Patient H.M. (20 page)

It was an open question, one awaiting an answer.

Or, at least, a patient.

In March 1953, the month before my grandfather traveled to Hollywood, Florida, for the Harvey Cushing Society meeting, he had another consultation with the Molaisons. Although a detailed record of this consultation doesn't exist, it's reasonable to make certain assumptions. He would have questioned them about the progress, or lack of progress, of Henry's treatment, and they would have told him about Henry's increasing difficulties. They would have made it clear that the drugs hadn't helped—or hadn't helped enough. Given the frequency of his petit mal seizures, it's possible that at some point during the consultation Henry experienced one of them, his mouth going slack, his head tilting to one side, his eyes open and blank, his fingers scratching listlessly, repetitively, mindlessly at his pant leg. If so, my grandfather would have watched closely, waiting for Henry to come to. By the end of the consultation, my grandfather would have been able to take full stock of the Molaisons' hopelessness.

Then he would have offered them hope.

The drugs hadn't helped, but something else might. Maybe he told them about Wilder Penfield's operations, the unilateral ones pioneered at the Montreal Neurological Institute. Maybe he told them about his own bilateral operations, the ones he'd honed at asylums around New England. Maybe he gave the Molaisons a quick primer in neuroanatomy, leaning in and tapping gently at the sides of Henry's head, just behind his temples, just above his ears, explaining that the source of Henry's affliction probably lay somewhere in his medial temporal lobes, a couple of inches beyond the tips of my grandfather's fingers. Maybe he told the Molaisons that he might, if they'd let him, be able to remove that affliction altogether.

The Molaisons—Henry, Gustave, Elizabeth—thought it over. They must have been frightened, as there is no medical prospect more frightening than brain surgery. They must also have been trusting, as my grandfather was an esteemed doctor in a position of authority, a professor at Yale, a man radiating competence. Whatever calculus the Molaisons used, however they weighed the pros and cons, debating the opaque risks of future surgery against the clear desperation of the status quo, is unknown. They may have taken their time, arguing among themselves, interrogating my grandfather. Or they may have come to a decision quickly.

What is known is this: They said yes.

The surgery was scheduled for August 25, 1953.

The week before, on August 17, Henry returned to Hartford Hospital to receive an electroencephalograph. Unlike the excruciating pneumoencephalograms, which had required the draining of his cerebrospinal fluid, the electroencephalograph, or EEG, as it was known, was painless. Henry lay on his back on a gurney, and a number of electrodes were affixed to his scalp. The electrodes registered Henry's brain activity, picking up on the faint currents passing between his neurons. The operator of the device was able to see that activity in real time, conveyed in visual form in spikes and waves that a pen made across a roll of crosshatched paper like a seismograph. An unusual amount of spikes coming from one hemisphere of his medial temporal lobes would be evidence that Henry's epileptic focus lay there, which would be evidence that surgically lesioning just that particular hemisphere might bring Henry relief. At one point during the exam, Henry had one of his petit mal seizures, going absent right there on the table. Despite this, the EEG failed to reveal an epileptic focus.

A psychologist named Liselotte Fischer met with Henry on August 24 to administer a battery of psychological tests, a baseline against which the effects of the operation could later be measured. Henry, Fischer noted, “admits to being ‘somewhat nervous' because of the impending operation, but expresses the hope that it will help him, or at least others, to have it performed. His attitude was cooperative and friendly throughout.”

When Fischer gave Henry a pad and pen and asked him to draw a man and woman, he drew the man first: a hospital patient, in a hospital gown, with a “crosspatch” mark on his temple. Fischer interpreted this as a manifestation of Henry's “acute anxious involvement with the impending operation.” Then, Henry began to draw the woman.

“She ain't going to be pretty,” he said as he sketched out a figure with an oversize head and bulging breasts. Fischer eyed the drawing and wrote that “with its aggressive stance and domineering features it is in glaring opposition to the male figure, and invites the interpretation of ‘aggressive, castrating mother figure.' ”

Fischer gave Henry a Rorschach examination, showing him a series of inkblots and asking him to describe what he perceived. Looking at one splotch, Henry said he saw a deer without horns, which turned into a doe. Fischer saw that as further evidence of Henry's preoccupation with castration. Another inkblot spurred a description of “a lion who moves away from the subject, so that his tail is oversized and ‘right in my lap,' ” which Fischer interpreted as an indication of “sexual confusion” and a “homosexual trend.” She also noted “some repetition of the concept of fleeing,” and of “concepts of mutilation.”

Finally, Fischer administered an IQ test. Henry scored 104, higher than average but lower than he would score postoperatively. This may or may not have had something to do with the fact that he'd been taken completely off his antiepilepsy medications in the weeks leading up to the surgery and had experienced as many as twelve petit mal seizures during the hours he spent with Fischer. She'd watch and take notes as he'd go absent for ten to fifteen seconds, swaying and breathing heavily, scratching at his arms, his clothes, his belt, before regaining his senses.

“I gotta come out of this again,” he'd say.

Henry spent the night in the hospital. The following day, August 25, somebody on the nursing staff shaved his head, then brought him to the operating room.

Just as he had done so many times before in the asylums, my grandfather injected a local anesthetic into his patient's scalp, sliced an arc across the top of his head, and rolled the skin of his forehead down like a carpet. He then used his trephine drill to remove two silver-dollar-size plugs of bone, a scalpel to cut through the meninges that protected the cerebrum, and a flat brain spatula to lever up the frontal lobes, exposing the deeper structures beyond. He scanned the region visually, his eyes picking out the glistening pink outlines of the hippocampus, the amygdala, the uncus, the entorhinal cortex, trying to identify any obvious defects, any coarse or atrophied tissue, any scars or tumors or other defects that might be the source of Henry's epilepsy. He saw nothing. Before proceeding further, he did something he didn't normally do in the asylums: Under the direction of the electroencephalographer W. T. Liberson, he used a slender, forcepslike instrument to reach into the holes and apply tiny wire-trailing electrodes to a number of spots along the surface of Henry's medial temporal lobes. He and the rest of his surgical team then waited while Liberson monitored the EEG readouts, making one last attempt to find a discrete epileptic focus. Liberson peered at the wavy lines on the scroll, looking for a telltale pattern, one that could point my grandfather toward a specific target in a specific hemisphere. He told my grandfather that once again he'd come up empty and had failed to find a focus.

Though the anesthetic ensured that Henry felt no pain, he was conscious, and throughout all the slicing and peeling and drilling, a symphony of unsettling and unfamiliar sensations had trickled through his blunted nervous system. When my grandfather leaned over to extract the electrodes, Henry had a direct view of his upside-down face, or at least the parts of his face that weren't covered by his surgical mask and surgical bonnet and surgical loupes. Henry's pupils contracted against the blinding light of the headlamp.

Maybe, at that moment, Henry told himself that this whole experience would all be worth it, that the frightening things that were happening to him would finally free him of epilepsy's burden, would allow him at last to be fully present, fully alive, able to achieve his potential. Whatever Henry was thinking, though, it didn't really matter at that point. He had said yes, had agreed to be operated upon, and whatever happened next was out of his control.

The same could not be said about my grandfather, who now had an important decision to make.

There was no focus.

This meant, of course, that there was no target, no specific place in Henry's medial temporal lobes to attack, not even a hint of which hemisphere Henry's seizures originated in.

If another neurosurgeon had been in my grandfather's shoes that day, things might have turned out differently. Wilder Penfield, for example, would have conceded defeat. Penfield had clear rules of engagement in the operating room: If he couldn't determine a focus either visually or through EEG, he wouldn't make any lesions. In fact, even if the EEG hinted at the presence of an epileptic focus, but visual inspection of the brain revealed no abnormalities, Penfield made it a point to do nothing rather than make an excision that might do more harm than good. “The neurosurgeon,” Penfield once wrote, “must balance the chance of freeing his patients from seizures against the risks and functional losses that may be associated with ablation.” In that balancing act, Penfield always erred on the side of caution, and in Henry's case, with no target, he would have decided not to proceed with the operation. He would have stitched Henry up, kept him a few days for observation, and sent him home with an apology and a refill of his prescriptions. He would have told him that there didn't appear to be anything he could do for him surgically, at least not then, and not with the information they had.

My grandfather was not Wilder Penfield.

Standing there in his operating room, looking down at the wet expanse of Henry's skull, glimpsing his exposed brain through the two trephine holes, my grandfather could have admitted defeat, could have ended the operation. This would have been the safest move. There was no chance Henry would be improved by following that course of inaction, but there was also no chance he would be hurt by it.

Alternately, he could have chosen to take one, and only one, of the paths ahead. He could have operated on Henry's left hemisphere, or Henry's right hemisphere, then withdrawn, patched him up, and seen what happened. He had no target, no specific evidence of an epileptic focus in either hemisphere, but maybe he would get lucky. This would be the surgical equivalent of a coin toss: If one hemisphere of Henry's medial temporal lobes was the hidden source of his epilepsy, then that approach would have a 50 percent chance of eliminating it. It would be much riskier, of course, than doing nothing, but that might be viewed as a reasonable risk considering the severity of Henry's condition. Also, by leaving the structures in one hemisphere intact, he would minimize the chance of destroying whatever the unknown functions of those structures were.

My grandfather chose a third option. He picked up his suction catheter, inserted it carefully into one of the trephine holes, and proceeded to suction out that hemisphere of Henry's medial temporal lobes. His amygdala, his uncus, his entorhinal cortex. His hippocampus. A good portion of all of those mysterious structures disappeared into the vacuum. Then he pulled the tool out of the first hole, cleaned it off, and inserted it into the second. Lacking a specific target in a specific hemisphere of Henry's medial temporal lobes, my grandfather had decided to destroy both.

This decision was the riskiest possible one for Henry. Whatever the functions of the medial temporal lobe structures were—and, again, nobody at the time had any idea what they did—my grandfather would be eliminating them. The risks to Henry were as inarguable as they were unimaginable.

The risks to my grandfather, on the other hand, were not.

At that moment, the riskiest possible option for his patient was the one with the most potential rewards for him. After years of straddling the line between medical practice and medical research in the back wards of asylums, of attempting to both cure insanity and gain an understanding of various brain structures, he was about to perform one of his medial temporal lobotomies on a man who was not mentally ill at all, whose only dysfunction was epilepsy. In the language of scientific research, Henry was a “normal,” or at least much closer to being a normal than anyone who'd previously received one of my grandfather's limbic lobe operations. For four years, my grandfather had been conducting “a study of the limbic lobe in man,” and so far he had only “small bits of passing data” to show for it. That afternoon, however, my grandfather's study was expanding to include a whole different class of research subject.

Imagine my grandfather peering into that second trephine hole, guiding his suction catheter deeper and deeper, his headlamp illuminating the intricate corrugations of the structures he was in the process of destroying. It's impossible to say exactly what thoughts drove him at that moment, what stew of motives. He had reason to believe his operation might help alleviate Henry's epilepsy. He also had reason to believe his operation might provide new insight into the functions of some of the most mysterious structures in the human brain. It's quite possible that he wasn't thinking much at all, at least not consciously. Years later, during a rare moment of introspection, he described himself as follows: “I prefer action to thought, which is why I am a surgeon. I like to see results.”

He pressed the trigger on the suction catheter, and the remaining hemisphere of Henry's medial temporal lobes vanished into the vacuum.

As my grandfather made that final cut, Henry lay there, looking up at him. He could catch glimpses of his mask, of his surgical cap, of his headlamp. He could see his glasses, those thick-rimmed surgical loupes with their magnifiying lenses. He could hear my grandfather's breathing, feel his warm exhalations.