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Loss of Recent Memory After Bilateral Hippocampal J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.20.1.11 on 1 February 1957. Downloaded from J. Neurol. Neurosurg. Psychiat., 1957, 20, 11. LOSS OF RECENT MEMORY AFTER BILATERAL HIPPOCAMPAL LESIONS BY WILLIAM BEECHER SCOVIILLE and BRENDA MILNER From the Department of Neurosurgery, Hartford Hospital, and the Department of Neurology and Neurosurgery, McGill University, and the Montreal Neurological Institute, Canada In 1954 Scoville described a grave loss of recent found that undercutting limited to the orbital sur- memory which he had observed as a sequel to faces of both frontal lobes has an appreciable bilateral medial temporal-lobe resection in one therapeutic effect in psychosis and yet does not cause psychotic patient and one patient with intractable any new personality deficit to appear (Scoville, seizures. In both cases the operations had been Wilk, and Pepe, 1951). In view of the known close radical ones, undertaken only when more conserva- relationship between the posterior orbital and mesial tive forms of treatment had failed. The removals temporal cortices (MacLean, 1952; Pribram and extended posteriorly along the mesial surface of the Kruger, 1954), it was hoped that still greater temporal lobes for a distance of approximately 8 cm. psychiatric benefit might be obtained by extending guest. Protected by copyright. from the temporal tips and probably destroyed the the orbital undercutting so as to destroy parts of the anterior two-thirds of the hippocampus and hippo- mesial temporal cortex bilaterally. Accordingly, in campal gyrus bilaterally, as well as the uncus and 30 severely deteriorated cases, such partial temporal- amygdala. The unexpected and persistent memory lobe resections were carried out, either with or with- deficit which resulted seemed to us to merit further out orbital undercutting. The surgical procedure investigation. We have therefore carried out formal has been described elsewhere (Scoville, Dunsmore, memory and intelligence testing of these two patients Liberson, Henry, and Pepe, 1953) and is illustrated and also of eight other patients who had undergone anatomically in Figs. 1 to 4. All the removals have similar, but less radical, bilateral medial temporal- been bilateral, extending for varying distances along lobe resections.* The present paper gives the results the mesial surface of the temporal lobes. Five were of these studies which point to the importance of limited to the uncus and underlying amygdaloid the hippocampal complex for normal memory func- nucleus; all others encroached also upon the anterior tion. Whenever the hippocampus and hippocampal hippocampus, the excisions being carried back 5 cm. gyrus were damaged bilaterally in these operations or more after bisecting the tips of the temporal lobes, some memory deficit was found, but not otherwise. with the temporal horn constituting the lateral edge We have chosen to report these findings in full, of resection. In one case only in this psychotic partly for their theoretical significance, and partly as group all tissue mesial to the temporal horns for a a warning to others of the risk to memory involved distance of at least 8 cm. posterior to the temporal in bilateral surgical lesions of the hippocampal tips was destroyed, a removal which presumably http://jnnp.bmj.com/ region. included the anterior two-thirds of the hippocampal complex bilaterally. Operations An equally radical bilateral medial temporal-lobe During the past seven years in an effort to preserve resection was carried out in one young man (H. M.) the overall personality in psychosurgery some 300 with a long history of major and minor seizures fractional lobotomies have been performed, largely uncontrollable by maximum medication of various on seriously ill schizophrenic patients who had failed and diffuse forms, showing electro-encephalographic on September 28, 2021 by to respond to other forms of treatment. The aim in abnormality. This frankly experimental operation these fractional procedures was to secure as far as was considered justifiable because the patient was possible any beneficial effects a complete frontal totally incapacitated by his seizures and these had lobotomy might have, while at the same time avoid- proven refractory to a medical approach. It was ing its undesirable side-effects. And it was in fact suggested because of the known epileptogenic quali- ties of the uncus and hippocampal complex and * These further psychological examinations by one of the authors, B. M., were made possible through the interest of Dr. Wilder Penfield. because of the relative absence of post-operative 11 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.20.1.11 on 1 February 1957. Downloaded from 12.....* , + ;,.. ... ... WILLIAM BEECHER SCO VILLE AND BRENDA MILNER i.O ,.r. ............ .f. .....:.i -.. ....... ,.:i ,:: .: guest. Protected by copyright. FiG. 1.-Area removed bilaterally from the medial temporal lobes.demonstrating 5 cm. as well as 8 cm. removals through supra-orbital trephines. seizures in our temporal-lobe resections as com- particularly clear in the case of the epileptic, non- pared with fractional lobotomies in other areas. The psychotic patient whose present cheerful placidity operation was carried out with the understanding does not differ appreciably from his pre-operative and approval of the patient and his family, in the status and who, in the opinion of his family, has hope of lessening his seizures to some extent. At shown no personality change. Neurological changes operation the medial surfaces of both temporal lobes in the group have also been minimal. The incidence were exposed and recordings were taken from both and severity of seizures in the epileptic patient were surface and depth electrodes before any tissue was sharply reduced for the first year after operation, removed; but again no discrete epileptogenic focus and although he is once again having both major and http://jnnp.bmj.com/ was found. Bilateral resection was then carried out, minor attacks, these attacks no longer leave him extending posteriorly for a distance of 8 cm. from stuporous, as they formerly did. It has therefore the temporal tips. been possible to reduce his medication considerably. As far as general intelligence is concerned, the Results epileptic patient has actually improved slightly since The psychiatric findings bearing upon the treat- operation, possibly because he is less drowsy than ment of schizophrenia have already been reported before. The psychotic patients were for the most (Scoville and others, 1953). Briefly, it was found part too disturbed before operation for finer testing on September 28, 2021 by that bilateral resections limited to the medial portions of higher mental functions to be carried out, but of the temporal lobes were without significant thera- certainly there is no indication of any general peutic effect in psychosis, although individual intellectual impairment resulting from the operation patients (including the one with the most radical in those patients for whom the appropriate test data removal) did in fact show some improvement. There are available. have been no gross changes in personality. This is There has been one striking and totally unexpected J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.20.1.11 on 1 February 1957. Downloaded from LOSS OF RECENT MEMORY AFTER BILATERAL HIPPOCAMPAL LESIONS 13 / 7eFIG.\ 2.-Diagrammatic cross-sections of iA . - }>i,/ \ human brain illustrating extent of -t- ; ,57 ^ \ attempted bilateral medial temporal - - - ---- -- lobe resection in the radical operation. .I - f- (For diagrammaticpurposes the resection has been shown on one side only.) A ~ \ BA guest. Protected by copyright. K, A C ~~~~~yr -\ flU)CX ;g94 1_ http://jnnp.bmj.com/ *A< W b eJ ) C <S Bi::) 5 7< ~~~~~~~~~~~t7 on September 28, 2021 by -, c, "t; r " ar pa L-)t: J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.20.1.11 on 1 February 1957. Downloaded from 14 WILLIAM BEECHER SCO VILLE AND BRENDA MILNER FIG. 3.-Post-operative skull radiograph with silver clip markers FIG. 4.-Post-operative skull radiograph with silver clip markers outlining extent of bilateral resections limited to the uncus and outlining the extent of the bilateral resections including the an- amygdala. terior hippocampal complex (approximately 6 cm. posterior to the tip of the anterior temporal fossa). behavioural result: a grave loss of recent memory after day without showing any practice effect and guest. Protected by copyright. in those cases in which the medial temporal-lobe that he will read the same magazines over and over resection was so extensive as to involve the major again without finding their contents familiar. This portion of the hippocampal complex bilaterally. The patient has even eaten luncheon in front of one of us psychotic patient having the most radical excision (B. M.) without being able to name, a mere half-hour (extending 8 cm. from the tips of the temporal lobes later, a single item of food he had eaten; in fact, he bilaterally) has shown a profound post-operative could not remember having eaten luncheon at all. memory disturbance, but unfortunately this was not Yet to a casual observer this man seems like a recognized at the time because of her disturbed relatively normal individual, since his understanding emotional state. In the non-psychotic patient the and reasoning are undiminished. loss was immediately apparent. After operation this The discovery of severe memory defect in these young man could no longer recognize the hospital two patients led us to study further all patients in staff nor find his way to the bathroom, and he seemed the temporal-lobe series who were sufficiently co- to recall nothing of the day-to-day events of his operative to permit formal psychological testing. hospital life. There was also a partial retrograde The operation sample included, in addition to the amnesia, inasmuch as he did not remember the two radical resections, one bilateral removal of the death of a favourite uncle three years previously, uncus, extending 4 cm.
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