Henry spent the night in the hospital. The next day, hospital staff members shaved his head and wheeled him into an operating room. Scoville’s operation report read: “Finally admitted for new operation of bilateral resection of medial surface of temporal lobe, including uncus, amygdala, and hippocampal gyrus following recent temporal lobe operations done for psychomotor epilepsy.”
This was a day of eager anticipation for Scoville, and of cautious optimism for the Molaison family. Scoville knew about the procedures other surgeons were using to quell their patients’ seizures, and he hoped to break new ground in surgical therapy with his own technique. Henry’s case was the first in this experiment. Henry and his parents looked forward to a time when they could once again live like a normal family without the unexpected intrusions from Henry’s seizures. The question on everyone’s mind was would the removal of brain tissue cure Henry’s epilepsy? No one anticipated that he would he lose his memory, but he did, and on that day, the entire course of his life was irrevocably altered.
Two
“A Frankly Experimental Operation”
On Tuesday, August 25, 1953, William Beecher Scoville stood over the operating table and injected an anesthetic into his patient’s scalp. Henry was awake, talking to the doctors and nurses; he did not need general anesthesia because the brain does not have pain sensors and would, therefore, not register any pain during the surgery. The only places that needed to be numbed were his scalp and dura, the fibrous tissue between his skull and his brain.
When the anesthetic took effect, Scoville made an incision along a wrinkle in Henry’s forehead and pulled the skin back to reveal its red underside and the bone beneath it. Just above Henry’s eyebrows, Scoville drilled two holes in the skull, one and a half inches in diameter and five inches apart. He removed two disks of bone from the drill sites and set them aside. The holes became doorways to Henry’s brain, through which the surgeon could insert his instruments.
Before Scoville proceeded, his team performed a final EEG study, this time with electrodes placed directly on and in Henry’s brain tissue. Scoville wanted to try one last time to locate the source of Henry’s seizures. The electrical activity in his brain appeared as a series of squiggled lines, called traces, on the EEG paper, with each trace corresponding to a different part of his brain. If Scoville could isolate the epileptic activity to one area, the experimental surgery he had proposed would be unnecessary; he could simply remove the discrete area from which the seizures arose. But again, the EEG showed electrical activity that was diffuse and difficult to isolate, so he moved forward with the operation as planned.
Scoville was trained in, and a strong proponent of, psychosurgery. Like many of his contemporaries, he believed that surgery offered a radical but potentially transformative solution for desperate cases. The destruction of brain tissue was, at the time, considered a valid, if experimental, treatment for numerous psychiatric diseases, including schizophrenia, depression, anxiety neuroses, and obsessional states.
Scoville believed that eventually surgeons would be able to delve into the brain and, by removing or electrically stimulating a critical area, fix problems directly, without the need for psychotherapy or drugs. Even though he was about to operate on Henry for epilepsy, not a psychiatric disease, it was through Scoville’s exploration of these procedures that he came to perform such an extreme operation on Henry.
When most people think about psychosurgery, they think of frontal lobotomy, disconnecting the frontal lobes from the rest of the brain. The 1975 Academy Award–winning movie One Flew over the Cuckoo’s Nest offers one of the most vivid cultural illustrations of the procedure. Based on the Ken Kesey novel, the movie tells the story of R. P. Mc-Murphy, a convict sent to a mental hospital for ostensibly crazy behavior. There, he rallies his fellow patients to defy the dictatorial and hated Nurse Ratched. When his plans backfire and result in a patient’s suicide, he blames Ratched and attempts to choke her to death. As punishment, McMurphy is lobotomized. The operation leaves him pitifully brain damaged, evoking the sympathy of another patient who mercifully suffocates him with a pillow (see Fig.1).
A real life example of the devastation caused by lobotomy is the well-known story of Rosemary Kennedy, daughter of Joseph Kennedy and sister to John, Robert, Edward, and Eunice. Rosemary was a pretty young woman who was said to be less intelligent than her siblings. In 1941, when she was living in a convent school in Washington, DC, the nuns reported that Rosemary was moody, had emotional outbursts, and escaped from the school at night. Concerned that she was meeting men and might get into trouble, Joseph Kennedy settled on lobotomy as a remedy for his twenty-three-year-old daughter, and took her to the renowned champion of psychosurgery, Walter Freeman. Freeman’s collaborator, James Watts, diagnosed Rosemary with agitated depression, thus making her a good candidate for the procedure. The outcome was devastating and horrific: Rosemary was left mentally and physically handicapped and was institutionalized for the next sixty-three years, isolated from her family.1
Now banned in some countries, frontal lobotomy has been discredited and is virtually obsolete. Knowing the devastating results of these operations, it is hard to understand how they ever came to be performed. From 1938 to 1954, however, proponents of lobotomy argued that the risks of the procedure were justified by the chance to rescue desperate patients, many of whom were living deplorable lives locked up in institutions. These operations sometimes allowed patients to return to their families and resume their lives at a higher level of function than before the operation.
Surely this logic guided Scoville in his recommendation to perform the procedure on Henry. The seizures were becoming more frequent, putting Henry’s life at risk, and he was no longer responding satisfactorily to even massive doses of medication. To Scoville, no doubt, surgery seemed the last, best option.
Unlike a tumor or scar tissue in the brain, which a surgeon can identify and remove, psychiatric diseases do not arise from visible changes in the anatomy of the brain or obvious disease in its tissue. The rationale for performing surgery to treat a psychiatric disease, then, is that a particular circuit in the brain is not functioning properly, even if the dysfunction is not observable.
Psychosurgery became popular as scientists began to map animal and human brains. Brain-mapping experiments began in the late nineteenth century and became increasingly popular as scientists began to understand that functions of the mind are localized in the brain. The idea behind these investigations was that specific sensory, motor, and even cognitive functions, such as language, were represented in discrete, specialized brain areas. These links between the brain and behavior, demonstrated in the late nineteenth and early twentieth centuries, raised the hope that mental illness could be localized and treated surgically.
Swiss psychiatrist Gottlieb Burckhardt published the first account of psychosurgery in 1891, removing parts of the cerebral cortex—the outside layers of the brain just under the bone—in six patients who experienced hallucinations. Burckhardt’s colleagues responded to his lengthy account of his operations by ostracizing him professionally, calling his procedure reckless and irresponsible.2
In the early 1900s, Estonian neurosurgeon Ludvig Puusepp tried a different approach. Puusepp’s three patients had manic-depressive disease or seizures, which he believed were caused by psychological disturbances. Instead of removing a chunk of brain tissue as Burckhardt had done, Puusepp cut the fibers—the “telephone lines”—that connect the frontal and parietal lobes. The surgery did not abate their disease, however, and Puusepp deemed his experiment unsuccessful.3
In the 1930s, psychosurgery began on a grand scale. Portuguese neurologist António Egas Moniz was a pioneer in the field whose attempts to create a biological treatment for psychiatric disorders ultimately won him a Nobel Prize. Moniz drew inspiration from an unexpected source: the Comparative Psychobiology Laboratory at the Yale University School of Medicine. Researchers there conducted experiments in chimpanzees to determine
the function of the brain’s frontal lobes, the part of the cerebral cortex located just behind the forehead.
In one such experiment, researchers trained Becky and Lucy, normal chimpanzees with intact frontal lobes, to perform a memory test in which they watched the experimenter hide a piece of food under one of two cups. The experimenters lowered a screen between the chimp and the cups, leaving it in place for different amounts of time, ranging from seconds to minutes. When the screen was raised, the chimp was allowed to choose one of the two cups to retrieve the reward. A correct choice reflected the animal’s ability to remember where the food had been hidden. Like humans, chimpanzees manifest individual differences in personality and emotionality. Unlike Lucy, Becky had a violent dislike for the entire training experience and would not cooperate; she threw temper tantrums and rolled on the floor, urinating and defecating, and had emotional outbursts when she performed the memory task incorrectly. The researchers concluded that Becky had an experimental neurosis, a behavioral disorder produced in the laboratory by exposing an animal to an extremely difficult cognitive task; in essence, Becky had a nervous breakdown. Lucy, on the other hand, showed no extreme reactions.4
Proceeding with their experiment to examine the role of the frontal lobes in complex behaviors, the researchers removed these structures in Becky and Lucy. Postoperatively, both chimps failed the memory test when the delay was longer than a few seconds, indicating that the frontal lobes were necessary to hold the location of the food in memory. Because other intelligent behaviors were preserved, researchers knew that the chimps’ failure on this task was not due to a general cognitive decline. Lucy continued to be a cooperative participant as she had been preoperatively, but Becky’s behavior changed completely. In an entirely unexpected turn of events, she performed the task quickly and enthusiastically, and was no longer excitable and prone to outbursts. The researchers concluded that the frontal-lobe operation had “cured” her neurosis.
This serendipitous discovery attracted Moniz’s attention. He believed that Becky’s case, along with other animal studies and several clinical reports, provided enough evidence to suggest that destroying frontal-lobe tissue in humans could treat emotional and behavioral disorders. Moniz speculated that the abnormal thoughts and behaviors exhibited by psychiatric patients resulted from aberrant wiring between the frontal lobes and other brain areas. He proposed that cutting these faulty connections would redirect neuronal communication into healthy circuits, thus restoring patients to their normal state.
To achieve this result, Moniz fashioned the leucotome, a new instrument that he deemed necessary for the operation. This tool consisted of a metal tube slightly longer than four inches and about three quarters of an inch wide that could be inserted into the brain through each of two small circular holes cut in the patient’s skull. Moniz’s neurosurgical collaborator, Almeida Lima, initially carried out all of their operations. Lima drilled the holes, lowered the leucotome to the desired spot in the brain, and then released a thin steel wire from the base of the leucotome, which could loop out as far as about two inches from the tube. To cut the connections—the white matter—under the frontal lobes, he turned the leucotome slowly for one full circle. To make a second cut, he retracted the wire slightly and rotated the leucotome again. Then, Lima pulled the wire back inside the leucotome, removed the leucotome from the brain, plugged the hole in the skull, and repeated the procedure on the other side. The maneuver resembled coring an apple, and the effects were irreversible. Moniz called his procedure prefrontal leucotomy.5
Moniz and Lima began performing prefrontal leucotomies on humans in 1935. In Moniz’s first published account of the surgeries, he described twenty patients ranging in age from twenty-seven to sixty-two. Eighteen were psychotic—they experienced irrational thinking, delusions, or hallucinations—and two were diagnosed as neurotic with anxiety disorders. Moniz described the results with this first series of patients in a 1936 monograph, in which he evaluated the therapeutic effect for different psychiatric disorders separately. He discovered that the outcome differed between psychiatric groups: patients with anxiety, hypochondriasis, and melancholy showed improvement, whereas those with schizophrenia or mania were unchanged. In his monograph, Moniz included before-and-after photographs that made his subjects appear more sane postoperatively. A close look at the individual case descriptions indicates that the outcomes were indeed mixed. Seven patients were considered cured, six showed some improvement, and seven did not benefit at all.6
Still, encouraged by this preliminary experiment, Moniz and Lima operated on a second series of eighteen patients. Although the surgeons had no way to evaluate the extent of the brain damage in the first twenty patients, they decided that more lesions would be better, and therefore cut six cores on each side in the second series. Moniz downplayed the severity of seizures and other troubling side effects that his patients experienced in the wake of the procedures. Notably, based on his results, he concluded that disconnecting the frontal lobes from the rest of the brain did not have “serious repercussions” on the intelligence and memory of his patients. Later, after years of performing frontal leucotomies on roughly one hundred patients, Moniz, considered the inventor of psychosurgery, turned his efforts to other interests and retired in 1944.7
The popularity of psychosurgery surged in the wake of Moniz’s results. The operation, renamed lobotomy, was performed widely in the late 1930s and 40s. This efflorescence was due largely to Moniz’s protégé, a young, ambitious American neurologist, Walter Freeman. In partnership with skilled neurosurgeon James W. Watts, Freeman performed Moniz’s procedure for the first time in the United States in September 1936. Postoperatively, the patient, a middle-aged woman with anxiety and depression, enjoyed symptomatic relief and was easier to care for. Over the next three years, Freeman and Watts presented the results for their growing series of cases at scientific meetings, and the procedure gradually took hold, even at such leading institutions as the Mayo Clinic, Mass General, and the Lahey Clinic.
Freeman and Watts fine-tuned their procedures, replacing Moniz’s leucotome with a new model they invented to lift up the brain and gain access to the surgical targets. This leucotome’s handle was inscribed with their names. They chose to enter the skull through the temples and targeted different areas in the frontal lobes, depending on the individual patient’s symptoms. Some operations were more radical than others. One modification, transorbital lobotomy, was designed to damage the thalamus—a major relay station for information entering the brain—and to minimize damage to the frontal lobes. This time, Freeman entered the brain through the bone over each eye using an instrument he found in his kitchen, an ice pick. The procedure could be carried out in ten minutes, with the patient seated in a dentist’s chair. Complications included black eyes, headaches, epilepsy, hemorrhages, and death. Watts did not approve of the ice-pick operation as a routine office procedure, so the long Freeman-Watts collaboration ended, leaving Freeman to push forward on his own.8
The number of operations Freeman performed during his career is staggering: he carried out lobotomies on more than three thousand people in twenty-three states, not only on adult psychiatric patients but also on violent criminals and schizophrenic children, one of whom was only four years old. The majority of Freeman’s patients were women, the most notable being Rosemary Kennedy. In Spencer, West Virginia, he set the dubious record of operating on twenty-five women in one day. Contrary to the Hippocratic Oath, Freeman’s focus was on his procedure, not his patients.9
Despite the large volume of patients Freeman saw, he was determined to keep in touch with them after their operations. In 1967, he purchased a Clark Cortez camper bus, which he christened “the Lobotomobile.” For years, he drove back and forth across the United States demonstrating his ice pick procedure in medical settings and visiting more than six hundred patients to note their progress. In 1967, Freeman lost his operating-room privileges at Herrick Memorial Hospital in Berkeley, California, after
one of his lobotomy patients died from a brain hemorrhage. According to another psychosurgeon, H. Thomas Ballantine, Freeman also lost his privileges at Georgetown and George Washington hospitals, meaning that he could no longer admit patients or treat them there, nor could he use hospital staff or facilities. But this was as far as the medical community went to stop his harmful procedures. Shockingly, at the end of his life, the University of Pennsylvania recognized Freeman as a distinguished alumnus. He died of colon cancer in 1972 at age seventy-six.10
Freeman certainly was not alone in his enthusiasm for lobotomy. In the wake of his modest success, hundreds of other practitioners entered the field of psychosurgery. In the four decades after Moniz’s first publication, forty to fifty thousand people were lobotomized, many against their will. But the widespread application of Freeman’s lobotomy techniques did not stem from physicians’ belief in Moniz’s theories about disrupting the twisted wiring between the frontal lobes and other brain areas. Instead, the appeal was pragmatic; physicians had few alternative treatments to offer. The history of lobotomy is marked by optimism and a lack of skepticism on the part of both the surgeons and families of the recipients. Thousands of patients from all walks of life were operated on, often with flimsy justifications and with little evaluation and documentation of the therapeutic benefit and side effects. Women were twice as likely to be lobotomized as men.11
Permanent Present Tense Page 4
