Psychosurgery

PHILOSOPHERS TELL US THAT THE HORIZON OF KNOWLEDGE IS always out of reach. How far out of reach is the practical question and the source of all dilemmas having to do with treating the sick. Do doctors wait until they really know -- or know more -- before they try this treatment or that? If they wait, will it mean more suffering for a patient? Is suffering tolerable if there are means of relieving it? Are some risks ever worth taking? Are some ever not?

The treatment dilemma posed by psychosurgery -- surgery to treat psychiatric disorders -- is this: Experts know something about mental illness and about operations that can help some patients; but they don't know enough to completely assure patients, families, each other, or the rest of us that surgery is the best, or proper, course. That it is ever worth the risk.

Perhaps they can never know enough. Driving the demand for, and use of, psychosurgery is the belief -- some call it the pretension -- that the human brain can understand and repair its own mind. And more, that scientists will come to understand the mind and brain better by studying it the way they study it now -- anatomically, biochemically, and empirically, by analyzing and observing its parts and the things it does.

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Publicly, the subject of psychiatric brain surgery hasn't been discussed since 1978, when the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research issued a report saying that psychosurgery had a deservedly bad reputation for wretched excess. But the report also documented successes, declared that psychosurgery was not the unmitigated horror its critics had labeled it, and decreed that -- with strict regulations and safeguards -- psychosurgery was acceptable for certain cases and that more research and good record -- keeping were needed.

As a result, perhaps, psychosurgery -- albeit under new names, more refined and more selective than the lobotomies that psychiatrists and neurosurgeons abandoned more than 30 years ago -- is still very much around. Actually, it never completely went away.

Although the number of procedures have plunged since the heyday of psychosurgery (50,000 estimated in the United States alone between 1939 and 1960), there are still at least 200 to 300 openly declared psychosurgeries labeled as such each year being performed by a few dozen surgeons here and abroad. Reports are trickling in of more operations being done in South America and the developing world. And if we count the operations that affect the "psyche" but disclaim changes in mood and behavior as primary goals, the total is certainly in the thousands and growing.

Psychosurgery has now greatly evolved. Surgeons no longer destroy large amounts of brain tissue in futile efforts to "cure" schizophrenia and neurosis. Instead, they take pinpoint aim at millimeter-long clusters of cells to stop suicidal depression, disable obsessive-compulsive disorders, cripple anxiety, and smother the uncontrollable rage and aggression that keep sick people in locked wards. They go after destructive behavior that accompanies organic diseases of the body and brain.

The great promise of psychosurgery is not without critics. For some, the abuses of the past remain open sores on the national conscience. Some see it as Frankenstein-style science. Others dismiss the whole idea as plain goofy -- based on oversimplified views of human behavior and emotional chaos. And certain religious groups, such as the Scientologists, brand psychosurgery and all physical treatment of mental illness as assassination attempts on the mind.

Practically nothing has been written to update the general public in the last 10 years about the new operations, their availability, and any ongoing problems they pose. While psychosurgery's past excesses have been forever characterized by Ken Kesey's Randle McMurphy in One Flew over the Cuckoo's Nest, the conventional wisdom of that era is now vulnerable to new knowledge and rising demands for help from the mentally ill and their advocates. Moreover, today, as in the past, the need to balance treatment with protection from abuse is especially important for the ill who are homeless, poor, female, children, imprisoned, and minorities: They were historically the guinea pigs of psychosurgery and could become so again. On the other hand, they could become beneficiaries of a therapy that still has promises to keep.

They could be Matthew.

I must tell you that I am very afraid of this man. Even under guard he is unpredictable, very scary. He is like a feral animal, a cat. He raises his arms and dives into people. He could kill.

-- Matthew's neurosurgeon, 1990

The story of Matthew frames much of the reasonable and unreasonable debate over the need for psychosurgery and its potential abuse. Matthew has a social history of violent behavior and a medical history that makes modem psychosurgery a last -- and long delayed -- hope. The following excerpts from a letter written on January 4, 1990, to Matthew's lawyer from a neurologist describe the cold, clinical details:

Dear Mr. --

Matthew is a 24 year old, right-handed man who has had severe and uncontrollable seizures since age 11. The cause of the seizures is encephalitis, which is an infection (presumed viral) of the brain. This infection produced scarring which resulted in spontaneously recurrent abnormal electrical discharges. When the electrical discharges build up to a certain level he will have seizures. During his seizures, he will have an aura [warning] of an unpleasant emotion, he will become confused, he will yell, grimace, turn his [head] side to side and will run about.

I have personally observed several of these episodes. He appears very frightening to others during the episodes. On one occasion we had a laboratory technician hide behind the door for many minutes after Matthew slammed into the door during a seizure. If someone is in his path, he will stare at them, then run into them or push them violently out of the way.

We monitored him in our critical care neurology unit with videoelectroencephalography recordings in June of 1986. During that time we could observe his typical range episodes, and correlate them with abnormal electrical activity in the brain. His seizures have occurred as often as 10 times a day.

On October 5, 1987, Matthew had surgery on the right side of his brain, and on November 24, 1987, on the left side of his brain in a structure called the amygdala. This is a structure that is often involved in seizures and in manifestations of violent behavior Unfortunately, the procedure was of no lasting benefit to Matthew. I believe that Matthew has sufficient brain injury that he cannot control his outbursts of aggression. Some of these are explicitly because of seizures [and] completely beyond his control. Others are not related to seizures, but occur because he has brain damage, delusional thinking, and lacks the normal inhibitory behavior that people must exert in society.

Regrettably, this is likely to be a continuing condition with Matthew.

It is sometimes difficult to tell whether violence is part of a seizure, or whether it is acting out of "bad temper. " In Matthew's case, I think all these are [beyond his control].

Matthew's medical situation is unfortunate. We have been unable to manage this satisfactorily with medications and with surgery. I would hope that the court and authorities would view his problems as a medical rather than a criminal issue.

Sincerely ...

Matthew is slight in build, with boyishly silky, slightly long, dark wavy hair; he sports a neatly trimmed beard. On an early June evening in 1990, he has permission for a special visit with his parents and a guest -- special because authorities at the high-security hospital for the criminally insane are strict about the number of visits to each inmate per week. Matthew has spent almost a year here, and 16 more years in schools and hospitals for young people with severe neurological and psychiatric disease. Since the beginnning of the summer, the internal review board of a prestigious medical center has been considering his parents' request for neurosurgery to get him out.

We had to put our belongings in a metal locker behind the guard's desk, keeping only a small tape recorder, and passed through an airport-style metal detector. Armed guards escorted us through two sets of locked doors, along a corridor into a room with brown Formica furniture upholstered in bright blue vinyl. Matthew sits in one of the chairs, facing us, wearing khakis, clean white socks, slip-on Keds, a hospital shirt tucked neatly into his beltless pants, and sunglasses. A burly security guard stays for the visit, too -- protection against Matthew's unpredictable and violent rages.

Matthew: (Shaking hands.) How do you do ma'am. How about a soundcheck? Sure. (Leaning forward, singing into the tape recorder.) "I just called to say I loooove you, I just called to say how much I care."

Visitor: I want to ask you about your feelings, Matthew, about getting a brain operation.

Matthew: Yes. I want to leave here. With violent seizures, I have been put here. They don't really know about them and they think it's just me being bad and acting out. When I was in [a state mental hospital] this lady named Fran told me I was a bad case, and making it up. Yes ma'am, she said it, but I'm not.

Visitor: If doctors said to you, "Matthew there's a chance this could help," you would do this, have an operation on your brain?"

Matthew: Yes. (Turning to look at the guard talking loudly on the wall phone.) Can you wait until he is off the phone? I am having trouble concentrating. I'm sorry for the interruption. Please excuse me for saying to wait.

Visitor: When you have your violent seizures, do you remember anything?

Matthew. No, wait, wait, yes. Sometimes. Yeah. Like I was telling my father last night. I don't know how I do it. But -- put your fingers over your ear (we all cup our hands over our ears) and for about a second, I hear a muffling sound. You can hear air coming.

Visitor: You mean like putting a seashell over your ear?

Matthew: Yes, yes, yes, exactly, exactly. After that, I get a ringing sound in both ears. One time with a violent seizure, I was in the shower room up at ward 8 and I went into one of the showers, and I went in there and I was hearing the ringing sound. And what happened was this man Rudolph --

Visitor: [Rudolph] works in the hospital?

Matthew: Yeah, and he walked in and I hit him, I forget where, I hit him and he grabbed me and I think we were fighting, (Matthew clenches his fists and works them back and forth to indicate a fight.) And he threw me in seclusion and it's just that I think some of this problem is 50-50, you know, part violent seizures, and they [the attendants] just ... just (a long pause).

Visitor: They don't know what to do?

Matthew: They don't know if it's a seizure or if like once when I was on [ward] 3, I just want my way. Wanting your way, what I mean by that is, on 3, here I am, and I was mad and when I get mad, first I'm mad, then I'm madder, then madder and madder and so forth. What happened was, they said, "Matt, how long would you like to be in your room?" [I guess all the] seclusion rooms were taken or something, I'm not sure. So they put me in my room and I was lying down like this (he leans over in the chair onto his side) and suddenly I went into a seizure like that (he snaps his fingers) and with no ringing in the ear or anything.

Visitor: Sometimes you have a warning and can remember and sometimes you can't.

Matthew: Yes ma'am. And what happened was I was lying on my bed and I guess I got scared or something else bad and I grabbed the pillow and put it over my face and I started to scream and after that, well, I forgot what happened but nothing positive. I went to a screened window in the room and I was banging on that, and screaming, not from the seizure but just screaming and a lady walked in and said, "Matthew, if you don't stop it I'll take your cigarettes away from you." And so I'm in this seizure.

Matthew's father: No, you said you were not in the seizure. That you are finished with the seizure. Did this happen after the seizure? Can you tell when the seizure is over? That's what you told us before. Your mind is fuzzy and you don't always know what's going on.

Matthew's mother: Can you feel when it's over?

Matthew: Sometimes I can. Sometimes I'm not really conscious. This one I'm talking about was one where I was still in seizure. I will say that when I went to the [screened-in] window, I was banging with my hand, and banged on the two beds and what happened is that I had a feeling like one time that I was looking through this window on 3 and so I (long pause) ... I couldn't control what I was doing, but my mind was telling me what to do. Like I -- if I was in seizure now I'd look at this wall (he points to a wall next to us) and say let's do that and I would go to the wall and kick it or whatever and that's what it was like at the screened window and I saw that and I thought of things.

Visitor: What things?

Matthew: (Glancing quickly at his parents.) My mother and father know about this. About God. What it is is that I had a feeling that this happened before, that I did that before and, well, what it was then was there was this other window and this man would always tell me to look out the window. He said, "Matt, look what's out there," and I'd say "what, what," and once he said to me, "Matt look out there, look at that," and I said, "No, no I'm not going to look out there because it will happen again."

Visitor: What happened then that you did not want to happen again?

Matthew: I'm not about for that to happen again. What it was, I had this feeling that the person said to me, "You'll see out the window, you'll see what happens when you die." And so I, um, I just had the feeling I was supposed to do this and do that and I was in the seizure but for some reason I, well, like what I said about the wall.

Matthew's mother: Is this the thing where you believed God was out there, out of heaven, and it was your fault that God wasn't in heaven anymore and that's why so many terrible things were happening to you and everyone else and --

Matthew: Yes. Also, I had a feeling I was supposed to bang the window and beds and I was there and I hit the window and [a] male staff [member] was called and he said, "Matt, calm down now," and they put me in bed and next thing I knew, they shut the door and took my clothes off.

Visitor: If you could leave here, what would you like to do?

Matthew: You mean a job?

Visitor: Anything.

Matthew: I would like to go home with my parents and see my sisters-in-law, my brothers, and my neighbors. And my grandmother. Whenever I get to two months without acting out, I act out or get a bad seizure and then I have to start over and I can't go home. But I like the things my father and I used to do. We went to [a] park and walked around a lot. I'd like to live in a group with other people, and the Epilepsy Foundation has places and that's where I'd like to go after I'm out of here, yes ma'am.

Matthew's father: After he got encephalitis, everything left. Matthew didn't remember knowing how to count, or say the alphabet, or even how to walk for a long time. Now he can do some things. Matt, you're a survivor. Don't forget that.

Matthew's mother: What mommy says. Say it. You don't belong here.

Matthew: I will get out if I can stay calm, cool, and collected. (Lots of laughter.)

The hour is over. Matthew shakes hands. The guard asks another to escort the visitors out so he can take Matthew back to his ward. Matthew is smiling in the hall. He extends his arms out wide and says something to the visitor in Polish. His father translates: "He says he loves you, and will you marry him?"

* * * *

Matthew's parents live in a middleclass neighborhood in a medium-size, mid-Atlantic city. His father, retired after a nearly fatal heart attack several years ago, worked in a maritime-industry plant as an engineer. His mother, robust and sad, is a full-time homemaker. Their superclean brick row house is pleasantly furnished and crowded with memorabilia of their children; but their memories are overwhelmed by the details of Matthew's sickness, which began with a viral illness during a vacation at the beach when he was 10. Matthew's mother: The first really awful time was after his initial illness, after we thought he might really get completely well. I'll never forget it. Matt came out of the bedroom shrieking that his hands were growing, that he had to go to the bathroom but the "poopie" was all over and was attached to him by strings, and begging us to cut them. We thought that he was having a nightmare. So his daddy went to lay down with him and soon he fell asleep.

Then at 8 A.M. we heard Matthew [again]. We heard him running. He was only a little boy. It was his first grand mal seizure and it left him delusional, hallucinating, and robot-like walking into walls. He stopped breathing [so] we headed for the hospital. That's when his hospitalizations became multiple and the specialists diagnosed him as having brain damage from a viral infection. That's what they think, though they never really know. And the seizures began in earnest, one after the other, sometimes hundreds a day and violent.

Matthew's father: We had to make sure he was restrained on the number of occasions that he was hospitalized. He would bite his mother's ear. And he would make these inhuman noises. If he ever got a hold of you, he'd grab you like a vice.

Matthew's mother: It's a helplessness you feel every day of Matthew's life. Among other things, it took more than a year for doctors at [the medical center] to finally witness one of the animal rages we were living with and fearing every day. You know. Like when you stop having a toothache when you go to the dentist. He wouldn't have them when we went to the hospital or for a check-up, and it got to the point where no one believed us. We were accused of being hysterical, of exaggerating, of not wanting to care for Matthew.

Matthew's father: One day we went to the seizure clinic for blood tests of his drug levels and we were in the courtyard to smoke and he began to attack me with animal noises, and he burst through the security guards and raced through the seizure clinic. Two doctors grabbed him. He growled and fought. He ripped their clothes. They really got an eyeful. He was well over 18 by then. When this happened, the doctor said to bring him into the intensive care unit to monitor him. Like always, it came from nowhere, out of the blue. They strapped him down and he just tore the cloth strips off. He made huge screams. He flipped his hospital bed upside down and shrieked and shrieked. His mother went into the room to try and calm him. She took her life in her hands.

Matthew's mother: Well, now he is in a hospital for the criminally insane, but he is not a criminal really, and whether or not he is psychotic is open to question. We know the things he does are bad. But his brain is damaged, and no one can predict when he'll get his attacks. Sometimes he gets depressed and obsessed with anything he hears, sees, or talks about for long periods of time.

Matthew's father: I visit him every day they let me, every day.

Matthew's mother: I feel guilty about not going to see him very much. I'm worried about it. If we tell him to get his okay for us to come, then he'll drive himself and us nuts asking about it. And then he might get upset while you're there. The Epilepsy Foundation has a group home. If he got better, they might be able to take him there. I know that. In the institution, I worry about men taking advantage of him. And I worry about what will happen to Matt when we go. His brothers will take care of him. They're very close, but it hurts and it's tough. God it's tough. What is especially heartbreaking is that his anger is not bad, not wrong. Matt knows what he has lost.

* * * *

Less clear is what he might gain from surgery. But on November 20, 1990, two days before Thanksgiving, Matthew, his family, and his doctors get the chance to find out.

Since the 1940s and '50s, neurosurgeons have removed areas of the amygdala and the temporal lobe to stop violent behavior, with variable success. In 1987, surgeons operated on both the right and left amygdala in Matthew, whose temporal-lobe epilepsy apparently damaged circuits involved in the hypothalamus. Located under the thalamus, the hypothalamus receives input from most other parts of the brain and regulates many body activities as well as the hormone-producing pituitary gland, at the base of the brain. Along with the pituitary, the hypothalamus is one of the major routes carrying signals of psychological stress -- good and bad -- to the heart, lungs, bladder, and other internal organs. The damage to Matthew's hypothalamus left him with an unpredictable, assaultive, dangerous, hair-trigger temper. He also suffers from obsessive thoughts and behavior.

The amygdalotomies unfortunately did not work. After three years, dozens of rage seizures, and a violent assault on a nurse, surgeons will try again to kill -- by cutting out a small part of Matthew's abnormal brain -- about a square centimeter of it. He'll have a cingulotomy: an operation designed to dampen motivation, to calm. It is also performed for cancer pain that even narcotics can't help. "I did one on a bone-cancer patient," said the surgeon. "Before the operation he cried in agony all day. After, he was completely relaxed. He read most of the time. He had no more suffering. He had no more emotions, either, nor was he capable of any real mental work. It was drastic. Like a lobotomy. Matthew's will not be that drastic."

Drastic or not, there is nothing left to try. "This kid's brain is totally out of control," says a child neurologist who consulted on Matthew's condition. "When the amygdalotomies failed, his own neurologist wept. He said he didn't know how to face the family. He cried, really cried. There's nothing left now but high-security institutionalization and sedation to the point of near coma. The new surgery is a chance. It's a Hobson's choice for us all," the neurologist added. "Even if it stops the violent rages, we don't know if it will stop the obsessive behavior."

* * * *

7:15 A.M. In the wide corridor of the medical center's basement neuroradiology suite, Matthew waits on a gurney, held securely in four point restraints. With him are his mother, older brother Jim, and a guard from the state mental hospital. In anticipation of his cingulotomy, he had been transferred from the high-security, prison-style hospital; there is hope that if the surgery succeeds, the halfway house, sheltered workshop training, and independence await. Matthew is nervous but cheerful, wrapped in pastel gowns, his feet and legs in vented stockings, IV line taped securely to his right arm. "I'm not getting my hopes too high this time," his mother says, her eyes on Matthew. "I am," his father says. Matthew is quiet.

Matthew's surgeon walks by in a three-piece suit he'll soon exchange for pale green scrubs. He stops for a minute to talk, holding on all the while to his briefcase. He pats Matthew's foot. "I'll see you soon," he says.

Matthew's family will see neither their son nor the surgeon for the next nine hours.

* * * *

Operating suite 2 really is a suite. The largest of the rooms is the operating room itself; unlike conventional ORs, it houses a modern CT scanner, with its hollow-scooped bed and donut-shaped scanning apparatus. Five freestanding monitors are on site as well, to track drugs and vital signs. Behind the scanner, Vincent Lerie, a radiation technician, and Gerry Beveringen, a scrub nurse, set up three sterile tables for equipment.

Most prominent alongside the usual scissors, knives, sutures, gauze pads, needles, and tubes are the Radio Frequency Lesion Generator and the stereotactic halo. This circular frame holds the patient's head in a fixed position and guarantees millimeter-precise positioning of the brain probe and needle tip that the Lesion Generator will heat to 75 degrees Centigrade. Over the next few hours, Lerie will switch it on 10 separate times to destroy 10 tiny pieces of brain tissue in Matthew's cingulate gyrus, deep in the temporal lobes beneath his cerebral cortex.

The cingulum itself is part of the limbic system (or "primitive" emotional brain) that carries signal-making nerve fibers around the system -- including the signals that trigger Matthew's rage-producing seizures. The heated needle will create dead space to act as "firebreaks" in Matthew's brain and hopefully stop transmission of these rage-triggering signals. The stereotactic equipment eliminates the risk of "blind" freehand reaches into the limbic system by automatically lining up points on the computer to make a topographic map of Matthew's brain.

The CT roadmaps guide the surgical probes safely past areas of the cerebral cortex that control sensory and motor functions (including smell and sight, and arm and leg movement) and safely away from the thalamus that is the main relay station taking messages to the higher centers of the cortex.

To compare this cingulotomy to old prefrontal lobotomies is like comparing a Civil War conscript's musket fire to the launch of a Tomahawk missile. The lesions to be made in Matthew's cingulum are anatomically "miles" from the frontal lobe, but the changes -- the calming, flattening -- they produce will be somewhat similar. That's because the neural fiber pathways work in parallel and bundle together in various spots deep in the brain. Thousands of psychosurgeries, along with modern technology have brought less of the knife and enough of the desired effect, without the mutilating damage of frontal lobotomy.

Space is crowded in the suite, especially with plans for a half-dozen or more onlookers: radiologists, students, physician assistants. A glass-walled anteroom faces the OR and contains four computer monitors and other equipment. All of it will be used to display and interpret scanner information and pinpoint targets for the team that has planned this sortie into Matthew's limbic system like a military operation.

An adjacent small room holds the computer that operates the scanner, and connecting the areas is a small corridor and cul-de-sac enclosing a "light wall" to read the pictures made of the scans. It also houses a 30-cup, ever-filled coffeepot.

7:50 A.M. Toby Eagle, the nurse anesthetist, and Steve Derrer, the anesthesiologist, bring Matthew in and transfer him to the CT scanner bed where he will stay, anesthetized, throughout the operation. They gently explain the tubes.

"Matt, I'm going to give you some medicine through the tube," Derrer says. "It'll feel hot for a second," adds Eagle. Matthew whimpers for an instant and then is quiet. Eagle puts a nose and mouth mask quickly over his face. "Just a little oxygen," she fibs to him. It's really nitrous oxide, and in just moments, he is asleep. Derrer has injected a cocktail of drugs through the tube -- Pentothal, fentanyl, flourane. "Have a good rest, Matt," Eagle says gently. He can't hear her.

7:56 A.M. Eagle passes a breathing tube into Matthew's throat, adds more line. The front part of his hair is shaved from his forehead to about halfway back. They leave the rest, including beard and sideburns. "He cares a lot about his hair," says Gerry. "Most young guys do." Matthew's eyes are taped shut now and the supporting part of the stereotactic frame is placed under his head and shoulders, clamped to the bed that supports him and screwed into his skull with four white screws at the temples.

8:35 A.M. Vince clears everyone out of the room so he can turn on the CT scanner, which hums. The surgeon, Sumio Uematsu, along with the radiologists, neurologists, and technicians, are crammed into the CT monitor room on and off for most of this first hour. At about 9 A.M., Uematsu looks at reconstructed scans that highlight an important landmark: the telltale butterfly-shaped structure of the corpus callosum. From there, it's only about two centimeters back to the cingulum -- the target. He also locates, among the varied shades of white, gray, and black, the cerebral artery he must avoid.

More than 35 scans are done. "It's got to be right, perfect, absolutely right. We need to check and recheck, check and recheck," says Uematsu. He keeps saying this aloud, yet to himself, almost like a prayer or a mantra.

9:30 A.M. A neurologist who has cared for Matthew for many years arrives with a copy of a medical-journal article written by Tom Ballantine, a Massachusetts neurosurgeon who has done more than 600 cingulotomies for chronic pain. In it are detailed photographs of the sites in the brain where Ballantine recommends placing lesions.

Still holding the article, he gazes at Matthew's draped form through the glass. He does not go into the operating room even when this first round of scanning is completed at 10: 15. Instead, he leaves the suite to see Matthew's family. He will come and go often during the day.

10:16 A.M. Physician's assistant Debbie Mandelblatt places a white stretch cap on Matthew's skull, and over the cap a clear, stretchable plastic -- not unlike thick Saran wrap -- and fastens it down like a sausage casing. The wrap holds the scalp skin taut and sterile and isolates the slits the surgeon will cut in it to reach the skull and brain. "We'll make two burr holes, or entries," Uematsu tells onlookers. "The right side first." Two hours and 15 minutes into this operation, the first real surgery is about to happen.

Five separate times the surgical team validates the settings on a mockup before the coordinates are locked down on the stereotactic frame. Now the electrode probe is positioned on every plane: It can be moved in any direction and the target will always be in the center of the probe.

10:30 A.M. Uematsu makes a one-inch cut in the Saran wrap and skull cap, the slices the skin and underlay scalp. He uses a retractor to hold the skin back and stitches it in place. It's quiet in the room as Uematsu picks up a hand drill, and drills the burr hole, beginning slowly and building to a vigorous circular motion with the handle. He drills and drills into the skull. With suction and irrigation, pieces of bone and tissue gush out on the table under Matthew's head, but very little blood. He sleeps peacefully.

10:45 A.M. Drilling Stops. Uematsu uses currettes (tiny, sharp, curved knives) to clean out the hole. The top half of the stereotactic frame is fastened over the hole. There is a faint smell of burning as he electrically seals the covering of the brain, or dura. Now it's time to set the electrode needle into the brain. The necessary apparatus, already locked into the right place, is lifted from the mockup frame and placed over the bottom half of the device affixed to Matthew's skull. The surgeon will not need to make any judgments about where to put it. The probe will go through the holder and stop automatically at the target area.

He selects the right-size probe from the stainless-steel tray held by Gerry Beveringen, and sets it aside. The frame is ready, the coordinates have been checked a dozen times.

"No," he says. "We'll scan again." Another cross check. He will inject air into the brain, take more scans and make sure the frame's positioned for exactly the fight spot. "Then," Uematsu says, "if we are, I put the needle in."

Vince clears the OR for the scans.

11:30 A.M. It has taken 45 minutes and two injections of air to learn that the black dots of air highlighted in the scanning images are right on target. "Better than textbook, better than perfect," Uematsu exclaims for the first of many times this day. "Now. Now we're ready to go."

The probe is in place, the needle tip resting on the target. Gerry wheels over the Frequency Lesion Generator, irreverently referred to as the "cooking machine." It is the only gallows humor of the day. But it is accurate.

The electrode is hooked up to the source of current. Gerry squirts a clear gel on a tinfoil-covered rigid plate and inserts it under Matthew's back. Then he runs a wire with an alligator clamp to the retractor handles and hooks it up. "Grounding Matthew," he says to no one in particular. "Grounded."

"In case something breaks," Uematsu explains.

11:43 A.M. "Set for seventy-five degrees for ninety seconds," Uematsu orders Gerry. The dials are set.

"Okay," Uematsu says, "cook." He forces a smile. No one returns it.

Through the same hole, Uematsu positions the probe four more times in the same plane to create four other tiny lesions around this first central lesion. Some at 90 seconds, some at 45 seconds. All at 75 degrees Centigrade. "Cook," he orders. "Cook," again. "Cook. Cook." The lesions are less than an eighth of an inch apart, all on the right side. That's Matthew's right, his right hemisphere, his right cingulum. It's close to noon.

The right side is pronounced finished, and a new set of scans is taken to confirm the lesions. "There," says Uematsu quietly, pointing to a perfect circle of black blots. "All there. Perfect. Better than the textbook. Now, ready to do the left side."

12:15 A.M. "Do you know how we learned how long to cook?" Uematsu asks as he makes the second burr hole. "Egg whites. We picked egg whites in 1967, in our first studies, to see how long and how hot to go through egg whites and create a hole of the right diameter that would not close up."

Over the next two hours, five more lesions are placed in the cingulum on the left side of Matthew's brain. The air target studies are again done to verify the placement, then they "cook," the heated tip cutting the brain. Then more scans make sure the lesions are sufficient and in place.

3:40 P.M. Steve Derrer has awakened Matthew and escorted him to the recovery room. Uematsu and others have talked to Matthew's family. "Perfect," Uematsu announces. "Better than the textbook." But they all must wait now, to see if the "textbook" surgery was not just successful in its execution, but also in its goal.

Matthew's neurologist is nervous. There's much that can still go wrong, he says. Brain damage or return of the seizures that might have found an alternative pathway for the abnormal electrical signals.

6 P.M. Matthew wakes fully and talks a "blue streak," but then unexpectedly lapses into a stupor. He apparently is unable to talk, move his limbs or arms. An angry, upset neurologist says, "It's not looking good." They take Matthew back to the OR for an emergency scan. Everything looks okay. The doctors hope the problem is temporary, from swelling that will subside. Matthew's parents are with him all night.

Wednesday, November 28, 11 A.M., eighth floor of the neuroscience wing: Matthew is propped up in bed in room 811, eating seedless red grapes from a plastic bag, half watching a television set suspended from the comer of the ceiling above his bed. His mother is all smiles; his father grinning.

"God, we are happy today," his mother says. "I knew it all the time. He's doing just great." Matthew has no pain, not even a headache, but he is still somewhat stunned and slow to react. Full recovery from the surgery is still days or more away, although he will return to Spring Grove Hospital on Sunday if all goes as planned. After six months without rages, they'll know if the cingulotomy has brought success -- peace and the chance for a better life.

This morning, little more than a week after his operation, Matthew remembers names and faces slowly, but he does remember. His arms and legs and toes work. He can talk. "Rodgers," he says after his mother's prompt of a visitor's first name. "Writing a book," he says. A moment later there's a smile, which broadens when his father says quietly, "Perfect. So far, perfect. Better than the textbook."

Over Memorial Day weekend, 1991, six months after Matthew's surgery, his parents are still careful not to trumpet their hope. But all the signs remain positive. Over the holiday, Matthew is spending most of his time on a home visit with his family, and weekend leave from the hospital is now regularly scheduled. Matthew's social worker has begun the process of enrolling him in a special course at the hospital that teaches independent living skills -- cooking fundamentals, washing clothes -- because paperwork is under way to place him in a community-based group home.

"There have been no rages since his operation," Matt's mother says. "He's still having seizures, but no rage episodes at all. And he seems to have much, much better control of his anger. It doesn't escalate into chaos. He takes the time to calm down when he becomes angry. We think we have a success here, but the doctors -- and we -- still don't know how long it will last.

The absence of experience is a lingering reminder of the ongoing ignorance surrounding the new psychosurgery -- of the continuing political and social isolation of patients like Matthew and of his family. There is still a giant wall of timidity surrounding surgical treatment of psychiatric and behavioral disorders that turns away heads and minds. Even in the wake of success, the doctors don't want to go public with their endeavor. Lost in the silence most of all is that there are newer psychosurgical treatments for mental illness that need cheering on. So far, the cheerleaders are mostly the families of patients. And even their cheers are muted, reflecting the cautions and concerns of the medical profession.

"Matt's still scared," his mother says. "We are, too. That suddenly something will happen. When Matt comes on visits, he gets angry with me at times because he senses that I'm still wary of being alone with him. I'm still remembering those rages, his physical strength; how he could hurt others and himself. It hurts Matt now to think that I'm leery of him, that I'm afraid to be alone around him."

Confidence that the scars made in his brain can keep control of his mind will take time to build. Meanwhile, the family cautiously moves ahead.

Epilogue: The week before Christmas, 1991, I talked at length with Matthew's father, the cockeyed optimist who always believed that his son deserved another surgical chance for a life free of rages.

"Everything," he told me, "is looking good. The best news is that Matthew is now living in a low-security area [of the state hospital] and has great freedom. We're working hard to get him into a group home next, and since he's been free of rages for more than a year now, we think this will work out."

"What will Matt do for Christmas?"

"He'll be home with us and the family. It's gonna be a great Christmas."

As we spoke, I sensed some reserve in the father who has seen too much to be sanguine and too little to be cynical. And yet, there was a future to hope for, to plan and to execute for Matthew and his family. A future of relative tranquillity and contentment, this Christmas and next.

From Psychosurgery: Damaging the Brain to Save the Mind by Joann Ellison Rodgers, copyright (c) 1992 (HarperCollins).

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