Patient H.M. (14 page)

T
he bright lights of the operating room, positioned just so, illuminated Marie Copasso's exposed skull. Earlier, the scrub nurse, Florence Dudin, had shaved the hair from the top front portion of Copasso's head, making it easy for my grandfather to scalpel a half-moon incision and then roll the skin of her forehead down like a carpet. The white bone beneath, once the blood had been flushed away, gleamed.

From a small, elevated observation room above the OR, a crowd of people watched the proceedings. The operation on Copasso was a standing-room-only performance: There were at least two dozen people in the audience, most of them neurosurgeons. The two who had traveled the farthest were probably Eben Alexander, who had flown to Hartford from his home in North Carolina, and Kenneth George McKenzie, Canada's first neurosurgeon and the current president of the international Society of Neurological Surgeons, who'd arrived from Toronto. Like Alexander and McKenzie, the other surgeons here were among the biggest names in the field: Buckley, Fox, German, Maltby, Whitcomb. Apart from all the surgeons, there were a number of psychiatrists, neurologists, and research scientists present as well.

The keenest observer of them all was probably Walter Freeman, the man who'd introduced the lobotomy to America. This was because Freeman, apart from my grandfather and Marie Copasso, had the most at stake. What was unfolding that day at the asylum was to be a surgical debate of sorts, and Freeman and my grandfather were pitted against each other. Freeman would have peered over the edge of the observation deck down into the theater and watched carefully as my grandfather lowered the drill onto Marie Copasso's skull.

The drill, or at least the drill bit, was something of a revelation. For the past few years, my grandfather had been renting one of the garage bays at the Mobil station on the corner of Washington and Jefferson in downtown Hartford, and most Sundays he would take one of his sports cars there and tinker with it. Recently he'd found a tool at the garage, a drill with a one-and-a-half-inch-diameter circular bit called a trephine, strong enough to penetrate autobody steel. It occurred to him that such a trephine might be perfect for cutting holes in skulls. He took one and sent it off with some instructions to a medical equipment manufacturer called Codman & Shurtleff; it custom-machined several just for him, slightly modified so that they would penetrate only as deep as the bone and stop short of the meninges, the delicate membranes surrounding the brain. Now he positioned one of these trephines on the exposed skull above one of Copasso's closed eyes and pressed the trigger on the drill, causing a violent whirring and a faintly visible plume of moist calcium. The drill itself, apart from its new bit, was the exact same type he might use to cut a hole in the body of his Buick.

He removed a small plug of bone from Copasso's forehead, then repositioned the drill above her other eye and repeated the process. When done, he placed the drill to the side, took up a scalpel, and sliced through the dura, arachnoid, and pia mater, exposing the rippled surface of Copasso's frontal lobes.

The operating room was state-of-the-art, all white tiles and antiseptic sheen. It had opened the month before, in the Institute of Living's newly constructed Burlingame Building, which sat adjacent to the Burlingame Research Building on the northern edge of the asylum's grounds. It was the world's first and only operating room designed exclusively for psychosurgery. Like my grandfather's custom trephine, his operating room had been outfitted to his precise specifications: There were six germicidal lamps, a pair of X-ray-viewing boxes, a dissection-and-coagulation machine, and an adjustable operating table that could be fixed in any position and extended or shortened at will, accommodating any patient, no matter their size.

The room was part of Superintendent Burlingame's full-court press on the lobotomy. The Institute of Living had been providing lobotomies to its guests for a decade, since 1938, and Burlingame's long-standing familiarity with the procedure gave him, he thought, unparalleled practical knowledge regarding how to care for psychosurgery patients. The basic benefit of the operation, in his view, was obvious: It obliterated a patient's preexisting personality, allowing enterprising psychiatrists such as himself an opportunity to rebuild a new and improved personality in its place. “Leucotomy,” he wrote, “ ‘clears the decks' for the construction of a more adequate personality.”

With an eye toward taking advantage of this malleability, Burlingame had built an independent psychosurgical unit at his asylum, a unit that began with my grandfather's operating suite and extended to an entire floor of classrooms and a segregated residence ward in the same building. Patients received special training meant to reacquaint them with the expectations of society, training that included “constant guidance and drill in matters of good personal hygiene,” vocational instruction, and even sexual reorientation. A significant portion of the Institute of Living's guests had been sent there for homosexuality, which Burlingame considered a mental illness, and he believed that gay patients' sexual preferences, postoperatively, were as flexible as their personalities. At a psychiatric conference earlier in 1948, he'd boasted of reversing the orientation of at least two lobotomized guests. There was the “young man who had always had difficulty in adjusting to the opposite sex. For some months postoperatively, he progressed in all respects except this one. But gradually, and carefully, he was introduced to the social hour and it is a source of considerable satisfaction to us that he is now dancing and acquiring quite a polished manner with members of the fair sex.” Then there was “the woman in whose illness the precipitating factor had been an unfortunate love affair. Preoperatively and postoperatively she was viciously antagonistic toward all men, but much the same thing has been accomplished with her as with the young man. In both instances, it is doubtful that resocialization would have been spontaneously accomplished merely by sending these patients home or allowing them to follow their own bent.”

Burlingame's affection for psychosurgery had made him both a leader in the field and a somewhat controversial figure: A few months earlier, during the 1948 meeting of the American Psychiatric Association, the nominating committee had backed Burlingame as its preferred candidate for the association's presidency, but Burlingame's presidential aspirations were upended by an anti-psychosurgery, pro-psychotherapy candidate named George Stevenson, who defeated Burlingame in large part by attacking him for being too quick to turn to the scalpel when it came to the treatment of his institution's guests. Burlingame, however, hadn't let that setback shake his faith in psychosurgery.

Soon Burlingame would begin overseeing the creation of Marie Copasso's new personality. First, though, her old personality had to be destroyed, and that part of her treatment was not Burlingame's domain. So that day in November, looking down on that shiny new operating room, Burlingame was just one more person in the audience watching my grandfather work.

Without him having to ask for it, the scrub nurse passed my grandfather a long, thin tool called a flat brain spatula, reminiscent of a shoehorn, which he inserted carefully into the hole in the right side of Copasso's forehead. He levered up that hemisphere of her frontal lobes and peered inside. He was looking for the neural fibers connecting the lower, orbital portions of the frontal lobes to some of the deeper structures in the brain. Once he spotted his targets, he inserted another tool, a suction catheter—a very small, slender, electric-powered vacuum—and sucked the fibers out. Then he retracted the spatula and the catheter and moved to the other hole.

He worked quickly, with gravity. He was often prickly while operating, snapping at nurses or residents if they displayed even a hint of sloppiness. He prided himself on precision. And that's what this operation was all about: precision. The problem with Walter Freeman and James Watts's standard lobotomy, like Egas Moniz's original leucotomy, which it descended from, was that it was sloppy. They made a mess of the frontal lobes. Even Freeman described his procedure as “mutilative.” My grandfather was now two years into his participation in the Connecticut Cooperative Lobotomy Study, and while he had become intimately familiar with the traditional approach that was the focus of the study, he was also somewhat disillusioned with it. Although he was now so expert and fluid a lobotomist that he sometimes performed as many as five in a single day, he'd come to believe that the standard lobotomy caused too much frontal-lobe mutilation, which in turn caused an insidious and irreversible blunting of the personality. Whatever good results came of the lobotomy, he believed, were due to the simple and specific severing of the fibers between the frontal lobes and other parts of the brain. So why not just focus on those fibers and leave the rest of the frontal lobes in peace?

That's what he was attempting with this operation. He called it a fractional lobotomy, or an orbital undercutting, since it focused on the lower, orbital portions of the frontal lobes. He'd been practicing this novel approach for several months now, at the Institute of Living and at Connecticut's three state asylums, alternating between the traditional lobotomy and this new one of his own design and comparing the results. The initial results, anecdotal though they were, generated excitement at the highest levels. John Fulton, whose work on frontal lobe ablations in chimpanzees had inspired Moniz to begin leucotomizing humans, had become particularly intrigued by this new technique. Fulton had been unable to make it to the Institute of Living, since he had a prior engagement at the Surgeon General's office in Washington, D.C., but a number of researchers from his laboratory were in attendance.

In all, the operation took about an hour. Afterward my grandfather replaced the bone plugs in Copasso's forehead and stitched her up. Orderlies wheeled her out to the recovery room. Soon she'd be brought to the fourth floor of the same building, to the special ward for postoperative lobotomy patients that included Superintendent Burlingame's “retraining classroom for psychosurgery guests.” My grandfather washed up and joined his friends and colleagues in the audience.

Another woman took Copasso's place on the operating table.

It was Walter Freeman's turn.

Freeman, too, had been working to come up with a new and improved lobotomy. Like my grandfather's procedure, with his customized autobody trephine, Freeman's new approach also involved a customized tool drastically repurposed from its original use. Whereas my grandfather's epiphany occurred in a garage, though, Freeman's happened in a morgue.

In Freeman's view, the principal problem with the lobotomy, as he and James Watts had devised it, was not that it mutilated the frontal lobes by slicing through too much of them but that it was too complicated to perform. As a major surgical operation, it required not only cutting holes in a patient's skull but also all the attendant complications and costs in terms of hospitalization and extended recovery times. And, most frustrating to Freeman, it required a neurosurgeon. The standard lobotomy was Freeman's idea, and he was its most vocal proselytizer, but when it came down to it he was relegated to being an observer in the OR while his colleague the neurosurgeon Watts did the actual cutting.

Watts was not there that day.

In fact, Freeman and Watts had become somewhat estranged recently, ever since Watts had arrived unexpectedly one afternoon at the office he and Freeman shared and was horrified to discover Freeman performing, unassisted, the new operation he was now about to demonstrate for this audience at the asylum.

The basic idea behind the new approach was to gain direct access to the frontal lobes without having to penetrate the walls of the skull. To perfect his technique, Freeman practiced on cadavers at the George Washington University morgue until he'd located their point of least resistance: the orbital bones at the rear of the eye sockets. Whereas most of the skull is thick and armored, this portion of it was comparatively thin and delicate. In the morgue, he experimented with several existing surgical tools, searching for something that was sufficiently thin to reach the orbital bones without damaging the eye and sufficiently strong to penetrate the bones themselves. He failed repeatedly, as the tips of these tools tended to snap off against the bone, a result that would be catastrophic in a living patient.

Then Freeman had an idea. It occurred to him that a certain slender, strong tool might be perfectly suited for breaking through the orbital socket.

The woman on the operating table was named Rebecca Adams. She was secured to the table with leather straps, and the electrodes of an electroconvulsive therapy machine had been attached to her forehead. Somebody flipped a switch on the generator, applying a burst of current that caused Adams to convulse against the straps and rendered her instantly unconscious. The electrodes were removed.

Freeman picked up his ice pick.

It didn't take long.

He pulled up one of Rebecca Adams's eyelids and inserted the ice pick just above her eyeball, sliding it back until it encountered the resistance of her orbital bone. He used a small hammer to tap it through, then pushed it approximately three inches into her frontal lobes. Once it reached the correct depth, he swished the ice pick quickly back and forth, slightly less than parallel to the horizontal plane of her skull. Then he returned the ice pick to its original position and drew it out the same way it went in. He wiped it clean and turned to Adams's other eye. Much like the earlier, standard lobotomy that he had pioneered, this operation was by its nature imprecise, since he could not see the connections he was hoping to sever and simply hoped that the ice pick was cutting them as it pivoted through her brain. But precision was not his goal. The transorbital lobotomy, as he had dubbed the procedure, was designed to be quick and easy. He believed that the only thing holding psychosurgery back from mainstream acceptance was the fact that it still constituted a major and expensive medical procedure, requiring the services of a neurosurgeon and a number of attending medical staff. In contrast, the transorbital lobotomy could be performed almost anywhere, by almost anyone. Freeman believed he could train any reasonably competent psychiatrist how to perform an ice pick lobotomy in an afternoon. He envisioned a day when patients might have their mental illnesses plucked from them even more easily than they might have a troublesome tooth pulled.