Patient H.M. (15 page)
Authors: Luke Dittrich
The entire operation, from the application of the electrodes to the final removal of the ice pick, took no more than fifteen minutes. Soon Rebecca Adams began to stir. Dark bruises were forming under her eyes, but other than that she was, physically at least, unchanged.
As I look back at that long-gone day, squinting through a haze of dusty surgical logs and old letters, it's tempting to ask whether the men in charge of the asylum were as mad as its inmates. From the perspective of the present, it can look as though the surgeons, the psychiatrists, the administrators, the whole lot of them, were trampling blithely, arrogantly, even insanely through the delicate soil of other people's brains.
But you can't put ghosts on the couch. Besides, madness usually implies a break with reality, a loss of rationality. This was something else. Those men in that operating room, like the men observing from the operating theater, were, as far as we know, all reasonable, intelligent, rational human beings. Their motivations in most cases were straightforward.
There was Walter Freeman, the striving son of a renowned surgeon, making his own play for greatness. There was Charles Burlingame, the asylum superintendent famous for his embrace of innovative new treatments, doubling down on his convictions. There was the audience, that assembly of surgeons and psychiatrists and physiologists, some seeing therapeutic promise, some seeing scientific potential, some seeing a little of both.
And there was my grandfather.
My grandfather's motivations were maybe more complicated than most. To begin with, his passion for medical research had always been equal to his interest in the purely healing aspects of the art. There was a through line of experimental curiosity you could trace from his early fascination with the misfiring adrenal glands of dwarfs to his later attacks on the frontal lobes of asylum dwellers. By 1948, the border between his work as a doctor and his work as a scientist had become impossibly blurred. For example, in the weeks leading up to that day's surgical showdown, he'd been putting the finishing touches on a paper that would announce his new procedure to the world. The paper's titleâ“Selective Orbital Undercutting as a Means of Modifying and Studying Frontal Lobe Function in Man”âperfectly captured the odd way in which medical practice and medical research overlapped in my grandfather's mind. His more precise operative approach to the lobotomy had opened up an entirely fresh cerebral landscape for him to alter at will, and while he hoped this new approach would be beneficial to his patients, he knew it also offered tantalizing and novel opportunities to illuminate the functions of the brain by means of experimental methods that were once, not long ago, limited to animals.
Plenty of neurosurgeons of his era straddled the line between practice and research, but none embraced psychosurgery with quite my grandfather's enthusiasm. By 1948, he was already well on his way to becoming one of the most prolific lobotomists in history, second only to Walter Freeman. Although there were other subfields within neurosurgery to which my grandfather also applied his inventive zealâthe treatment of spinal trauma, the removal of tumors, the clamping of aneurysmsâpsychosurgery had become his dominant interest.
The genesis of his passion was something he never discussed, at least not in public. He revealed it explicitly only once that I'm aware of, and that was in a very private forum, in a note he wrote to his second son, my uncle Peter, in the 1950s. Peter and my grandfather had a difficult relationship, and the note was clearly written after some sort of argument: “My constant bullying of you is only a desire to make you strong so that you can be independent of me and other âbosses.' I shall not bring up the past,” my grandfather wrote. Their argument apparently had something to do with my grandmother, whom my grandfather referred to as “E,” short for “Emily.”
“E's illness was constitutional and grave, and not environmental,” my grandfather wrote. “I don't wish to discuss it but you will have to believe me in that, for I have spent 20 years in studying and operating on mental illness in the hopes of contributing to a cure of itâfor E's sake.”
Before the day was done, two more women would be led into the operating theater. Walter Freeman performed another transorbital lobotomy, and my grandfather concluded the session with a final orbital undercutting. By two
P.M.
, the last patient had been wheeled away and the men were ready to leave the asylum. They met up a short while later at the University Club in downtown Hartford for dinner and debate.
The ostensible reason for that day's Psychosurgical Conference, as the Institute of Living had dubbed the exhibition, was to review and assess the preliminary results of the Connecticut Cooperative Lobotomy Study. The numbers were impressive: In the previous two years, under the auspices of the study, 550 men and women had been lobotomized in Connecticut's public and private asylums. By some measures, the clinical results of these lobotomies were encouraging: Some patients left the asylums and returned home, while others at least became more sedate and easier for staff to manage. In a note in the 1948 annual report of Connecticut State Hospital, Superintendent Yerbury, after noting that his asylum remained overburdened and that conditions there were “unfair to the patients and their families and continue unduly an economic burden to the State,” had thrown in the following dash of optimism: “On the other hand, there have been brighter sides to the picture during the biennium. Most notable has been the introduction of the procedure known as the prefrontal lobotomy.” The report goes on to enumerate a number of interesting facts about the procedure's rapid adoption at his asylum, including the fact that during the previous year more inmates had received lobotomies than had received dentures.
The drawbacks of the traditional lobotomy, however, were by then becoming well known, and there was a hunger for a new direction. Psychosurgery was at a crossroads, and my grandfather and Walter Freeman had just demonstrated two starkly different ways forward. My grandfather's “fractional lobotomy” was technical, complicated, precise, requiring the deft hands of a skilled neurosurgeon. Freeman's operation was the opposite: Anyone could do it. Freeman himself, after all, wasn't a trained surgeon of any sort. In fact, the operations he'd just performed were technically illegal, since he'd never had surgical privileges in Connecticut, or any other state for that matter.
There is no record of how the debate at the club unfolded, though later writings by both my grandfather and Walter Freeman give a hint of what might have been the basic thrusts of their arguments. “In spite of its extreme simplicity,” my grandfather would write, Freeman's transorbital lobotomy was “undesirable” because of “its complete lack of precision.” He added pointedly that even if such a lobotomy were ever to be a viable option, “it should be performed by surgeons and not psychiatrists.” Walter Freeman, for his part, and somewhat bizarrely considering the fundamentally blind and rough aspects of his own method, criticized my grandfather's use of a suction catheter in his orbital undercuttings as being less precise than using a scalpel, deriding it as being like “using a vacuum cleaner over a bathtub of spaghetti.”
Unsurprisingly in this contest waged largely in front of neurosurgeons, my grandfather won the day. Freeman's approach, after all, was a direct attack on their livelihood, since it opened up the practice of psychosurgery to nonsurgeons. And this was putting aside all questions of the blind, mutilative guesswork that lobotomizing by ice pick necessitated. The speed and ease of the operation was a poor trade-off, and many people were as horrified on a visceral level by the transorbital lobotomy as Freeman's estranged partner, James Watts. John Fulton captured the prevailing opinion when he wrote, in a letter to Freeman about his new approach, “Why not use a shotgun? It would be quicker.” After that day at the asylum, despite having introduced the lobotomy to America, Freeman found himself on the outside of the tight-knit neurosurgical clique.
In another sense, both approaches prevailed. Freeman might not have been able to win over the neurosurgeons, but his whole point was that he didn't need to. He and a platoon of eager psychiatrist acolytes would soon spark a rapid uptake of his ice pick method. Over the next decade, Freeman, touring asylums around the country in a camper van he dubbed his Lobotomobile, would perform over 2,400 transorbital lobotomies, sometimes as many as twenty-five in one day.
My grandfather's orbital undercutting procedure, on the other hand, quickly replaced the old Freeman-Watts method as the preferred lobotomy technique among neurosurgeons. It was also clear that this first type of selective lobotomy was just the beginning. Indeed, from that day forward, whenever my grandfather performed an orbital undercutting, hoisting up the frontal lobes to get at the connections beneath, he would catch a glimpse of not only the frontal tracts that were his target but also some of the deeper structures that lay beyond them, specifically the mysterious uncharted territory of the medial temporal lobes and their network of intriguing structures, the purposes of which remained unknown: the uncus, the amygdala, the entorhinal cortex.
The hippocampus.
One of the neurosurgeons who knew my grandfather best once said to him, “Bill, the only criticism I have of you is that you never do the same operation twice.” He was known as a tinkerer, a restless explorer in the operating room, never satisfied with existing techniques or methods, even the ones he had invented.
Maybe it was inevitable that once he had spotted that new and mysterious landscape on the horizon, he would eventually attempt to reach it.
THE HUNT
IT WAS BROUGHT INTO THE SEA
T
he psychologist told the man a story. She asked him to listen closely. She was reading from a booklet on her lap, and she pronounced each word carefully in her brisk British accent.
“Anna Thompson,” she said, “of South Boston, employed as a scrub woman in an office building, reported at the City Hall Station that she had been held up on State Street the night before and robbed of fifteen dollars. She had four little children, the rent was due, and they had not eaten for two days. The officers, touched by the woman's story, made up a purse for her.”
The man, who would later be known to the world as Patient P.B., listened attentively with a somewhat anxious expression on his face. It was October 23, 1951, and he was a forty-eight-year-old civil engineer. For most of the past thirteen years he had been suffering from recurring seizures. Unlike the grand mal, full-body seizures that the public generally associated with epilepsy, his were of the type known as psychomotor seizures. A person with psychomotor epilepsy experienced a temporary bout of automatism, perhaps performing a nonsensical motion or repeating a single word or simply standing still. For the duration of their seizures, usually less than a minute, these patients would be entirely absent. In the case of the civil engineer, his seizures usually began with a dawning sensation that the world around him had suddenly become absurd, that reality itself had become, in some ineffable way, unreal. Then he would lose awareness. He would stare straight ahead, moving his mouth as though he were chewing and fumbling the air with his hands. This would go on for several minutes. The man was an amateur meteorologist, kept a barometer outside his house, and was in the habit of making daily notations about the weather. If one of his attacks occurred while he was at home, he would often go to the porch, check the barometer during his period of automatism, and make an accurate note of what he found, though he never remembered having done so once the seizure subsided.
His first surgery had taken place five years previously. The surgeon removed a small portion of the brain region known as the medial temporal lobes. The operation did not have any apparent adverse effects, but it was not a success, either: Soon after he left the hospital, the seizures returned. So he came back here, to the Montreal Neurological Institute, for a second operation. This time, the same surgeon performed a more extensive removal, lesioning a larger portion of his brain. And now, three weeks later, the psychologist, whose name was Brenda Milner, was examining him to see if the second operation had caused any functional deficits.
The initial results were impressive. He didn't seem to demonstrate any of the usual postoperative aphasia that people who undergo brain surgery often do. That is to say, words came to him without effort. His intelligence quotient, measured on the standard Wechsler scale, had gone up slightly, from 119 to 120. This wasn't entirely unexpected: Epilepsy often left people somewhat foggy-headed, and the alleviation of symptoms following an operation often brought about a crispness of thought. In any case, both scores were indicative of a superior intelligence, markedly above the average. Then she moved on to testing the patient's memory. Like intelligence, memory was also usually unaffected by the operations performed here. After reading him the story about the mugging victim, Milner asked him to recount it to her, including every detail he could recall.
He paused for a moment, gathering his thoughts, then began.
“Anna X,” he said, “reported that she had been robbed last night of several hundred dollars that she needed to pay for the sustenance of her children. They said that they would do what they could immediately to help her.”
Milner made a note that “although the gist of the story has been retained,” apparently “all the precise details of names, places, and quantities have been lost.” Then she immediately read him another story, asking him again to listen carefully and repeat it back to her.
“The American liner
New York,
” she read, “struck a mine near Liverpool Monday evening. In spite of a blinding snowstorm and darkness the sixty passengers, including eighteen women, were all rescued, though the boats were tossed about like corks in the heavy sea. They were brought into port the next day by a British steamer.”
The patient recounted this second story back to her as follows:
“The American liner
New York
struck a mine near Liverpool in a blinding snowstorm. The people vainly attempted to be brought into port by boats, but great dismay was sustained.”
Milner noted that his version of the story “begins accurately and well, but after the first sentence the thread is lost and the story is completely distorted.”
Then she asked him to tell her what he remembered of the first story.
He couldn't remember a word of it. He told her that this was because he had been “concentrating too heavily on the second one” and added that trying to remember the first story “created terrible confusion and pandemonium.”
They moved on to some additional tests, which took about five minutes to complete. Afterward, Milner asked him to tell her whatever he remembered of the two stories she had told him just a little while earlier.
He looked at her blankly.
He did not remember that she had read any stories to him at all.
Brenda Milner had herself once sailed through a sea full of mines in an American liner off the coast of the United Kingdom. In 1944, during World War II, she and her husband, Peter, left their homes in Britain, bound for North America. At night, out in the open water, any light would have made them a target for U-boats, so the captain ordered a complete blackout, with not even candles permitted. They churned westward for more than a week, zigzagging over moonlit seas, avoiding predictable routes, and when they reached Boston, with its incandescent skyline, Milner felt giddy, drunk on light itself, and flush with the sudden sensation of safety and possibility. In England, she and Peter, who was an electrical engineer, had spent the previous year working together at an isolated military radar research center, battling the ever-present worry that one or the other of them would be kidnapped, spirited across borders, and put to work for the Reich, as was rumored to have happened to many other promising young Allied scientists. Brilliance made you a target, too.
Milner was born in Manchester in 1918 and grew up in an old house surrounded by delphiniums. Her father was a music critic and piano instructorâher mother, twenty-six years younger, had been one of his studentsâand his somewhat ad hoc work schedule allowed him to spend time with his daughter, immersing her in Shakespeare and German and math. He homeschooled her until the age of seven, when he died of tuberculosis. Her widowed mother sent Milner to a girls' boarding school, where she excelled. She went on to attend Cambridge University and contemplated majoring in philosophy before settling on psychology, mainly because she decided there would be more job opportunities for psychologists than philosophers.
She graduated in 1939, but her examination results won her a prestigious fellowship, which allowed her to stay on at Cambridge for an additional two years. At first her research there explored sensory conflictâwhat happens when external cues clash with internal ones, such as when a visual illusion makes it look as though you're leaning to the left even if your proprioceptive senses tell you you're standing up straight. That project ended abruptly when the war broke out in September 1939, and Milner and a group of her Cambridge colleagues were put to work on a project designing psychological aptitude tests meant to help the military determine which recruits were better suited to being, say, bombardiers as opposed to fighter pilots. In 1941, she was reassigned again, sent to that isolated radar research center, which is where she met Peter, who in 1944 surprised her by telling her that A) he had just been assigned to an atomic-energy research facility in Montreal, and B) he wanted her to marry him and come along.
After an evening eating planked steak and ice cream in Boston and a night at the Copley Plaza hotel, the newlyweds headed north to Montreal. Languages were one of Milner's strengths, and while her husband spent his days working on the top-secret problem of transforming matter into energy, she took a nonfaculty job at a francophone university, lecturing undergraduates on the basics of experimental psychology. She found honing her French stimulating but missed research. After taking a seminar at nearby McGill University with Donald Hebbâa psychologist who had just written
The Organization of Behavior,
a soon-to-be-classic book that postulated that every aspect of human behavior could be understood on the basis of neural circuitry in the brainâMilner was inspired to apply for the doctoral program in psychology at McGill. Hebb became her adviser and mentor, and in June 1950 he told her about a unique research opportunity at the nearby Montreal Neurological Institute.
The Neuro, as the institute was commonly known, was the most prestigious center for neurosurgery in Canada. It was helmed by Canada's most renowned neurosurgeon, an imperious American transplant named Wilder Penfield. Penfield had pioneered a new surgical method for the treatment of epilepsy, one that involved targeting the temporal lobes of the brain. Because the general function of the temporal lobes was a mystery, Penfield decided that it would be good to have a psychologist study his patients before and after their operations, to see whether his surgical lesions were causing any notable changes beyond their purely therapeutic effects. He only had room for one researcher. Hebb told her that the job was hers if she wanted it.
Brenda Milner had spent her academic career up until then trying to glean a deeper understanding of the hidden processes taking place inside the black box of the human skull. As soon as she arrived at the Neuro, the black box was, for the first time, flung wide open to her.
In 1892, at a meeting of the New York Neurological Society, a prominent doctor named Joseph Price presented a paper called “The Surgical Treatment of Epilepsy,” which was later published in
The Journal of Nervous and Mental Disease.
In his introduction, Price described the long, hard road that generations of doctors had walked in their attempts to treat this stubborn and ancient sickness. “Its history, from a therapeutical standpoint,” he wrote, “is one that has taxed the efforts of supremest superstition and defied the resources of scientific medication. Its treatment has been one of trial and disappointment, for it still remains one of the greatest opprobria of medicine.”
There were, however, grounds for optimism. The age of reason had dawned, and superstitions were dropping away. The principal causes of the disease, Price declared, were finally coming to light.
“Debauchery leads to it,” he said. “Young widows are prone to it, and its origin outside of physical causes may be traced to amorous songs and certain stimulants, such as chocolate and coffee.” Onanism, Price continued, was also associated with many cases of epilepsy, and in those cases there was a straightforward remedy. “In women, efforts in a surgical way have long been tried for its relief,” he noted. “One table I have consulted gives as high as 73.7 per cent of cases cured of masturbation by clitoridectomy. This surely makes it not presumptive in its claims for recognition.”
Not all epilepsies had their roots in lust. Price noted that some epileptic fits were characterized by guttural, convulsive noises originating in the throat. This presented surgeons with an obvious area of attack. “Tracheotomy,” he said, “was urged by Marshall Hall and others on the ground that many convulsions began in and were limited to the larynx.” Other surgical approaches that he listed with approval included male castration and female ovariectomies, the benefits of which, he noted, would accrue to the epileptics as well as to the societies in which they lived. “So far as unsexing an epileptic is concerned,” he continued, “I do not understand how or why there is reason to feel compunction at such a suggestion. I can hardly question the protective value to society, not only of forbidding epileptics to marry, but of rendering them unable to procreate.” The amputation of the left arm also reportedly had occasional success, and nonsurgical treatments included doses of belladonna, a plant-derived poison with its roots in Europe, and curare, a plant-derived poison with its roots in South America. Leeches, too, showed promise.
Price wrote about both medical and surgical treatments for epilepsy, though he tended to favor the surgical approach. “Operation has the best of the argument,” he wrote. “Out of seventy-one cases treated medically, and out of a second series of seventy-one treated surgically, the statistics as exhibited in my collection, the advantage is all with the surgical treatment, as in these four all were at least benefited, while in the medical series a great proportion showed no effect at all, and some grew worse. The exact percentage someone may calculate who has a greater taste for such work than I.”
Six decades later, when Brenda Milner arrived at the Montreal Neurological Institute, epilepsy treatments still consisted of an assortment of medications and operations, although the medications and the operations had changed. Doctors had by then zeroed in on the disease's true point of origin, which, it turned out, had never been in the nether regions, the throat, or the limbs. Instead, the modern medical establishment rediscovered that, as Hippocrates had prophesied 2,400 years earlier, “the brain is the cause of this affection.”
While the fact that epilepsy is a brain disorder may seem obvious today, that knowledge was hard-won and was built, once again, upon the backs of broken men and women whose damaged brains illuminated the functions of our own. The 1861 postmortem examination of the brain of Monsieur Tan, the monosyllabic patient discovered by the French doctor Paul Broca, provided neurologists with the first clear evidence that a specific facultyâin this case, speechâwas localized in a specific patch of cortex, and it wasn't long before doctors interested in the etiology of epilepsy correctly guessed that epileptic seizuresâwhich often consistently provoked convulsions of speech or movementâmight be caused by damage to the associated parts of the brain. A complementary development, also in the late 1800s, was the discovery that by electrically stimulating portions of exposed brains of living humans or animals, it was possible to create automatic, convulsive physical responses: Shock a particular portion of the surface of the brain and a patient's fingers might twitch. Shock another and his biceps might flex. Slowly doctors developed the concept that epilepsy might sometimes result from a similar effect, with portions of the brain discharging uncontrollably as though touched with an electrode. This convulsiveness might be caused, they surmised, by tumors or scar tissue or other damage to the brain. Careful observation of a patient's seizures could give surgeons a clue to where to look for this “epileptic focus”: If a patient tended to convulse on the left side, for example, there might be reason to believe that there was an abnormality in the brain's right hemisphere. Surgeons would then simply open the right side of the patient's skull and look around for damage. If they found the problem, they would take it out.
