The
Norman Dott case notes are an invaluable source for the history of neurosurgery.
They contain many examples of pioneering medical techniques, but also of treatments and
diagnoses which are now obsolete. One of the most striking examples is the
psychosurgical procedure on the frontal lobe better known under the name
‘lobotomy’. Nowadays, this word evokes a botched, barbaric practice that
trampled the rights of patients and stripped them of their individual and
humane qualities. However in the 40s and 50s, this operation was regarded as a
way to relieve some patients of their sufferings when all the other
treatments had failed.
In Britain,
where the term ‘leucotomy’ was used rather than the American word ‘lobotomy’, the
first operations were carried out at the Burden Neurological Institute in
Bristol in 1940, at the instigation of Frederick Golla, Effie Hutton and F.
Wilfred Willway. The use of the procedure peaked in the late 1940s and early
1950s, with nearly 1500 operations a year. However, the poor results of the
operation, the harmful consequences observed in patients, and the
progressive introduction of psychiatric drugs led to a sharp decline of the
practice by the end of the 1950s. The vast majority of the case notes I have been working
on as the cataloguing archivist of the Norman Dott project date from this
period; and indeed, out of the 2500 case notes I have catalogued so far, less
than twenty mention a leucotomy. However, these cases greatly help to
understand in what context it was used and on what kind of patient, and for which
results.
The vast majority of patients
who underwent a leucotomy in the Norman Dott case notes at the end of the 1950s were
women, aged from 24 to 73 years old. They were usually suffering from various
mental illnesses described in the case notes as: ‘hebephrenic schizophrenia’, ‘catatonic
schizophrenia’, ‘chronic depression’, ‘agitated depression’; or more precisely:
‘long-standing and deep seated neurotic illness in an inadequate personality’,
‘recurrent depression with maniac depressive personality’.
Doctors were well aware that leucotomies were not a ‘miracle solution’, far
from it. They knew that recovery was not guaranteed and that it could change
the patient’s personality and make them less socially apt; however the
alternative was judged worse and the goal was to dull the symptoms of psychiatric
illness to enable the patient to lead a more peaceful life or at least to make
him or her easier to nurse. This sentiment is expressed by two doctors
considering a leucotomy at the Royal Infirmary for their patients: ‘I think
that leucotomy would relieve his suffering and might make it possible for him
to make some sort of adjustment outside hospital’; ‘[I feel] that a leucotomy
would allow of a modified social recovery enabling [the patient] to lead a
fairly normal life though leaving her rather ineffectual and needing guidance
in her day to day activities’.
 |
| Excerpt from a case note relating to a female patient suffering from chronic depression, 1959. LHB1 CC24 PR2.20898. |
One must
keep in mind that the procedure was only used as a last resort. The patient had
to be in a deeply disturbed state which would make living in these conditions
unbearable. Again quoting from Norman Dott case notes, it is said that one
patient ‘was inaccessible and auditorily hallucinated. There was
considerable volitional retardation and she was monosyllabic’. For another
patient, ‘operation was especially commended because of intractable noisy
perseveration; the word “money” occurring endlessly’. Moreover, leucotomies
were only performed when all other treatments had failed: in the case note
PR2.20920, it is said that ‘ECT has only produced temporary improvement and
tranquillizers have not been effective’, in the case note PR2.20698, the
doctors who examined the patient agreed that ‘he should have a leucotomy
carried out in view of the prolonged period of unsuccessful conservative
treatment’. At the time, other treatments included electroconvulsive therapy
(ECT), tranquilizers, and modified insulin injections, also known as insulin
coma therapy (ICT).
The
following extract from a case note describes a leucotomy performed in 1959 on a
patient suffering from ‘agitated depression’ at Ward 20 of the Royal Infirmary
of Edinburgh. Essentially, the surgeon would drill a pair of burr holes into
the skull in order to insert a sharp instrument called a leucotome
into the brain, that he would then sweep from side to side to separate the
frontal lobes from the rest of the brain.
 |
| Operation notes describing a leucotomy, 1959. LHB1 CC24 PR2.20920 |
From what we
can gather, the outcomes of the leucotomies carried out in the Norman Dott case
notes were very mixed. Only one patient seemed to do better: ‘in the few days
after the operation and prior to her return to Bangour, [the patient] certainly
appeared more relaxed, approachable and less disinclined to talk’. However most
of the time the results were more disappointing: ‘little change was noted after
operation’; ‘however, [in the following days], there was some suggestion of her
being less accessible’; ‘in the first post-operative days [the patient] was
confused and towards the end of the first week still disorientated in time;
somnolent and incontinent of urine and faeces. He recognised his surroundings;
knew that he had been operated on and why. There was no appreciable change in
his mood’ and he ‘still appear[ed] to be grossly preoccupied and depressed’.
Unfortunately, the case notes
only mention the days immediately following the operation so we have no way of
knowing how the situation evolved for these patients on the long term, but from
other leucotomy cases, we know that it was not uncommon for patients to be
crippled for life or to live in a vegetative state.
The use of leucotomy has been criticized
from the very beginning for the risks it posed for the patients and for its very
limited and often unpredictable results, although it was performed in
situations in which the doctors thought that the benefits would outweigh the
risks. The cases we find in the Norman Dott collection, although few in number,
enable us to understand the context of this operation, and what the reasoning
behind its use was. The study of medical failures and outdated treatments is
essential to understand the evolution of neurosurgery.
Sources:
History of psychosurgery in the United Kingdom [online]. Wikipedia. Available from: https://en.wikipedia.org/wiki/History_of_psychosurgery_in_the_United_Kingdom [Accessed 19/05/2016].
Levinson, H. (2011),
The strange and curious history of lobotomy [online]. BBC News magazine.
Available from: http://www.bbc.co.uk/news/magazine-15629160 [Accessed 19/05/2016].
No comments:
Post a Comment