Patient H.M. (8 page)

C
LINICAL
N
OTES,
M
RS.
W
ILLIAM
B
.
S
COVILLE (
E
MILY
L
EARNED)

April 5, 1944: Mrs. Scoville has been started on a course of electric shock treatment.

April 12, 1944: Mrs. Scoville has been receiving electric shock treatments. She has shown some improvement in her behavior in that her relatively clear periods are of longer duration. However, there are many periods when she sings, laughs and dances about the hall; bangs loudly on the piano and is otherwise quite annoying to the other guests. She recognizes relatives when they come to visit, but her…interest appears to be very short-lived and she soon begins to ramble incoherently about herself and her operation, by which she means the removal of her head. She also talks about a trial she has undergone, and considers that she has been in prison since that time.

April 19, 1944: Mrs. Scoville has been receiving electric shock treatment since the preceding note. She shows some improvement in that she is more quiet and less disturbing to others. However, her psychotic ideation has shown little change. She still talks about being on trial and in prison following a trial, about having her [missing word] altered, about the way in which her boy talked to her, about migration of souls from one individual to another.

[The Clinical Notes for May through June are missing and don't pick up again until three months later, in July.]

July 12, 1944: Mrs. Scoville continues to show some improvement. She continues to be somewhat afraid of the shock treatment.

My grandmother was not the only asylum guest who was afraid of the shock treatment. The fear had become so pervasive, leading to so many disturbances and breakdowns among the patient population, that Burlingame had mounted a campaign to eliminate it.

Not the shock treatment. The fear.

The campaign was outlined in the asylum's counterpart to
The Chatterbox,
a for-staff-eyes-only newsletter called
Personews,
which ran a two-part series on the subject in successive issues in August 1944. The first of these articles, “Fear-Free Psychiatry,” laid out the general problem. “The destructive force of fear,” Burlingame wrote, “presents a special problem for the psychiatrist who is attempting to build up the confidence of his patient. Consequently, those assisting in this aim should be well acquainted with the psychology of fear, so that they may help rather than hinder the course of treatment.” He recommended that nurses and aides should “not discuss treatments with guests but if the conversation reaches a point where it is impossible or awkward to avoid the topic, the positive side always should be stressed. It is never advisable to refer to or present these measures as punishment or threats.”

By working toward “dispelling fear from the patient's mind,” Burlingame believed his asylum staff would be “bolstering the foundation for life on leaving the hospital as well as facilitating the treatments here. Fear gets us nowhere since it stands in the way of a guest's progress, thus defeating our purpose. Bear this in mind and act accordingly so you will be contributing to, rather than obstructing, our collective goal—helping to get sick people well.”

A second article, in the next issue of
Personews,
outlined one specific and disarmingly simple measure that Burlingame was taking to eliminate the fear infecting his institution. The article was called “ ‘Sleep'—Not ‘Shock,' ” and it noted that there were three forms of shock treatment practiced at the asylum: insulin shock, Metrazol shock, and electric shock. The first, insulin shock, required injecting guests with massive amounts of insulin until their blood sugar levels collapsed and they fell into a hypoglycemic coma. (As with all three forms of shock treatment, the rationale for insulin shock was murky. Nobody claimed to have a clear understanding of
why
inducing unconsciousness through artificial means apparently helped alleviate, at least temporarily, the symptoms of mental illness. They just claimed that it did, for reasons unknown, and justified its continued use on this basis.) After one to two hours, attempts were made to revive the patient, which often involved artificial respiration or injections of adrenaline. As Burlingame himself noted in a journal article from 1938, the insulin treatment was dangerous, a “skillful sparring with death, where a few moments of neglect, inattention or inadvertence may cost a life.” The second such treatment, Metrazol shock, required overdosing the guest with Metrazol, a chemical compound, which typically caused a few moments of primal panic followed by a daylong coma. The third treatment, electric shock therapy, was the latest of the three therapies to gain a foothold at the asylum and involved the induction of unconsciousness through the repeated application of high-voltage bursts of electricity to guests' brains.

Burlingame had latched on to all three shock treatments with a vengeance and, in a previous annual report, wrote a paragraph that perfectly captured the strange, two-sided nature of his institution, with its country club veneer and hidden underbelly: “The success of the indoor swimming pool as a therapeutic agent seemed to urge the construction of an outdoor swimming pool which was finished last spring. At the time this seemed to be somewhat of a new departure for a psychiatric hospital but a single season demonstrated its worth and its use has become an important feature on our program of normality. The continued development and increased importance of shock therapy demanded the construction of a specially equipped air-conditioned unit of twenty-five beds exclusively for this form of therapy. It has been used to capacity since its completion.”

But now my grandmother and many other asylum guests were becoming increasingly afraid of these shock treatments, and this was posing a problem. Burlingame had come to the conclusion that the fear of his guests had less to do with the treatments themselves than with how the treatments were described. It was, in short, a problem of presentation, not substance. And so he ordered a change.

“Unfortunately,” he wrote, “the misleading term ‘shock' has come into common usage in reference to insulin, metrazol and electric treatments for mental and nervous illnesses and has proved the source of unwarranted fear. Rightly, since these three treatments produce states of unconsciousness akin to normal slumber, they should be known as insulin, metrazol and electric sleep—with ‘sleep' replacing ‘shock' in all three instances….Because of these facts and for the benefit of those receiving treatment, we are adopting the names that are more truly descriptive of these treatments—INSULIN, METRAZOL and ELECTRIC SLEEP. By thus deleting the misnomer ‘shock' from our psychiatric vocabulary, we demonstrate that the Institute of Living is not inhibited by traditions and morals that harm rather than further our aims.”

It's likely that my grandmother and Burlingame had crossed paths prior to her becoming a guest at his asylum, though neither may have been aware of it. Long before he became the superintendent of the Institute of Living, Burlingame had worked at my grandmother's family business. When the Cheney Brothers Silk Manufacturing Company ran into labor problems in 1915, they hired him to assess the problem and come up with solutions. He worked full-time for the company for two years, becoming America's first “industrial psychiatrist.” He would observe the daily toil at the factories, collecting worker complaints and attempting to generate remedies for them, tweaking rules and regulations to minimize friction between labor and management. As he made the rounds, he may have seen my towheaded young grandmother pedaling her bicycle around the campus now and then.

But that's just speculation.

What is certain is that Burlingame had met my grandfather. Starting with the asylum's annual report of July 1, 1941, three years prior to my grandmother's arrival, Dr. William Beecher Scoville was listed as a member of the asylum's “consulting staff.” The question of why a neurosurgeon would serve as a consultant to an asylum is a good one, and to answer it, it's necessary to leave my grandmother for a while, alone and afraid, and step back several years, and south several hundred miles, to a Halloween morning in Washington, D.C.

“O beautiful for spacious skies,

For amber waves of grain!”

T
he singing woman lay on her back on an operating table. It was October 31, 1939, and she was thirty-four years old. She worked in sales. She was having an operation because recently, while listening to CBS radio news broadcasts, she had realized that the announcers were talking about her. They didn't mention her by name, but she could tell. And she knew that other people could tell, too. Sometimes, even when the radio wasn't on, she still heard voices, and those voices said one thing to her, over and over: It was time for her to kill herself.

“For purple mountain majesties

Above the fruited plain!”

Her head rested on a small sandbag, and the table was at a slight incline, so her feet were somewhat below the level of her head. This was to minimize bleeding, although some blood was inevitable. Earlier they had shaved the hair from both sides of her head, as well as some from the front, so it didn't get in the way. They also administered injections of novocaine, numbing her temples completely, before cutting through the flesh and muscle on both sides and then pulling it back and away with a mastoid self-retaining retractor, exposing the bone. Once they found the spot they were looking for—approximately three centimeters back from the eye socket and six centimeters above the apex of the upper jaw—they drilled two one-centimeter burr holes into the sides of her skull, then removed the little plugs of bone. A razor then sliced neatly through the dura mater, and a jet of saline solution washed away the reddish mix of blood and cerebrospinal fluid beneath, exposing the pale, mottled surface of the woman's brain with its ripples like molten copper.

“America! America!

God shed his grace on thee!”

A neurologist stood behind the patient's head, looking down on her. His perspective was a useful one, and from the beginning of the operation he guided the surgeon, advising him, for example, how far into the hole on the right side of the woman's head to insert the scalpel, which was long and thin and had a two-sided blade. The key was to stop just short of the midpoint, to avoid the arteries there. Once the scalpel had reached a certain depth, about eight centimeters in, the neurologist told the surgeon to stop and to begin the incision of the upper right quadrant. (To visualize the upper right quadrant, imagine a cross section of a forward-facing human brain and then imagine superimposing an X/Y axis over it.) As the surgeon slowly levered the handle of the scalpel down against the lower portion of the burr hole, the blade inside the woman's skull pivoted upward, slicing through the upper right quadrant of her frontal lobes and severing tens of millions of connections between those lobes and the structures deeper in her brain.

“And crown thy good with brotherhood

From sea to shining sea!”

After that first cut, the neurologist told the surgeon to pivot the blade in the opposite direction so that it sliced slowly down through the lower right quadrant. Then the surgeon extracted the blade, walked around to the patient's left side, and inserted it into the burr hole there. The neurologist again told him when to halt the insertion. Symmetry was crucial. The surgeon then pivoted the scalpel up, and the blade sliced down through the lower left quadrant of the woman's frontal lobes, severing millions more connections.

“Oh beautiful for pilgrim feet,

Whose stern impassioned stress!”

Throughout the operation, the neurologist, peering down at the patient from above and behind her, invisible to her, his voice disembodied, occasionally asked her questions. She was only under a local anesthetic and was completely conscious. Her answers to the questions helped the neurologist monitor the progress of the operation. During the first two cuts, on her right side, her answers were accurate and lucid, just as the neurologist's experiences with fifty-one previous operations of this sort had led him to expect.

“Do you know my name?”

“Dr. Walter Freeman.”

“Do you know where you are?”

“Washington, D.C.”

“Where in Washington, D.C.?”

“George Washington University.”

“Very good.”

After the first cut on the left side, the woman's voice changed, becoming flatter, deader, slower. It lost its previous liveliness, was much more of a monotone than her normal speaking voice. This was also as expected. But the woman was still conscious and able to converse. When she began spontaneously telling Freeman about her love for music, and for singing, he asked her to sing him her favorite song. She picked “America the Beautiful.”

“A thoroughfare of freedom beat

Across the wilderness!”

As the woman began to sing, Freeman took excited notes. This was something new, something unexpected. Not the singing, but the quality of it. While the woman's speaking voice had lapsed into the expected dullness after the cutting of the third quadrant, her singing voice seemed untouched. She was singing, Dr. Freeman wrote, “without quavering, showing excellent articulation, as well as true pitch and some expression.”

“America! America!

God mend thine every flaw!”

As she completed the song's second stanza, Freeman told the surgeon to proceed with the final cut. The scalpel sliced through the upper left quadrant of the woman's frontal lobes, severing the final portion of the targeted connections. At that point the singing stopped, and the woman fell silent. Freeman looked down into her eyes for two minutes, waiting to see if she'd say anything. As expected, she did not. The effects of the fourth cut almost always included the cessation of spontaneous speech. Eventually he began to ask her questions again.

“What is my name?”

“I don't know.”

He took off his hat and surgical mask and leaned over her so she could see him. He had a large, expressive face, with deep-set eyes and a meticulously trimmed goatee.

“Look at me, don't you recognize my head?”

“Sure.”

The patient, lying there with her partially shaved head, waved up at Freeman's bald pate, then cracked a joke.

“Did they do that to you, too?”

Freeman made another note. He was always pleased when he found evidence of a preserved sense of humor. Recently, during another operation, just prior to the cutting of the fourth quadrant, he had asked a fifty-three-year-old patient what was going through his mind. The man thought for a minute, then said, “A knife.” Now Freeman smiled down at his current patient and continued the questioning.

“Who am I?”

“William Randolph Hearst.”

Freeman nodded, satisfied.

In the late nineteenth century, Dr. Gottlieb Burckhardt, a Swiss psychiatrist, performed the first modern neurosurgical attacks on mental illness. Burckhardt ran a private asylum in the town of Prefargier, in a rugged and mountainous region known for its watchmaking firms. Over the course of decades interacting with the mentally ill, he'd developed a theory about the neurological roots of madness and how the physical destruction of brain tissue might alleviate its symptoms. In 1888, he decided to put his theory to a test. He had no experience or training as a neurosurgeon, but he obtained a set of neurosurgical tools and set to work. One of the first patients he selected for these experiments was a “forever disturbed, unapproachable, noisy, fighting, spitting, all but straight-jacketed, untidy, smearing” fifty-one-year-old “particularly vicious woman,” who'd been institutionalized for sixteen years. Over a yearlong period, and five different operations, Burckhardt opened up the left side of the woman's skull and removed a total of eighteen grams of her brain. The removals were done in a somewhat scattershot way, not focusing on any particular part of her neuroanatomy but instead targeting a broad sampling, including her postcentral, third frontal, parietal, and temporal cortices. As a result of the operations, Burckhardt reported that his patient had become “more tractable.” Her previous intelligence, he added, “did not return,” but he noted that by her final surgery, “Mrs. B. has changed from a dangerous and excited demented person to a quiet demented one.”

By the end of 1889, Burckhardt had operated on five more patients. Two of them died, two became epileptic, and one committed suicide. Still, he considered his experiments a success. “Doctors are different by nature,” he wrote. “One stands fast on the old principle ‘primum non nocere' (‘first, do no harm'); the other states: ‘melius anceps remedium quam nullum' (‘it is better to do something than nothing'). I belong naturally to the latter category….Every new surgical approach must first seek its special indications and contraindications and methods, and every path that leads to new victories is lined with the crosses of the dead. I do not believe that we should allow this to hold us back from approaching the goal, the curing of our patients by surgical methods. The purely medical side of our calling must and shall lead us nolens volens (whether we like it or not) along this pathway.”

When Burckhardt published his account of these experiments, in 1892, the medical community reacted with revulsion. As one French psychiatrist put it in a pointed response to Burckhardt's better-to-do-something-than-nothing argument, “an absence of treatment was better than a bad treatment.”

The path that Burckhardt began to trailblaze would remain blocked for the next four decades, until the 1930s, when a Portuguese neuroanatomist named Egas Moniz cut his own way forward. Unlike Burckhardt, Moniz focused his attacks on a specific part of the brain: the frontal lobes. His ideas had been gestating for years, but his decision to act probably crystallized in 1935, during a symposium at the Second International Congress of Neurology, in London.

The chairman of Yale's department of physiology, John Fulton, had been on the stage at the symposium describing the results of a series of experiments he and a colleague, Carlyle Jacobsen, had recently performed on two chimpanzees. The chimps were named Becky and Lucy, and Fulton and Jacobsen had run a number of basic cognitive tests on them, finding that they were, like most chimps, ornery. They quickly grew frustrated when they were unable to perform the tests correctly and would throw dangerous temper tantrums or just sulk in the corners of their cages. They would also grow impatient with the repeated test-taking itself, becoming less and less willing to participate, exhibiting what Fulton called “experimental neurosis.” Then, Fulton told the audience, he and Jacobsen had surgically destroyed Becky's and Lucy's frontal lobes and readministered the same tests as earlier. They observed a profound change. “While the animal repeatedly failed and made a far greater number of errors than it had previously,” Fulton said, “it was impossible to evoke even a suggestion of experimental neurosis.” That is, the operation had disabled the chimps cognitively but had also made them more placid and less neurotic.

A question-and-answer period followed Fulton's presentation.

Moniz raised his hand.

“Do you think,” he asked, “that this operation could be applied to humans, with the same results?”

Three months later, Moniz sought to answer the question on his own.

On November 12, 1935, he oversaw the performance of the world's first leucotomy.
Leuco
is from the Greek for “white matter,” which is how the brain's connective neural tissue is commonly described.
Tome
is from the Greek for “to cut.” A neurosurgeon colleague of Moniz's, Almeida Lima, drilled two holes in the forehead of a patient suffering from a deep depression, then inserted a long, narrow metal tube through the opening to a depth of approximately eight centimeters. The tube—which Moniz dubbed a leucotome—contained a coil of narrow-gauge wire, and when the tube reached a sufficient depth Lima pressed a plunger at the end of the instrument, causing a small loop of the wire to extrude into the white matter of the frontal lobes. He then spun the instrument 360 degrees, disconnecting a small core of tissue from the rest of the brain. Then he withdrew the wire, pulled the leucotome out about a centimeter, and pushed the plunger again, repeating the process. In all, Lima cut four cores out of each side of the patient's frontal lobes.

The results of the operation were “sufficiently encouraging,” and over the next few months, Moniz oversaw nineteen more leucotomies on a variety of patients suffering from mental disorders before publishing his preliminary results in March 1936 in a French medical journal under the title “The Possibilities of Surgery for the Treatment of Certain Psychoses.” Not long after the paper's publication, Walter Freeman stumbled across it. Reading that paper changed Freeman's life, as well as the lives of thousands of his future patients.

Freeman came from a family of physicians. His father had been a urologist, a decent and modest if somewhat reticent man, but Freeman seemed to inherit his ambition, along with a penchant for showmanship, from his grandfather William Keen, a famous surgeon who had served for many years as president of the American Medical Association. In 1888, Keen became one of the first surgeons to successfully remove a brain tumor and was known for putting on public demonstrations of his work, with as many as a hundred students and physicians crowding into the seats of his medical amphitheater as he performed his delicate procedures.

Freeman's first job as a neurologist was at an insane asylum in Washington, D.C., where he quickly saw how hopeless traditional therapies were in the face of the demons tormenting his patients. He was eager to employ any novel treatments as they came along, and experimented with the full battery of shock treatments—from insulin to Metrazol to electric—but he was never satisfied, partly because these treatments all seemed so blunt and imprecise, their mechanisms unclear. For a period of years he became obsessed with the idea of finding an actual physical cause for insanity, and he spent hours in the hospital morgue, autopsying the brains of his deceased patients, seeking out the neurological root of their madness. He always came up empty.