Dittrich luke: Patient H.M.: A story of memory, madness, and family secrets
Title : Patient H.M.: A story of memory, madness, and family secrets.
Author : Dittrich Luke
Hardcover Publisher : New York: Random House
Year : 2016
Number of pages : 464
Cost : Rs. 1400
ISBN : 9780812992731
Henry Molaison's life changed forever after the operation on his brain in 1953 by the author's (Mr. Dittrich's) grandfather, Dr. William Beecher Scoville. In an interview in 1986, Molaison told of how, as a child, he had wanted to be a brain surgeon. In later life, Molaison was to say, 'Every day is alone in itself. Whatever enjoyment I've had and whatever sorrow I've had.'
The explanation for Molaison's statement follows in the Prologue, where Mr. Dittrich describes Dr. Jacopo Annese's examination of Molaison's brain slices, taking great care as he works around the 'two gaping holes, one in each hemisphere… The holes are historic, precious in their own way. Annese does not want to become famous as the second doctor to desecrate this particular brain.' Annese joked with Mr. Dittrich as he carefully continued with his work, 'See how much work I have to do to clean up the mess your grandfather made?'
The holes were in the temporal lobes and followed Dr. Scoville's attempt to rid Molaison of his epilepsy. Molaison lost his memory, especially for recent events and most past events. Hence '…Every day is alone in itself…'
The word 'epilepsy,' Mr. Dittrich reminds us, dates back to Hippocrates, who derived it from the Greek word epilambanein, which means 'to seize.' This, in turn, takes us to the use of the word seizure. Molaison's epilepsy dated to the injury he sustained as a child after being knocked down by a person on a bicycle. The impact of the left side of his head hitting the ground had been sufficient to tear the scalp and cause a short coma.
Mr. Dittrich provides us with several fascinating glimpses of his grandfather, including the incident that occurred when the author was eight years old. He was shown the crumpled bullet that a burglar had shot into Dr. Scoville's father's chest. Fortunately, a rib deflected it away from the heart. Mr. Dittrich wondered at the fact that if the bullet had entered its intended target, his grandfather and, indeed, he himself would never have existed. He also provides interesting historical details, such as the tale of the beautiful, long-tressed Greek goddess of memory, Mnenosyne, who was the mother of the nine muses; the Socratic dialogue that may have led to the introduction of the term tabula rasa ( an absence of preconceived ideas or predetermined goals); Paul Broca's view that the Incas carried out trepanations on the skulls of children; the description of the role played by James Henry Breasted in deciphering the scroll Edwin Smith purchased in 1862 from a dealer in Luxor; the knowledge learnt from Phineas Gage's injury to the frontal lobe; the evolution of frontal lobotomy and an account of Dr. Freeman directing such an operation; the debate between Dr. Scoville and Dr. Freeman on which surgical procedure was better for a frontal lobotomy; and, how Dr. Scoville's father, 'an eccentric polymath – a lawyer, a writer of children's adventure books and an amateur naturalist- used to keep a variety of venomous serpents as pets until his wife forced him to stop.'
In Chapter 30, you will find Dr. Karl Pribram's recollections on eminent neuroscientists he had worked with. Dr. Pribram was then 93 years old and seriously ill from colonic cancer. You will find his pithy observations interesting. Here is an example. Talking of Dr. John Fulton, he said, 'Brilliant. Financially dependent on his wife. A drunk. Bitter that he never won the Nobel Prize. Ran one of the world's great laboratories.'
Chapter 12 contains vivid details of the experiments carried out in Dachau and other concentration camps by the Nazis during World War II. A clerk, recording the details and outcomes of many of these experiments, told American investigators that most of his reports ended with the remark, 'Experiment successful but the patient died.' It also describes other inhumane experiments: vivisection by Herophilus and Erasistratus; the manner in which Cleopatra satisfied her curiosity on whether male fetuses developed more slowly in the womb than female fetuses; J. Marion Sims' experimental operations on black women slaves whilst attempting to cure vesico-vaginal fistulae; and, the Tuskegee Syphilis Experiment.
Mr. Dittrich wrote this chapter as a prelude to the descriptions of the experiments on primates by Drs. Paul Bucy and Heinrich Klüver. When, at Dr. Klüver's instance, Dr. Bucy removed most of the temporal lobes including the hippocampus, uncus and amygdala from a monkey named Aurora, they noted 'psychic blindness'. Aurora would pick up any object in front of her – '…a comb, Bakelite knob, a sunflower seed, a screw, a stick, a piece of apple, a live snake, a piece of banana, a live rat…,' transfer the object to her mouth and then discard it if not edible. They concluded that the temporal lobes were involved with emotions, sex drive and memory. Aurora could not recognize previously known objects. Egged on by the eminent physiologist, Dr. John Fulton, to participate in studies on lobotomy, Dr. Bucy, to his credit, demurred on ethical grounds. He also referred to the findings of a mother of a woman on whom Swedish neurosurgeon, Dr. Gosta Rylander, had performed a frontal lobotomy. 'She is my daughter,' said the mother, 'but yet a different person. She is with me in body but her soul is in some way lost.' He advocated caution in the performance of this operation.
In the early 1950s, Dr. Karl Pribram (who had worked with Dr. John Fulton) and Dr. Mortimer Mishkin, joined the Institute of Living, where Dr. Scoville performed most of his frontal lobotomies. Instead of studying the functions of the frontal lobes, however, they looked at those of the temporal lobes. Working on baboons and rhesus macaques, they excised parts of the temporal lobes, kept the animals alive for four to eight months after surgery and studied the behavioral and neurological effects of their lesions. They correlated their findings over these several months with findings at autopsies. They noted an absence of the ability to detect noxious and unpleasant stimuli in the damaged animals. These monkeys ate cotton balls soaked in quinine and repeatedly handled razor-sharp pieces of metal and burning paper even though they were cut and burnt in the process. They did not learn from these harmful experiences. Their memories with regard to learning under which cup the peanuts were hidden were, however, intact. Dr. Pribram wanted to study Henry Molaison in detail but never did so.
Mr. Dittrich traces the lives of his two protagonists – Dr. Scoville and Henry Molaison from their childhood.
An early publication by Dr. Scoville described his own illness, diagnosed by his physician as neurasthenia. Dr. Scoville correctly attributed his symptoms and lassitude to brucellosis contracted in Norway. He worked with the endocrinologist Dr. Fuller Albright and the neurologist, Dr. Stanley Cobb. It was then that he discovered his penchant for Neurosurgery. He trained with Dr. James Poppen and Dr. Walter Dandy. After setting up a department of Neurosurgery at Hartford Hospital, Dr. Scoville was called up for service in the U. S. Army during World War II and sent off to Walter Reed General Hospital at Walla Walla in the state of Washington, to treat soldiers wounded in the South Pacific.
In the mid-1940s, his wife displayed evidence of mental illness. After hospitalization, she was subjected to hypothermia, fever therapy (her body temperature being elevated to 105 – 106 degrees), electroconvulsive therapy and insulin shock therapy. The description of Mrs. Scoville descent into madness is wrenching, especially since before her illness she had been assessed as being markedly above the average in intelligence and a true lover of music. Dr. Scoville wrote to his parents, 'I have been so happily married and am utterly heartbroken.' Her own assessment of the marriage was different, being influenced by Dr. Scoville's infidelity and promiscuity. The answer to whether Dr. Scoville performed a prefrontal lobotomy on her is to be found in Dr. Pribram's observations in Chapter 30.
Dr. Scoville was well-known for his directness. Mr. Dittrich describes how, after accidentally, cutting open a patient's middle cerebral artery and failing to stop bleeding from it, he walked to the patient's wife and said, 'Ma'am, I think I killed your husband.' He was also scrupulously honest, ensuring that others too learned from his errors. Chapter 23 has a description of his attempts at excising a herniated intervertebral disc with the patient in the sitting position. Air embolism occurred with the patient that led to his remaining life-long in a locked-in state. Dr. Scoville made it mandatory for each of his new residents to go and study this patient.
Dr. Scoville introduced the trephine as a neurosurgical instrument. Fond of tinkering with cars, he learnt of the 1.5 inch circular bit called a trephine, that was used by mechanics to cut through automobile steel. He took one, sent it off to Codman and Shurtleff company to convert into a neurosurgical tool that would make openings in the skull.
The evolution of bilateral medial temporal lobectomy by Dr. Scoville is described in fair detail in Chapter 18. He had started off by an 'uncotomy' (removal of the uncus only) and then moved on to excise the amygdala and most of the hippocampus.
By 1953, despite the administration of phenytoin, mesentoin, trimethadoine and phenobarbitone, Molaison continued to get several fits daily, some of them being 'absences.' As Molaison's epilepsy worsened, he was taken to the forty-seven year old Dr. Scoville, who had performed several mutilating operations on the temporal lobes of 230 psychiatric patients by then. Whilst there were no dramatic successes with regard to amelioration of psychiatric symptoms, those patients who also had epilepsy were free from their fits. Thus, at a meeting of the Harvey Cushing Society on 23 April 1953, Dr. Scoville proposed the procedure of bilateral resection of the medial temporal lobes for the treatment of psychomotor epilepsy. Henry Molaison was operated upon by Dr. Scoville on 25th August 1953. Electrocorticography during the surgery showed no localized epileptic activity. Mr. Dittrich tells us that faced with a similar situation, Dr. Wilder Penfield might had stopped the operation for fear of causing brain damage. 'My grandfather was not Wilder Penfield.' He performed bilateral medial temporal lobectomies. Mr. Dittrich comments: 'This decision was the riskiest possible one for Henry Molaison. Whatever the functions of the medial temporal lobe structures were – and, again, nobody at the time had any idea of what they were – my grandfather would be eliminating them. The risks to Henry Molaison were as inarguable as they were unimaginable. The risks to my grandfather, on the other hand, were not.' In Chapter 23, Mr. Dittrich provides more information on the daredevil attitude of Dr. Scoville.
Molaison's temporal lobe damage robbed him not only of his memory but also reduced his sensitivity to pain and rendered him asexual. His neurological deficits after surgery made him the subject of innumerable studies. To preserve his privacy all publications and accounts of these studies referred to him only as H.M. for over six decades. It was only after his death that his full name could be used.
In the print version of his talk before the Harvey Cushing Society sent to the Journal of Neurosurgery, Scoville noted that his limbic lobe operations 'resulted in no marked physiologic or behavioural changes, with the one exception of a very grave, recent memory loss, so severe as to prevent the patient from remembering the locations of the rooms in which he lives, the names of his close associates or even the way to the toilet or urinal.' As Mr. Dittrich dramatically puts it, 'It was the birth announcement of Patient H.M. and the obituary of Henry Molaison.'
Surgery had been used in the treatment of epilepsy for decades. In 1892, Dr. Joseph Price presented a paper on The surgical treatment of epilepsy at the New York Neurological Society. At the Montreal Neurological Institute, Dr. Wilder Penfield developed unilateral partial temporal lobectomy for the treatment of psychomotor seizures. He focused on the limbic system. The unilateral operation permitted the opposite hemisphere to 'pick up the slack for its departed twin'. Dr. Brenda Milner, a psychologist, studied all of Dr. Penfield's patients subjected to this operation before and after surgery. In two of ninety such patients, she noted memory deficits following this unilateral destructive operation on the medial temporal lobe. She and Dr. Penfield suspected that in these two patients, the opposite temporal lobe may have been damaged prior to the operation (perhaps by the application of forceps at birth or a stroke that occurred later in life) and had been unable 'to pick up the slack'. If this was true, it would mean that memory resided in the medial temporal lobes. They lacked the means for proving this assumption.
When Penfield learnt about Dr. Scoville's patients with postoperative loss of memory, he asked for Dr. Scoville's permission to send Dr. Brenda Milner to study them. Dr. Scoville assented at once. He also brought to Dr. Penfield's notice the case of Henry Molaison, who, unlike the other patients, had no psychiatric illness and in whom, 'one and three-quarter year post resection of the medial surfaces of the temporal lobes including the uncus, amygdala and hippocampal gyrus' had left the patient with such bad memory according to his mother, that he could not even be sent alone to the store to make purchases.
The first of the many studies on Henry Molaison was carried out by Dr. Brenda Milner starting in August 1955. Molaison was then twenty-nine years old. Whilst the average person scores a hundred on the Wechsler Memory Scale, Molaison scored sixty-seven, the lowest Dr. Milner had ever seen. At the same time, his intelligence quotient was 118 despite this marked loss of memory. This first interview and those of the psychiatric patients subjected to the same operation are described in fascinating detail.
In May 1957, the Journal of Neurology, Neurosurgery and Psychiatry published the paper by Dr. William Beecher Scoville and Dr. Brenda Milner entitled 'Loss of recent memory after bilateral hippocampal lesions'. This paper introduced Henry Molaison to the world. Dr. Milner's recollections of Dr. Scoville and Henry Molaison are touching (Chapter 20). Dr. Milner's uncovering of more than one memory system in the brain and the other findings discovered on her repeated tests on Henry Molaison will interest all neuroscientists. Later, Dr. Suzanne Corkin, a student of Dr. Milner and a close friend of Mr. Dittrich's mother, studied Henry Molaison's neurological deficits. Dr. Corkin was to continue her studies on Henry Molaison at Massachusetts Institute of Technology (MIT) till the patient's death. She became possessive about these studies and restricted the access of any researcher to Henry Molaison. Mr. Dittrich describes how she frustrated his own attempts learn about Henry Molaison. In Chapter 24, he described how he eventually found Henry Molaison's full name without Dr. Corkin's help. Despite all his efforts, Mr. Dittrich could never meet Henry Molaison whilst the latter was alive.
Dr. Mishkin later worked at the National Institute of Mental Health at Bethesda. He continued with his experiments on the higher apes, trying to replicate the fate of Henry Molaison, by making a variety of lesions on the temporal lobes. In an interview with Mr. Dittrich in 2010, Dr. Mishkin reminded him that in the 1950s, nobody knew the functions of the structures they were destroying in patients. He commented that it was terrible of neurosurgeons to mutilate human brains on nothing more than a glorified hunch. By improving upon the older techniques employed by Dr. Pribram and himself in studying the effects of bilateral temporal lobectomies, he showed that in the higher mammals too, these lesions abolished complex forms of memory. Whilst these higher mammals could recognize the cup under which peanuts were hidden, anything more complex than this action, caused them to fail.
In the 1970s, Dr. Scoville was a panelist at a meeting where Dr. José Delgado demonstrated his dramatic experiment where he halted a charging bull by stimulating an implanted electrode via remote control. Whilst Dr. Delgado boasted of how his experiment could eventually even revolutionize evolution, Dr. Scoville, 'responded with uncharacteristic humility, “With all due respect to Dr. Delgado, I work almost wholly with humans and we are more aware of the disastrous effects that sometimes occur in Neurosurgery.”'
I found some of Molaison's definitions – which are the creations of his own damaged brain – fascinating. Take for example his description of the word brainwash. To him this word signified 'the fluid that surrounds and bathes the brain.' As I ponder, I find this an excellent depiction of the function of cerebrospinal fluid, which, in a sense does wash the brain.
I also found his attempt at analyzing his fate thought provoking. Explaining that he did not go out, '…because I would forget, when getting through to work, to come home. And the way home…' And when asked why he would forget, he responded, '…I think of an, ah, operation. And then I have an argument with myself right there. Did the knife slip a little? Or was it a thing that's naturally caused by it, naturally, when you have this kind of operation…' (Chapter 25).
As he aged, Molaison's general health deteriorated. By 2006, he had gained weight, was 'on massive doses of anticonvulsants as well as antipsychotics, anxiolytics, antidepressants, blood thinners and various other medications… He'd fallen and broken his ankle at least twice in the past two decades and had his hip replaced in 1986. His bones were brittle. He'd had a stroke two years earlier… (he) now also suffered from dementia…His hearing was going too…' Dr. Suzanne Corkin brought a neuroanatomist, Dr. Jacopo Annese, to see him. The purpose was to secure and study his brain after his death. They wished to supplement half a century of observation, experimentation and testing by an actual examination of his brain. Mr. Thomas Mooney was the court-appointed guardian of Molaison and he authorized the removal of his brain upon his death for research at MIT.
In December 2008, Molaison, aged eighty-two, showed evidence of respiratory failure. As his heart stopped, his body was cooled, special care being taken to keep the brain chilled. Magnetic resonance imaging scans were carried out at the Massachusetts General Hospital before the brain was removed for preservation and study. As Dr. Corkin accompanied the brain to the airport for the flight to San Diego, the The New York Times revealed H.M.'s full name for the first time, describing him as 'the most important patient in the history of brain science.' Dr. Annese was at the airport to take charge of the precious organ. He took it with him to the Brain Observatory at the Institute for Brain and Society, which he had founded.
Dr. Annese has studied Molaison's brain in great detail and has released a digitized 3-dimensional model of it that can be accessed by anyone. (To use this facility go to http://brainandsociety.org/patient-hm/, register free of charge and start your study.)
Towards the end of the book, Mr. Dittrich describes the battle between Drs. Corkin and Annese for the custody of Molaison's brain and everything connected with it. He also expresses his horror at learning that whilst Dr. Corkin was keen on ensuring the preservation of Molaison's brain, she told him that she had shredded her own notes made over half a century of study of Molaison's mind and its functions. (In a letter submitted to The New York Times on 9 August 2016, after Dr. Corkin's death, Professor James Dicarlo, Head, Department of Brain and Cognitive Sciences at MIT, disputed Mr. Dittrich's assertion and stated that regardless of what she had stated in her interview with Mr. Dittrich, Dr. Corkin had taken steps to preserve her records).
I found this book very interesting. It provides an immense amount of information on Molaison, his life and handicaps. It also gives us considerable insights into the workings of the mind of Dr. Scoville and pen-portraits of a host of other neuroscientists who worked on frontal and temporal lobes and performed lobotomies and leucotomies for the treatment of agitated and violent psychiatric patients. It also recounts the development of surgery on the temporal lobes for the treatment of epilepsy.
I strongly commend it.