An Evaluation of Bimedial Leucotomy

This report is based on a consecutive series of patients of the Bethlem Royal and Maudsley Hospitals who were accepted for bimedial leucotomy after many other forms of treatment had failed to produce more than transitory relief over periods which in most cases exceeded five years. Patients who failed to show anxiety, tension or distress, or who had exhibited behaviour disorders or sociopathic tendency before they had fallen ill, were, as a rule, not accepted for operation. Most patients had supportive family backgrounds. On account of these stringent indications for leucotomy, the annual numbers of patients operated on at the Guy's-Maudsley Neurosurgical Unit have not declined during the last ten years. The progress of patients before and for three years after operation was compared on a variety of measures of differing degrees of objectivity. These included serial ratings of blindly scored brief extracts from case notes, follow-up reports covering various relevant aspects of illness and adjustment, and global estimates of outcome. SEE TABLE XXIV IN SOURCE PDF. After excluding six schizophrenics, and four patients with insufficient data, 54 patients remained as subjects of this investigation. Two died during the first three post-operative years, death being related to the leucotomy (remotely) only in one elderly patient. Of the 52 patients, 35 continued to suffer some psychiatric disability throughout the whole of the three year follow-up period. On the other hand, 36 of 52 remained permanently relieved of their most severe and incapacitating symptoms. In terms of "blind" rating scores, 37 per cent. were completely or almost completely symptom-free by the end of the follow-up period; 57 per cent. had lost all, or almost all, tension, distress, and anxiety; 37 per cent. had regained full, and an additional 30 per cent. almost full working ability. Global estimates were in good agreement with ratings made in isolation from knowledge of the general picture. Undesirable leucotomy effects occurred in a permanent form in 59 per cent. of cases. They were troublesome in 21 per cent. In 8 per cent. serious disability resulted, and in the case of one elderly man, chronic depression was converted into chronic hypomania. Apart from these severe sequelae, even quite troublesome personality changes affected the patients' adjustment, surprisingly little, provided there had been a marked relief of the original symptoms. A few unfavourable prognostic features were isolated in a sample from which patients with sociopathic personalities and those failing to register tension and distress had as a rule been excluded. These were: the never-married status, severe premorbid temperamental deviations, a duration of more than two years of the most severe stage of the illness (but not, of course, of the illness as a whole), and age below 40 at the time of the operation. Members of all diagnostic groups derived benefit from bimedial leucotomy. This was greatest, however, in those exhibiting the depressive reaction type, especially when it occurred in a pure and psychotic fashion and over the age of 60. Neurotic states without depressive admixtures, which in this sample were seen only in younger patients, responded disappointingly. Patients were observed beyond the original follow-up period, over an average total of 7.9 years. Some further improvement occurred with the passage of time in most of them. By comparing symptom scores before operation with those obtained blindly six months, one year, two years, and three years later, it could be demonstrated that in 40 per cent. leucotomy had been a decisive event, which after a prolonged period of severe mental illness had initiated a lasting change for the better. No other specific therapies were found to have been operating. In 21 per cent. the effectiveness of the operation had been less clear; it was probably absent in 31 per cent.; and it had proved harmful in 8 per cent. These findings suggest that the modified forms of leucotomy should not be withheld for too long from patients of middle and late adult life with persistent and seriously disabling non-schizophrenic functional psychiatric disorders. Best results may be expected in elderly patients with uncomplicated chronic depressions.