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 were measured by the Leyton Obses- in-patient therapy had failed to bring about im- sional Inventory (LOI; Cooper, 1970), which sub- provement (case history 4). jectively assesses obsessional symptoms and traits Most of the patients were admitted to the psychia- by means of a card-sorting procedure. Feelings of tric unit approximately 1 week before operation. resistance and the degree of interference produced by The unit, containing the professorial unit of St obsessions are also quantified and questions from the George's Hospital, consists of a male and a female Cornell Health Questionnaire (Brodman, Deutchen- ward, with a total of forty-two beds, and for the berger & Wolff, 1956), which provide an estimate of Stereotactic limbic leucotomy 867 Postgrad Med J: first published as 10.1136/pgmj.49.578.865 on 1 December 1973. Downloaded from the subject's general psychiatric complaint level, are period, clinical ratings were made by D.K. and also included. The LOI was a later addition, and N.M-H. and these were repeated at between 1 and has, to date, been completed by twenty-one patients 2 years post-operatively (mean 17 months), when Dr before operation and at 6 weeks, and by only two of Maurice Partridge also independently assessed the those who have been assessed at follow-up (case his- patients. The scale used had been employed for tory 7). The obsessional scale of the MHQ was also assessing mainly 'free-hand' operations ofthe RostraL used. and Harvey Jackson type (Kelly, Walter & Sargant, Neuroticism and extraversion were assessed by 1966; Kelly, Walter, Mitchell-Heggs & Sargant, the Maudsley Personality Inventory (MPI; Eysenck, 1972) and was originally devised by Pippard (1955): 1959) and hysterical symptoms and traits by the I, symptom free; II, much improved (minimal re- MHQ. sidual symptoms); III, improved (definite improve- Intelligence was assessed by the Wechsler Adult ment, but significant residual symptoms); IV, not Intelligence Scale (WAIS; Wechsler, 1955), which improved; and V, worse. The reports of nursing was administered by an experienced clinical psy- staff, occupational therapists and relatives were all chologist, Miss Juliet Greenup. The verbal sub- taken into account in these ratings. scales are: information, comprehension, arithmetic, The Wechsler Adult Intelligence Scale was again similarities, digit span, and vocabulary. The per- administered by the psychologist 6 weeks after the formance sub-scales are: digit symbol, picture operation and all the psychological scales and phy- completion, block design, picture arrangement and siological measurements which were made pre- object assembly. These yield verbal, performance and operatively were repeated 6 weeks and 17 months full scale intelligence quotients. post-operatively. Physiological assessment and observer and self-ratings of anxiety and depression Before the physiological recordings were made, all The operations medication, including night sedation when possible, The operation slowly evolved over the period ofthe Protected by copyright. was discontinued for at least 24 hr. Forearm blood study. Initially comprised of a few lesions, which flow was measured in the supine position, using a were insufficient to produce substantial benefit, it mercury-in-rubber strain-gauge on the left arm, and gradually developed into a more standardized opera- the heart rate was recorded on a pulse meter, using a tion (Kelly et al., 1973b). The present operation photo-electric transducer on the right index finger usually consists of three lesions in the lower medial (Kelly, 1967; Kelly, Pik & Chen, 1973a). Forearm quadrant of the frontal lobe and two pairs of cingu- blood flow was recorded at 1-min intervals late lesions (Richardson, 1973). Its purpose is two- during a resting period of 15 min, and then during a fold: (1) to interrupt some connections between the 21 min period of stressful mental arithmetic. The frontal cortex and the limbic system in the lower blood pressure was taken from the right arm at the medial quadrant of the frontal lobe and, (2) to make commencement of the resting period, and again 10 lesions in the cingulate region in one of the main min later. It was also taken during the last j- limbic circuits, the Papez Circuit (1937). Important min of the mental arithmetic. The mean of the fronto-limbic connections also run caudalwards in three lowest forearm blood flows, the corresponding the cingulum bundle (Nauta, 1973) and are, there- http://pmj.bmj.com/ heart rates and the lower of the two resting blood fore, also interrupted by lesions at this site. Electrical pressure readings were designated 'basal' values, as stimulation of the target areas prior to lesion- in previous assessments of patients before and after making is employed and the plotted target site may leucotomy, and the peak measurements during be moved a few millimetres until adequate physio- mental arithmetic were called 'stress' values. logical responses are obtained (Kelly, 1972). Using a self-rating scale, with zero corresponding Laitinen (1972) reported favourable results from to complete relaxation and '10' to maximal tension lesions in the genu of the corpus callosum, with an and anxiety, the patient was asked to rate the degree immediate reduction in anxiety. In view of this, on September 27, 2021 by guest. of anxiety he had experienced during the resting genu lesions have occasionally been added to the period andduringthe mental arithmetic (self-ratings). standard configuration of lesions. The distribution of Observer ratings were made prior to this, using the lesions in individual patients has, therefore, varied same scale. Observer and self-ratings of depression considerably, especially during the early part of the were made on a similar scale, with zero correspond- study, when the operation was evolving. The follow- ing to complete lack of depression and '10' to maxi- ing combinations of lesions were made in the mal depression. thirty patients: Post-operative assessment (a) in seven patients, two or three bilateral lesions Following a 6 week post-operative rehabilitation were made in the rostral or anterior cingulum; 868 Desmond Kelly and Nita Mitchell-Heggs Postgrad Med J: first published as 10.1136/pgmj.49.578.865 on 1 December 1973. Downloaded from

(b) three patients received two, three or four gradual, but, with his growing confidence, the patient bilateral lesions in the lower medial quadrant can be increasingly pressurized, and behaviour of the frontal lobe; modification which was totally unacceptable to him (c) in two patients, two bilateral lesions were made pre-operatively, now becomes possible and rapidly in the lower medial quadrant; in one of them yields results. an additional bilateral lesion was made in the A patient who has had obsessions involving wash- rostral cingulum and in the other two bilateral ing and bathing might, for example, be timed in the lesions were made in the rostral and two in the bath and his progress noted on a chart; he would be anterior cingulum; encouraged to spend 5 min less each day in the (d) seventeen patients received the later more bathroom, until he no longer needed to spend an usual combination of lesions, with two, three excessive time. During this period of anxiety- or very rarely four bilateral lesions in the provoking re-training a minor tranquillizer is some- lower medial quadrant and two bilateral times prescribed. lesions in the anterior cingulum (Sites 1, 2, 3, 4, Patients suffering from phobic anxiety may re- 5; Richardson, 1973); quire treatment by desensitization following surgery, (e) in one patient three bilateral lesions were but those suffering from chronic 'free-floating' made in the lower medial quadrant, three anxiety, depression and schizophrenia may not re- bilateral lesions in the anterior cingulum and quire a specific rehabilitation programme. It is often one bilateral lesion in the genu of the corpus necessary, however, to rehabilitate them with regard callosum (case history 2). to day-to-day tasks and such activities as cooking, typing, gardening and housework are undertaken in Psychiatric rehabilitation the occupational therapy department. Before stereotactic limbic leucotomy, patients and In schizophrenics, it is usually necessary to re- their relatives are warned that they should not commence phenothiazines following psychosurgery. expect a dramatic improvement in their symptoms Generally, however, they need these in smaller doses Protected by copyright. immediately following surgery. They are told that than pre-operatively, as the operation is designed to they may notice an immediate reduction in tension reduce the tension and fear which is so often associa- and, possibly, depression, but that most of their ted with their delusions. symptoms will regress gradually, with improvement After 3-4 weeks patients generally go home for a reaching its maximum after a year or even longer. trial week-end. At this stage they and their relatives Following surgery, the patient spends the first are warned that they should do very little initially, few post-operative days in the neuro-surgical ward but during subsequent visits they are advised to and then after his bandages have been removed, attempt increasingly 'normal' modes of behaviour, returns to the psychiatric unit. until they are able to function outside the hospital Although the exact contribution of the rehabilita- and can be discharged. tion period to the patient's progress is not entirely certain, it is in most cases considered useful, and in a Statistical analysis number is essential. Chronically sick patients will A statistical comparison, using Student's 't' test, usually, because of their illnesses, have developed was made between the pre-operative psychometric http://pmj.bmj.com/ abnormal patterns of behaviour, which affect their and physiological data and that at 17 months. Similar work, their social life and their family relationships. statistical comparisons were also made between the Surgery alone cannot automatically change this pre-operative and 6 weeks post-operative results on state of affairs and patients will often require simple the WAIS and the LOI. support and advice following their operations. In some cases, where problems and long-standing con- Results flicts are more serious, psychotherapy is indicated. The clinical, psychological and physiological Most patients spend a minimum of 6 weeks in the results at 6 weeks, on the first forty patients who on September 27, 2021 by guest. psychiatric unit following surgery. During this time a underwent limbic leucotomy, have been reported special programme is set up to fit the needs of the elsewhere (Kelly et al., 1973c). individual patient. If, for example, the operation has In the present paper, the results on thirty of these been performed for obsessional neurosis, the pro- patients at 6 weeks and at a mean of 17 months gramme is modelled on behaviour therapy lines, (range 12-24 months) post-operatively are reported. so that the patient is gradually assisted in abandon- ing his obsessions. Some obsessional patients be- Psychological measurements come anxious when first encouraged to give up The mean values on the psychometric scales before, patterns of behaviour which they have followed for 6 weeks and 17 months after limbic leucotomy are many years. Progress is, therefore, necessarily shown in Table 1. The patients were significantly Stereotactic limbic leucotomy 869 Postgrad Med J: first published as 10.1136/pgmj.49.578.865 on 1 December 1973. Downloaded from

TABLE 1. The mean psychometric values pre-, 6 weeks five were unable to complete the WAIS; four be- and 17 months post-limbic leucotomy (n=29) cause they came from abroad and their comprehen- p sion of English was too poor, and one because she (pre- vs was too agitated. A further five did not complete it Pre- 6 weeks 17 months 17 months) because of the psychologist's leave at one or other MPI time of assessment. Neuroticism 31-66 23-10 23-03 0-001 There was no fall-off in intelligence following Extraversion 13-76 15-07 13-86 NS* Depression limbic leucotomy, as evidenced by an increase in the Beck 24-38 18-00 16-38 0-001 mean full-scale, verbal and performance scores on Hamilton 20-36 9-68 11 86 0.001 the WAIS 6 weeks post-operatively (Table 3). The Anxiety practice effect, which is seen when such tests are Taylor 30 90 23-28 22-28 0 001 in some of Hamilton 21 03 11134 12 18 0 001 repeated, probably explains the increase MHQ the scores post-operatively. Anxiety 1110 955 7-83 0.001 Selfand observer ratings of depression and anxiety Phobic 6-55 5 48 5 79 NS (Table 4). Both the self and observer ratings of Obsessional 11-93 10-38 8-90 0 001 at 17 Somatic 7 45 5-10 3-86 0-001 depression had fallen significantly months Depressive 10-10 7-62 7-17 0-001 (P < 001), as had the 'basal' anxiety observer rating Hysteric 5-52 4 97 4-76 0 05 (P < OO1). The 'basal' anxiety self rating and the 'stress' self and observer anxiety ratings, though less *NS, not significant. at 17 months, were not reduced to a significant degree. less neurotic 17 months post-operatively, as evi- denced by a total fall of 8-6 points on the Neuroticism TABLE 2. Leyton Obsessional Inventory scores pre- and Score of the MPI 0 were also 6 weeks post-limbic leucotomy (n=21). Mean scores for (P < 001); they slightly normal men and women given for comparison (Cooper, more extraverted, but not significantly so. 1970) Protected by copyright. The mean values on the Hamilton, Beck and MHQ depression scales were all significantly less 17 Normal Normal months following surgery, at the P < 0-001 level. women men A highly significant decrease in anxiety was shown Pre- 6 weeks P (n=60) (n=41) on the Taylor and Hamilton Scales and on the Symptom 26X00 17-19 0-01 11-4 8-7 anxiety scale of the MHQ (P<0K001). Seventeen Traits 12-00 9-38 0-01 5 1 5-1 months after operation the obsessional, and somatic Cornell 24-33 16-10 0-01 4-9 1-8 scores on the MHQ were all highly significantly de- (Sections M-R) creased (P < 0 001); the hysteric scale was also Resistance 40 90 24-30 0 05 7-3 4-4 significantly less at the P < 0 05 level, but the reduc- Interference 44 50 21-95 0-01 3-8 3-6 tion in the phobic scores was not statistically signi- ficant. TABLE 3. The mean scores on the Wechsler Adult Intel- The Leyton Obsessional Inventory. This psycho- ligence Scale pre- and 6 weeks post-limbic leucotomy (n= 30) metric test, a later addition to the psychological http://pmj.bmj.com/ measurements, has, to date, been completed by Differ- twenty-one patients before operation and at 6 weeks. Pre- Post- ence P Two patients have, in addition, completed it at a year (see results in case history 7). The mean scores Verbal IQ 107-7 108-3 +0-6 NS* for the twenty-one patients are shown in Table 2, Performance IQ 98-3 102-2 +3-9 0-01 and the scores for 'normal' men and women are Full scale IQ 103 9 106-0 +2-1 0 05 Verbal sub-scales shown for comparison (Cooper, 1970). The patients' Information 10-2 10-6 +0 4 0 05 scores at 6 weeks showed that they had significantly Comprehension 13-4 13-3 -0-1 NS on September 27, 2021 by guest. fewer obsessional symptoms and traits than pre- Arithmetic 10-2 10-8 +0-6 NS operatively (P < 0 01). The degree of resistance they Similarities 11 1 11-0 -01 NS experienced (P < 0 05) and the level of interference Digit span 10-4 10-3 -0-1 NS produced their Vocabulary 12-2 12-4 +0-2 NS by symptoms (P< 0-01) were also Performance sub-scales significantly reduced. Their overall psychiatric Digit symbol 7 9 8 5 +0-6 NS symptom score was also significantly reduced, as Picture completion 10-0 10-5 +0 5 NS evidenced by a fall in their Cornell Questionnaire Block design 9-7 10-5 +0-8 0-01 (Sections M-R) mean score (P < 0 01). Picture arrangement 8-3 9-2 +0 9 0-05 Wechsler Adult Intelligence Scale. Of the first Object assembly 9 3 9.9 +0-6 NS forty patients who underwent limbic leucotomy *NS, not significant. 870 Desmond Kelly and Nita Mitchell-Heggs Postgrad Med J: first published as 10.1136/pgmj.49.578.865 on 1 December 1973. Downloaded from

TABLE 4. The mean 'basal' and 'stress' physiological Agreement occurred between D.K. and N.M-H. in values and psychological ratings pre-, 6 weeks and 17 months all but one case at 6 weeks and one at 17 months. post-limbic leucotomy (n=28) Of the twenty-four patients seen by Dr Partridge P at 17 months, in all but three cases his rating was in (pre- vs agreement with those of both of the other two asses- Pre- 6 weeks 17 months 17 months) sors and in two of these, his rating was one grade 'Basal' more favourable than those of the others. In one Forearm further Dr D.K. a blood flow 3-96 2-78 3-57 NS* case, Partridge and both rated Heart rate 83-43 74-29 76-57 0-01 patient as unchanged (Grade IV), while N.M-H. Systolic BP 128-88 118-06 121-17 0-05 rated her as marginally worse (Grade V; vide infra). Diastolic BP 83-18 76-12 83-23 NS In all cases where disparity occurred between the Anxiety OR 4-25 2-93 3-18 0-01 assessors' ratings the least favourable rating is Anxiety SR 4-21 3-46 3 39 NS shown on Table 5. 'Stress' Forearm Three patients were rated as worse by at least one blood flow 8-46 6-70 7 00 NS assessor 17 months after the operation. One of these, Heart rate 96-32 87-11 89-54 0-01 a female suffering from very severe obsessional Systolic BP 135-50 127-94 126-87 NS neurosis in a very inadequate (case his- Diastolic BP 88-00 83-06 86-56 NS personality Anxiety OR 6 07 5 50 5-67 NS tory 5), had noticed no worsening of her symptoms, Anxiety SR 6-64 6-50 6-61 NS but had felt increasingly depressed following the Depression break-up of her marriage and had made four serious Observer rating 4 50 3-89 3-11 0-01 suicidal attempts. Another female patient had suf- Self rating 5-21 3-82 3-71 0-01 fered for over 4 years from severe depersonalization *NS, not significant. and depression. Ten months following limbic leucotomy she had shown no improvement in her

Physiological measurements condition and was, thus, referred to another hospital,Protected by copyright. The mean 'basal' and 'stress' physiological scores where a stereotactic tractotomy was performed. before and after operation are shown in Table 4. When seen at follow-up a year later her symptoms The 'basal' and 'stress' heart rates were both signi- were unchanged. Her feelings of despair at the failure ficantly reduced at 17 months (P < 0 01), as was the of surgery to improve her mental state caused 'basal' systolic blood-pressure (P < 0 05). The 'basal' N.M-H. to rate her as worse (subsequent to the time and 'stress' forearm blood flow mean scores and the of follow-up she has, in fact, improved considerably). 'stress' systolic blood-pressure were all reduced 17 A further patient, who had suffered from obses- months after the operation, but the differences failed sional neurosis, died, possibly by suicide, 14 weeks to reach a statistically significant level. after surgery. He is, thus, included in the follow-up, with a clinical rating of worse. Clinical ratings Of the thirty patients, 77°4 were rated as clinically The clinical ratings, on the 5 point scale, 6 weeks improved 6 weeks after surgery and 80%. at 17 and 17 months after limbic leucotomy are shown, by months. Nine (30%O) patients were symptom free diagnostic category, in Table 5. or much improved (minimal residual symptoms) at 6 http://pmj.bmj.com/

TABLE 5. Clinical ratings by diagnostic category 6 weeks and 17 months post-limbic leucotomy (n = 30) 6 weeks 17 months % of total % of total n I* lIt lilt IV§ V** improved I II III IV V improved Obsessional neurosis 16 1 6 7 2 - 87 5 6 3 - 2 87 on September 27, 2021 by guest. Depression 1 ------Chronic anxiety 7 - 1 3 3 - 57 1 - 4 2 - 71 Schizophrenia 3 - - 3 - - - - 2 - l -- - Depersonalization 1 - -- - I ------Anorexia nervosa 1 - - I - - - l - - - - - Personality disorder (with phobic anxiety)l ------1 - - - Total 30 2 7 14 7 77 7 8 9 3 3 80 *1, symptom free; tIl, much improved; tIll, improved; §IV, unchanged; **V, worse. Stereotactic limbic leucotomy 871 Postgrad Med J: first published as 10.1136/pgmj.49.578.865 on 1 December 1973. Downloaded from weeks, while fifteen (50°%) were placed in these Some of the female patients had noticed that their categories at 17 months. periods were irregular for the first few months The largest diagnostic grouping was that of those following surgery, but by 17 months their normal suffering from obsessional neurosis (sixteen), of menstrual rhythm was restored. The operation did whom 87% were rated as improved both at 6 weeks not appear to have any direct effect on patients' and 17 months. Further improvement had been libido, although some had experienced greater gained over the period of follow-up, however, as sexual enjoyment since loss of psychiatric symptoms seven (44°4) were rated as symptom free or much had increased their general feeling of well-being. improved at 6 weeks, while eleven (69%4) fell in No adverse effects on concentration or memory these categories at 17 months. were experienced by the majority of patients. One Four patients (57°/O) suffering from chronic anxiety female patient, however, who was of hysterical were improved at 6 weeks, as were five (71 Y.) at 17 premorbid personality, complained of patchily dis- months. Of three patients suffering from schizo- turbed memory. Psychological tests were re- phrenia or schizo-affective disorder, all were rated as performed on her a year post-operatively, therefore, improved at 6 weeks. At 17 months, two of the three and no disturbance of cognitive function was re- had moved from the improved to the much improved vealed. Her scores on the WAIS were the same as category, while one, suffering from mono-delusional those she had obtained pre-operatively and at 6 schizophrenia, had resumed her pre-operative state. weeks, and the psychologist's impression was that One patient suffering from depression was rated her complaints were of hysterical origin. as symptom free at 6 weeks; he had had a recur- None of the patients or their relatives had noted rence of symptoms over the period of follow-up, but any blunting of emotions post-operatively and none these were not of the same severity as pre-operatively felt that they had lost their warmth of feeling for and he felt the operation had helped him. He was, others, or, in those who were interested, their ap- therefore, rated as improved at 17 months. preciation for art or music. One patient, a keen

A patient with anorexia nervosa (Crisp & Kalucy, violinist, commented that the operation, in freeing Protected by copyright. 1973; Case 103) rated as improved 6 weeks after him from many of his symptoms, had allowed his surgery, was symptom free and training to be a nurse feeling for music to become, if anything, deeper at the time of the 17-month follow-up. A young (case history 3). Capacity for enjoyment was also woman who had suffered from long-standing crip- unaffected by the operation; an obsessional patient, pling phobic anxiety in the setting of a very severe who underwent two operative procedures, said that personality disorder and had been in hospital almost her enjoyment of life following the operation was continuously since the age of 12, though rated as incomparably better than previously. She now unchanged at 6 weeks, was almost phobia free at enjoyed social activities, sport and her work to a 17 months and was thus rated as improved. degree that had never been possible for her prior to surgery (case history 2). Post-operative clinical changes and adverse ejfects Increase in aggression, or impulsive or irritable Most patients passed through a period of con- behaviour had not occurred in any of the patients fusion which lasted for one to several days. In- post-operatively. A few patients, who had been

continence of urine, and rarely of faeces, was also particularly anxious prior to the operation, had http://pmj.bmj.com/ common for a few days post-operatively. When become more outspoken as their feelings of tension assessed at 6 weeks no adverse effects were in and insecurity had decreased and their confidence evidence. At the time of the 17-month follow-up no increased, but in no case did the patient or his patients were suffering from sphincter distur- relatives consider his increased outspokeness to be bances, these having cleared completely after the other than a favourable change. initial post-operative period. Lethargy and laziness were not problems after No adverse effects on physiological functions were the first few post-operative weeks and the majority noted at 17 months. For the first few months follow- of patients felt that their energy was not altered by on September 27, 2021 by guest. ing surgery some of the patients had noted that they the operation. One patient had complained of exces- required less sleep, but this pattern had gradually sive tiredness for several months post-operatively, subsided, sometimes with the help of a hypnotic, or but this appeared to improve when she had become a small dose of a tricyclic at night. None of the less depressed. patients had noticed any change in appetite and For 6 months following limbic leucotomy all none, apart from a patient with anorexia nervosa, patients were advised to take prophylactic phenytoin had gained more than a few pounds in weight over (100 mg/day). To date, no patients have developed the year. Many of the patients, requiring less pheno- epilepsy post-operatively; one patient, however, thiazine or antidepressant therapy post-operatively, who had undergone two previous 'free-hand' hadlost weight followingthe operation (casehistory4). leucotomies and had experienced grand mal seizures 872 Desmond Kelly and Nita Mitchell-Heggs Postgrad Med J: first published as 10.1136/pgmj.49.578.865 on 1 December 1973. Downloaded from prior to limbic leucotomy, had had further seizures, despite phophylactic phenytoin and phenobarbitone. 0 30 Discussion Clinical ratings Six weeks: A previous paper described the pre- liminary results of limbic leucotomy in the first forty patients who underwent the operation (Kelly 25 et al., 1973c). The patients were assessed clinically, Neuroticism psychologically and physiologically 6 weeks after QD ~~~~~~~~--0-- surgery and the results at that stage were very en- Anxiety x couraging, with an overall improvement of 67%. Seventy-six per cent improvement was gained in 20 obsessional neurosis, 80%. in depression, 55°/O in chronic anxiety and 66%/ in schizophrenia, and these b _Depression results compared favourably with those of a previous study, in which similar methods were used to assess the results of 'free-hand' leucotomy operations, 6 135 weeks post-operatively (Kelly et al., 1972). 0 4 8 12 16 Seventeen months: The present paper describes Months longer-term results in thirty of the original forty FIG. 1. Mean scores pre- and post-limbic leucotomy on patients, who have been followed up after a mean the Maudsley Personality Inventory (Neuroticism), Taylor Scale of Manifest Anxiety and Beck Depression interval of 17 months. In these thirty patients the Scale (n=29). outcome at 17 months compares favourably with their results at 6 weeks. Six weeks after operation Protected by copyright. 77°o of them were rated as improved, nine of them (30°/) being in the symptom free or much improved categories. At 17 months, 80°O were improved, now with fifteen (50°%) rated as symptom free or much improved. Psychometric ratings The patients were, as a group, less depressed at 17 months than pre-operatively, as evidenced by significant reductions in their mean scores on the Beck, Hamilton and MHQ depression scales. Sub- stantial reductions in depression scores had also occurred 6 weeks after surgery, but the improve- ments at 17 months were superior to these (Figs. 1 http://pmj.bmj.com/ and 2). Self and observer ratings of depression were also significantly lower at 17 months than pre- operatively and the mean ratings at 17 months were again lower than those at 6 weeks. Significant reductions in the mean scores of scales rating anxiety (Taylor, Hamilton and- MHQ) had occurred at 17 months as at 6 weeks, but once again the scores at 17 months were lower than those at 6 on September 27, 2021 by guest. weeks (Figs. 1 and 2). The observer rating of 'basal' anxiety at 17 months was also significantly reduced, but the mean scores of 'basal' self-rating, and 'stress' self and observer ratings, though reduced, were not so to a statistically significant degree. On the Middlesex Hospital Questionnaire signi- 0 4 8 12 16 ficant changes at 17 months were also shown on those scales measuring obsessions, hysterical symp- Months toms and FIG. 2. Mean scores pre- and post-limbic leucotomy on traits, and somatic anxiety. Changes had The Middlesex Hospital Questionnaire (n=29). Phobic also occurred on these scales 6 weeks post-opera- and Hysterical Scales not shown. Stereotactic limbic leucotomy 873 Postgrad Med J: first published as 10.1136/pgmj.49.578.865 on 1 December 1973. Downloaded from tively, but with regard to the obsessional and somatic Obsessional neurosis scores, considerable further improvement had been More than half of the patients seen at 17 months achieved between 6 weeks and 17 months (Fig. 2). were suffering from obsessional neurosis, an illness The Leyton Obsessional Invenztory (Cooper, 1970) known to be refractory to all forms of therapy, provides a very useful measure of obsessional including psychosurgery, and four of them had symptoms and traits, feelings of resistance, and de- undergone previous psychosurgery without benefit. gree of interference produced by the symptoms in Eighty-seven per cent (fourteen) of the sixteen obses- day-to-day tasks. A later addition to the psychologi- sional patients were clinically improved at 6 weeks, cal measures used in the present study, only two as were 87%4 at 17 months. The quality of improve- patients have completed this test at follow-up (see ment, however, had gradually increased over the case history 7). Preliminary results at 6 weeks have to period of follow-up. In a number of cases, sub- date been obtained on twenty-one patients of various stantial improvement was not gained until several diagnoses and significant reduction in mean scores months after the operation (case history 7), the of symptoms, traits, resistance and interference patient progressively gaining in confidence and have been achieved (Fig. 3). The LOI also includes abandoning his obsessions one by one. Thus, 6 questions from the Cornell Health Questionnaire weeks after operation seven (44°4) of the sixteen (Sections M-R), which provide a measure of the patients were rated as symptom free or much im- subject's general psychiatric complaint level and proved, while at 17 months, eleven (69%4) were placed significant reduction in the mean score occurred at in these two categories. These results are superior to 6 weeks. those of modified prefrontal and rostral leucotomy, where they were 25%4 and 50°% respectively (Kelly et al., 1972). 45 r- Two obsessional patients were rated as worse at 17 months. The first, a female of very

inadequate Protected by copyright. personality, had not noted any worsening of her obsessions, but, due to the breakdown of her marri- 40K age, her general state had deteriorated; she had become increasingly depressed and had made four serious suicidal attempts (case history 5). The second, a male of very inadequate and schizoid personality, 35K who had been subject to attacks of depression for many years, died 31 months after the operation. His post-operative course had been uneventful and his death, on the day that he was to have been dis- 301- charged from hospital, was entirely unexpected. The autopsy reported that death was due to asphyxia caused by inhalation of vomit due to barbiturate overdose. The levels of barbiturate found were not of a lethal level, but it appeared likely that there may http://pmj.bmj.com/ 251- Resistance have been potentiation with other drugs which he was taking. At inquest the Coroner's verdict was I nterference 'death by incautious overdose' and it was not felt that the patient intended to commit suicide. 20 - Initial failure of the operation and of intensive re- habilitation. It has been suggested that the value of

Symptoms leucotomy lies, in part, in its placebo response. on September 27, 2021 by guest. Patients suffering from obsessional neurosis are, 15F however, notably resistant to suggestion and it is this characteristic which contributes to their failure in general to respond to psychotherapy and psycho- analysis. One patient in the present series (case 10 Traits history 2), who had undergone a great deal of pre- vious therapy, was not subjectively or objectively Pre- PoCst- improved by a stereotactic limbic leucotomy. Following her operation her anxiety level and need FIG. 3. Mean scores pre- and 6 weeks post-limbic leucotomy on the Leyton Obsessional Inventory (n=21). to carry out her obsessions were as severe as pre- Cornell scores not shown. operatively; she, was unable to co-operate in the 874 Desmond Kelly and Nita Michell-Heggs Postgrad Med J: first published as 10.1136/pgmj.49.578.865 on 1 December 1973. Downloaded from intensive re-training programme which was set up months. With the more extensive operations the for her and she became increasingly despondent and mean score on this scale had fallen by only 3 points distressed. Three months after the operation she initially and this was not a significant change (Kelly underwent a further stereotactic procedure, in which et al., 1972). It was, perhaps, surprising that more additional lesions were made in the cingulum and patients with chronic depression did not enter the also in the genu of the corpus callosum. Following series. Several patients were referred, but subsequent this, she noticed an immediate reduction in anxiety treatment improved their symptoms, so that they and was able to participate fully in a programme of did not require surgery. Eight of the first seventy behaviour modification. The need for her to carry patients to undergo limbic leucotomy have suffered out her obsessions gradually became less important from severe depressive illness. to her and a year following surgery she was com- Poor premorbid personality. A poor previous pletely symptom free. There was no doubt in this personality has generally been suggested to carry patient's mind as to the difference in effect of her a poor prognosis with leucotomy (Schurr, 1969). two operative procedures and it would appear that In the present study, however, a poor previous the placebo responses were in this case, minimal. personality does not appear to be a definite contra- Prognosis and age of onset of symptoms. The indication to operation (case histories 3, 4, and 7). results of leucotomy in obsessional neurosis are In some patients, while not affecting the underlying generally thought to be best in those cases with an personality, the operation may provide sympto- underlying depressive illness, although Lewin (1961) matic help. A young woman who had suffered from reported favourable results with bilateral cingulec- long-standing crippling phobic anxiety in the setting tomy in patients without prominent depression. of a very severely disordered personality, had been Bridges (1972), reporting on the results of stereotac- in mental hospitals almost continuously since the tic tractotomy in obsessional neurosis, suggested that age of 12. Though after limbic leucotomy she was the illness responds less well when it is of early onset, unchanged at 6 weeks, she was almost phobia-free than when the symptoms begin later in life: 'the when seen at follow-up and was, therefore, rated asProtected by copyright. possibility is suggested that tractotomy is less effec- improved. She remained, however, dependent and tive in the true obsessional neurosis, which Pollitt vulnerable and unable to cope unaided with life's (1957) described as beginning at a mean age of 20-21 day-to-day stresses. She was, therefore, still an in- years. It is likely that for the true obsessional illness patient at the referring hospital at that time. Her surgery has to be undertaken at another site and the general level of anxiety had been reduced by the cingulate area has been considered for this.' In the operation and she had become less tense and aggres- present series, the mean age of onset of obsessional sive. She was now more helpful to the nurses and to illness was at 21 years (range 12-39 years), fourteen other patients, and was able to enjoy week-ends at of the sixteen obsessional patients being less than home. A severely institutionalized patient, her re- 25 years old at the onset of their symptoms. This habilitation is likely to be prolonged, but the refer- would suggest that they were suffering, in the main, ring psychiatrist, the nurses who care for her and the from primary obsessional neurosis and that, there- patient herself all considered that the operation had fore, stereotactic limbic leucotomy is beneficial in been of benefit to her.

this condition. Schizophrenia. Results of leucotomy in schizo- http://pmj.bmj.com/ phrenia have varied considerably from series to Other diagnostic categories series. Some workers have reported favourable Anxiety and depression. Four (57°4) of seven results, particularly with traditional techniques patients suffering from chronic anxiety were rated (Freeman, 1971), and others have considered the as improved at 6 weeks, as were five (71%Y) at 17 operation to have little effect in this illness (Schurr, months. The initial results of more extensive 'free- 1969; Strom-Olsen & Carlisle, 1971). Generally, hand' operations were more satisfactory, with 90°4 leucotomy is considered to be of little value in the improvement, but there was a marked deterioration chronic case of schizophrenia of long duration. The on September 27, 2021 by guest. during an 18-month follow-up period, with only 55°4 most favourable results have usually been in cases improvement in chronic anxiety states at this time with illnesses of short duration (Freeman, 1971), (Kelly et al., 1972). This preliminary evidence sug- who have some insight into their illness and show gests that limbic leucotomy produces better long- marked tension and anxiety. In the present series, term results, while employing smaller lesions than three patients suffered from schizophrenia or schizo- the 'free-hand' operations. affective illness. At the time of follow-up two of the Significant improvement in anxiety and depression three were rated as much improved. Both of these scores were seen in the group of patients as a whole patients had shown marked affective components in (Figs. 1 and 2). The Beck depression scale had fallen their illnesses and one of them had considerable by a highly significant amount at 6 weeks and 17 insight into his condition. The third patient had Stereotactic limbic leucotomy 875 Postgrad Med J: first published as 10.1136/pgmj.49.578.865 on 1 December 1973. Downloaded from suffered from a mono-delusional state, with para- and none felt that their capacity for enjoyment or noid features, for over 20 years. The operation appreciation of the arts had been affected. Increase in failed to benefit her and a year post-operatively her aggression, or impulsive or irritable behaviour had delusion was as firmly entrenched as ever. not occurred in any of the patients post-operatively, Anorexia nervosa. A patient with anorexia nervosa and volubility or excessive outspokenness were not rated as improved 6 weeks after surgery, was symp- reported. A few patients, who had been very shy, tom free, and nursing, at the time of follow-up. Her anxious and lacking in confidence while ill had, in case in particular (case 103), and the results of fact, become more outspoken as their symptoms de- leucotomy in anorexia nervosa in general, have been creased, but in no case did they or their relatives described in detail by Crisp & Kalucy (1973). consider the change to be other than favourable. Unreality states. The results of leucotomy in un- Lethargy and laziness were not generally in evidence reality states have not, in general, been rewarding. In after the first few post-operative weeks, although one the present study one patient, who had suffered from patient complained of excessive tiredness for several severe depersonalization and depression for several months post-operatively. Her energy had begun to years, failed to improve with limbic leucotomy. Ten increase, however, when she became less depressed. months later, therefore, she underwent a stereotactic tractotomy at another hospital. When seen at follow- Epilepsy and weight up her symptoms were unchanged and her despair at For 6 months following surgery all patients were the failure of surgery to change her symptoms caused advised to take prophylactic phenytoin and no N.M-H. to rate her as worse. Recently, however, patients, to date, have developed epilepsy, an adverse her mental state has started to improve, and her effect which complicated 'free-hand' operations not feelings of hopelessness are considerably diminished. uncommonly. Significant weight gain, another serious complication of more traditional operations, Adverse ejfects had not occurred in any of the patients following The risk of adverse effects has been the main prob- limbic leucotomy and many of them, requiring less Protected by copyright. lem with open or blind operations. Stereotactic pro- phenothiazine or tricyclic post-operatively, had cedures have reduced this risk (Str6m-Olsen & actually lost weight (Case history 4). Carlisle, 1971), although the side-effects of trac- In a previous study (Kelly et al., 1972), excessive totomy have included volubility, outspokenness, weight gain was demonstrated to be a serious side- irritability and lethargy. These effects have been a effect of 'free-hand' leucotomy. More than half of nuisance in a very small number of cases, but almost the patients had gained weight over a period of 18 never socially disabling (Bridges, 1972). In the present months follow-up and in many of them the gain was study, transitory confusion and sphincter distur- of the order of 28 lb (12-7 kg). bances have been common for the first few post- Sexual appetite was unchanged by limbic leuco- operative days and one patient, not in the present tomy and menstruation, irregular in some patients series, who had had a previous bilateral rostral for the first few post-operative months, was also operation, suffered a transient neurological compli- unaffected at 17 months. cation post-operatively (Richardson, 1973). Ejfects on sleep http://pmj.bmj.com/ Intelligence Many patients noticed that their sleep patterns Tests of intellectual function (WAIS) 6 weeks were changed for several months post-operatively. post-operatively showed an increase over pre- They appeared to require less sleep, most commonly operative means scores in the verbal performance falling asleep later and waking earlier than pre- and full-scale IQs and at the time of the 17-month viously, and this effect was different from that seen follow-up no adverse effects on memory or concen- after rostral (McKissock, 1959) and modified pre- tration were experienced by the majority of the frontral leucotomy (Jackson, 1954), where somno- on September 27, 2021 by guest. patients. Only one patient, of hysterical personality, lence, especially in the early post-operative period, complained of patchily disturbed memory. Psycho- was common. The increased wakefulness following logical tests, were, therefore, re-performed a year limbic leucotomy gradually subsided, sometimes post-operatively. Her scores on the WAIS were the with the help of a hypnotic, or a small dose of tri- same as those she had obtained pre-operatively and cyclic at night. the psychologist's impression was that her complaints Similar changes in sleep following leucotomy have were of hysterical orgin. previously been described by Hauri & Hawkins (1972), who studied a depressed, obsessive patient in Personality the sleep laboratory before and after leucotomy. None of the patients, nor their relatives, felt that Following leucotomy, she too passed through a limbic leucotomy had produced emotional blunting stage of increased wakefulness and this subsided 876 Desmond Kelly and Nita Mitchell-Heggs Postgrad Med J: first published as 10.1136/pgmj.49.578.865 on 1 December 1973. Downloaded from after a few months. Before leucotomy her EEG had unlikely, therefore, that the period of rehabilitation shown a scarcity of delta (stages 3 and 4) and REM would alone have accounted for the degree of im- sleep (a pattern typical for sleep in depression) and provement achieved (case history 2). this pattern continued for 10 days post- operatively. After this time, delta sleep gradually The independent assessor increased until 5 months after leucotomy, when age- Dr Maurice Partridge, who has had a great deal of adequate delta levels appeared. Hauri & Hawkins experience in assessing leucotomy operations (Part- suggested that 'this very slow recovery of delta sleep ridge, 1950), has been the independent assessor for the after leucotomy makes it seem very unlikely that the present study. He has, to date, seen twenty-four improvement is directly related to the interruption of patients pre-operatively and at 17 months, and his some neurological pathways during the operation. impressions of stereotactic limbic leucotomy have Rather, one might speculate the neuro-endocrine been very favourable, particularly with regard to its mechanisms could be involved as intervening results in obsessional neurosis. With regard to his variables.' They postulated that their patient's clinical ratings (on the 5 point scale), in all but three pre-operative psychiatric state had caused some cases his rating was in agreement with those of neuro-endocrine balance to stabilize on a new and both of the other two assessors (D.K. and N.M-H.) pathological level manifesting itself in low levels and in two of these his ratings were one category of delta sleep. When the leucotomy abolished the more favourable than those of the others. In one chronic state of psychological stress the 'underlying further case he and D.K. both rated a patient as endocrine balance may have needed time to readjust unchanged, while N.M-H. rated her as minimally to the new state of well-being'. worse. In all cases where disparity occurred between An association between delta sleep and serotonin the assessors' ratings, the least favourable rating was has been reported (Jouvet, 1969; Koella & Czieman, attributed to the patient for the purposes of the 1966) and it is interesting to speculate that one of present study. the factors involved in the therapeutic outcome of Favourable points particularly cited by Dr Protected by copyright. leucotomy might be its effects on biogenic amine Partridge have been the absence of emotional blunt- production in the brain. In the light of Hauri & ing, disinhibition, post-operative epilepsy or exces- Hawkins' work, this might provide a partial ex- sive weight-gain, all of these having been well-recog- planation for the pattern of gradual improvement nized complications of 'free-hand' operations. which is often seen. They suggested that the change Dr Partridge's opinion of the operation is that it in neuro-endocrine balance was secondary to the is a safer, much more limited procedure than more improvement in mental state produced by leucotomy, traditional leucotomy operations, but that its overall but it is, perhaps, possible that it is this which is the therapeutic effects are comparable and, in obsessional primary effect of leucotomy. neurosis, probably superior. Rehabilitation Conclusion The importance of a period of rehabilitation fol- Psychosurgery remains, and will continue to re- lowing leucotomy has often been stressed. It was main, a controversial treatment. It would appear, of essential following standard leucotomy, when post- however, to have a part to play in the therapy http://pmj.bmj.com/ operative confusion, lethargy and laziness were chronically and severely ill patients, in whom other frequent and severe, but its role following less exten- therapeutic measures have failed. Preliminary find- sive operations is rather different, being directed at ings indicate that limbic leucotomy produces more altering old unhealthy behaviour patterns set up favourable results in obsessional neurosis, with during the patient's illness. Behaviour therapy, smaller lesions, than the more extensive 'free-hand' systematic desensitization and psychotherapy may operations we have studied. The changes in anxiety each play an appropriate part in the rehabilitation and depression psychometric scores are comparable programme, as may advice regarding work and to those produced by the more extensive operations. on September 27, 2021 by guest. social life. Whether such a programme is absolutely Rostral leucotomy, which was devised at this hospi- essential to a favourable outcome in limbic leuco- tal by Sir Wylie McKissock, is now rarely employed tomy is not entirely clear, as a small number of here. patients were unable to take part in a formal re- habilitation programme and improved in spite of Acknowledgments this (case history 6). Thecontribution ofthe period of We are grateful to the Wellcome Foundation and to the rehabilitation to the results of limbic leucotomy Research Grants Committee of St George's Hospital for financial support during this study. We should also like to cannot be overlooked. All of the patients had, how- thank the consultant psychiatrists who referred patients to ever, undergone a great deal of previous therapy, us, Miss Juliet Greenup for performing intelligence tests and during illnesses of a mean duration of 12 years. It is Mrs Mary Clark for secretarial assistance. Stereotactic limbic leucotomy 877 Postgrad Med J: first published as 10.1136/pgmj.49.578.865 on 1 December 1973. Downloaded from

References NAUTA, W.J.H. (1973) Connections of the frontal lobe with BECK, A., WARD, C., MENDOLSON, M., MARK, J. & ERBAUGH, the limbic system. In: Surgical Approaches in Psychiatry J. (1961) An inventory for measuring depression. Archives (Ed. by Laitinen and Livingston), p. 303. Medical and of General Psychiatry, 4, 561. Technical Publishing Co. Ltd, Lancaster. BRIDGES, P.K. (1972) Psychosurgery today: psychiatric PAPEZ, J.W. (1937) A proposed mechanism of emotion. aspects. Proceedings of the Royal Society of Medicine, 65, Archives of Neurology and Psychiatry, 38, 725. 40. PARTRIDGE, M. (1950) Prefrontal Leucotomy. Blackwell Scientific Publications, Oxford. BRODMAN, K., DEUTCHENBERGER, J. & WOLFF, H.G. (1956) PIPPARD, J. (1955) Rostral leucotomy: a report on 240 cases Manual for the Cornell Medical Index Health Question- personally followed up after 1l to 5 years. Journal of naire. Cornell University Medical College, New York. Mental Science, 101, 756. COOPER, J. (1970) The Leyton Obsessional Inventory. POLLITT, J. (1957) Natural history of obsessional states: a Psychological Medicine, 1, 48. study of 150 cases. British Medical Journal, 1, 194. CRISP, A.H. & KALUCY, R.L. (1973) The effect of leucotomy REGISTRAR GENERAL (1968) Studies on Medical and Popula- in intractable adolescent weight phobia (primary anorexia tion Subjects, Number 22, A Glossary ofMental Disorders. nervosa). Postgraduate Medical Journal, 49, 883. Her Majesty's Stationery Office, London. CROWN, S. & CRIsP, A.H. (1966) A short clinical diagnostic RICHARDSON, A. (1973) Stereotactic limbic leucotomy: self-rating scale for psychoneurotic patients. British surgical technique. Postgraduate Medical Journal, 49, 860. Journal of Psychiatry, 112, 917. SARGANT, W. & SLATER, E. (1972) An Introduction to Physical EYSENCK, H. (1959) Manual of the Maudsley Personality Methods of treatment in Psychiatry, p. 98. Churchill Inventory. London. Livingstone, Edinburgh and London. FREEMAN, W. (1971) Frontal lobotomy in early schizo- SCHURR, P.H. (1969) Leucotomy. British Journal of Hospital phrenia. Long follow-up in 415 cases. British Journal of Medicine, 1712. Psychiatry, 119, 621. STROM-OLSEN, R. & CARLISLE, S. (1971) Bi-frontal stereotac- HAMILTON, M. (1959) The assessment of anxiety states by tic tractotomy. A follow-up study. British Journal of rating. British Journal of Medical Psychology, 32, 50. Psychiatry, 118, 141. HAMILTON, M. (1967) Development of a rating scale for TAYLOR, J. (1953) A personality scale of manifest anxiety. primary depressive illness. British Journal of Social and Journal ofAbnormal and Social Psychology, 48, 285. Clinical Psychology, 6, 278. WALTER, C.J.S., MITCHELL-HEGGS, N. & SARGANT, W.

HAURI, P. & HAWKINS, D.R. (1972) Human sleep after leu- (1972) Modified narcosis, ECT and antidepressant drugs: Protected by copyright. cotomy. Archives of General Psychiatry, 26, 469. a review of technique and immediate outcome of 674 JACKSON, H. (1954) Leucotomy-a recent development. courses of combined treatment in 484 patients. British Journal of Mental Science, 100, 62. Journal of Psychiatry, 120, 651. JOUVET, M. (1969) Biogenic amines and the states of sleep. WECHSLER, D. (1955) Manual for the Wechsler Adult Intelli- Science, 163, 32. gence Scale. New York. KELLY, D. (1967) The technique offorearm plethysmography for assessing anxiety. Journal of Psychosomatic Research, Appendix 10, 373. KELLY, D. (1972) Physiological changes during operations on Clinical case histories the limbic system in man. Conditional Reflex, 7, 127. Case 1: severe intractable obsessional neurosis. KELLY, D. (1973) Psychosurgery and the limbic system. Postgraduate Medical Journal, 49, 825. J.G., Aged 34, Female. Referred for treatment of an KELLY, D., PIK, R. & CHEN, C. (1973a) A psychological and intractable obsessive-compulsive disorder. Her physiological evaluation of the effects of intravenous symptoms began when she was 23, after an unwanted diazepam. British Journal ofPsychiatry, 122, 419. pregnancy had forced her into an unhappy marriage. KELLY, D. RICHARDSON, A. & MITCHELL-HEGGS, N. (1973b) Stereotactic limbic A year later, when the baby developed asthma, her

leucotomy: neurophysiological aspects http://pmj.bmj.com/ and operative technique. British Journal ofPsychiatry, 123, feelings of guilt deepened and from that time her 133. symptoms were of such severity that she was unable KELLY, D., RICHARDSON, A., MITCHELL-HEGGS, N., GREEN- to cope with even the simplest tasks of everyday life. UP, J., CHEN, C. & HAFNER, R.J. (1973c) Stereotactic limbic leucotomy: a preliminary report on forty patients. Her day was totally occupied with checking and re- British Journal of Psychiatry, 123, 141. checking actions such as washing, dressing and KELLY, D., WALTER, C.J.S. & SARGANT, W. (1966) Modified household tasks. She had, for example, to wash her leucotomy assessed by forearm blood flow and other face in a special order-starting with the left side, measurements. British Journal of Psychiatry, 112, 871.

nose, right side, forehead-up to thirteen A on September 27, 2021 by guest. KELLY, D., WALTER, C.J.S., MITCHELL-HEGGS, N. & times. SARGANT, W. (1972) Modified leucotomy assessed clini- similar elaborate system was involved in her bathing, cally, physiologically and psychologically at 6 weeks and which took her over an hour each day. After washing 18 months. British Journal of Psychiatry, 120, 19. clothes she had to squeeze them a certain way, KOELLA, W.P. & CZIEMAN, J. (1966) Mechanism of the EEG repeating the proceedings twenty-two times, the synchronizing action of serotonin. American Journal of Physiology, 211, 926. bottom of the bowl was then examined, checking LAITINEN, L.V. (1972) Stereotactic lesions in the knee of the the maker's mark numerous times to make sure the corpus callosum in the treatment of emotional disorders. bowl was empty. Cleaning her teeth was a major Lancet, i, 472. task, taking over half an hour. Making a bed, with LEWIN, W. (1961) Observations on selective leucotomy. Journal ofNeurology, Neurosurgery and Psychiatry, 24, 37. checking at each stage that the sheets and blankets McKISSOCK, W. (1959) Discussion on psychosurgery. Pro- were exactly symmetrical, might take over half an ceedings of the Royal Society of Medicine, 52, 206. hour. 878 Desmond Kelly and Nita Mitchell-Heggs Postgrad Med J: first published as 10.1136/pgmj.49.578.865 on 1 December 1973. Downloaded from Household chores such as washing-up or polishing and was leading a completely normal life. The opera- a table were completely impossible for her, as they tion had not produced any unwanted side-effects took so long and caused her such distress. Her and, apart from follow-up visits, she no longer saw husband and mother were, therefore, forced into a psychiatrist. Rated as symptom free. running her home and, on medical advice, her two children were at boarding school. The patient felt Case 2: re-operation in a case ofsevere obsessional extreme guilt at her disruption of the family's exist- neurosis. S.S., aged 29, female. Referred for treat- ence and, at times, felt very depressed and that life ment of an incapacitating obsessional illness of 10 was not worth living. Between 1962 and 1970 she years' duration. Her illness involved fears of con- was admitted to Severalls Hospital seven times, and tamination and death and resulted in the patient's received a variety of treatments including ECT, performing almost continuous ruminations and MAOI drugs, tricyclics, major and minor tran- rituals in order to relieve her anxiety. Prior to her quillizers and psychotherapy. During 1968 and 1969 illness she had had a meticulous, well-adjusted she was admitted on two occasions to the Royal personality and had an excellent work record, Waterloo Hospital and had a total of five courses of managing, despite very severe symptoms, to work as modified narcosis, combined with ECT and anti- a solicitor's assistant until 3 years before her admis- depressants. After each admission she obtained sion. Gradually, however, her obsessions occupied symptomatic relief for about 2-4 weeks and then an increasingly greater part of the day and, although relapsed. she stayed in her office till late at night, she became On 2 March 1971 she underwent a stereotactic unable to keep up with her work. For the year prior cryogenic limbic leucotomy. Two lesions were made to her admission she had been unable to leave her in the lower medial quadrant of each frontal lobe home, to read, write, converse, watch television or and two lesions (each with a medial and lateral get dressed. For 2 months she had walked about her component) were also made ineachanteriorcingulate home naked, for she was forced to throw away any

gyrus. Thus, a total of six lesions was made in each clothes which she considered to be contaminated. Protected by copyright. hemisphere, each lesion being 8 mm in diameter. No improvement in her condition had been Her post-operative course was uncomplicated and achieved with any treatment, including anti-depres- following the operation she felt an immediate sants, tranquillizers; 2 months' narcosis, combined reduction of tension. The compulsion to carry out with ECT and antidepressants; desensitization, her rituals was of diminished intensity, and a 4-week employing i.m. diazepam; a course of i.v. chlomi- rehabilitation programme along behavioural lines pramine; and hypnotherapy. reinforced this. She spent a week's leave at home On 10 November 1971 she underwent a cryogenic before being discharged and during this she was stereotactic limbic leucotomy; three lesions were relaxed and obsessional to a minor degree. made in the lower medial quadrant of each frontal A year after the operation (14 March 1972) she lobe and two lesions (each with a medial and lateral said her improvement had continued after she left component) in each cingulum. Following the opera- hospital and she was now completely symptom free. tion there was no subjective or objective change in She commented; 'Now I can't really imagine what the patient's obsessive-compulsive symptoms, nor in it's like to be obsessional.' She found no difficulty in her feelings of anxiety and she was unable to http://pmj.bmj.com/ caring for her home and children and, for the first co-operate in the desensitization programme which time since her marriage, was happy withherhusband. was set up for her. After 7 weeks she went on holiday She no longer suffered from depression or tension to the West Country for a month's leave and during this was as obsessional as she had ever been and, for the Pre- 6 weeks I year first time during her illness, felt depressed and Psychometry leucotomy post post hopeless. On 16 February 1972 a further stereotactic opera-

Taylor Anxiety 12 2 2 tion was performed, two lesions being made in the on September 27, 2021 by guest. Beck Depression 6 0 0 genu of the corpus callosum (one to the right and MPI Neuroticism 8 1 0 one to the left of the mid-line) and one lesion (with a Extraversion 14 12 8 medial and lateral component) in each MHQ Anxiety 6 6 0 cingulum. Phobia 0 0 0 Immediately following the operation the patient Obsessional 11 11 2 noted a reduction in her feelings of anxiety and felt Somatic 3 0 0 more able to tackle her obsessions. Over the follow- Depression 5 0 0 ing 6 weeks she co-operated vigorously in a desensiti- Hysteria 2 0 0 zation programme and when she left hospital Hamilton Anxiety 11 4 0 Hamilton (20 May 1972) was almost symptom free. Depression 10 3 0 At follow-up a year later, she said she was com- Stereotactic limbic leucotomy 879 Postgrad Med J: first published as 10.1136/pgmj.49.578.865 on 1 December 1973. Downloaded from pletely free from obsessions. She had obtained a boy-friend and was enjoying sport, parties and post as secretary to the manager of travel firm, was cinemas. She had no fears or anxieties and rated her promoted to manager's assistant within 6 weeks and operation as an unqualified success. Rated as symp- was travelling to Europe each month. She had a tom free.

Pre 1st 6 weeks 6 weeks 1 year Psychometry Operation post 1st post 2nd post Taylor Anxiety 17 17 8 4 Beck Depression 8 17 1 0 MPI Neuroticism 17 12 10 4 Extraversion 16 36 32 34 MHQ Anxiety 6 6 1 1 Phobia 5 6 6 2 Obsessional 15 13 15 7 Somatic 0 7 0 0 Depression 4 4 3 3 Hysteria 7 7 7 5 Hamilton Anxiety 14 16 7 0 Hamilton Depression 9 11 6 0

Case 3: patient with severe obsessional neurosis. lacked the courage to oppose them). He was taking Lesions in cingulum only. E.M., aged 42, male. De- chlomipramine 25 mg t.d.s. and nitrazepam 5 mg scribed by the referring psychiatrist as 'one of the at night and was seen by his psychiatrist at 2-monthly most severe obsessionals I have ever come across', intervals. Rated as much improved. Protected by copyright. he was very poorly adjusted in social and sexual spheres and had suffered from non-specific neurotic Pre- 6 weeks 2 years symptoms nearly all his life. His very severe obses- Psychometry leucotomy post post sional illness had commenced in 1968, and had prevented his carrying out his work as a teacher for Taylor Anxiety 25 24 16 almost a year. His symptoms resulted in his per- Beck Depression 20 17 11 MPI Neuroticism 23 10 24 forming numerous rituals and involved his checking Extraversion 13 32 14 and re-checking almost every simple day-to-day task. MHQ Anxiety 11 11 10 He experienced a feeling ofperpetual fear and anxiety Phobia 5 5 2 and had been 'brought to a standstill'. Despite treat- Obsessional 14 14 9 ment with antidepressants, tranquillizers, ECT, Somatic 13 4 3 psychotherapy and 6 months' treatment in a mental Depression 7 8 9 improved, were still Hysteria 6 7 6 hospital, his symptoms, though Hamilton Anxiety 11 5 6 extremely crippling and prevented his working. Hamilton Depression 12 2 5 http://pmj.bmj.com/ On 9 December 1970 the patient underwent a cryogenic stereotactic limbic leucotomy; one lesion was made in each rostral cingulum and two lesions Case 4: long-standing phobic anxiety state, with re- in each anterior cingulum. Immediately following the current depression, in a vulnerable pre-morbid per- operation his anxiety was greatly reduced, but for sonality. C.W., aged 53, female. This patient had 4 days he was noticeably paranoid. Following this suffered from severe agoraphobia with panic attacks his post-operative course was uncomplicated and he for 20 years and from recurrent attacks of depression remained relaxed, cheerful and almost obsession- for 8 years. Ever since a child, she had been anxious, on September 27, 2021 by guest. free and was discharged from hospital after 6 weeks. emotionally labile and dependent, but her phobic Two years following the operation (15 January symptoms commenced abruptly 3 months after she 1973) he said 'the operation was the turning point in set up home with a married man (whom she later my life.' He no longer suffered from the symptoms married). The symptoms tended to fluctuate, but of anxiety and fear which he had experienced before following the birth of her second child in 1960, her the operation and, though still possessing some minor anxiety worsened, her panic attacks increased in obsessions, was teaching 20 hr a week. He was, in frequency and she also suffered from severe back addition, taking music lessons, with a view to pain for which she received osteopathy. becoming a violinist (he had wished to do this all his In 1963 she became depressed when her husband, life, but had been dissuaded by relatives and had who had always drunk heavily, became more alcohol- 880 Desmond Kelly and Nita Mitchell-Heggs Postgrad Med J: first published as 10.1136/pgmj.49.578.865 on 1 December 1973. Downloaded from dependent and between 1963 and 1969 she was was phobia free, lacking anxiety and depression, and admitted to mental hospitals on six occasions. She had lost 42 lb (191 kg) in weight. She was coping generally responded rapidly to treatment with MAOI well with shopping and had enjoyed visits to theatres drugs and tranquillizers, but tended to relapse and restaurants. She attended Alcoholics Anony- within weeks of discharge from hospital. mous meetings with her husband and took an active By 1969 her husband had ceased to drink and had part in these, managing to visit a lapsed AA member joined Alcoholics Anonymous; nevertheless, the in Brixton Prison. She was still taking small doses of patient became increasingly phobic and by 1970 was a tricyclic and of a minor tranquillizer at night, and completely housebound. She was commenced on these were being reduced. She commented that she combined antidepressants (MAOI and tricyclic) and 'had not been as well as this for years'. Rated as became less depressed; she was, however, still symptom free. extremely phobic and, on these drugs, gained 42 lb (19 1 kg) in weight in a few months. Case 5: severe obsessiob.al neurosis in an inadequate In 1971 her psychiatrist referred her to D.K. for personality-unimproved following surgery. J.B., advice regarding further management and she was aged 27, female. This patient was referred for treat- admitted to Atkinson Morley's Hospital, where she ment of her extremely severe obsessional illness. She underwent desensitization therapy, first under i.v. was known to be of below average intelligence and methohexitone and then i.v. diazepam. She failed to to possess a highly immature, hysterical personality. respond to this, however, and became increasingly Her illness exhibited many reactive features, having phobic in hospital. Further attempts at desensitiza- commenced after she married at the age of 21. She tion as an out-patient were again unsuccessful and was sexually frigid and was unable to cope with the her condition deteriorated further. roles of wife and mother, being at her happiest She was re-admitted for a stereotactic limbic and least obsessional when working as a bar-maid. leucotomy, which was performed on 14 August Her symptoms consisted of repetitive household

1971. Three lesions were made in the lower medial cleaning and list-making, and she spent all day long,Protected by copyright. quadrant of each frontal lobe and two (each with till the early hours of the morning, employed in this two components) in each cingulum. way. She had developed elaborate and incapacitating Her post-operative course was uneventful and rituals involving nearly every household chore- immediately following the operation she was cheer- boiling a kettle on the stove necessitated her cleaning ful, relaxed and phobia-free. She successfully attemp- the whole stove, including the oven, afterwards; ted increasingly distant walks from the hospital, but floors had to be scrubbed after anyone had walked 3 weeks post-operatively went further than advised, across them; members of the family had to be con- got lost and had a panic attack. This event dis- stantly followed and their clothes checked, in case couraged her, as did a severe recurrence of her old they had become disarranged or contaminated by back pain. Nevertheless, when discharged 4 weeks dirt; her two small children were not allowed to later, she was able to go for short unaccompanied move from their chairs for hours at a time in case walks. they caused even minute disorder in the house. For several months her back caused her much Although not usually aggressive to them, the patient distress; following a course of physiotherapy, how- had, at times, physically attacked her children when http://pmj.bmj.com/ ever, this improved and gradually, with this, so did they had unwittingly disturbed her obsessional order. her mental state. By 1968 her condition had deteriorated; she was By the time of follow-up (19 September 1972) she deeply depressed and after a number of suicidal gestures was admitted to a mental hospital where she Pre- 6 weeks 13 months remained almost continuously, unable to cope with Psychometry leucotomy post post even a weekend at home. She was treated with the full range of anti-depressants and tranquillizers and

Taylor Anxiety 31 27 29 received intensive psychotherapy, no treatment pro- on September 27, 2021 by guest. Beck Depression 17 13 5 ducing any change in her obsessional state. She MPI Neuroticism 22 18 14 became increasingly depressed, particularly regard- Extraversion 16 12 8 ing the effect of her illness on her family, and shortly MHQ Anxiety 12 9 7 Phobia 15 9 7 before her referral to Atkinson Morley's, was dis- Obsessional 13 10 10 covered, by chance, taking a suicidal overdose. Somatic 7 9 6 At the time of assessment it was felt that if psycho- Depression 5 5 3 surgery achieved a degree of symptomatic relief, she Hysteria 5 4 2 might become more accessible to the psychotherapy Hamilton Anxiety 19 19 8 which was required to help her resolve her many real- Hamilton Depression 34 21 8 life conflicts. Stereotactic limbic leucotomy 881 Postgrad Med J: first published as 10.1136/pgmj.49.578.865 on 1 December 1973. Downloaded from

A stereotactic limbic leucotomy was performed on and widespread that it totally preoccupied her 25 August 1971. Three lesions were made in the lower thoughts. She performed numerous rituals of de- medial quadrant ofeach frontal lobe and two lesions contamination if she had even the remotest contact (each with a medial and lateral component) in each with death and spent most ofher day washing herself cingulum. Following the operation she was incon- and her possessions. If she spoke to someone who tinent of urine for 2 weeks and remained rather re- had recently been to a funeral she would have to tarded for 3 weeks; following this period her post- destroy the clothes she was wearing at the time and operative recovery was uncomplicated and she would be overwhelmed by intense panic and fear. noticed a reduction in her feelings of anxiety and Four years after the death of a neighbour she was depression and in her need to carry out her obses- still unable to open a door in her house which faced sions. Rehabilitation consisted of behavioural her neighbour's home. She had become increasingly therapy aimed at her obsessions and psychotherapy, distraught and depressed and had made several which dealt mainly with her family relationships. serious suicidal attempts, including one by drown- In the setting of the hospital she remained less ing. obsessional, but on weekend visits home her symp- Various treatments had been given, with no suc- toms recurred. She continued to have little insight cess. These included psychotherapy, ECT, anti- into the relationship of her illness with her life depressants, tranquillizers and, latterly, a course of situation and made little progress in psychotherapy. i.v. chlomipramine. She was discharged to the care of her referring On 15 September 1971 she underwent a stereotac- psychiatrist after 10 weeks and at follow-up (24 tic limbic leucotomy. Three lesions (8 mm diameter) October 1972) had been under his in-patient care for were made in the lower medial quadrant of each the previous 9 months. Since her operation she rated frontal lobe and two (each with a medial and lateral herself as 'unchanged'; she was as obsessional and component) in each cingulum. Her post-operative depressed as previously and had made four serious recovery was uneventful and a week after her opera- suicidal attempts. Her husband, 'no longer able to tion she was transferred to a nursing home for 2 Protected by copyright. stand the strain' had petitioned for divorce, wanting weeks' convalescence. Because of her lack of under- sole custody of the children, and the patient, feeling standing of English it was not possible to embark on her family would be better without her, saw no an organized re-habilitation programme. The im- future for herself. Because of the seriousness of her portance of her trying to resist her obsessions at this suicidal attempts and the deterioration in her marital stage was, however, explained to her and attempts state, she was rated as Grade V (worse). were made to encourage her to do this. Six weeks following her operation she returned to Pre- 6 weeks 14 months her village in Cyprus. At this time she was less de- Psychometry leucotomy post post pressed and anxious than pre-operatively, but she continued to perform many of her washing rituals. Taylor Anxiety 42 16 36 Regular reports regarding her progress have been Beck Depression 42 17 41 received from her son and from the referring psychi- MPI Neuroticism 48 32 44 atrist. She has to Extraversion 20 16 2 continued improve, lacking anxiety and depression and progressively abandoning her http://pmj.bmj.com/ MHQ Anxiety 15 2 12 Phobia 9 6 t 1 obsessions. Three months following the operation Obsessional 16 6 14 she went to church for the first time since her illness Somatic 10 5 4 commenced and her husband, who had left her 16 Depression 4 8 12 years before because of her symptoms, had returned Hysteria 9 7 7 to live with her. Nine months later the death of a Hamilton Anxiety 32 7 32 neighbour caused her to suffer no more than normal Hamilton Depression 34 6 34 grief and 18 months post-operatively she was com- pletely free from obsessions and depression. (No on September 27, 2021 by guest. clinical rating and not included in the present series, Case 6: severe depression with obsessional symp- as no personal follow-up. No psychometry because toms. No rehabilitation programme. M.K., aged 49, of language difficulties.) female. This semi-literate Cypriot patient was re- ferred by her psychiatrist in Nicosia, for psycho- Case 7: long-standing obsessional neurosis in a surgical treatment of her severe obsessional and patient of poor pre-morbid personality. Use of the depressive illness. Leyton Obsessional Inventory. A.C., aged 45, female. Her symptoms had commenced in 1954, following Had suffered for 20 years from fear of pregnancy. the death of a priest. She had developed a morbid Gradually her anxieties regarding impregnation and fear of death and her fear had become so intense contamination extended to involve many other sub- 882 Desmond Kelly and Nita Mitchell-Heggs Postgrad Med J: first published as 10.1136/pgmj.49.578.865 on 1 December 1973. Downloaded from jects and, despite a great deal of in-patient and out- and she had not drunk alcohol to excess. Her Leyton patient psychiatric treatment, her condition had Obsessional Inventory Scores confirmed the clinical deteriorated over the year. She had become seriously impression of continuing improvement after the 6- depressed and on one occasion attempted suicide by week assessment. Rated as much improved. drinking disinfectant. Her personality had never been robust and she had at times drunk excessively, particularly when Pre- 6 weeks 1 year depressed. Psychometry leucotomy post post On 10 May 1972 a stereotactic limbic leucotomy made in Leyton Symptoms 31 18 14 was performed, three bilateral lesions being Traits 8 12 7 the lower medial quadrant of the frontal lobe and Resistance 44 15 12 two bilateral lesions in the anterior cingulum. Her Interference 38 8 4 post-operative course was uneventful and she claimed Cornell 10 8 1 to be less anxious and depressed immediately follow- Taylor Anxiety 16 8 9 ing surgery. Six weeks after the operation she de- Beck Depression 0 3 3 manded to be discharged from hospital, although MPI Neuroticism 22 19 10 at this stage her obsessions, while considerably Extraversion 8 15 32 MHQ Anxiety 3 1 3 decreased, were still prominent. Phobia 3 3 3 When seen at follow-up a year later both she and Obsessional 11 6 7 her husband said that she was '98%Y better'. She had Somatic 2 0 0 gradually improved over the year, at first very slowly Depression 4 0 4 and then much more obviously. She was cheerful, Hysteria 2 2 2 confident and almost completely obsession free. Hamilton Anxiety 15 8 1 There had been no adverse effects from the operation Hamilton Depression 14 9 2 Protected by copyright. http://pmj.bmj.com/ on September 27, 2021 by guest.