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.

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).