worked nights and had been asleep at home when the phone rang, arrived.  Physicians explained the situation.  Would Mr. Knowles send to a reattachment operation?  Knowles signed the release.

Dr. Malt asked Dr. John Herrmann, his assistant in surgery, to take the arm upstairs to Operating room No 5.  There Dr. Herrmann scrubbed, donned a surgical gown, and wet to work.  First he fished out the arm’s three major nerve trunks and the torn blood vessels.  They appeared reasonable intact.  Placing a syringe in the artery, he flushed the blood channels with heparin, and anticoagulant, with antibiotics and with a solution approximating the body fluids.  The antibiotics severed to kill any grantee of lockjaw bacteria that might be starting.  There were no lacerations on the arm.  The bone was broken and jagged, one side longer than the other, but it was not crushed.  Then Dr>Herrmann injected a radiopaque solution into the artery.  A technician took X rays to determine whether there were any blood-vessel blocks.

Eddy Knowles, meanwhile, was wheeled into the “White 3” anesthesia induction room.  Here at 3:40p.m. Dr. Joan Flacke injected a muscle relaxant into Eddy’s leg and gave him an intravenous dose of thiamylal, a sedative.  “I just thought of something,” said Eddy to her.  “My family was going on a vacation in a couple of weeks, and now I guess I’ve spoiled it.”

Malt looked at the X-ray plated of Eddy’s arm.  The limb appeared to be fine.  No blood clots, no obstructions appeared.  It was 4:05p.m. When Malt reached his crucial decision: they would try to sew back the severed arm of Eddy Knowles.  Malt ordered Joan Flacke to begin anesthesia.  Then he phoned Dr. Robert S. Shaw, an expert in vascular surgery who was working in another hospital building.  “Bob,” said Malt, “there’s a boy here with his arm off, and I think we’ve got a chance to put it back on.”  Shaw came, on the run.

Under great overhead light in OR 5, Dr. Flacke fitted a mask over Eddy’s face. The boy began to breathe a mixture of halothane, nitrous oxide and oxygen from three tanks.  He fell quickly into a sound sleep.

Judy Moberly, the scrub nurse, felt queasily for the first time in months of watching operations.  The sight of an arm on one table and a boy on another had strangely upset her.  “Do I have to watch?” she asked.  But then, as soon as the arm was brought close to Eddy, she was no longer disturbed.

Around the boy now stood three doctors, two nurses, three anesthetists and two orderlies.  The glassed balcony above them was crowded with a score of doctors and nurses, drawn there as word spread through Massachusetts General that a limb was to be reattached.

Eddy’s right side was propped up, the bloody stump irrigated with salt water and draped with gray linens.  The Shaw directed the initial step, the sewing of the veins.  These had to be connected first, so the blood would have a way to get back to the heart when the artery was repaired.  The arm has two outer veins and one deep plexus entwined about the artery.  Ignoring the outer veins, Shaw selected two veins from the intern network.  With forceps, he gasped the minuscule curved needle attached to green but hardly visible Dacron 6-0 thread. Through a vein he pushed the needle, let loose, picked it up on the other side and pulled.  He did that again and again, 30 stitches to the vein.

It was painstaking work.  Save for the occasional asides of the doctors, muttered though their gauze masks, the room was hushed.  Malt’s job required excruciating patience.  He had to hold Eddy’s arm so firmly that not the slightest movement would occur.  Occasionally, Herrmann helped with this.  One little tilt, and the delicately stitched veins would rip.  When the two veins were reunited, the doctors joked a bit, to crack the tension.

Now Shaw tackled the brachial artery, still self-sealed and throbbing with each heartbeat.  This task was easier, for Eddy’s artery was large—about two-thirds the size of a lead pencil.  Still, the procedure was complicated and took 45 minutes.  Anatomists, of the suturing of blood vessels, were completed just three and a half hours after Eddy fell form the train.

And now came the moment of truth.  While Malt still held the arm tightly, Shaw removed the artery clamp.  Blood rushed down the arm.  People in the balcony stopped talking.  Not a word was spoken around the operating table.  Everybody watched.  Slowly, the waxen limb began to regain its flesh coloring.  A glow seemed to envelop the arm.  The doctors wanted to cheer.  In the balcony, there were exclamations of joy.

“My,” said Malt, “its nice and pink, isn’t it?” Judy Moberly, the scrub nurse, felt the hand.  It is warm.

In the huddle of surgeons now were Dr. Bradford Cannon, a plastic-surgery specialist, and Dr. David C. Mitchell, an orthopedist.  Now it was time to repair the bone.

Consulting with other bone experts and with Malt, Mitchell decided the bone would have to be reinforced.  If not held securely in place, it might snap and tear the blood vessels again.  There are many shapes of stainless-steel rods for intramedullary fixation, as the profession calls it.  Mitchell tried several of these, forcing them into the marrow of the bone, but wasn’t satisfied.  At last, he and Malt settled on the Kuntscher nail, which in cross section is roughly the shape of a cloverleaf and grumps firmly.  They measured the length required—six and a quarter inches.  Malt drove the nail part way up the marrow of the stump bone with a stainless-steel mallet.  Then Mitchell held the arm and forced it onto the rod.  It was 8p.m.

Next job: nerve suture.  The doctors struck a snag here.  They couldn’t find all the nerves in the stump, and they couldn’t be sure how badly damaged the located nerves were.  The smallest scar on a nerve end could thwart full healing, giving Eddy a lifelike but useless arm.  With an eye on the clock, because Eddy already had been on the operating table four hours, Malt made another one of the scores of decisions made that day.  He decided to postpone nerve rejoining for a later operation.

Malt now removed dead tissue to block infection.  Normally this would have been done first, but the doctors postponed it because, until circulation was restored, they couldn’t be sure how much would ultimately be dead.  Next: the muscle.  Malt jointed the muscle with 12 large stitches of catgut.

A skin graft was clearly called for now, since a large, raw wound showed.  But Malt, in still another decision, ruled against an immediate graft.  A graft would take 45 minutes, and there was little time.  It was now past 10p.m., with much work still to be done.  A dry dressing was placed on the patched arm.  Then Eddy was fitted with a spica cast covering both his shoulders and down to the hip tops and holding the rejoined arm firmly, crooked at the elbow.

Eddy’s left hand still had to be cared for.  Dead tissue was cut away from the smashed thumb and two fingers, and a skin graft taken from Eddy’s right foot was applied.

It was almost 1 a.m. when Eddy was wheeled into the recovery room, eight and a half hours after the operations started.  As he emerged from unconsciousness, Eddy smiled at Joan Flacke.  “How’s my broken arm?” he asked.  Then he thought something.  “Next time,” he said, “just give me the gas.  I don’t like those needles.”

Eddy stayed in the recovery room until daylight, and then was wheeled into a private room on the 12^th floor.  Although Eddy and his arm were one again, the doctors’ vigil had just begun.  When days passed with no sign of infection, they breathed more easily.  On the fifth day they took a large piece of skin from Eddy’s right thigh and grafted it onto his arm in two places.  On the 12^th day they changed the cast, and again on the 15^th day, June 13, Eddy went home to his family’s two-story frame house on Dell Street in Somerville.

Eddy Knowles, at age 30, is doing well.  His recovery has been good, and his hobbies include weight lifting and tennis.  He has held various jobs, among them, delivering 200-pound slabs of meat and cross-country truck driving.  All in all, a very remarkable, productive life for Everett Knowles, jr., once a brave little boy who never cried, and who helped to blaze a new trial in medical science.  Suture of Right upper Extremity.” Ronald Malt called it in his laconic one-page official report.