Lobotomy in Private
Practice
Long-Term Follow-up Irving C. Bernstein, MD; William
A.
Callahan, MD; James M. Jaranson, MD
In a follow-up of 43 private psychiatric patients referred for open bimedial prefrontal lobotomies between 1948 and 1970, patients were rated by personal interviews and review of medical records for symptom improvement and organic brain syndromes. Initial diagnoses were obsessive-compulsive neurotic (27), hypochondriacal neurotic (five), manic-depressive (depressed) (one), and schizophrenic (ten). All had been severely impaired by illness intractable to extensive previous treatment. Thirty-five were found to be virtually free of symptoms that prompted operation, six had some improvement, and two were unimproved. Six had moderate to severe organic brain syndromes; three had seizure disorders necessitating treatment; and 17 incurred substantial weight gains. Best results were for hypochondriacal and obsessive-compulsive neurotic patients with phobic symptoms: poorest results were for paranoid schizophrenic subjects. This study was undertaken to provide some increment of data that could aid ongoing efforts to evaluate the consequences of this treatment.
the efficacy and morality of Both of illnesses sial topics, perhaps only slightly treatment
mental
brain surgery for the are
highly
controver¬
less provocative than the issues of psychosurgery for violent behaviors. This report focused on data that were available and relevant to the use of lobotomy in mental illness. Moral arguments against psychosurgery are generally concerned with per¬ manent impairment of mental, emotional, or spiritual ca¬ pacity, and with issues of appropriate definition of in¬ formed consent. Disputes about the scientific rationale for surgery in the mental illnesses are based on outcome crite¬ ria; methods of assessment of outcome variables, assess¬ ment of preoperative status, degree of suffering and prog¬ nosis; as well as the status of basic knowledge concerning brain function and mental disorder and its alleviation. This report offers some data bearing on the issue of therapeutic efficacy and outcome of lobotomy in certain psychiatric conditions. Disputes about therapeutic effi¬ cacy are concerned with the appearance or persistence of what in a normal population would be grossly undesirable postoperative effects, such as seizures; excessive weight gain, with or without associated apathy, lethargy, or faAccepted for publication Nov 12, 1973. From the departments of psychiatry, University of Minnesota Medical School, Minneapolis (Dr. Bernstein); Yale University, New Haven, Conn (Dr. Callahan); and Ramsey Hospital, St. Paul, Minn (Dr. Jaranson). Reprint requests to General Psychiatry, 1011 Medical Arts Bldg, Minneapolis, MN 55402 (Dr. Bernstein).
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tigue; and organic brain syndrome, the term we have
ap¬
plied to a constellation of symptoms that may include in¬ tellectual deficit, memory deficit, loss of drive, confusion, and outbursts of unmanageable behavior. Because empir¬ ical data are relevant to any position taken on these is¬ sues, we thought it useful to assess the outcome of a group of patients seen in the private practice setting. Since Moniz first introduced the standard bilateral lo¬
botomy in the 1930s, modifications in technique have been attempted, including unilateral, bimedial, precoronai, and orbital sections, as well as ultrasonic wave, chemical, and electrocoagulation techniques. Lobotomy of any type has generally been reserved for chronically ill patients who were refractory to psychotherapy, psychotropic drugs, and electroshock therapy. Miller,' who followed up 116 mental hospital patients in a series in Canada, agreed with this approach, stating, "if prefrontal lobotomy is used for se¬ lected cases of intractable mental disorder only, it has probably found its proper place in psychiatric treatment." Pippard,2 in his comprehensive questionnaire survey of mental hospitals in Great Britain, reached a less conserva¬ tive position, stating, "It is not necessary that a patient should be so ill that operation can be thought of only as a last desperate resort; nor need a patient be permanently institutionalized before operation can be considered." The decision of whether, or when, to operate has usually captured more attention important in the literature than the precise operative technique used. Greenblatt3 has ex¬ plained, "The experience suggests that the reactions to se¬ vere brain cutting are not to be predicted on the basis of the type and amount of brain cut or destroyed, but in rela¬ tion to many factors from the background and personality of the patient." An abiding question is whether or not there are criteria that can be reliably used to select pa¬ tients for whom the results of surgery—if elected—could be predicted to be, on balance, favorable. Prognostic Factors Many authors have attempted to delineate personality characteristics and psychiatric symptoms that have or have not responded to surgery and, consequently, can be used to predict success or failure. The tentative nature of
much of the descriptive psychiatric nosology must be noted here. The "observer effect" undoubtedly also influ¬ ences such attempts. Premorbid characteristics reported in the literature to have positive prognostic value are "conscientious, driving, obsessive, and over-anxious per-
sonality."4 Negative variables have included severe tem¬ peramental deviations5 and schizoid and paranoid fea¬ tures.6
Psychiatric diagnoses and symptoms have also been as a basis for patient selection. Again, issues of reli¬ ability of diagnostic systems and the fact that diagnostic categories may overlap present problems. Holden et al7 found that patients with "symptomatology of a compul¬ sive nature, with a high emotional or affective loading," responded favorably. Sargant" stated, "when good results used
also because the illness has marked are obtained, it is obsessional or obsessive trends." Greenblatt,3 in his series of 181 patients, noted, "as for diagnostic category, hypochondriasis and obsessive-compulsive psychoneurosis cases were most likely to improve; however, dementia praecox, catatonic type or paranoid type did poorly." Baker et al,8 found that pure phobic neurotic patients and those with phobic components did better than classic obsessivecompulsive patients. The indications cited by Tucker9 at the Lahey Clinic are agitation, depression, obsession, or intractable pain. Miller1 has written, "symptoms of per¬ sistent anxiety, fear, tension and marked pre-occupation with inner conflict consumed with guilt, inadequacy, fail¬ ure, self-destruction wishes are usually relieved by pre¬ frontal lobotomy." A 1971 overview in the British Medical Journal10 concluded that patients with depressive and anxiety states and obsessional neuroses have best results while schizophrenic patients do poorly. Pippard'2 claimed that lobotomy ". is valuable in persistent depressive states in older patients, especially those with obsessional personalities, and in some schizophrenic syndromes, par¬ ticularly the paranoid and pseudoneurotic." Other factors used to prognosticate favorable outcome have included duration of illness, age of patient, and social factors. Sykes and Tredgold,6 from their series of 350 pa¬ tients, concluded that illness lasting longer than five years presages adverse results in depressive patients and in pa¬ tients with anxiety states. Post and his co-workers5 fol¬ lowed up 52 patients for 7.9 years postoperatively and found in their series, that, severe illness present longer than two years prior to surgery was associated with unfa¬ vorable prognosis. The greatest improvement was found in patients with depressive reaction, ". especially when it occurred in a pure, psychotic form after age 60." Sar¬ gant1 contended, "Youth is often a bar to success, and pa¬ tients tend to do much better when they are nearing middle age, or even becoming elderly." There is general agreement that high social class is a fa¬ vorable prognostic feature. Freeman" reported that pri¬ vate patients did considerably better than state hospital patients. From a series of 27 unilaterally lobotomized pri¬ vate patients, Shobe and Gildea12 stated that favorable outcome is "related to the presence of interested, devoted families who could care for the patients after their dis¬ charge." Sykes and Tredgold6 supported this, claiming, "the sense of support at home is of prime importance, especially in the reactive depressive, anxiety and obses¬ sional states." .
.
.
.
.
.
.
.
.
Seizures
are
.
Complications common complication resulting
the most
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from
lobotomy. Postoperative
seizures have occurred, for in and than 50%14 of patients. more example, 12%,' 26%,13 Miller1 found personality defects to be a major complica¬ tion in 91% of his cases. Baker et al,8 claimed that neither basic intelligence nor memory is altered. Scherer and his co-workers15 studied psychological changes in lobotomized and control schizophrenic patients during the five-year postoperative period and found that "the lobotomy group was generally superior to its preoperative level and to the control group.. .." Partridge16 noted a weight gain in ap¬ proximately 90% of the 300 subjects followed up in his study. The largest weight gain was 45.2 kg (99 lb); several patients gained 22.6 to 27.1 kg (50 to 60 lb), and 9-kg (20lb) weight gains were "not uncommon." However, only about one-third of these patients remained overweight af¬ ter the first postoperative year.
Therapeutic Results
Reports vary considerably. Post et alr> reported improve¬ ment in 40% of their subjects and deterioration in 8%. Shobe and Gildea12 found improvement in 18 of their 27 private patients, while Baker and associates8 stated that 76% of their 42 patients had an outcome that was excellent or satisfactory. Freeman11 claimed in his follow-up studies that "some 70% of schizophrenics, 80% of affectives, and 90% of psychoneurotics are functioning outside of the hos¬ pital" five to ten years after lobotomy. Design of the Study This study was an uncontrolled follow-up of 43 patients,
men and 33 women who were treated with open bime¬ dial prefrontal lobotomies between 1948 and 1970. All of the patients had initially been evaluated or treated preoperatively by the senior author; 25 were his private pa¬ tients; 18 patients were referred by colleagues for consid¬ eration of lobotomy. These patients had incapacitating obsessions and compulsions, severe hypochondriasis, unre¬ lenting depression, or chronic phobias. In all cases, long-
ten
psychotherapy by competent psychiatrists, psychotropic drugs in large doses, and courses of shock electroconvulsive therapy (ECT) or insulin in various com¬ binations had failed to produce satisfactory remission. Forty-two patients received bimedial prefrontal lobot¬ omies. One patient had a unilateral left prefrontal lobot¬ omy followed by a unilateral right prefrontal lobotomy, and later a bimedial procedure due to nonpersistent re¬ sponse to the first procedure. Within 48 hours after sur¬ gery, most patients were subjected to a program that in¬ cluded physical, recreational, and occupational therapy in addition to encouragement from staff and family. A few patients were discharged to their homes within a week and most within three weeks of the operation. The two coauthors, who had had no previous contacts with the patients, did the follow-up and evaluated the re¬ sults. Follow-up was accomplished by reviewing medical records and interviewing the patients or their relatives. A standardized questionnaire was utilized (Table 1). Thirtyfive patients were followed up to 1972: 29 with personal in¬ terviews, four with telephone interviews, and two with letter questionnaires; six patients were followed up to the time of their deaths; and two patients could not be loterm
cated. The average follow-up was 9.7 years, and the range was 1 to 25 years. Changes in patients' symptoms with respect to preoper¬ ative status were clinically evaluated at follow-up and rated on a global scale. These arbitrary ratings were de¬ rived from changes in symptomatic findings and need for inpatient or outpatient psychiatric care, including the use of psychotropic drugs. Ratings were from 0 to +4, as fol¬ lows:
symptomatic improvement, with continued need for psy¬ chotropic drugs and permanent hospitalization; +1—Minimal symptomatic improvement, with continued need for psychotropic drugs and frequent hospitalization; + 2—Fair improvement of symptoms, with continued need for psychotropic drugs and regular outpatient interviews; + 3—Symptom-free, with need for small doses of psychotropic drugs and occasional outpatient interviews; + 4—Symptom-free, with no need for psychiatric treatment.
0—No
The postoperative presence of organic brain syndromes with respect to preoperative status was also determined
Table 1.—Routine
Questionnaire
Please try to answer the following questions: 1. Age: Marital status: Number of children: Present address and living arrangements: Occupations, time spent with each employer, and reason for leaving, (if any): 2. Do you have the initiative and drive to get your work done or are you tired or do you need motivation? 3. How is your memory for past and recent events, your ability to think clearly about difficult topics, and your abil¬ ity to talk well? 4. Are you more or less inhibited, impulsive, or not so fussy in your speech and behavior since the operation? 5. How is your state of mind? Are you comfortable with your¬ self and your situation? 6. Are your feelings weaker or stronger now? Are you, for example, angered more or less easily now? Do you remain mad for long? (All these since the operation) 7. Do you have more or less self-confidence? Are you more or less friendly and out-going since the operation? 8. What Is your present religion? Are you more or less reli¬ gious since the operation? 9 Have there been any changes In your sexual activities or in your use of tobacco and alcohol? Have you been In any trouble with the law? (All since the operation) 10. What were the problems that brought you to me to begin with? Why did you decide to have surgery? Did you get re¬ lief from these problems after the surgery or do they still bother you? If so, how much do they bother you now? 11. What changes in your personality and/or mental, emo¬ tional, or physical problems have you noticed since the surgery? Were these changes for the better or for the worse? 12. Since you last saw me, have you been seen by a doctor, been in a hospital, or received any medicine or other treat¬ ment for an emotional or mental problem? 13. What do the other members of your family think about the effect of the surgery on you? How would they answer the preceding questions? 14. Did you ever have a convulsion or seizure after the sur¬ gery? Do you take any medicine to prevent convulsions? 15. Have there been any marked changes in your appetite or weight since the surgery? 16. Have you had any other medical problems since I last saw you? Did you need hospitalization or surgery for these? 17. Are there any other comments or questions that you have concerning your emotional health and the surgery? Under similar circumstances, would you have the operation again? If not, why
hot?_
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clinically. Patients were evaluated for deficits in drive, re¬ cent memory, and intellectual functioning, and for the presence of confusion or outbursts of unmanageable be¬ havior. Arbitrarily, global organic brain syndrome ratings were assigned as follows: 0, no organic brain syndrome; —1, mild; —2, moderate; —3,
with —4s requiring constant
severe; and
—4, very
severe,
supervision and —3s some su¬
pervision. These ratings, from 0 to —4, were then combined with our 0 to +4 improvement ratings to achieve a measure¬ ment of postoperative status. Admittedly, a number on a nine-point scale is a crude and subjective indicator, espe¬ cially when applied to such a delicate area as psychological functioning. However, no finer evaluative method was available to us, and we generated this scale in represent overall postoperative results.
an
attempt
to
RESULTS Neurotic Patients
Of 43 patients, 27 had obsessive-compulsive neuroses and five had hypochondriacal neuroses (Table 2). Of the neurotic patients, the obsessive-compulsive group showed an average improvement of symptoms of 3.2 and the hypochondriac patients showed an average improvement of 3.4 out of a possible 4, with none showing no improve¬ ment of symptoms. Although patients in the obsessivecompulsive group had a high average symptomatic im¬ provement, 12 of the 27 had organic brain syndromes, ten of which were mild. Of the five hypochondriac patients, only one showed a mild organic brain syndrome. It is en¬ tirely possible that the high frequency of brain syndromes in the obsessive-compulsive group is clinical artifact. Preoperatively, this group manifested a great deal of compul¬ sive ritualistic behavior; postoperatively, when this behav¬ ior subsided, these patients were the most likely to assess themselves as slowed down, tired, lazy, or apathetic. Of the 27 obsessive-compulsive neurotics, the 11 with associ¬ ated phobic symptoms (No. 17 to 27) had the best overall improvement, with greatest relief of symptoms and few¬ est organic brain syndromes after surgery.
Psychotic
Patients
The psychotic patients in our series included one manicdepressive patient and ten schizophrenic patients (Tables 2 and 3). The one manic-depressive patient (No. 33) had +4 symptomatic improvement, with no organic brain syn¬ drome after psychosurgery. The indication for operation in his case was severe, uncontrollable depression. The ten schizophrenic subjects included five schizoaffective, two chronic undifferentiated, and three paranoid. The associ¬ ated symptomatic indications for lobotomy were obsessive thoughts and fears or compulsive behavior in seven pa¬ tients, severe hypochondriasis in two, and incapacitating anxiety in one. Symptomatic improvement displayed by the schizophrenic group was primarily in the associated symptoms listed above, not in the schizophrenic symp¬ toms; however, in four patients, improvement was noted in both areas. The symptomatic remissions in the schizoaf¬ fective group, 3.2 out of a possible 4, and chronic undif¬ ferentiated types, 3.0 out of a possible 4, are comparable to those found in the neurotic categories. Of the three para-
Table 2.—Data for Neurotic Patients* Case
Years
Pre-op Diagnosis
No.,
Sex Neurotic 1, F 2, F
3, 4, 5, 6, 7, 8,
F M F F F F F F F F F F F F F F
9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, F
patients Obsessive-compulsive, dp Obsessive-compulsive, dp Obsess ive-compuls ve, dp Obsess ive-compuls ¡ve, dp Obsessive-corn puls ve, dp Obsessive-compuls ve, dp Obsessive-compuls ve, dp Obsessive-compuls ve, dp Obsessive-compuls ve, dp Obsessive-compuls ve, dp Obsessive-compuls ve, hypo Obsessive-compuls ve, hypo Obsessive-compuls ive, hypo Obsessive-compuls ive, hypo Obsessive-compu Is ve, hypo Obsessive-compuls ve, hypo Obsessive-compuls ve phob Obsessive-compuls ve phob Obsessive-compuls ve phob
20, F Obsessive-compuls ve phob 21, F Obsessive-compuls ve phob 22, F Obsessive-compuls ve phob 23, F Obsessive-compulsi ve phob 24, M Obsessive-compuls ve phob 25, F Obsessive-compuls ve phob 26, F Obsessive-compulsi ve phob 27, M Obsessive-compulsive phob 28, F Hypochondriac 29, F Hypochondriac 30, F Hypochondriac 31, F Hypochondriac 32, M Hypochondriac Psychotic patients 33, M Manic-dp; dp type SC-SA type with anxiety SC-SA type with _ob-comp behavior SC-SA with hypo¬ 36, M
34, M 35, F
37, F 38, F 39, F
40, M 41, M 42, F 43, F
Illness
Pre-opt
yr
30,30 24 15 10
10
17 20 25 23 25 10 10
46 37 33 31 50 34 42 31 41 34 51
Years of
Post-op Follow-upt 14 13 12 12
11 10 10 12
41,59 49,49 55,55
10
41 43 39 46
11 10 12 11
34 41 28
17
Improve-
Status at
ment of
Symptoms +3 +1 +3 +3 +4 +3 +3 +4 +3 +3 +3 +1 +1 +2 +3 +4 +4 +4 +4
OBS
-1
Testing and at Death
Housewife, bookkeeper Nursing home patient Housewife, supervisor Bindery foreman Housewife
-2 -It
-1* -1
Housewife, died
at 53
Housewife
Housewife Housewife Housewife
Housewife, bookkeeper Housewife, died at 59 Housewife, died at 59
hospital patient Housekeeper State
-1
Housewife -1
Housewife, clerk Landlady Housewife, game assembler
35
24
11 18
43,44
24,24,245
25
+4 +4 +4 +4 +4 +4 +3 +3 +4 +3 +3 +3 +4
Housewife, cashier
0
Housewife Housewife Housewife Minister
Housewife, cashier Housewife, receptionist
15
36
16 27
59 58 27 50 63
24
57
16
+4
Businessman; retired attorney
16
39 23
11
+4 +4
Truckd river Stockclerk
19
10
+3
Mailman
31 36
14
+3 +2 +3
23
12
+3
26,35
"
chondriacal thoughts SC-SA with hypochondriasis SC-SA with phobias SC chronic, undifferentiated with obsessive behavior SC chronic, undifferentiated with obsessive thoughts SC-PA with obsessive thoughts SC-PA with phobias SC-PA with
Age at Surgery,
12 15
13 15
49,49
+2
30 10
58,58 33
obsessive thoughts
Abbreviations used
12
-1
Laborer Housewife Nursing home patient Housewife, waitress
Housewife,
seamstress
Supervisor, died
-2
at 67
Housewife, died at 56
Nursing home Janitoress
patient
Stockroom clerk
hospital patient
-1
State
-4 -2
Housewife, died State
at 59
hospital patient
are as follows: pre-op, preoperatively; post-op, postoperatively; OBS, organic brain syndrome; dp, depressed; hypo, hypochrondriac; phob, phobic manifestations; SC, schizophrenia; SA, schizoaffective; and PA, paranoid. t Years of illness preoperatively and years of postoperative follow-up are both with reference to most recent lobotomy. *
§
At least one seizure postoperatively. Left unilateral, right unilateral, and bimedial
prefrontal
lobotomies.
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Table 3.—Average Patient Data For AH Diagnostic Groups
Preoperative Diagnosis Obsessive-compulsive (n 27) Hypochondriac (n = 5) Manic-depressive (n 1) Schizophrenic-schizoaffective type (n 5) Schizophrenic-chronic, undifferentiated type (n = 2) Schizophrenic, paranoid type (n = 3) * OBS indicates organic brain syndrome.
Age at Operation, yr
Operation
Length of Follow-Up
39.1 51.4 57 32.2 29.5 40.3
11.2 9.0 24 10.8 4.5 6.7
10.1 8.5 16 9.2 8.5 7.3
=
=
=
Table 4.—Complications After Lobotomy*
Preoperative Diagnosist
Organic Brain Syndrome
At Least One Post-
,-*-, operative —4 —3 —2 —1 0 Seizure
Obesity
Obsessive-
compulsive neurotic
(n 27) Hypochondriac =
1
1
10
15
5
10
neurotic
(n = 5) Schizophrenic
schizoaffective
type
(n = 5) Schizophrenic chronic,
undifferentiated
(n = 2) Schizophrenic paranoid type (n=3) Total patients (n
=
43)_1
1
4
13
23
9
17
As stated in the text, there were isolated instances of hemiparesis, osteomyelitis, and hydrocephalus, one of each. t The one manic-depressive patient had no organic brain syndrome and no postoperative seizure.
noid schizophrenic subjects, two showed no improvement in symptoms and one showed a +2 improvement, an aver¬ age of only +0.7. The early average at surgery found in the schizophrenic group may reflect the early onset and progressive deterioration that characterized these par¬ ticular patients. The more serious brain syndromes were seen in the schizophrenic group. However, the "organic brain syndromes" rating in this group may reflect a clini¬ cally inseparable combination of postlobotomy organic brain syndrome and schizophrenic impairments. Miscellaneous Considerations
Some miscellaneous results are not included in any table. At follow-up, 31 patients have maintained their marriages, three are still single, one is still divorced, and one is still separated. One patient has married postopera¬ tively, five have been divorced, and one is widowed. Postoperative changes in religious interest, in sexual activity, and in the use of alcohol and tobacco were also in¬ vestigated and found to be variable.
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Improvement of
Symptoms +3.2 +3.4 +4 +3.2 +3.0 +0.7
OBS* -0.5 -0.2 -0.8 -0.5 -2.3
Complications Noted in This Series An analysis of the occurrence of organic brain syn¬ dromes according to the preoperative diagnosis and major operative complications can be found in Table 4. The high
frequency of organic brain syndromes in the obsessivecompulsive and schizophrenic groups has been discussed above. Among the nine patients with more than one lobot¬ omy, six had organic brain syndromes. Nine of the 43 pa¬ tients experienced at least one seizure postoperatively. Three patients have had one seizure, three have had three seizures, one has had eight seizures, and two have had more than ten seizures. None of the six patients with three seizures or fewer is currently taking medication for seizure control. Among the nine patients with more than one lobotomy, three have had at least one seizure postop¬ eratively; one has had one, one has had three, and one has had
*
Years of Illness Before
more
than ten.
Obesity is another long-term complication. At followup, 17 patients had gained from 11.3 to 45.2 kg (25 to 99 lb). One patient has a persistent mild right-sided hemi-
paresis (see
case
No.
9). Another patient (No. 28) needed
postlobotomy for osteomyelitis of the left frontal bone button. Following a second lobotomy, one patient (No. 42) sustained a low-pressure, nonobstructive hydrocephalus that necessitated two shunt procedures. She eventually died of bilateral lobular pneumonia eight months postlobotomy after a prolonged, vegetative surgery
one
year
course.
REPORT OF CASES The following case histories illustrate typical patients from each diagnostic group. Case 9.—A 34-year-old woman, mother of three children and a high school graduate, had a history of obsessive thinking, compul¬ sive behavior, and depressive symptomatic condition of 12 years' duration. She was continually involved in cleaning her house, which she knew was inappropriate but "I just can't stop." She tried to maintain a minute schedule of work but was unable to do so. Because of her inability to "catch up," she was almost con¬ stantly depressed. At 27 years, she was referred for psychiatric treatment because of her inability to act out her obsessions for or¬ der, schedule, and details. She was so depressed, electroconvulsive therapy (ECT) was prescribed, which relieved her depression, but not her obsessive-compulsiveness. She then made a borderline ad¬ justment outside of the hospital with antidepressants and tranquilizers until she was 30, when she had the same complaints of depression and obsessive-compulsiveness. Because of her fear of pregnancy, a tubai ligation was done and ECT was again pre-
scribed for her depression. Because of the severeity of her obses¬ sive-compulsive symptoms, a prefrontal lobotomy was suggested, but she and her husband refused. She went home but could not ad¬
just with supportive psychotherapy and tranquilizers so she was readmitted to the hospital for the lobotomy. She refused again and was discharged, unimproved, after 25 days of hospitalization. She was seen supportively as an outpatient with psychotherapy and tranquilizers for three months, with no improvement. She was readmitted to the hospital and again given ECT, but with no bene¬ fit. Permission was then given for prefrontal lobotomy. Within a few days of the bimedial lobotomy, she was no longer depressed or obsessed, but unfortunately developed a right-sided hemiparesis that still persists in a mild form, which is believed to be in part hysterical. Since the operation four years ago, she has functioned well as a mother and wife and requires no medication or psycho¬ therapy. Symptom improvement is rated at + 3, and organic brain syndrome, —1. Case 23.—A 53-year-old married woman with five children is a high school graduate and former prostitute. At 29, she had the on¬ set of the thought that she might contaminate her children with her vaginal secretions. At an appointment with her obstetrician, she mentioned her fear that her vaginal secretions might contami¬ nate her children. In desperation, he told her to boil her pants. She
did this on her kitchen stove and from then on she believed her kitchen was contaminated, and she could barely function there. At this point she left her psychoanalyst and became the patient of the senior author. Her obsession was refractory to intensive psy¬ chotherapy, including care by a psychoanalyst and ECT. Diag¬ nosis was obsessive-compulsive neurosis with phobic manifesta¬ tions. Bimedial lobotomy was performed when she was 35 years old. Her follow-up included the following: three years after the op¬ eration the patient had a child without any medical or psychiatric difficulty. Since her psychosurgery, she has seen a psychiatrist less than once a year. She was hospitalized at age 50 for ten days for depression. She currently admits to periodic mild anxiety feelings for which she takes an occasional tranquilizer. She has made an excellent adjustment living with her husband and family. Symp¬ tom improvement is rated at +4, organic brain syndrome, 0. Case 28.—A 67-year-old woman who had finished two years of high school, married and mother of four children, complained bit¬ terly of problems since childhood with many parts of her body that all the operations she had undergone had not remedied. In addition, she complained of severe feelings of depression. During the years, numerous physicians had used many tranquilizers and antidepressants with negative results. She was diagnosed as hav¬ ing a hypochondriacal neurosis with some depressive features. Electroconvulsive therapy was recommended in addition to sup¬ portive psychotherapy. In the subsequent five months, because of her depression, agitation, and hypochondriasis, she was admitted to the hospital four times for a total of 71 days and four courses of ECT. During the second hospitalization, lobotomy was recommended but refused by patient and family. At the fifth admission, the rec¬ ommendation for bimedial lobotomy was accepted. Postopera¬ tively, she was not hypochondriacal. One year postoperatively, she had surgery for osteomyelitis of the frontal bone button. At fol¬ low-up eight years postoperatively, she has a few somatic com¬ plaints for which she takes aspirin. She is quite comfortable and functioning very well as housewife and mother. Symptom im¬ provement rating is +4, organic brain syndrome, 0. Case 35.—A 27-year-old, single woman, with two years of col¬ lege, was first hospitalized at age 17 for schizoid behavior and sui¬ cidal gestures. She developed auditory and visual hallucinations and a compulsion to hurt or injure other young women or herself. She did not improve with huge doses of tranquilizers, intensive ECT, and insulin coma treatments. Lobotomy was recommended, but permission was not granted. She was referred to a private
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psychiatrie hospital
in another
city, where she stayed for four
years, most of the time in seclusion. Her behavior became so de¬ structive her family was advised to take her elsewhere. At this time the recommendation for lobotomy was accepted. The diag¬ nosis of schizophrenia, schizoaffective type, with compulsive be¬ havior was made. Bimedial lobotomy was performed at age 33.
The first three months postoperatively, she had mild obsessive thinking without compulsive acting out or destructive behavior. In the first postoperative year, she had a poor employment and scho¬ lastic record and was seen for supportive psychotherapy and med¬ ication management. Subsequently, she spent one year at a reha¬ bilitation workshop. For the last 18 months she has maintained an excellent employment record as a stock clerk. She lives in a girls' dormitory and requires neither medication nor psychiatric sup¬ port. Symptom improvement is rated at +4, organic brain syn¬ drome, 0. Case 40.—A 35-year-old single man had two years of college. At the age of 19, his family noted him to be peculiar and withdrawn. He spent much of his time daydreaming about being either a bum or a prefessional wrestler. He became agitated and depressed be¬ he was unable to fulfill his obsessive desire to tickle and massage the feet of young women. He would approach girls on the street and ask them if he could tickle their feet. Some would agree for a fee; others would just walk away; and some would notify the police. He was arrested a few times. He showed no response to weekly psychotherapy, tranquilizers, or ECT. A diagnosis of schiz¬ cause
ophrenia, chronic, undifferentiated type with obsessive thoughts was made. Bimedial lobotomy was performed at age 23 years. For
short time after surgery, his obsession was still present, but he did not feel compelled to act it out. He was seen for supportive psychotherapy for a time. He has required no psychiatric care or medication since the age of 28. For the last five years, he has been steadily employed as a stockroom clerk. He is now free of his sex¬ ual obsession but still has other mild obsessive symptoms. Symp¬ tom change is rated as +3, organic brain syndrome, 0. Case 43.—A 45-year-old divorced woman, a high school graduate with three children, had periods of episodic agitation, paranoid thinking, withdrawal, and sexual fantasy since age 26. At the age of 30 years, she had multiple obsessive thoughts about hurting her children or herself, extreme agitation, and delusions of demonic possession. She did not improve with psychotherapy, large doses of tranquilizers, and numerous trials of ECT. The diagnosis made was schizophrenia, paranoid type, with obsessive thoughts. Bime¬ dial lobotomy was performed at age 33. At age 37, after her ninth admission for schizophrenic reaction with suicidal gestures and assaultive behavior, she was committed to a state hospital. She has continued to be agitated, assaultive, and extremely hypo¬ chondriacal. She has spent most of the last eight years in the state hospital. Symptom improvement was rated at 0, organic brain a
syndrome,
—2.
COMMENT
This study supports the findings of several of the stud¬ ies previously mentioned. We find, as did Greenblatt,1 that patients with a preoperative diagnosis of hypochondriasis and obsessive-compulsive neurosis had the best prognosis, while those with schizophrenia, especially paranoid schizo¬ phrenia, had a poorer prognosis. Our data are in accord with Baker et al8 in that obsessive-compulsive neurotic pa¬ tients with phobic symptoms responded better than classic obsessive-compulsive neurotic patients. A favorable re¬ sponse found especially in patients with obsessive or com¬ pulsive symptoms was also noted by Sargant,4 Holden et al,7 and Pippard.2 The tendency for schizophrenic patients to do less well is cited by an editorial in the British Medi-
as well as by Greenblatt.3 Although our is sample small, we disagree with Pippard2 in his assertion that lobotomy is indicated in treatment of paranoid schiz¬
cal Journal10
ophrenia. Sykes and Tredgold" and
Post et al5 concluded that pa¬ tients who had been ill for more than five or two years, re¬ spectively, before lobotomy had an unfavorable prognosis. Our series, in contrast, showed no particular correlation between duration of illness and outcome. In fact, the pa¬ tient who, at the time of surgery, had been ill for the long¬ est time (27 years), showed a +4 improvement. While Sargant4 and Post et al5 state that youth is a less favorable prognostic indicator, our study shows no par¬ ticular correlation between successful results and the age of the patient at the time of surgery. We found examples of success in all age categories from the late teens to the seventh decade. The supportive social environment6·11·12 seen so often in
private patient population is, we suggest, an important factor in our relatively high rate of success compared with series from state hospitals. Eighty-one percent of the pa¬ tients in our series are symptom-free, with long-term fol¬ low-up ratings of +3 or +4. In terms of the most frequently noted complication of a
the
operation, our 21% incidence of seizures compared closely with the 26% cited by Freeman.13 Weight gains in our patients resembled those enumerated by Partridge.16 Because this report was based on patients referred by most
the senior author, it is relevant to comment on our belief that those physicians who do include the option for sur¬ gery among their therapeutic methods should not recom¬ mend it lightly. The preoperative condition of the patient, the nature of the persisting incapacitation, and the rela¬ tive efficacy of the entire range of alternative treatments must be carefully weighed against the assessment of the relative efficacy of surgery and risk of side-effects and thoroughly discussed. Our view of the literature is that there are some relevant data that speak to the issue of in¬ dications, to the importance of psychosocial resources, and to the least and most favorable psychiatric conditions, should the surgical treatment option be considered. In our own opinion, for example, we, as Pippard,2 would not con¬ sider surgery as a treatment of last resort for obsessivecompulsive neurotic patients with incapacitating phobic symptoms, since such patients rarely respond to alterna¬ tive treatments. Whatever the deliberate position ulti¬ mately taken by the field with respect to these indications and procedures, these and other such data that may be available should be of some utility in the ongoing broadly based process of assessing therapeutic efficacy. This investigation was supported by the Marian Foundation Mary's Hospital, Minneapolis. Martha Ross assisted in the preparation of the manuscript.
of St.
In accepting the above article, the editors endorse only the need for evaluated data in this area and the necessity for thorough and dispassionate review of the problem in the context of clinical re¬ search, science, and concern for the individual patient. The report
could have been improved by various methodological refinements and the use ofevaluators totally outside the treatment system, but
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nevertheless represents a sincere effort at clinical evaluation of available data that has recently been all too infrequent. Currently, the ethical and scientific questions raised by psycho¬ surgery generally, as well as its use in major mental illnesses, are under intensive review by the National Commission for Protec¬ tion of Human Subjects of Biomédical and Behavioral Research. Recent reviews conducted by institutes of the Department of Health, Education, and Welfare (HEW) have emphasized both the paucity of information and the necessity for fundamental scien¬ tific animal study of brain behavior interrelationship, as well as social and ethical study. Some sense of the relevant considerations can be found in Psychosurgery: Perspective on a Current Issue by Bertram S. Brown, Louis A. Wienckowski, and Lyle W. Bivens (HEWPublications, No. [HSM] 73-9119,1973). An interesting dis¬ cussion by Judith P. Swazey, PhD, associate professor in the De¬ partment of Sociomedical Sciences at Boston University School of Medicine, appears in Frontiers of Psychiatry (5:1, 2, 11,1975). Dr. Swazey, with Rennee C. Fox, PhD, has examined the range of clin¬ ical, scientific, and ethical issues involved in transplantation
(The Courage to Fail, Chicago, University of Chicago Press, 197k),
and Swazey offers some more recent perspective on issues relating to clinical reality and ethical choice with respect to psychosur¬ gery. Views of the Society for Neurosciences are presented in an editorial by Theodore Bullock (Arch Neurol 32:73-71,, 1975). Ethi¬ cal, social, and legal policy issues are surveyed in a forthcoming volume, Operating on the Mind: The Psychosurgery Conflict (W. Gaylin, R. Neville, J. Meister [eds], New York, Basic Books Ine, to be published), in which Herbert G. Vaughan, Jr, MD, provides a brilliant historical overview of the experimental basis for surgical procedures. Finally, a good scientific, historical background that can provide the reader with some of the necessary information to form his own judgments about this complex area may be found in a book by Elliot Valenstein, PhD, Brain Control: A Critical Exami¬ nation of Brain Stimulation and Psychosurgery (New York, John Wiley & Sons Ine, 1973).-Ed.
References 1. Miller A: The lobotomy patient\p=m-\Adecade later: A follow-up study of a research project started in 1948. Can Med Assoc J 96:1095-1103, 1967. 2. Pippard J: Leucotomy in Britain today. Br J Psychiatry 108:249-255, 1962. 3. Greenblatt M: Relation between history, personality and family pattern and behavioral responses after frontal lobe surgery. Am J Psychiatry 116:193-202, 1959. 4. Sargant W: The present indications for leucotomy. Lancet 1:1197-1200, 1962. 5. Post F, Rees WL, Schurr PH: An evaluation of bimedial leucotomy. Br J Psychiatry 114:1223-1246, 1968. 6. Sykes MK, Tredgold RF: Restricted orbital undercutting: A study of its effects on 350 patients over the ten years 1951-1960. Br J Psychiatry 110:609-640, 1964. 7. Holden JMC, Itel TM, Hofstatter L: Prefrontal lobotomy: Stepping stone or pitfall? Am J Psychiatry 127:591-598, 1970. 8. Baker EFW, Young MP, Gauld DM, et al: A new look at bimedial prefrontal leukotomy. Can Med Assoc J 102:37-41, 1970. 9. Tucker WI: Indications for modified leucotomy. Bull Lahey Clin Found 15:131-139, 1966. 10. Modified prefrontal leucotomy, editorial. Br Med J 3:595-596, 1971. 11. Freeman W: Frontal lobotomy 1936-1956: A follow-up study of 3,000 patients from 1 to 20 years. Am J Psychiatry 113:877-886, 1957. 12. Shobe FO, Gildea MC-L: Long-term follow-up of selected lobotomized private patients. JAMA 206:327-332, 1968. 13. Freeman W: Lobotomy and epilepsy: A study of 1,000 patients. Neurology 3:479-494, 1953. 14. Logothetis J: A long-term evaluation of convulsive seizures following prefrontal lobotomy. J Nerv Ment Dis 146:71-79, 1968. 15. Scherer IW, Klett CJ, Winne JF: Psychological changes over a fiveyear period following bilateral prefrontal lobotomy. J Consult Clin Psychol 21:291-295, 1957. 16. Partridge M: Complications and sequelae, in Pre-Frontal Leucotomy: A Survey of 300 Cases Personally Followed Over lH-3 Years. Oxford, En¬ gland, Blackwell Scientific Publications, 1950, 31.
Practice
Long-Term Follow-up Irving C. Bernstein, MD; William
A.
Callahan, MD; James M. Jaranson, MD
In a follow-up of 43 private psychiatric patients referred for open bimedial prefrontal lobotomies between 1948 and 1970, patients were rated by personal interviews and review of medical records for symptom improvement and organic brain syndromes. Initial diagnoses were obsessive-compulsive neurotic (27), hypochondriacal neurotic (five), manic-depressive (depressed) (one), and schizophrenic (ten). All had been severely impaired by illness intractable to extensive previous treatment. Thirty-five were found to be virtually free of symptoms that prompted operation, six had some improvement, and two were unimproved. Six had moderate to severe organic brain syndromes; three had seizure disorders necessitating treatment; and 17 incurred substantial weight gains. Best results were for hypochondriacal and obsessive-compulsive neurotic patients with phobic symptoms: poorest results were for paranoid schizophrenic subjects. This study was undertaken to provide some increment of data that could aid ongoing efforts to evaluate the consequences of this treatment.
the efficacy and morality of Both of illnesses sial topics, perhaps only slightly treatment
mental
brain surgery for the are
highly
controver¬
less provocative than the issues of psychosurgery for violent behaviors. This report focused on data that were available and relevant to the use of lobotomy in mental illness. Moral arguments against psychosurgery are generally concerned with per¬ manent impairment of mental, emotional, or spiritual ca¬ pacity, and with issues of appropriate definition of in¬ formed consent. Disputes about the scientific rationale for surgery in the mental illnesses are based on outcome crite¬ ria; methods of assessment of outcome variables, assess¬ ment of preoperative status, degree of suffering and prog¬ nosis; as well as the status of basic knowledge concerning brain function and mental disorder and its alleviation. This report offers some data bearing on the issue of therapeutic efficacy and outcome of lobotomy in certain psychiatric conditions. Disputes about therapeutic effi¬ cacy are concerned with the appearance or persistence of what in a normal population would be grossly undesirable postoperative effects, such as seizures; excessive weight gain, with or without associated apathy, lethargy, or faAccepted for publication Nov 12, 1973. From the departments of psychiatry, University of Minnesota Medical School, Minneapolis (Dr. Bernstein); Yale University, New Haven, Conn (Dr. Callahan); and Ramsey Hospital, St. Paul, Minn (Dr. Jaranson). Reprint requests to General Psychiatry, 1011 Medical Arts Bldg, Minneapolis, MN 55402 (Dr. Bernstein).
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tigue; and organic brain syndrome, the term we have
ap¬
plied to a constellation of symptoms that may include in¬ tellectual deficit, memory deficit, loss of drive, confusion, and outbursts of unmanageable behavior. Because empir¬ ical data are relevant to any position taken on these is¬ sues, we thought it useful to assess the outcome of a group of patients seen in the private practice setting. Since Moniz first introduced the standard bilateral lo¬
botomy in the 1930s, modifications in technique have been attempted, including unilateral, bimedial, precoronai, and orbital sections, as well as ultrasonic wave, chemical, and electrocoagulation techniques. Lobotomy of any type has generally been reserved for chronically ill patients who were refractory to psychotherapy, psychotropic drugs, and electroshock therapy. Miller,' who followed up 116 mental hospital patients in a series in Canada, agreed with this approach, stating, "if prefrontal lobotomy is used for se¬ lected cases of intractable mental disorder only, it has probably found its proper place in psychiatric treatment." Pippard,2 in his comprehensive questionnaire survey of mental hospitals in Great Britain, reached a less conserva¬ tive position, stating, "It is not necessary that a patient should be so ill that operation can be thought of only as a last desperate resort; nor need a patient be permanently institutionalized before operation can be considered." The decision of whether, or when, to operate has usually captured more attention important in the literature than the precise operative technique used. Greenblatt3 has ex¬ plained, "The experience suggests that the reactions to se¬ vere brain cutting are not to be predicted on the basis of the type and amount of brain cut or destroyed, but in rela¬ tion to many factors from the background and personality of the patient." An abiding question is whether or not there are criteria that can be reliably used to select pa¬ tients for whom the results of surgery—if elected—could be predicted to be, on balance, favorable. Prognostic Factors Many authors have attempted to delineate personality characteristics and psychiatric symptoms that have or have not responded to surgery and, consequently, can be used to predict success or failure. The tentative nature of
much of the descriptive psychiatric nosology must be noted here. The "observer effect" undoubtedly also influ¬ ences such attempts. Premorbid characteristics reported in the literature to have positive prognostic value are "conscientious, driving, obsessive, and over-anxious per-
sonality."4 Negative variables have included severe tem¬ peramental deviations5 and schizoid and paranoid fea¬ tures.6
Psychiatric diagnoses and symptoms have also been as a basis for patient selection. Again, issues of reli¬ ability of diagnostic systems and the fact that diagnostic categories may overlap present problems. Holden et al7 found that patients with "symptomatology of a compul¬ sive nature, with a high emotional or affective loading," responded favorably. Sargant" stated, "when good results used
also because the illness has marked are obtained, it is obsessional or obsessive trends." Greenblatt,3 in his series of 181 patients, noted, "as for diagnostic category, hypochondriasis and obsessive-compulsive psychoneurosis cases were most likely to improve; however, dementia praecox, catatonic type or paranoid type did poorly." Baker et al,8 found that pure phobic neurotic patients and those with phobic components did better than classic obsessivecompulsive patients. The indications cited by Tucker9 at the Lahey Clinic are agitation, depression, obsession, or intractable pain. Miller1 has written, "symptoms of per¬ sistent anxiety, fear, tension and marked pre-occupation with inner conflict consumed with guilt, inadequacy, fail¬ ure, self-destruction wishes are usually relieved by pre¬ frontal lobotomy." A 1971 overview in the British Medical Journal10 concluded that patients with depressive and anxiety states and obsessional neuroses have best results while schizophrenic patients do poorly. Pippard'2 claimed that lobotomy ". is valuable in persistent depressive states in older patients, especially those with obsessional personalities, and in some schizophrenic syndromes, par¬ ticularly the paranoid and pseudoneurotic." Other factors used to prognosticate favorable outcome have included duration of illness, age of patient, and social factors. Sykes and Tredgold,6 from their series of 350 pa¬ tients, concluded that illness lasting longer than five years presages adverse results in depressive patients and in pa¬ tients with anxiety states. Post and his co-workers5 fol¬ lowed up 52 patients for 7.9 years postoperatively and found in their series, that, severe illness present longer than two years prior to surgery was associated with unfa¬ vorable prognosis. The greatest improvement was found in patients with depressive reaction, ". especially when it occurred in a pure, psychotic form after age 60." Sar¬ gant1 contended, "Youth is often a bar to success, and pa¬ tients tend to do much better when they are nearing middle age, or even becoming elderly." There is general agreement that high social class is a fa¬ vorable prognostic feature. Freeman" reported that pri¬ vate patients did considerably better than state hospital patients. From a series of 27 unilaterally lobotomized pri¬ vate patients, Shobe and Gildea12 stated that favorable outcome is "related to the presence of interested, devoted families who could care for the patients after their dis¬ charge." Sykes and Tredgold6 supported this, claiming, "the sense of support at home is of prime importance, especially in the reactive depressive, anxiety and obses¬ sional states." .
.
.
.
.
.
.
.
.
Seizures
are
.
Complications common complication resulting
the most
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from
lobotomy. Postoperative
seizures have occurred, for in and than 50%14 of patients. more example, 12%,' 26%,13 Miller1 found personality defects to be a major complica¬ tion in 91% of his cases. Baker et al,8 claimed that neither basic intelligence nor memory is altered. Scherer and his co-workers15 studied psychological changes in lobotomized and control schizophrenic patients during the five-year postoperative period and found that "the lobotomy group was generally superior to its preoperative level and to the control group.. .." Partridge16 noted a weight gain in ap¬ proximately 90% of the 300 subjects followed up in his study. The largest weight gain was 45.2 kg (99 lb); several patients gained 22.6 to 27.1 kg (50 to 60 lb), and 9-kg (20lb) weight gains were "not uncommon." However, only about one-third of these patients remained overweight af¬ ter the first postoperative year.
Therapeutic Results
Reports vary considerably. Post et alr> reported improve¬ ment in 40% of their subjects and deterioration in 8%. Shobe and Gildea12 found improvement in 18 of their 27 private patients, while Baker and associates8 stated that 76% of their 42 patients had an outcome that was excellent or satisfactory. Freeman11 claimed in his follow-up studies that "some 70% of schizophrenics, 80% of affectives, and 90% of psychoneurotics are functioning outside of the hos¬ pital" five to ten years after lobotomy. Design of the Study This study was an uncontrolled follow-up of 43 patients,
men and 33 women who were treated with open bime¬ dial prefrontal lobotomies between 1948 and 1970. All of the patients had initially been evaluated or treated preoperatively by the senior author; 25 were his private pa¬ tients; 18 patients were referred by colleagues for consid¬ eration of lobotomy. These patients had incapacitating obsessions and compulsions, severe hypochondriasis, unre¬ lenting depression, or chronic phobias. In all cases, long-
ten
psychotherapy by competent psychiatrists, psychotropic drugs in large doses, and courses of shock electroconvulsive therapy (ECT) or insulin in various com¬ binations had failed to produce satisfactory remission. Forty-two patients received bimedial prefrontal lobot¬ omies. One patient had a unilateral left prefrontal lobot¬ omy followed by a unilateral right prefrontal lobotomy, and later a bimedial procedure due to nonpersistent re¬ sponse to the first procedure. Within 48 hours after sur¬ gery, most patients were subjected to a program that in¬ cluded physical, recreational, and occupational therapy in addition to encouragement from staff and family. A few patients were discharged to their homes within a week and most within three weeks of the operation. The two coauthors, who had had no previous contacts with the patients, did the follow-up and evaluated the re¬ sults. Follow-up was accomplished by reviewing medical records and interviewing the patients or their relatives. A standardized questionnaire was utilized (Table 1). Thirtyfive patients were followed up to 1972: 29 with personal in¬ terviews, four with telephone interviews, and two with letter questionnaires; six patients were followed up to the time of their deaths; and two patients could not be loterm
cated. The average follow-up was 9.7 years, and the range was 1 to 25 years. Changes in patients' symptoms with respect to preoper¬ ative status were clinically evaluated at follow-up and rated on a global scale. These arbitrary ratings were de¬ rived from changes in symptomatic findings and need for inpatient or outpatient psychiatric care, including the use of psychotropic drugs. Ratings were from 0 to +4, as fol¬ lows:
symptomatic improvement, with continued need for psy¬ chotropic drugs and permanent hospitalization; +1—Minimal symptomatic improvement, with continued need for psychotropic drugs and frequent hospitalization; + 2—Fair improvement of symptoms, with continued need for psychotropic drugs and regular outpatient interviews; + 3—Symptom-free, with need for small doses of psychotropic drugs and occasional outpatient interviews; + 4—Symptom-free, with no need for psychiatric treatment.
0—No
The postoperative presence of organic brain syndromes with respect to preoperative status was also determined
Table 1.—Routine
Questionnaire
Please try to answer the following questions: 1. Age: Marital status: Number of children: Present address and living arrangements: Occupations, time spent with each employer, and reason for leaving, (if any): 2. Do you have the initiative and drive to get your work done or are you tired or do you need motivation? 3. How is your memory for past and recent events, your ability to think clearly about difficult topics, and your abil¬ ity to talk well? 4. Are you more or less inhibited, impulsive, or not so fussy in your speech and behavior since the operation? 5. How is your state of mind? Are you comfortable with your¬ self and your situation? 6. Are your feelings weaker or stronger now? Are you, for example, angered more or less easily now? Do you remain mad for long? (All these since the operation) 7. Do you have more or less self-confidence? Are you more or less friendly and out-going since the operation? 8. What Is your present religion? Are you more or less reli¬ gious since the operation? 9 Have there been any changes In your sexual activities or in your use of tobacco and alcohol? Have you been In any trouble with the law? (All since the operation) 10. What were the problems that brought you to me to begin with? Why did you decide to have surgery? Did you get re¬ lief from these problems after the surgery or do they still bother you? If so, how much do they bother you now? 11. What changes in your personality and/or mental, emo¬ tional, or physical problems have you noticed since the surgery? Were these changes for the better or for the worse? 12. Since you last saw me, have you been seen by a doctor, been in a hospital, or received any medicine or other treat¬ ment for an emotional or mental problem? 13. What do the other members of your family think about the effect of the surgery on you? How would they answer the preceding questions? 14. Did you ever have a convulsion or seizure after the sur¬ gery? Do you take any medicine to prevent convulsions? 15. Have there been any marked changes in your appetite or weight since the surgery? 16. Have you had any other medical problems since I last saw you? Did you need hospitalization or surgery for these? 17. Are there any other comments or questions that you have concerning your emotional health and the surgery? Under similar circumstances, would you have the operation again? If not, why
hot?_
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clinically. Patients were evaluated for deficits in drive, re¬ cent memory, and intellectual functioning, and for the presence of confusion or outbursts of unmanageable be¬ havior. Arbitrarily, global organic brain syndrome ratings were assigned as follows: 0, no organic brain syndrome; —1, mild; —2, moderate; —3,
with —4s requiring constant
severe; and
—4, very
severe,
supervision and —3s some su¬
pervision. These ratings, from 0 to —4, were then combined with our 0 to +4 improvement ratings to achieve a measure¬ ment of postoperative status. Admittedly, a number on a nine-point scale is a crude and subjective indicator, espe¬ cially when applied to such a delicate area as psychological functioning. However, no finer evaluative method was available to us, and we generated this scale in represent overall postoperative results.
an
attempt
to
RESULTS Neurotic Patients
Of 43 patients, 27 had obsessive-compulsive neuroses and five had hypochondriacal neuroses (Table 2). Of the neurotic patients, the obsessive-compulsive group showed an average improvement of symptoms of 3.2 and the hypochondriac patients showed an average improvement of 3.4 out of a possible 4, with none showing no improve¬ ment of symptoms. Although patients in the obsessivecompulsive group had a high average symptomatic im¬ provement, 12 of the 27 had organic brain syndromes, ten of which were mild. Of the five hypochondriac patients, only one showed a mild organic brain syndrome. It is en¬ tirely possible that the high frequency of brain syndromes in the obsessive-compulsive group is clinical artifact. Preoperatively, this group manifested a great deal of compul¬ sive ritualistic behavior; postoperatively, when this behav¬ ior subsided, these patients were the most likely to assess themselves as slowed down, tired, lazy, or apathetic. Of the 27 obsessive-compulsive neurotics, the 11 with associ¬ ated phobic symptoms (No. 17 to 27) had the best overall improvement, with greatest relief of symptoms and few¬ est organic brain syndromes after surgery.
Psychotic
Patients
The psychotic patients in our series included one manicdepressive patient and ten schizophrenic patients (Tables 2 and 3). The one manic-depressive patient (No. 33) had +4 symptomatic improvement, with no organic brain syn¬ drome after psychosurgery. The indication for operation in his case was severe, uncontrollable depression. The ten schizophrenic subjects included five schizoaffective, two chronic undifferentiated, and three paranoid. The associ¬ ated symptomatic indications for lobotomy were obsessive thoughts and fears or compulsive behavior in seven pa¬ tients, severe hypochondriasis in two, and incapacitating anxiety in one. Symptomatic improvement displayed by the schizophrenic group was primarily in the associated symptoms listed above, not in the schizophrenic symp¬ toms; however, in four patients, improvement was noted in both areas. The symptomatic remissions in the schizoaf¬ fective group, 3.2 out of a possible 4, and chronic undif¬ ferentiated types, 3.0 out of a possible 4, are comparable to those found in the neurotic categories. Of the three para-
Table 2.—Data for Neurotic Patients* Case
Years
Pre-op Diagnosis
No.,
Sex Neurotic 1, F 2, F
3, 4, 5, 6, 7, 8,
F M F F F F F F F F F F F F F F
9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, F
patients Obsessive-compulsive, dp Obsessive-compulsive, dp Obsess ive-compuls ve, dp Obsess ive-compuls ¡ve, dp Obsessive-corn puls ve, dp Obsessive-compuls ve, dp Obsessive-compuls ve, dp Obsessive-compuls ve, dp Obsessive-compuls ve, dp Obsessive-compuls ve, dp Obsessive-compuls ve, hypo Obsessive-compuls ve, hypo Obsessive-compuls ive, hypo Obsessive-compuls ive, hypo Obsessive-compu Is ve, hypo Obsessive-compuls ve, hypo Obsessive-compuls ve phob Obsessive-compuls ve phob Obsessive-compuls ve phob
20, F Obsessive-compuls ve phob 21, F Obsessive-compuls ve phob 22, F Obsessive-compuls ve phob 23, F Obsessive-compulsi ve phob 24, M Obsessive-compuls ve phob 25, F Obsessive-compuls ve phob 26, F Obsessive-compulsi ve phob 27, M Obsessive-compulsive phob 28, F Hypochondriac 29, F Hypochondriac 30, F Hypochondriac 31, F Hypochondriac 32, M Hypochondriac Psychotic patients 33, M Manic-dp; dp type SC-SA type with anxiety SC-SA type with _ob-comp behavior SC-SA with hypo¬ 36, M
34, M 35, F
37, F 38, F 39, F
40, M 41, M 42, F 43, F
Illness
Pre-opt
yr
30,30 24 15 10
10
17 20 25 23 25 10 10
46 37 33 31 50 34 42 31 41 34 51
Years of
Post-op Follow-upt 14 13 12 12
11 10 10 12
41,59 49,49 55,55
10
41 43 39 46
11 10 12 11
34 41 28
17
Improve-
Status at
ment of
Symptoms +3 +1 +3 +3 +4 +3 +3 +4 +3 +3 +3 +1 +1 +2 +3 +4 +4 +4 +4
OBS
-1
Testing and at Death
Housewife, bookkeeper Nursing home patient Housewife, supervisor Bindery foreman Housewife
-2 -It
-1* -1
Housewife, died
at 53
Housewife
Housewife Housewife Housewife
Housewife, bookkeeper Housewife, died at 59 Housewife, died at 59
hospital patient Housekeeper State
-1
Housewife -1
Housewife, clerk Landlady Housewife, game assembler
35
24
11 18
43,44
24,24,245
25
+4 +4 +4 +4 +4 +4 +3 +3 +4 +3 +3 +3 +4
Housewife, cashier
0
Housewife Housewife Housewife Minister
Housewife, cashier Housewife, receptionist
15
36
16 27
59 58 27 50 63
24
57
16
+4
Businessman; retired attorney
16
39 23
11
+4 +4
Truckd river Stockclerk
19
10
+3
Mailman
31 36
14
+3 +2 +3
23
12
+3
26,35
"
chondriacal thoughts SC-SA with hypochondriasis SC-SA with phobias SC chronic, undifferentiated with obsessive behavior SC chronic, undifferentiated with obsessive thoughts SC-PA with obsessive thoughts SC-PA with phobias SC-PA with
Age at Surgery,
12 15
13 15
49,49
+2
30 10
58,58 33
obsessive thoughts
Abbreviations used
12
-1
Laborer Housewife Nursing home patient Housewife, waitress
Housewife,
seamstress
Supervisor, died
-2
at 67
Housewife, died at 56
Nursing home Janitoress
patient
Stockroom clerk
hospital patient
-1
State
-4 -2
Housewife, died State
at 59
hospital patient
are as follows: pre-op, preoperatively; post-op, postoperatively; OBS, organic brain syndrome; dp, depressed; hypo, hypochrondriac; phob, phobic manifestations; SC, schizophrenia; SA, schizoaffective; and PA, paranoid. t Years of illness preoperatively and years of postoperative follow-up are both with reference to most recent lobotomy. *
§
At least one seizure postoperatively. Left unilateral, right unilateral, and bimedial
prefrontal
lobotomies.
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Table 3.—Average Patient Data For AH Diagnostic Groups
Preoperative Diagnosis Obsessive-compulsive (n 27) Hypochondriac (n = 5) Manic-depressive (n 1) Schizophrenic-schizoaffective type (n 5) Schizophrenic-chronic, undifferentiated type (n = 2) Schizophrenic, paranoid type (n = 3) * OBS indicates organic brain syndrome.
Age at Operation, yr
Operation
Length of Follow-Up
39.1 51.4 57 32.2 29.5 40.3
11.2 9.0 24 10.8 4.5 6.7
10.1 8.5 16 9.2 8.5 7.3
=
=
=
Table 4.—Complications After Lobotomy*
Preoperative Diagnosist
Organic Brain Syndrome
At Least One Post-
,-*-, operative —4 —3 —2 —1 0 Seizure
Obesity
Obsessive-
compulsive neurotic
(n 27) Hypochondriac =
1
1
10
15
5
10
neurotic
(n = 5) Schizophrenic
schizoaffective
type
(n = 5) Schizophrenic chronic,
undifferentiated
(n = 2) Schizophrenic paranoid type (n=3) Total patients (n
=
43)_1
1
4
13
23
9
17
As stated in the text, there were isolated instances of hemiparesis, osteomyelitis, and hydrocephalus, one of each. t The one manic-depressive patient had no organic brain syndrome and no postoperative seizure.
noid schizophrenic subjects, two showed no improvement in symptoms and one showed a +2 improvement, an aver¬ age of only +0.7. The early average at surgery found in the schizophrenic group may reflect the early onset and progressive deterioration that characterized these par¬ ticular patients. The more serious brain syndromes were seen in the schizophrenic group. However, the "organic brain syndromes" rating in this group may reflect a clini¬ cally inseparable combination of postlobotomy organic brain syndrome and schizophrenic impairments. Miscellaneous Considerations
Some miscellaneous results are not included in any table. At follow-up, 31 patients have maintained their marriages, three are still single, one is still divorced, and one is still separated. One patient has married postopera¬ tively, five have been divorced, and one is widowed. Postoperative changes in religious interest, in sexual activity, and in the use of alcohol and tobacco were also in¬ vestigated and found to be variable.
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Improvement of
Symptoms +3.2 +3.4 +4 +3.2 +3.0 +0.7
OBS* -0.5 -0.2 -0.8 -0.5 -2.3
Complications Noted in This Series An analysis of the occurrence of organic brain syn¬ dromes according to the preoperative diagnosis and major operative complications can be found in Table 4. The high
frequency of organic brain syndromes in the obsessivecompulsive and schizophrenic groups has been discussed above. Among the nine patients with more than one lobot¬ omy, six had organic brain syndromes. Nine of the 43 pa¬ tients experienced at least one seizure postoperatively. Three patients have had one seizure, three have had three seizures, one has had eight seizures, and two have had more than ten seizures. None of the six patients with three seizures or fewer is currently taking medication for seizure control. Among the nine patients with more than one lobotomy, three have had at least one seizure postop¬ eratively; one has had one, one has had three, and one has had
*
Years of Illness Before
more
than ten.
Obesity is another long-term complication. At followup, 17 patients had gained from 11.3 to 45.2 kg (25 to 99 lb). One patient has a persistent mild right-sided hemi-
paresis (see
case
No.
9). Another patient (No. 28) needed
postlobotomy for osteomyelitis of the left frontal bone button. Following a second lobotomy, one patient (No. 42) sustained a low-pressure, nonobstructive hydrocephalus that necessitated two shunt procedures. She eventually died of bilateral lobular pneumonia eight months postlobotomy after a prolonged, vegetative surgery
one
year
course.
REPORT OF CASES The following case histories illustrate typical patients from each diagnostic group. Case 9.—A 34-year-old woman, mother of three children and a high school graduate, had a history of obsessive thinking, compul¬ sive behavior, and depressive symptomatic condition of 12 years' duration. She was continually involved in cleaning her house, which she knew was inappropriate but "I just can't stop." She tried to maintain a minute schedule of work but was unable to do so. Because of her inability to "catch up," she was almost con¬ stantly depressed. At 27 years, she was referred for psychiatric treatment because of her inability to act out her obsessions for or¬ der, schedule, and details. She was so depressed, electroconvulsive therapy (ECT) was prescribed, which relieved her depression, but not her obsessive-compulsiveness. She then made a borderline ad¬ justment outside of the hospital with antidepressants and tranquilizers until she was 30, when she had the same complaints of depression and obsessive-compulsiveness. Because of her fear of pregnancy, a tubai ligation was done and ECT was again pre-
scribed for her depression. Because of the severeity of her obses¬ sive-compulsive symptoms, a prefrontal lobotomy was suggested, but she and her husband refused. She went home but could not ad¬
just with supportive psychotherapy and tranquilizers so she was readmitted to the hospital for the lobotomy. She refused again and was discharged, unimproved, after 25 days of hospitalization. She was seen supportively as an outpatient with psychotherapy and tranquilizers for three months, with no improvement. She was readmitted to the hospital and again given ECT, but with no bene¬ fit. Permission was then given for prefrontal lobotomy. Within a few days of the bimedial lobotomy, she was no longer depressed or obsessed, but unfortunately developed a right-sided hemiparesis that still persists in a mild form, which is believed to be in part hysterical. Since the operation four years ago, she has functioned well as a mother and wife and requires no medication or psycho¬ therapy. Symptom improvement is rated at + 3, and organic brain syndrome, —1. Case 23.—A 53-year-old married woman with five children is a high school graduate and former prostitute. At 29, she had the on¬ set of the thought that she might contaminate her children with her vaginal secretions. At an appointment with her obstetrician, she mentioned her fear that her vaginal secretions might contami¬ nate her children. In desperation, he told her to boil her pants. She
did this on her kitchen stove and from then on she believed her kitchen was contaminated, and she could barely function there. At this point she left her psychoanalyst and became the patient of the senior author. Her obsession was refractory to intensive psy¬ chotherapy, including care by a psychoanalyst and ECT. Diag¬ nosis was obsessive-compulsive neurosis with phobic manifesta¬ tions. Bimedial lobotomy was performed when she was 35 years old. Her follow-up included the following: three years after the op¬ eration the patient had a child without any medical or psychiatric difficulty. Since her psychosurgery, she has seen a psychiatrist less than once a year. She was hospitalized at age 50 for ten days for depression. She currently admits to periodic mild anxiety feelings for which she takes an occasional tranquilizer. She has made an excellent adjustment living with her husband and family. Symp¬ tom improvement is rated at +4, organic brain syndrome, 0. Case 28.—A 67-year-old woman who had finished two years of high school, married and mother of four children, complained bit¬ terly of problems since childhood with many parts of her body that all the operations she had undergone had not remedied. In addition, she complained of severe feelings of depression. During the years, numerous physicians had used many tranquilizers and antidepressants with negative results. She was diagnosed as hav¬ ing a hypochondriacal neurosis with some depressive features. Electroconvulsive therapy was recommended in addition to sup¬ portive psychotherapy. In the subsequent five months, because of her depression, agitation, and hypochondriasis, she was admitted to the hospital four times for a total of 71 days and four courses of ECT. During the second hospitalization, lobotomy was recommended but refused by patient and family. At the fifth admission, the rec¬ ommendation for bimedial lobotomy was accepted. Postopera¬ tively, she was not hypochondriacal. One year postoperatively, she had surgery for osteomyelitis of the frontal bone button. At fol¬ low-up eight years postoperatively, she has a few somatic com¬ plaints for which she takes aspirin. She is quite comfortable and functioning very well as housewife and mother. Symptom im¬ provement rating is +4, organic brain syndrome, 0. Case 35.—A 27-year-old, single woman, with two years of col¬ lege, was first hospitalized at age 17 for schizoid behavior and sui¬ cidal gestures. She developed auditory and visual hallucinations and a compulsion to hurt or injure other young women or herself. She did not improve with huge doses of tranquilizers, intensive ECT, and insulin coma treatments. Lobotomy was recommended, but permission was not granted. She was referred to a private
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psychiatrie hospital
in another
city, where she stayed for four
years, most of the time in seclusion. Her behavior became so de¬ structive her family was advised to take her elsewhere. At this time the recommendation for lobotomy was accepted. The diag¬ nosis of schizophrenia, schizoaffective type, with compulsive be¬ havior was made. Bimedial lobotomy was performed at age 33.
The first three months postoperatively, she had mild obsessive thinking without compulsive acting out or destructive behavior. In the first postoperative year, she had a poor employment and scho¬ lastic record and was seen for supportive psychotherapy and med¬ ication management. Subsequently, she spent one year at a reha¬ bilitation workshop. For the last 18 months she has maintained an excellent employment record as a stock clerk. She lives in a girls' dormitory and requires neither medication nor psychiatric sup¬ port. Symptom improvement is rated at +4, organic brain syn¬ drome, 0. Case 40.—A 35-year-old single man had two years of college. At the age of 19, his family noted him to be peculiar and withdrawn. He spent much of his time daydreaming about being either a bum or a prefessional wrestler. He became agitated and depressed be¬ he was unable to fulfill his obsessive desire to tickle and massage the feet of young women. He would approach girls on the street and ask them if he could tickle their feet. Some would agree for a fee; others would just walk away; and some would notify the police. He was arrested a few times. He showed no response to weekly psychotherapy, tranquilizers, or ECT. A diagnosis of schiz¬ cause
ophrenia, chronic, undifferentiated type with obsessive thoughts was made. Bimedial lobotomy was performed at age 23 years. For
short time after surgery, his obsession was still present, but he did not feel compelled to act it out. He was seen for supportive psychotherapy for a time. He has required no psychiatric care or medication since the age of 28. For the last five years, he has been steadily employed as a stockroom clerk. He is now free of his sex¬ ual obsession but still has other mild obsessive symptoms. Symp¬ tom change is rated as +3, organic brain syndrome, 0. Case 43.—A 45-year-old divorced woman, a high school graduate with three children, had periods of episodic agitation, paranoid thinking, withdrawal, and sexual fantasy since age 26. At the age of 30 years, she had multiple obsessive thoughts about hurting her children or herself, extreme agitation, and delusions of demonic possession. She did not improve with psychotherapy, large doses of tranquilizers, and numerous trials of ECT. The diagnosis made was schizophrenia, paranoid type, with obsessive thoughts. Bime¬ dial lobotomy was performed at age 33. At age 37, after her ninth admission for schizophrenic reaction with suicidal gestures and assaultive behavior, she was committed to a state hospital. She has continued to be agitated, assaultive, and extremely hypo¬ chondriacal. She has spent most of the last eight years in the state hospital. Symptom improvement was rated at 0, organic brain a
syndrome,
—2.
COMMENT
This study supports the findings of several of the stud¬ ies previously mentioned. We find, as did Greenblatt,1 that patients with a preoperative diagnosis of hypochondriasis and obsessive-compulsive neurosis had the best prognosis, while those with schizophrenia, especially paranoid schizo¬ phrenia, had a poorer prognosis. Our data are in accord with Baker et al8 in that obsessive-compulsive neurotic pa¬ tients with phobic symptoms responded better than classic obsessive-compulsive neurotic patients. A favorable re¬ sponse found especially in patients with obsessive or com¬ pulsive symptoms was also noted by Sargant,4 Holden et al,7 and Pippard.2 The tendency for schizophrenic patients to do less well is cited by an editorial in the British Medi-
as well as by Greenblatt.3 Although our is sample small, we disagree with Pippard2 in his assertion that lobotomy is indicated in treatment of paranoid schiz¬
cal Journal10
ophrenia. Sykes and Tredgold" and
Post et al5 concluded that pa¬ tients who had been ill for more than five or two years, re¬ spectively, before lobotomy had an unfavorable prognosis. Our series, in contrast, showed no particular correlation between duration of illness and outcome. In fact, the pa¬ tient who, at the time of surgery, had been ill for the long¬ est time (27 years), showed a +4 improvement. While Sargant4 and Post et al5 state that youth is a less favorable prognostic indicator, our study shows no par¬ ticular correlation between successful results and the age of the patient at the time of surgery. We found examples of success in all age categories from the late teens to the seventh decade. The supportive social environment6·11·12 seen so often in
private patient population is, we suggest, an important factor in our relatively high rate of success compared with series from state hospitals. Eighty-one percent of the pa¬ tients in our series are symptom-free, with long-term fol¬ low-up ratings of +3 or +4. In terms of the most frequently noted complication of a
the
operation, our 21% incidence of seizures compared closely with the 26% cited by Freeman.13 Weight gains in our patients resembled those enumerated by Partridge.16 Because this report was based on patients referred by most
the senior author, it is relevant to comment on our belief that those physicians who do include the option for sur¬ gery among their therapeutic methods should not recom¬ mend it lightly. The preoperative condition of the patient, the nature of the persisting incapacitation, and the rela¬ tive efficacy of the entire range of alternative treatments must be carefully weighed against the assessment of the relative efficacy of surgery and risk of side-effects and thoroughly discussed. Our view of the literature is that there are some relevant data that speak to the issue of in¬ dications, to the importance of psychosocial resources, and to the least and most favorable psychiatric conditions, should the surgical treatment option be considered. In our own opinion, for example, we, as Pippard,2 would not con¬ sider surgery as a treatment of last resort for obsessivecompulsive neurotic patients with incapacitating phobic symptoms, since such patients rarely respond to alterna¬ tive treatments. Whatever the deliberate position ulti¬ mately taken by the field with respect to these indications and procedures, these and other such data that may be available should be of some utility in the ongoing broadly based process of assessing therapeutic efficacy. This investigation was supported by the Marian Foundation Mary's Hospital, Minneapolis. Martha Ross assisted in the preparation of the manuscript.
of St.
In accepting the above article, the editors endorse only the need for evaluated data in this area and the necessity for thorough and dispassionate review of the problem in the context of clinical re¬ search, science, and concern for the individual patient. The report
could have been improved by various methodological refinements and the use ofevaluators totally outside the treatment system, but
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nevertheless represents a sincere effort at clinical evaluation of available data that has recently been all too infrequent. Currently, the ethical and scientific questions raised by psycho¬ surgery generally, as well as its use in major mental illnesses, are under intensive review by the National Commission for Protec¬ tion of Human Subjects of Biomédical and Behavioral Research. Recent reviews conducted by institutes of the Department of Health, Education, and Welfare (HEW) have emphasized both the paucity of information and the necessity for fundamental scien¬ tific animal study of brain behavior interrelationship, as well as social and ethical study. Some sense of the relevant considerations can be found in Psychosurgery: Perspective on a Current Issue by Bertram S. Brown, Louis A. Wienckowski, and Lyle W. Bivens (HEWPublications, No. [HSM] 73-9119,1973). An interesting dis¬ cussion by Judith P. Swazey, PhD, associate professor in the De¬ partment of Sociomedical Sciences at Boston University School of Medicine, appears in Frontiers of Psychiatry (5:1, 2, 11,1975). Dr. Swazey, with Rennee C. Fox, PhD, has examined the range of clin¬ ical, scientific, and ethical issues involved in transplantation
(The Courage to Fail, Chicago, University of Chicago Press, 197k),
and Swazey offers some more recent perspective on issues relating to clinical reality and ethical choice with respect to psychosur¬ gery. Views of the Society for Neurosciences are presented in an editorial by Theodore Bullock (Arch Neurol 32:73-71,, 1975). Ethi¬ cal, social, and legal policy issues are surveyed in a forthcoming volume, Operating on the Mind: The Psychosurgery Conflict (W. Gaylin, R. Neville, J. Meister [eds], New York, Basic Books Ine, to be published), in which Herbert G. Vaughan, Jr, MD, provides a brilliant historical overview of the experimental basis for surgical procedures. Finally, a good scientific, historical background that can provide the reader with some of the necessary information to form his own judgments about this complex area may be found in a book by Elliot Valenstein, PhD, Brain Control: A Critical Exami¬ nation of Brain Stimulation and Psychosurgery (New York, John Wiley & Sons Ine, 1973).-Ed.
References 1. Miller A: The lobotomy patient\p=m-\Adecade later: A follow-up study of a research project started in 1948. Can Med Assoc J 96:1095-1103, 1967. 2. Pippard J: Leucotomy in Britain today. Br J Psychiatry 108:249-255, 1962. 3. Greenblatt M: Relation between history, personality and family pattern and behavioral responses after frontal lobe surgery. Am J Psychiatry 116:193-202, 1959. 4. Sargant W: The present indications for leucotomy. Lancet 1:1197-1200, 1962. 5. Post F, Rees WL, Schurr PH: An evaluation of bimedial leucotomy. Br J Psychiatry 114:1223-1246, 1968. 6. Sykes MK, Tredgold RF: Restricted orbital undercutting: A study of its effects on 350 patients over the ten years 1951-1960. Br J Psychiatry 110:609-640, 1964. 7. Holden JMC, Itel TM, Hofstatter L: Prefrontal lobotomy: Stepping stone or pitfall? Am J Psychiatry 127:591-598, 1970. 8. Baker EFW, Young MP, Gauld DM, et al: A new look at bimedial prefrontal leukotomy. Can Med Assoc J 102:37-41, 1970. 9. Tucker WI: Indications for modified leucotomy. Bull Lahey Clin Found 15:131-139, 1966. 10. Modified prefrontal leucotomy, editorial. Br Med J 3:595-596, 1971. 11. Freeman W: Frontal lobotomy 1936-1956: A follow-up study of 3,000 patients from 1 to 20 years. Am J Psychiatry 113:877-886, 1957. 12. Shobe FO, Gildea MC-L: Long-term follow-up of selected lobotomized private patients. JAMA 206:327-332, 1968. 13. Freeman W: Lobotomy and epilepsy: A study of 1,000 patients. Neurology 3:479-494, 1953. 14. Logothetis J: A long-term evaluation of convulsive seizures following prefrontal lobotomy. J Nerv Ment Dis 146:71-79, 1968. 15. Scherer IW, Klett CJ, Winne JF: Psychological changes over a fiveyear period following bilateral prefrontal lobotomy. J Consult Clin Psychol 21:291-295, 1957. 16. Partridge M: Complications and sequelae, in Pre-Frontal Leucotomy: A Survey of 300 Cases Personally Followed Over lH-3 Years. Oxford, En¬ gland, Blackwell Scientific Publications, 1950, 31.
