PATIENT 39

 

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Prof Andrews Lees on Henry Molaison and the Doctor-Patient Relationship

By Patient 39, Feb 19 2014 11:34AM

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.


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