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Stereotactic Limbic Leucotomy-A Follow-Up Study of Thirty Patients

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Stereotactic Limbic Leucotomy-A Follow-Up Study of Thirty Patients Postgraduate Medical Journal (December 1973) 49, 865-882. Postgrad Med J: first published as 10.1136/pgmj.49.578.865 on 1 December 1973. Downloaded from Stereotactic limbic leucotomy-a follow-up study of thirty patients DESMOND KELLY NITA MITCHELL-HEGGS M.D., M.R.C.P., M.R.C.Psych. M.B., B.S. St George's Hospital Medical School, Atkinson Morley's Hospital, 31 Copse Hill, Wimbledon, London, S. W.20 Summary 17 months following surgery. An additional, inde- This prospective study reports the results of stereotac- pendent clinical assessment of the patients has been tic limbic leucotomy at a mean of 17 months following made by Dr Maurice Partridge, who took no part in surgery. Clinical improvement had occurred in the selection or treatment of the patients. Dr twenty-four (80%y) of the patients, fifteen (50/0) of Partridge has a very wide experience of the clinical them being symptom free or much improved. Fourteen evaluation of psychosurgery (Partridge, 1950) and of sixteen patients suffering from obsessional neurosis more particularly of rostral leucotomy and was able, were improved, as were five of seven with chronic therefore, to draw on this experience when comparing anxiety and the degree of improvement at 17 months the results of the more extensive 'free-hand' pro- was superior to that at 6 weeks. Psychometric scores cedures with those of the present, much more limi- of anxiety, obsessions and neuroticism were all signi- ted, stereotactic operation. ficantly reduced at 17 months. The mean depression scores were also significantly reduced and this result Method Protected by copyright. was superior to that reported in a previous study of The patients 'free-hand' operations. Stereotactic operations were performed by Mr Adverse effects were not a problem following limbic Alan Richardson (1973), at Atkinson Morley's leucotomy. Emotional blunting, disinhibition, post- Hospital, on forty consecutive patients between operative epilepsy and excessive weight gain were not February 1970 and January 1972. Of these patients, encountered, and intelligence was unaffected by the twenty-nine have, to date, been followed up at operation. Limbic leucotomy is a much more limited between 1 and 2 years post-operatively. It was and precise procedure than older 'free-hand' opera- initially proposed that all patients should be followed tions which we have studied, but its therapeutic effects up exactly a year post-operatively; due, however, to are comparable and in obsessional neurosis, superior. the great distance of many of their homes from the hospital, it was not always possible to arrange this. THE preliminary results of stereotactic limbic leuco- An additional patient, who died, probably by tomy in the first forty patients who underwent the suicide, 14 weeks after surgery, is also included in operation were discussed in a previous paper (Kelly this follow-up. http://pmj.bmj.com/ et al., 1973c). The patients were assessed clinically, There were eleven men and nineteen women and psychologically and physiologically pre- and 6 weeks their mean ages were 34A4 (± 11 3) years and 34 0 post-operatively and the results, at that stage, were (±8 2) years, respectively. The patients' mean dura- most encouraging. Since that time, twenty-nine of tion of symptoms was 12 years and the diagnostic these patients have been followed up at between 1 categories were as follows: obsessional neurosis and 2 years post-operatively (mean 17 months) and (300 3, Registrar General, 1968), sixteen patients; more than seventy patients have been examined chronic anxiety (300 0, 300 2), seven; depression before surgery and at 6 weeks. (296-2), one; schizophrenia or schizo-affective dis- on September 27, 2021 by guest. The physiological principles underlying limbic order (295-6; 295-7), three; depersonalization with leucotomy and the operative technique employed depression (300-6; 300 4), one; anorexia nervosa have been described in a series ofpapers (Kelly, 1972; (306 5), one; personality disorder with phobic anxiety Sargant & Slater, 1972; Kelly, Richardson & (301-6, 300 2), one. Mitchell-Heggs, 1973b; Richardson, 1973; Kelly, The patients were all severely ill and had failed to 1973). The present paper describes the clinical out- respond satisfactorily to every other form of treat- come ofthose patients who have been followed up for ment. In most cases the quality of their lives had over a year. The results have been assessed clinically reached an intolerably low level; they were grossly (by the authors), psychologically and physiologically incapacitated by their symptoms, their family before operation, at 6 weeks and at a mean interval of relationships had been placed under enormous 866 Desmond Kelly and Nita Mitchell-Heggs Postgrad Med J: first published as 10.1136/pgmj.49.578.865 on 1 December 1973. Downloaded from strain and they were unable to work or carry out past 4 years it has been run on therapeutic community day-to-day tasks (see clinical case histories). Their lines. All patients take part in general ward activities mean number of previous hospital admissions was both before and after operation. four, and six of the thirty patients had made a deter- During the week prior to surgery the patients were mined suicidal attempt. All but three had received at examined clinically by D.K. and N.M-H. and, in least one course of ECT and sixteen had undergone addition, seen entirely independently by Dr Part- one or more courses of continuous narcosis treat- ridge. A close relative of the patient was interviewed, ment, combined with antidepressants and ECT unless this was not possible, and if a patient had been (Walter, Mitchell-Heggs & Sargant, 1972). Twenty- in a mental hospital for a prolonged period, a one had received formal psychotherapy or psycho- nurse who knew him well was also questioned. The analysis, but this, as opposed to superficial psycho- patient was presented at a ward round, where his case therapy, had not been undertaken in all of the was discussed with those members of staff who might patients prior to surgery, as in England, unlike be concerned in his care; these included junior medi- America, it is not considered appropriate therapy cal staff, nurses, occupational therapists and psychia- for all types of psychiatric disorder, the results in tric social workers. Medical students and occasion- severe intractable obsessional neurosis, schizophrenia ally clinical psychologists were also present. and endogenous depression generally being un- Following the psychiatric assessment and selection satisfactory. for psychosurgery, the patient was seen at a joint Previous leucotomy operations of a more exten- consultation by Mr Alan Richardson and the sive type (Modified pre-frontal: Harvey Jackson, authors. The exact siting of the lesions was discussed 1954; Rostral: McKissock, 1959) had been carried and decided, taking into account the patient's out on seven patients, of whom five had undergone individual symptomatology and past psychosurgical more than one previous operation. history. A number of patients were selected for operation Selection ofpatients who had poor pre-morbid personalities and others Protected by copyright. The patients were, in general, referred to D.K., by were selected whose illnesses carried a very poor other consultant psychiatrists, for a second opinion prognosis, even with psychosurgery. The surgical regarding their suitability for leucotomy. From St risks of the operation were considered to be mini- Thomas' Hospital, Dr William Sargent had referred mal, as was the possibility of adverse personality fourteen patients and Dr John Pollitt, two; from the change; it was considered, therefore, that the chances National Hospital, Queen Square, Dr Pratt referred of the operation making the patient worse were very two; from St George's, Professor Crisp referred one, small indeed and, in view of this, a small number of Dr de Mare, one and Dr Priest, one. Eight further institutionalized poor prognosis patients were patients were each referred by a different consultant offered the operation. In these, the prospect of im- psychiatrist and one patient, who had undergone a provement was less than 50%O and both the patients great deal of previous psychiatric treatment, had and their relatives were made aware of this. been referred to D.K. by her general practitioner for a further opinion regarding management. Psychological assessment The following criteria were used in assessing the During the week before surgery psychological and http://pmj.bmj.com/ patient's suitability for psychosurgery: (1) the sev- physiological measurements were made. Anxiety erity of the illness, which in most cases was totally was assessed by the Taylor Scale of Manifest incapacitating and intolerable; (2) the chronicity of Anxiety (Taylor, 1953), the Hamilton Anxiety Scale the condition; (3) failure to respond to other appro- (Hamilton, 1959) and the Free Floating Anxiety, priate forms of treatment; (4) absence of contra- Phobic Anxiety and Somatic Anxiety scales of the indications, and (5) the patient's full agreement to Middlesex Hospital Questionnaire (MHQ; Crown the operation. & Crisp, 1966). Some of the patients were admitted to the psy- Depression was assessed by the Beck (Beck et al., on September 27, 2021 by guest. chiatric in-patient unit for further assessment before 1961) and Hamilton (1967) Depression Scales, and a final decision was made. Others were initially re- the Depression Scale of the MHQ. jected for surgery and only accepted after additional Obsessions
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