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At the outset of World War Two, St Hugh’s College Oxford was requisitioned as a 300 bedded military hospital specializing in head injuries. A number of brick buildings were hurriedly constructed on the lawns to house the wards and therapy services while the College’s female undergraduates were moved into alternative accommodation.
The specialist unit was led by Australian born neurosurgeon Hugh Cairns who pursued an aggressive policy of early intervention, often in the field hospital before transfer to Oxford. The arrival of penicillin also dramatically reduced the mortality of open head injury. It is likely that a soldier like Patient 39 would have ended up as one of the 13000 patients treated at the Oxford Military Hospital (Head Injuries), and that he would have been flown in from France via Brize Norton.
Although head injuries have always been and remain an unpopular subject with neurologists, there have been a number of notable exceptions. One of these was William Ritchie Russell (1903-1980), a Scot from a distinguished dynasty of Edinburgh doctors who in 1932 published an influential paper in the journal ‘Brain’ entitled Cerebral Involvement in Head Injury in which he emphasized how long the patient was completely unconscious after the trauma as an important prognostic factor. In his paper, he provides an account of how the unconscious patient recovers. On coming round, the first attempts to speak usually take the form of repeated groans or shouts followed by the utterance of a few words. There is still no level of understanding or reason and speech is often repetitive, restricted to pat phrases and nonsensical. There is often profound social disinhibition and delirium. Eventually orientation returns along with alertness and the patient then begins to think of events leading up to the injury.
After a period of training at the onset of war at my hospital, Queens Square in London, Ritchie Russell joined Cairns in Oxford. Had Dr. Moran in Patient 39 been a real character, it is Russell we should look to. By this time his earlier research had been enshrined as post-traumatic amnesia. Although he recognized the importance of very early childhood memories to the adult and had an interest in psychoanalytical theory, after the war at Oxford he devoted a considerable amount of time to collaborative neuropsychological studies. He is said to have bubbled with ideas and to have been painstaking in taking clinical histories from his patients. He gave the appearance of unhurried serious dedication in his work, lightened by the occasional humorous dedication but like many neurologists of his generation he could be brutally frank with patients and colleagues.
After the war the Oxford Military Hospital was closed and St Hugh’s returned to being a college, though the case notes of the patients and fascinating archival materials are still stored in the college library. Here is recorded that local children would bring cowslips for the injured men and that the female undergraduates would push the wounded soldiers into Oxford for a day out. Perhaps too hidden away amongst Ritchie Russell’s case notes can be found more insights into Patient 39’s beatific visions.
A patient’s medical history, like the plot of a film, has a beginning, a series of unfolding events and an anticipated ending. Neurologists hear new descriptions of disordered brain function every day of their working lives. It is the deconstruction of these, combined with an element of abductive reasoning, that results in accurate diagnosis.
There are certain stories that may be particularly instructive. Ray Kennedy, the former Arsenal and Liverpool football player who developed Parkinson’s disease towards the end of his career in his early thirties, taught me what it is like for an athlete to live with chronic motor handicap. He also reminded me of the importance of narrative and humility in the healing process.
Narrative-based medicine differs from a series of measurements such as blood pressure or blood sugar, and may also provide information that has no direct bearing on the unfolding events. The filmmaker instinctively knows its dramatic power and its capacity to invite interpretation. Doctors and film-makers are bound together by this dying art of story telling.
Currently there is an epidemic of neurobling in the arts with computer generated brain mapping and its pretty but indecipherable pictures at risk of providing a new generation of intellectual quackery. The story of Patient 39 is uncontaminated by modern medical technology and contains many truths that neuroscience is in no position to trump. It is often said that doctors need their patients more than patients need their doctors and the beauty that Dr Moran glimpses through his care of Patient 39 may be one reason why.
In 1953, a few years after the death of Patient 39, 27 year old Henry Gustav Molaison, in a final desperate attempt to control his disabling childhood onset convulsions, submitted to radical brain surgery. William Scoville, Molaison’s surgeon at Hartford Hospital Connecticut, removed parts of the sides of his brain including the hippocampus.
After the surgery, Molaison’s seizures abated but it was soon observed that he was unable to form any new memories and had great difficulties recollecting events from the two years before the operation. He could no longer remember what he had talked about ten minutes earlier and friends had to reintroduce themselves on each visit as if they were meeting him for the first time.
But instead of complete amnesia, Molaison’s impairment was very specific. Whilst he could no longer remember what he had eaten for lunch, he was still able to learn new motor skills and to complete crosswords that referred to memories acquired before his surgery. Neurologists expressed surprise that partial removal of his two temporal lobes had led to such severe and selective memory impairment.
Molaison agreed willingly to be studied by neuropsychologists. Through his cooperation, conclusive evidence was accumulated that the hippocampus, despite being such a small area of the brain, was fundamental to the formation of new memories. But it is important to remember that HM, as he was known in the medical literature up until his death, was far more than a lesion and a heap of test scores. During one session with a psychologist he wryly remarked, ‘It's a funny thing- you just live and learn. I’m living and you are learning.’
Before he died Molaison made the ultimate sacrifice to science by donating his body for further study. In 2008, his 82 year old brain was carefully removed from the skull and transported in dry ice from Connecticut to the Brain Observatory in San Diego. There it was deep frozen and cut into 2401 separately preserved slices, each 70 micrometers thick. Three-dimensional models were then digitally constructed and this revealed that a larger part of the back of the hippocampus had survived the operation than had been estimated from the imaging studies carried out during his life . However, because parts of the brain next to the hippocampus had been completely removed, it had been disconnected from the circuitry involved in consolidating long-term memories.
In life and death Henry Molaison’s tragic loss has helped us to learn more about how memory works than any other single research project and more than the previous one hundred years endeavour. He has become as famous as Phineas Gage and his heroic contribution to our understanding of remembering and forgetting should perhaps have jointly won him the Nobel Prize for Medicine.
Subsequent, similar research on patients with selected brain lesions has shown that memory can no longer be envisaged as a single all encompassing faculty, and that different brain areas and connections are involved with different types of memory. One broadly accepted division now is into that which is called explicit or declarative memory, which is available to conscious access, and those types of learning including motor skill acquisition, priming and conditioned reflexes referred to as implicit or procedural memory.
Dr Moran would have wanted to examine Patient 39’s brain after his death in order to try to make sense of his complex neurological deficits. This should not lead to him being considered cold, ruthless or unethical. Finding out why Patient 39 died and what caused his cognitive impairment would have taught him humility and made him a better doctor in the future. A physician should treat all his patients as if they were his close friends but at the same time strive to maintain professional objectivity. He should be kind, offer hope without being untruthful.
In the increasingly managed technological world of modern medicine the importance of the individual is in danger of being forgotten W H Auden the son of a doctor reminds all physicians of the art of good medicine:
A doctor like anyone else who has to deal with human beings, each of them unique, cannot be a scientist; he is either, like the surgeon, a craftsman, or, like the physician and the psychologist, an artist. This means that in order to be a good doctor a man must also have a good character, that is to say, whatever weaknesses and foibles he may have, he must love his fellow human beings in the concrete and desire their good before his own.