Patient H.M. (3 page)

“Now, Henry, I want you to go back as far as you can, and I want you to try to tell me what you think is your very first, earliest childhood memory, the memory which you think comes before any other.”

“Well, I can go back to, uh, taking a sleigh ride for the first time….”

He described being on Spruce Street, in Manchester, Connecticut, midwinter. He remembered the sleigh being pulled by a single horse. He thought the sleigh and horse belonged to the father of playmates of his, two brothers, Frankie and Jimmie. As he told the story, he picked up the pace, added more details, lost himself in the memory. The horse was on its way to a stable to be reshod. Frankie and Jimmie and Henry were nestled warmly in the back. Some other local kids, seeing them go by, threw snowballs, but the walls of the sleigh kept them safe.

Henry chuckled.

“It was good,” he said. “I liked that.”

The scientist nodded.

“You remember things from before the operation quite well, don't you?”

Later, when a graduate student transcribed the tape of this session, she noted in parentheses that Henry's response to this last question arrived in a hushed voice, and that he was almost in tears.

“Yes,” Henry whispered. “Before that, yes. I do remember.”

I
remember midway through one Christmas dinner, when I was about eight, my grandfather pushing himself up from his chair at the head of the table, wandering off to his study, and returning a few minutes later with something in his hand. He placed the object beside his plate: It was a crumpled wad of dark metal, not much bigger than a pencil eraser. I looked at it, wondering what it was. Then he sat back down and told us a story.

Stamford, Connecticut, turn of the century. A burglar broke into the home of a young bachelor, and the bachelor woke up. He reached for the pistol he kept in his nightstand, aimed it at the intruder, but the pistol jammed. The burglar's didn't. A bullet entered the bachelor's chest, where it encountered a rib, deflecting it away from his heart. The bachelor survived and kept the bullet as a memento. He eventually passed it down to his son, my grandfather.

The bullet sat there for the rest of the dinner, and I found it both fascinating and terrible to contemplate. Had it found its target, had its aim been true, then my grandfather, his children, his children's children, most of the people sitting around the table, would have never existed. It was a matter of centimeters—a fluke of aim, bone, ballistics—and it had made all the difference, its repercussions rippling down through generations.

There were other artifacts in my grandfather's home, many equally fascinating—like the bleached human skull that sat on a shelf in his study—and some equally terrible. Each had its own story.

A carved wooden totem hung on one wall of the dining room, a representation of some sort of pagan king or god. It was maybe three feet tall, with a mournful look on its face. He'd received it during a trip to South America, an expression of gratitude for an operation he'd performed. The carving had apparently once been an object of worship, owing mainly to the fact that it would sometimes cry, drops of water trickling from the corners of its eyes. Did seasonal moisture variations and the way the wood responded to them cause the tears? Probably. That or magic. My grandfather had appreciated the totem's beauty but was unsentimental about its emotions. When he brought it home, he had someone shellac it before he hung it on the wall. It never cried again.

Hanging on a wall near the front door was something that at first glance looked like another piece of tribal art. It was made of metal, had a green patina, was about eight inches tall. Its top and bottom both had similar half-moon shapes, though the top had a face carved into it, and the bottom, which was sharpened to a razor's edge, did not. It was part of my grandfather's collection of ancient Inca neurosurgical instruments. The top was a handle, the bottom a blade. It used to mesmerize me. It wasn't just its age, it was its purpose. Somewhere, hundreds of years in the past and thousands of miles to the south, in a time and place incredibly far from my grandfather's warm New England home, this relic had been used to do the same sort of work he did. I would imagine that half-moon sweep of metal slicing through flesh, exposing the bone beneath, then cutting even deeper. I used to wonder if it was still flecked with old blood.

Neurosurgery, whatever the era, always requires at least two frightening qualities in its practitioners: the will to make forcible entry into another human's brain, and the hubris to believe you can fix the problems inside.

The early history of neurosurgery is written in skulls, not words.

Hundreds of skulls, thousands of skulls, all over the world. In Europe, Africa, South America, Asia. Skulls from different races, different societies, different millennia. All these different skulls, all telling variants of the same story.

The skulls have holes in them. Man-made holes. More than ten thousand years ago, people began cutting holes into the skulls of other people.

Medical historians have noted that ancient Inca skulls in Peru, when they had holes in them, almost always had those holes on the upper left side, the so-called left frontoparietal area. The Incans were a martial culture, fought hard at close quarters with maces and clubs. They were also, like modern humans, predominantly right-handed. When a right-handed man swings a club at the head of an adversary, it tends to land on the left frontoparietal area. So, the theory goes, these surgical holes in the Inca skulls were probably part of the treatment for head wounds they'd received in battle. Perhaps they were made to relieve intracranial pressure or were cut around smaller, brute-force holes and cracks made by the impact of the weapons to better reach and remove the bony shrapnel inside.

In other parts of the world—more specifically, in a trove of skulls discovered at a seven-thousand-year-old grave site in Ensisheim, France—the holes seemed to be evenly divided between the left and the right sides of the head. This was taken as evidence that not all the skull openings had been made to treat war wounds. But if not, then what were they for? To release evil spirits? To cure headaches? To accelerate enlightenment? Nobody knows for sure.

One thing we do know: Having a hole cut in your skull, even seven thousand years ago, didn't necessarily kill you. A close examination of the edges of the holes in those ancient skulls revealed that in most of them, stretching inward from the serrated or punched or smooth edge where surgeons made their marks, new bone had grown, the beginning of an attempt by the skull to reseal itself. The bones in our heads grow slowly, and stop growing as soon as we die. Which means that the owners of those skulls, with their indications of postoperative growth, had survived their surgeries.

In some skulls, in some cultures, the holes weren't so much cut as they were scraped away by surgeons wielding tools more like Brillo pads or sanders than scalpels or drills. Paul Broca, a pioneering French nineteenth-century neuroanatomist, was fascinated by these scraped skulls. He noted that they predated anesthesia—which originated in its crudest form around 400
B.C.E.
, when Assyrian surgeons would induce unconsciousness by compressing the carotid arteries of their patients—by at least 3,500 years, and speculated that the surgeries must have been performed when the patients were young children, because a child's thinner skull wouldn't take so agonizingly long to rub through. To prove his point, Broca obtained a number of corpses of all ages and demonstrated that while it took him almost an hour to rub through the skull of an adult, he could do the same to a two-year-old child's in less than five minutes. Others took exception to Broca's theory, noting that although dying from these operations was evidently rare—see again: the evidence of postoperative bone growth—it did sometimes happen, and if ancient brain surgeons had been scraping holes in ancient infants, you would expect to find at least a few ancient infant skulls with holes in them, victims of unsuccessful operations. No such skulls had been found.

These sorts of debates will go on and on. People continue to study these silent skulls, trying to read the stories their preliterate former owners couldn't document.

Eventually, of course, humans did gain the ability to record their own lives. We began to write. And among the first things we wrote about?

Brain injuries and how to treat them.

In 1862, an American collector of antiquities named Edwin Smith bought a scroll of papyrus from a dealer in Luxor, Egypt. The papyrus was fifteen feet long, and an unknown ancient had used a reed brush and inks derived from clay and burnt oils to cover it in a thicket of hieratic script. Hieratic was the less formal and ornate descendant of the Egyptian hieroglyphs, their version of shorthand. For almost all of the thousand years prior to Smith's purchase, both forms of writing—hieroglyphs and hieratic—had been relics of a dead language, unused and untranslatable. The Egyptians themselves debated whether the two scripts even represented a language at all or whether their ancestors had just enjoyed covering scrolls and tombs with meaningless decorative symbols. In one often-repeated tale, an Italian merchant visiting the Giza pyramids in the 1700s was offered a wooden chest containing forty ancient papyrus rolls. He purchased only one of them, and the villagers supposedly “burned the rest in order to enjoy the smell they gave off.”

But by 1862, things had changed. The 1822 translation of the Rosetta Stone—which contains versions of the same text in hieroglyphs, hieratic,
and
Greek—provided sudden access to an entire epoch of the ancient world that had been previously sealed off. For people interested in history, or in profiting from it, this was the equivalent of the gold rush: Egypt swarmed with tomb raiders and treasure hunters, such as Edwin Smith, who gathered up as many of these formerly inscrutable documents as they could.

Smith took the scroll home to Connecticut and spent much of the rest of his life trying to make sense of it. Even the best linguist might spend years translating a single passage of hieratic. Edwin Smith was not the best linguist. He'd obtained an objectively beautiful piece of writing—the papyrus was incredibly well preserved, and its ink changed intriguingly from a deep black to, for certain words and lines, a crimson made out of ground ochre—but it refused to give up its secrets. When Smith died in 1906, his daughter donated the scroll to the New-York Historical Society, where it was found by James Henry Breasted, a professor of Egyptology at the University of Chicago.

Breasted spent nearly ten years working on his own translation of the scroll, and when he published it, in 1930, he declared the so-called Edwin Smith Papyrus “the oldest nucleus of really scientific knowledge in the world.”

The scroll, Breasted revealed, was a medical textbook. And in its formatting, it was a strikingly modern one: The passages written in red, for example, were done to highlight the key parts of the text that the author wanted the reader to remember. But much more surprising was how modern its contents were, this despite the fact that the scroll itself was at least 3,600 years old and contained archaic turns of phrase that indicated it may have been a transcription of a text eight hundred years older than that.

Up until Breasted's translation, the prevailing view of medicine in ancient Egypt was that it was based in magic, not science. Previously discovered papyri about medical topics limited their prescriptions to incantations and dubious potions. And the Edwin Smith Papyrus had some of that: The scroll was organized as a series of forty-eight case studies of battlefield injuries, each with its own treatment recommendation. In case nine, a man with a bashed-in forehead, the would-be attending physician was advised to chant the following spell while standing over his patient: “Repelled is the enemy that is in the wound / Cast out is the evil that is in the blood / The adversary of Horus, on every side of the mouth of Isis / This temple does not fall down / There is no enemy of the vessel therein / I am under the protection of Isis / My rescue is the son of Osiris!”

Most of the prescriptions, however, were secular. And most of the case studies—twenty-seven out of forty-eight—involved head trauma.

For example:

Case 6: Medical instructions for an oozing gash/cutting wound in his head that penetrates to the bone, smashing in his cranium and exposing the brain in his cranium.

—You have to probe his wound.

—Should you find [in] that smash fracture that is in his cranium, ripples [like] those that occur [in] copper in the smelting process,

—and something within that throbs and flutters under your fingers like the weak spot of the crown of a child not yet fused and made “whole.”

You should daub that wound of his with oil.

—Do not bandage it.

—Do not put dressings on it until you know that he has passed the crisis!

The smash fracture is large, opening to the inside of his cranium and the membrane enveloping his brain is ruptured and its fluid falls from the interior of his head.

Although the treatment in this case by modern standards is conservative—clean the wound and hope for the best—it's about as promising an approach as you could hope to find in a four-thousand-year-old hospital. Sealing the wound, for example, would have probably done more harm than good, causing death through swelling or infection. The Egyptians were apparently not only restrained physicians but accomplished neuroanatomists as well: Up until the translation of the Smith papyrus, nobody had found the word
brain
in any prior hieratic or hieroglyphic documents. In this one, however, they didn't just name the brain, they described it in vivid poetic detail—with its “ripples [like] those that occur [in] copper in the smelting process”—along with the membranes and cerebrospinal fluid that swaddled it. The brain, the ancients clearly understood, was a delicate and important organ. It was also an organ that, in general, should be protected and not actively messed with. In the case of a patient with a fractured skull, you might “clean it for him with a swab of linen until you see its fragments of bone,” but the brain itself should remain untouched.

After the revelations of the Edwin Smith Papyrus, some Egyptologists argued that the Egyptian ankh—which represents the human spinal column—would make a more historically accurate symbol for the medical arts than the traditional snake-twined staff. (That symbol derived from myths about the staff-wielding, snake-revering Greek doctor-god, Asclepius, who was so good at keeping people alive that Zeus killed him to prevent overpopulation.) In any event, the papyrus seemed to prove that modern medicine had begun far earlier than was previously thought, and the cautious treatments it prescribed indicated that at least some ancient doctors were adhering to the central tenet of the Hippocratic oath more than a thousand years before Hippocrates's birth.

“Abstain from doing harm….”

A simple principle, and an enduring one.

For most of the long history of the healing arts, that principle has guided the care and treatment of our most mysterious and delicate organ.