Patient H.M.

by Luke Dittrich

  —

  On August 31, 1950, orderlies at Connecticut State Hospital led a woman with the initials D.M. from her ward to room 2200, where my grandfather was waiting. She was twenty-eight years old and had been at the asylum for ten years. She had been diagnosed as a “homosexual schizhophrenic, actively hallucinating.” She lay down on the operating table. The records don’t indicate whether she was sufficiently cooperative to undergo surgery under local anesthesia or whether a general anesthetic was required to subdue her. In either event, my grandfather proceeded to slice a wide arc across the top of her head, roll her forehead down, and use his custom trephine to drill his usual two holes in the front of her skull. After using a scalpel to slice an opening in her arachnoid mater membrane, he inserted his flat brain spatula into one of the holes and levered up her frontal lobes. He squinted through the magnifying lenses of his loupes, peering inside. He oriented himself, taking visual notes of the various cerebral landmarks as his eyes traced a path past the frontal lobes and toward the structures beyond. He spotted the “slight bulge” of the uncus, approximately three centimeters past the tips of the temporal lobe, opposite an area known as the dural ridge.

  Although the day’s operation would be a landmark one, my grandfather’s first, tentative steps into the mysterious landscape of the “hippocampal zone” had actually taken place more than a year earlier. That was when, in collaboration with an electrophysiologist colleague named W. T. Liberson, he administered electric shocks to the uncuses of eight “sufficiently cooperative” lobotomy patients. The uncus is a hook-shaped, dime-size tangle of neurons that is either the farthest-forward portion of the hippocampus or its own independent structure, depending on which neuroanatomist you ask. Research with monkeys had hinted that removing the uncus might pacify agitated primates, but regardless, like with the rest of the medial temporal lobes, the purpose of the uncus was unknown.

  “Striking effects were exhibited,” my grandfather later wrote of his electrical experiments. Specifically, “in all but one patient complete and prolonged apnea was recorded after stimulation.” In other words, they stopped breathing. Although the apnea often “considerably outlasted the duration of the stimulation,” all the patients eventually began breathing again, though one required artificial respiration to do so and another remained in a state of only “periodic respiration” for at least an hour. Many of the patients experienced seizures, and several fell into prolonged states of unconsciousness.

  The function of the uncus, however, remained an open question, and my grandfather eventually decided that he’d need more than electricity to find the answers.

  So on that late August day in 1950, instead of inserting one of his electrodes and giving D.M.’s uncus a jolt, my grandfather picked up his suction catheter and its attached “electrosurgical coagulating wire.” He fed the tool into her head, moving it carefully under the spatula, trying not to touch or damage anything he shouldn’t. Three centimeters past the tip of the temporal lobe, he reached the uncus. He activated the tool. The suction catheter came to life and began vacuuming out D.M.’s uncus while the wire cauterized any veins that the vacuuming caused to burst. If D.M. was in fact under local anesthetic, she would then notice that the musty smell of her bone dust had been joined by a richer, more pungent smell as portions of her neural tissue were burnt away.

  She did not stop breathing. This may have been something of a surprise, given his previous experiments. D.M.’s ability to continue breathing as he destroyed her uncus was, as my grandfather later pointed out, “in marked contrast to the profound physiologic changes resulting from electrical stimulation.” Once he was satisfied that he’d removed the entire uncus, a quantity of brain matter measuring approximately three centimeters long, two centimeters high, and one and a half centimeters wide, he removed the vacuum and proceeded to the other hole.

  Immediately after her uncotomy, which is what my grandfather named the procedure, D.M. appeared to be more stuporous than patients who’d undergone his orbital undercutting lobotomy. The orderlies wheeled her away, and my grandfather changed out of his scrubs and drove back to Hartford. Initial reports on her condition weren’t particularly encouraging, as she exhibited little psychiatric improvement, but they weren’t particularly discouraging, either, since she didn’t appear to have been compromised at any essential physiological level. She continued to breathe, for example. So ten weeks later, on November 16, 1950, my grandfather returned to room 2200 and performed four more uncotomies on four more women.

  First was patient I.S., a forty-eight-year-old paranoid schizophrenic with a history of suicide attempts. During this operation, my grandfather’s hand slipped and his electrocautery device accidentally caused “severe damage” to an untargeted part of I.S.’s midbrain. This damage provoked a “violent jerk on the operating table,” and his patient immediately fell unconscious. He proceeded with the uncotomy and noted that I.S.’s limbs continued to spasm unpredictably throughout the procedure.

  Then there was patient E.M., a twenty-seven-year-old schizophrenic who’d been hospitalized for four years. She’d recently shown “temporary improvement” after shock therapy but was still “lacking in initiative and activity” and displayed “impaired judgment.” E.M. was cooperative, which allowed my grandfather to perform the surgery under local anesthesia. This time, his hand didn’t slip.

  The third patient, B.P., was twenty-five years old and had been hospitalized for two and a half years for, among other things, “religious delusions,” “excessive masturbation,” and “homosexual trends.” She vomited while my grandfather suctioned away her uncus, but the operation went smoothly otherwise.

  His final operation of the day was on M.D., an “occasionally mute” and “actively hallucinating” twenty-five-year-old woman. She also vomited.

  In attempting to assess the subsequent psychiatric effects of these uncotomies, my grandfather borrowed the protocols of the Connecticut Cooperative Lobotomy Committee. For each patient, at some indeterminate time following the operation, he tallied the opinions of five people, each of whom was asked to rate the patient’s improvement on a scale from negative one to plus four. These five people were the asylum’s ward physician, charge nurse, supervisor, ward attendant, and my grandfather himself. Occasionally a relative of the patient would be allowed to contribute to the scoring as well. A score of negative one indicated that the patient had become worse, while a positive score would indicate varying degrees of improvement. The highest score, positive four, was reserved for patients who’d been able to leave the institution altogether.

  What he found was that, in general, lesioning the uncus didn’t appear to have much negative or beneficial effect. Instead, four of the five patients he’d operated on showed little to no change whatsoever in their conditions, and received scores of zero, zero, zero, and one. The exception was Patient I.S., the woman who had received extensive accidental damage to some of her deep midbrain structures when my grandfather’s electrocautery slipped. During the eight hours immediately following operation, I.S. remained in a stupor, her legs and arms periodically spasming. Her spasticity cleared up after a week, though she remained “vegetative and withdrawn” for two weeks. Then, after a month, she suddenly began to show marked improvement. After five months, she had improved to such a degree that she was able to leave the asylum and return home. This gave her a rating of four plus.

  —

  My grandfather continued his experiments, pushing deeper into uncharted territories of the human brain. On the morning of Thursday, December 14, 1950, he performed his first complete medial temporal lobotomy. This was “a far more extensive resection” than the uncotomy, which had served as a prelude to this more drastic procedure. The setup was similar, however: He drilled open his patient’s skull using the same trephines, levered up her frontal lobes using the same flat brain spatula, and vacuumed and burned his patient’s gray matter using the same suction catheter and custom electrocautery tip. Only this time, after
destroying the uncus, he kept on going, suctioning out her amygdala and most of her hippocampus. Although the messy mechanics of burning and suctioning made it impossible to preserve what he’d removed for later histological inspection, he was able to weigh most of it and found that he’d removed twelve and a half grams of brain tissue out of each lobe, for a total of twenty-five grams. Twenty-five grams is approximately what two tablespoons of water weigh. The question he was trying to answer, however, was more qualitative than quantitative.

  That is, what did those twenty-five grams of brain, with their millions of neurons and billions of synaptic connections, do?

  He once explained the line of reasoning that had led him to target the medial temporal lobes, pointing out that anatomical studies seemed to indicate a “close functional relationship” between the medial temporal lobes and the frontal lobes. So, his reasoning went, why not follow those connections back from the frontal lobes to the medial temporal lobes to see if the latter were the root cause of madness? He brought up Paul Bucy’s work on the mescaline-dosed macaques who appeared “tamer” after having their temporal lobes removed, and explained that those “previously reported alterations in the behavior of experimental animals following temporal lobe surgery were primarily responsible” for his decision to see what effects similar surgeries might produce in man. Or, more accurately, in woman. My grandfather, like most lobotomists, performed a disproportionate number of psychosurgeries on women. This discrepancy never received a satisfactory explanation, but it seems worth pointing out that the known clinical effects of lobotomy—including tractability, passivity, and docility—overlapped nicely with what many men of the time considered to be ideal feminine traits.

  That same Thursday, as soon as my grandfather finished his first medial temporal lobotomy, he proceeded to perform three more.

  The first was V.M., a “destructive, assaultive, noisy” twenty-eight-year-old woman who’d been “hospitalized since 1946, unimproved on shock therapy” and whose aggressive tendencies often required “packs and seclusion.” (“Packs” was asylum shorthand for ice packs, a form of tranquilizing therapy in which patients were bound tightly in soaking wet, ice-cold bedsheets.) Immediately after the operation V.M. vomited, then became restless and hunched over. She “wished to be left alone,” my grandfather wrote, before adding that the final result of the operation was to make her “more childish” and “more active with self-mutilation.” She rated a zero to one plus.

  There was E.S., a thirty-eight-year-old “mental defective with psychosis,” who also had epilepsy and whom my grandfather described as follows: “Impulsive, assaultive, resistive, mutters, huddles in fetal position in a chair.” She also vomited right after the operation and had seven major seizures during the first month of recovery. In the year that followed, however, those seizures steadily improved in “number and severity.” Her behavior improved somewhat, and by the end of 1951 she no longer required seclusion all of the time and was “slightly less assaultive.” Final rating: one plus.

  There was G.M., fifty-eight years old, who despite “temporary improvement on shock” remained largely “deteriorated, untidy, assaultive, impulsive.” After her medial temporal lobes were removed, she experienced an “emotional regression with baby talk” but was otherwise “cheerful” and “no longer assaultive.” She did, however, appear aged and was “still actively hallucinating.” One plus.

  As with the uncotomies, the preliminary results of the medial temporal lobotomies were inconclusive. Before he could evaluate the operation’s therapeutic promise or begin to answer the larger question of what the medial temporal lobes did, there was more to be done. Like most experimentalists, my grandfather believed that the more research subjects you worked with, the better. An N of one does not count for much. Luckily for my grandfather, he suffered no shortage of material. The lobotomy continued to rise in popularity—just the year before, in December 1949, Egas Moniz had received the Nobel Prize in medicine for his invention—and asylum superintendents around the world were still giving neurosurgeons unlimited access to their patients. By the 1950s, a dizzying variety of approaches to the procedure had been developed, each targeting different parts of the brain: topectomy, gyrectomy, cingulotomy, capsulotomy. The Nobel committee had endowed psychosurgery with a patina of nobility, demonstrating that future breakthroughs in the field might pay great professional, therapeutic, and scientific dividends. For ambitious tinkerers like my grandfather, the lure was irresistible.

  In the weeks following his first four medial temporal lobotomies, he performed ten more:

  Patient B.B.

  Patient C.G.

  Patient A.G.

  Patient A.R.

  Patient G.D.

  Patient R.B.

  Patient D.B.

  Patient M.S.

  Patient A.D.

  Patient A.Z.

  The case of Patient A.Z. was interesting.

  She’d been institutionalized for the past eight years at Connecticut State Hospital. She was thirty years old, and although prior to surgery she’d been “temporarily helped by extensive shock therapy,” she was nevertheless classified as “tense,” “assaultive,” “tidy,” and “impulsive.” She was also, my grandfather said, “preoccupied with sex thoughts” and “sex threats,” which he classified as paranoid delusions. He operated on her on November 19, 1950. She was cooperative and under local anesthetic during the operation. She remained conscious throughout until, while my grandfather was in the process of suctioning out portions of her right hippocampal cortex, he “inadvertently went through the arachnoid and injured by suction a portion of the right peduncle, geniculate or hypothalamic region.” A.Z.’s immediate response was to fall into a deep coma. She remained in the coma for seventy-two hours, incontinent, spasming periodically. Then she slowly came to, remaining in something of a stupor for a week but was eventually able to walk without support and regain control of her bladder.

  She emerged from the coma with what my grandfather described as “complete remission in her delusions, anxiety, and paranoid trends.” This “immediate and marked” result, he said, had “delighted” her family.

  The case of A.Z., like the earlier case of I.S.—in which surgical slipups led to unexpected benefits—reminded my grandfather of a story he was told while at one of the asylums, about a female patient who’d been tied down in a bath for twenty-four hours. The bath had a broken thermostat, and the water was far hotter than intended. This resulted in the patient developing “extreme hyperthermia,” “beyond the limits of the thermometer.” Presumably, according to my grandfather, such prolonged overheating would damage some of the same parts of the brain that he had accidentally lesioned in I.S. and A.Z. So it seemed to him significant that the hyperthermic woman also “underwent a remarkable remission of all psychotic trends.”

  He wondered whether “the unexpected benefit accruing from deep central damage,” as exhibited in these three “fortunate misfortunes,” indicated that “the primary mechanisms of mental disease” might lie in regions even deeper within the brain than his own aggressive procedures were targeting.

  But those were questions for another time. For now, in contemplating the case of A.Z., my grandfather thought that one more thing might be a significant factor in her “excellent results.” Not only did she seem to have experienced a dramatic remission, but she also exhibited a “retrograde amnesia for her entire psychosis (of three years’ duration).”

  She hadn’t just recovered from her illness. She didn’t even remember it.

  —

  My mother had no idea what my grandfather was doing in the asylums back in those days. He worked a lot and talked about it very little. His career, in her mind, remains vague and indistinct. What she remembers is his presence. She remembers the times when he was home.

  He was a good father, that’s what she remembers.

  A busy one, of course. On a typical workday, he came home late after dinner, past eight or nine P.M. He would re
treat to his study for an hour or two, where he’d sit surrounded by his collection of neurosurgical bric-a-brac—ancient blades, old books, a bleached and anonymous skull—and use a Dictaphone to keep up with his correspondence. My mother knew not to bother him while he was in his study. She did other things instead, getting ready for bed. She read, or listened to The Shadow or The Lone Ranger on the radio, or gossiped on a tin can telephone with a girl who lived across the street. Just before my mother went to sleep, though, my grandfather would always go to her room and say good night. Often, she remembers, he told her a story, one he made up on the spot. It was a serial, a continuing saga about three animals: a deer, a bear, and a talking monkey. They’d go on new adventures every night. She doesn’t remember the details of these adventures. I’ve asked her if she remembers the monkey’s name. She doesn’t. But the details don’t matter. What matters is that these stories came from her father. What matters is that he took the time, late at night, exhausted from whatever he’d done that day, to sit with her and tell her stories. What matters is that even now, more than a half century later, those acts of storytelling glow warm and golden in her memory. Afterward, he’d tell her to say her prayers, then he’d leave, shutting the door softly behind him. She was never sure where he went, but she imagines him going back to his study to continue with his work, whatever that work was, while she drifted off to sleep, the latest escapades of the deer and the bear and the monkey tumbling in her head.

  A person can be many different things to many different people.

  He was good to her.

  NINETEEN

  HENRY GUSTAVE MOLAISON (1926–1953)

  MIT NEUROPSYCHOLOGY LABORATORY, FEBRUARY 1986