The Tale of the Dueling Neurosurgeons Page 2
On the third day of festivities, a Friday, June 30, Henri himself decided to joust. Despite the heat he wore fifty pounds of gold-plated armor adorned with Diane’s colors, mostly black-and-white swirls. Whatever his faults, Henri looked regal upon a horse, and he entered the list on a handsome, chestnut-colored steed. During his first run he unmanned (which is to say, unhorsed) his future brother-in-law with a blow from his lance; a short while later he unmanned a local duke, knocking him onto his arse as well. When young, Henri had had a reputation as a brooding sort, but he was in high spirits that day, and arranged for a third and final joust against a powerful young Scotsman, Gabriel Montgomery.
The king and Montgomery put perhaps a hundred yards between them, and when a trumpet sounded, they took off. They clashed—and Henri got his bell rung. Montgomery bludgeoned him just below the neck, and Henri lost a stirrup and nearly careened off his horse.
Embarrassed, the king wheeled around and announced that “we” would tilt with Montgomery again—a bad idea for any number of reasons. It violated the laws of chivalry, as he’d already jousted the maximum three times. It also spooked his court. Catherine had dreamed the night before of Henri lying facedown in blood, and two of her astrologers had already prophesied the king’s doom. (One of them, Nostradamus, had written a quatrain four years earlier that read, “The young lion overcomes the old / on the field of war in single combat. / He pierces his eyes in a cage of gold. / Two wounds one, then dies a cruel death.”) Unnerved, Catherine sent a messenger to warn Henri off.
Finally, Henri had been suffering from vertigo and headaches recently, and his attendants found him shaken after his latest joust. Cruelly, though, a blow to the head can cloud someone’s judgment when he needs it most, and like a linebacker or boxer of today, Henri insisted on jousting again. Montgomery demurred, and the crowd watched in embarrassment as Henri berated him and challenged him—on his allegiance, before God—to tilt again. At 5 p.m. they lined up. Some eyewitnesses later claimed that an attendant fastened the king’s visor improperly. Others said that Henri wiped his brow and, in his fog, forgot to refasten the visor. Still others insisted that he cocked it up, in spite. Regardless, this time Henri didn’t wait for the trumpet before charging.
During a joust, a low timber fence separated the combatants, and they charged each other left shoulder to left shoulder, shield hand to shield hand. They held their fourteen-foot wooden lances in their right arms and had to angle them across their bodies to strike. A proper blow therefore not only jolted but twisted the opponent, and the force often broke the lance. Sure enough, the king’s lance shattered when it met Montgomery, and Montgomery’s lance exploded into splinters when it struck the king just below the neck. Both men jerked, and the courtiers in hose and doublets, the women adorned with ostrich feathers, the peasants hanging on the eaves, all of them whooped at the teeth-rattling blow.
The action, though, was not over. Given the commotion, no one quite knows what happened next. Perhaps Montgomery’s broken shaft buckled upward like an uppercut, or perhaps a splinter of wood leapt up like shrapnel. But somewhere in the melee, something knocked open the king’s gold-plated visor.
Now, many contemporaries blamed Montgomery for what happened next, because the moment his lance splintered he should have flung it aside. But the brain can react only so quickly to stimulus—a few tenths of a second at best—and a brain fogged from jousting would have responded more slowly still. Besides, Montgomery had an awful momentum, and even as the crowd’s roar lingered, his horse took another gallop. An instant later the jagged lance butt in his hand struck the king dead between his eyebrows. It raked across his naked face, wrenching his skull sideways and digging into his right eye. He pierces his eyes in a cage of gold.
But Nostradamus spoke of two wounds, and a second, deeper wound, to Henri’s brain, proved worse. Compared to those of most mammals, the four lobes of the human brain are grotesquely swollen. And while our skulls provide some good protection, the very hardness of the cranial bones also poses a threat, especially since the skull is surprisingly jagged on the inside, full of edges and ridges. What’s more, the brain actually floats semifreely inside the skull; it’s attached to the body really only at the bottom, near the stalk of the brainstem. We do have cerebrospinal fluid between the skull and brain to buoy and cushion it, but the fluid can absorb only so much energy. During impact, then, the brain can actually slide counter to the skull’s motion and slam into its bones at high speed.
As the butt of Montgomery’s lance struck home, Henri would have felt both a blow and a twist, like a mean hook to the jaw. The blow likely sent a small shock wave through his brain, a ripple of trauma. The rotational force was likely even worse, since torque stresses the brain unequally at different points, tearing at its soft seams and opening up thousands of microhemorrhages. Henri, an expert equestrian, nevertheless kept his saddle after the impact: the muscle-memory circuits in his brain kept him balanced and kept his thighs squeezing the horse. But on a deeper level, the twist and the blow tore open millions of neurons, allowing neurotransmitters to leak out and flood the brain. This would have caused untold numbers of other neurons to fire in panic, a surge of electrical activity reminiscent of a mini-seizure. Although few men of science believed in such things, at least one doctor in Paris knew that Henri had suffered a mammoth concussion.
After the clash Montgomery yanked his horse’s reins and whirled to see what he’d done. Henri had slumped down onto the neck of his Turkish steed, a horse forevermore known as Malheureux, unlucky. But however unlucky, Malheureux was disciplined, and when it felt its reins slacken upon Henri’s collapse, it kept galloping. The now-unconscious king bobbed on his horse’s back as if keeping time, his visor clanging down on the shards of wood protruding from his eye.
The two greatest doctors in Europe would soon converge on the king, but before they could do so, courtiers and sycophants of all stripes poured out of the stands toward Henri, each one craning for a glimpse and calculating whether his fortunes would rise or fall if Le Roi died. To most observers the entire French monarchy now looked as rickety as the timber grandstands. The dauphin (the heir apparent) was a frail, milquetoast boy of fifteen; he fainted at the mere sight of Henri’s injury. The shaky truce between Catherine and Diane depended entirely on Henri’s living, as did the false peace between other political factions. The two royal weddings, not to mention the peace of Europe, threatened to unravel as well.
Eased down from his horse, Henri lay stunned. Montgomery pushed to the front of the crowd to beg, somewhat incongruously, that the king both forgive him and also cut off his head and hands. Upon surfacing to consciousness, the king instead absolved him, without beheading or behanding. Henri drifted in and out after that, and finally insisted on rising and walking (albeit with support) up the palace steps to his bedroom. His physicians set about removing a four-inch splinter from his eye, but had to leave many smaller ones in place.
Dueling neurosurgeon Ambroise Paré. (National Library of Medicine)
Among those doctors attending the king was Ambroise Paré. A thin, prim man, Paré served as royal surgeon—a job less prestigious than it sounds. The son of a cabinetmaker, Paré hailed from a village in north France, where he’d trained as a “barber-surgeon.” In short, barber-surgeons cut things, which differentiated them from proper physicians. He might start his day at 6 a.m. shaving beards and trimming periwigs, then amputate a gangrenous leg after lunch. In the early 1200s, the Catholic church had declared that no proper Christians, including physicians, could shed blood; physicians therefore looked down upon surgeons as butchers. Early in his career Paré had stood below even most surgeons because he spoke no Latin. Nor could he afford his licensure fee, so he became a battlefield surgeon at twenty-six, joining the army as a ragtag follower with no rank or regular salary. Injured soldiers paid what they could, be it casks of wine, horses, a half crown, or (sometimes) diamonds.
Paré took to soldiering like a house afire, hobn
obbing with generals by day and getting drunk with lower-ranked officers at night. Over the next thirty years he worked in seventeen campaigns across Europe. But he made his first important discovery while a tyro. Most doctors in the early 1500s considered gunpowder poisonous, and cauterized any bullet wound, however slight, by dousing it with boiling elderberry oil. To his mortification, Paré ran out of elderberry oil one night after a battle. Begging their forgiveness, he patched up his patients’ wounds with a paste of egg yolk, rose water, and turpentine instead. He expected every one of these “untreated” soldiers to die, but they were fine the next morning. In fact they were thriving compared to those treated with boiling oil, who writhed in pain. Paré realized he’d effectively run an experiment, with astounding results, since his trial group had fared much better than his controls.
That morning changed Paré’s entire outlook on medicine. He refused to use boiling oil ever again, and set about perfecting his egg/turpentine paste instead. (Over the years the recipe changed somewhat, and eventually included earthworms and dead puppies.) On a deeper level, that morning taught Paré to experiment and to observe results for himself, no matter what ancient authorities said. It was a symbolic conversion, really: by abandoning boiling oil—with all its medieval overtones—Paré effectively abandoned a medieval mentality that accepted medical advice on faith.
As is evident from his case reports, Paré lived in an era of near-cartoonish violence: one day might find him treating a twelve-year-old girl mauled by the king’s pet lion; the next might find him literally standing on a duke’s face, to get enough leverage to yank a broken spearhead out. But Paré handled it all with aplomb, and his willingness to experiment made him an innovative surgeon. He developed a new drill-and-saw contraption to “trepan” the skull—that is, open a hole in the bones and relieve pressure on the brain, whether from inflammation or fluid buildup. He also developed tests to distinguish—in particularly gory head wounds—between fat, which was harmless to scrape away, and oozing bits of fatty brain tissue, which weren’t. (In short, fat floats on water, brain sinks; fat liquefies in a frying pan, brain shrivels.) When describing a patient’s recovery, Paré usually pooh-poohed his own role: “I treated him, God healed him,” he famously said. But his many near resurrections earned Paré quite a reputation, and Henri eventually appointed him “surgeon to the king.”
Despite his expertise with head wounds, Paré still stood below the king’s physicians in the medical hierarchy, and he deferred to them in the busy hours after the jousting disaster. The physicians force-fed Henri a potion of rhubarb and charred Egyptian mummy (a treatment Paré rolled his eyes at in private), and they opened the king’s veins to bleed him, even as he bled spontaneously from his colon. The English ambassador noted the king had a “very evil rest” that first night, but most of the attending doctors remained optimistic that he’d suffered little damage beyond his right eye. And in fact, when the king surfaced into consciousness the next morning, he seemed to have his wits about him.
But Henri soon had to face the fact that Catherine had effectively seized control of France. He asked after Montgomery, and frowned to learn that the Scotsman, not trusting Catherine, had already fled. Henri called out for his mistress, but Catherine had stationed soldiers at the palace door to bar Diane’s entrance. Perhaps most startlingly, Henri learned that Catherine had ordered the decapitation of four criminals—then bade Henri’s doctors to experiment on their heads with Montgomery’s broken lance stump, to devise a strategy for treatment.
Meanwhile, a messenger on horseback was sprinting northeast through forest and field to Brussels, bound for the court of Philip II, the king of Spain. (Confusingly, Spanish kings lived in northern Europe, in conquered territory.) Although the recent peace treaty had secured Philip’s marriage to Henri’s daughter, Philip hadn’t deigned to attend his own wedding in Paris, explaining that “kings of Spain do not run after brides.” (Philip sent a proxy, a duke, to stand in at the ceremony instead. To legally “consummate” the marriage, the duke approached the princess’s bedchamber that night, removed his boot and hose, and slipped his foot beneath the bedcovers to caress the girl’s naked thigh. There was much ribald speculation in Paris about whether this satisfied her.*) Despite his haughtiness toward Henri’s family, Philip wanted Henri to live, and soon after the messenger arrived, Philip roused his best physician, the one man in Europe whose expertise with the brain rivaled Paré’s.
As a teenager in Flanders, Andreas Vesalius had dissected moles, mice, cats, dogs, and whatever other animals he could snare. But animal dismemberment couldn’t quite sate him, and before long he began pursuing his real passion, human dissection. He began robbing graves at midnight, sometimes fighting wild dogs over scraps. He also let himself get locked outside the city walls at night to rob skeletons from the gallows, clambering up thirty-foot gibbets to cut down swaying pickpockets and murderers, counting himself lucky if crows hadn’t refashioned their anatomies too much already. He smuggled the cadavers back into the city beneath his garments, then stored them in his bedroom for weeks, to linger over their dissections like a cannibal gourmand over a meal. He delighted in clutching every organ, too, even crushing them between his fingers to see what oozed out. However creepy, his obsession revolutionized science.
Dueling neurosurgeon Andreas Vesalius. (National Library of Medicine)
Vesalius eventually enrolled in medical school, and like everyone else in the previous thirteen centuries, his medical training basically consisted of memorizing the works of Galen, a physician born in AD 129. Human dissection was taboo back then, but luckily for him, Galen served as a doctor for Roman gladiators, which was just about the best training possible for an anatomist: gladiator wounds could get pretty gnarly, and he probably saw more human innards than anyone alive then. He soon founded a school of anatomy, and his work was so innovative and all-encompassing that he stunted the field, since his small-minded followers couldn’t evolve past him. By the Renaissance, the birth pangs of a new science of anatomy had begun, but most “anatomists” still cut into the body as little as possible. Anatomy lectures were similarly a joke: they mostly consisted of an expert sitting on a throne and reciting Galen aloud while, beneath him, a lowly barber hacked open animals and held their greasy entrails up. Anatomy was theory, not practice.
Vesalius—a swarthy man with a virile black beard—adored Galen, but after immersing himself in human flesh, he began to notice discrepancies between the gospel of Galen and the evidence on the dissecting table. At first Vesalius refused to believe his own eyes, and told himself that he must have cut into some anomalous bodies. He even entertained the theory that the human body had changed since Galen’s time, possibly because men now wore tight trousers instead of togas. Eventually, though, Vesalius admitted he was grasping, and that, however unthinkable it seemed, Galen had erred. Around 1540 he compiled a list of two hundred howlers, and determined from them that Galen had supplemented his gladiatorial work by dissecting sheep, apes, oxen, and goats, and then extrapolated to humans. This bestiary left human beings with extra lobes on the liver, a two-chambered heart, and fleshy “horns” on the uterus, among other mutations. Galen’s shortcomings became glaringly obvious when Vesalius probed the brain. Galen had dissected mostly cow brains, cow brains being large and abundant in the butcher stalls of Rome. Unfortunately for Galen, humans have vastly more complex brains than cows, and for thirteen hundred years, physicians were left trying to explain how the brain worked based on a faulty notion of how it was put together.
Vesalius vowed to reform the science of anatomy. He began calling out, even exposing, prominent “anatomists” who never bothered dissecting bodies themselves. (About one, Vesalius sneered that he’d never seen the man with knife in hand, except when carving mutton at dinner.) More important, Vesalius reached a wider audience by composing one of the cherished works of Western civilization, De Humani Corporis Fabrica (On the Fabric of the Human Body).
Drawings from Andreas
Vesalius’s On the Fabric of the Human Body, one of the most beautiful scientific books ever published. (National Library of Medicine)
Beyond the few crude diagrams in other books, this was the first anatomy text to include realistic drawings of the human form. And what drawings these were. Vesalius sought out the best local artist to illustrate his magnum opus, and since he was working in Padua then, this happened to be Titian, whose school of artists soon brought Vesalius’s vision of the human form to life. Unlike in modern textbooks, the bodies in Fabrica don’t lie flat and lifeless on a table. They rise and strut and pose like classical statues. Some do a veritable striptease with their flesh, peeling back layer after layer to reveal their inner organs and organic essence. In darker scenes, bodies sway from ropes or clasp their hands together in agonized prayer. One skeleton digs his own grave; another contemplates a skull, alas-poor-Yorick-like. Titian’s apprentices labored over even the backgrounds of the pictures, planting the cavorting cadavers in the lovely, rolling landscapes near Padua. As in that era’s painting and sculpture, the realism was unsurpassed, making Fabrica one of the greatest marriages of art and science* ever produced. Pictures in the book’s seventh and crowning volume, on the brain and related structures, distinguished scores of important details for the first time. Other anatomists had passed their eyes over the brain, but in a literal sense Vesalius, like a great artist, was the first person to really see it.