Canad. Med. Ass. J.
April 15, 1967, vol. 96
The Lobotomy Patient.A Decade Later:
A Follow-up Study of a Research Project Started in 1948
A. MILLER, M.D., D.Psych.,* Toronto
One hundred and fifty patients with chronic mental
illness were treated with prefrontal lobotomy be¬
tween 1948 and 1952 as part of a research study.
Follow-up assessments were made by the author in
1952 and again in 1962. One hundred and sixteen
patients of the original 150 were available for the
follow-up study which provides the basis for this
report. Sixty-seven per cent improved sufficiently to
live out of hospital, although 26% did have periods
of relapse requiring further treatment. The maximum
postoperative response usually occurred at six months
and was usually maintained subsequently. Most sig¬
nificant complications of lobotomy were epilepsy
(12%) and a personality defect (91%). The results of
this lobotomy study were examined in relationship
to current psychiatric therapy, with particular refer¬
ence to recent clinical experience with lobotomy. It
was concluded that if prefrontal lobotomy is used
for selected cases of intractable mental disorder
only, it has probably found its proper place in
psychiatric treatment.
of mental dis¬
THE neurosurgical treatment
order and behaviour abnormality reaches
of the
back into ancient times.when trephining
skull was practised to 'let out the demons" re¬
sponsible for disturbed actions. Modern "psycho-
surgery"f is attributed to Dr. G. Burckhardt, a
Swiss psychiatrist who performed brain surgery
on a series of psychotic patients in 1888. His
procedure was to sever connections between the
frontal lobe and subcortical structures or to
excise parts of the temporal cortex, on the basis
that "sensory stimuli of abnormal quality and
intensity reaching the motor area resulted in im-
pulsive and violent behaviour". Although Burck-
hardt's treatment was successful in relieving
aggressive behaviour in the small series of five
patients treated, there was no follow-up with this
form of treatment and it was abandoned until
1935, when it was revived by Egas Moniz, the
Portugese psychiatrist. Moniz, influenced by
Fulton and Jacobsen's report that chimpanzees
became placid and docile after frontal lobe abla¬
tion, treated 20 chronic psychotic patients at first
with alcohol injected into the frontal lobe white
matter and later by operation.prefrontal leuk-
otomy. His monograph, published in 1936, de-
* Associate
Professor, Department of Psychiatry, Univer¬
sity of Toronto; Clinical Director, Ontario Hospital,
Toronto.
tPsychosurgery a term introduced by Freeman and
Watts, about 1940, which referred to neurosurgical pro¬
cedures used to influence psychological function.
Reprint requests to: Dr. A. Miller, The Ontario Hospital,
Box 14, Postal Station "C'\ Toronto 3, Ontario.
Miller: Lobotomy 1095
Une lobotomie prefrontale a ete* effectuee chez 150
malades souffrant de maladie mentale chronique, de
1948 a 1952. Cette operation etait prevue dans un
projet de recherches. L'auteur a revu les malades et
eValue* les resultats en 1951 et de nouveau en 1962.
De ces 150 malades, 116 etaient disponibles pour
Fevaluation de leur cas, qui fait l'objet du present
rapport. De ce nombre, 67% etaient suffisamment
ameliores pour pouvoir vivre en dehors de Thopital,
bien que 26% de ceux-ci aient presente" des periodes
de rechute n£cessitant d'autres traitements. La
reaction post-operatoire maximum eut lieu g£n£rale-
ment dans un delai de six mois et put habituelle¬
ment etre maintenue. Les principales complications
de la lobotomie etaient l'epilepsie (12%), et un
trouble de la personnalite (91%). Les resultats de la
lobotomie ont ete compares a ceux que donne la
psychotherapie moderne, et cette comparaison
s'etendait notamment a Fexperience clinique recente
sur la lobotomie. La conclusion est que, si on
reserve la lobotomie prefrontale a des cas choisis de
maladies mentales rebelles, cette operation a pro¬
bablement trouve sa place dans le traitement
psychiatrique.
scribes a reduction of tension and aggressive
behaviour and general improvement in most of
the treated patients. Moniz theorized that the
operation interrupted the "action of faulty cellu¬
lar synapses which were regarded as responsible
for abnormal mental processes."
In the United States, Freeman and Watts
started their program of prefrontal leukotomies
which led to the publication of their book,
"Psychosurgery," in 1942. The rapid spread of
psychosurgery in the United States and the
United Kingdom was stimulated by the favour¬
able reports that appeared in the literature.
Along with this wave of popularity in neuro¬
surgical treatment, a variety of surgical tech¬
niques emerged to improve the operative effi¬
ciency, prevent postoperative complications
and/or enhance the clinical effects. The pre¬
frontal leukotomy (or lobotomy) was the first
neurosurgical procedure to be developed. This
consisted of sectioning the width of the fronto-
thalamic fibres on a plane anterior to the
sphenoidal ridge with a leukotome introduced
through burr holes in the skull. Later, modifica¬
tions of this operation were devised, such as:
(a) Bimedial lobotomy.in which the medial
half of the frontothalamus radiations is sectioned.
(b) Transorbital lobotomy.in which the
frontothalamic fibres are sectioned through a
 1096 Miller: Lobotomy
leukotome introduced supra-orbitally into the
frontal lobes.
(c) Cortical undercutting of orbital-medial
regions of frontal lobes.
(d) Ultrasonic lobotomy.in which the ultra¬
sonic waves are used to destroy fibres of the
thalamofrontal radiation.
(e) Topectomy.in which ablation of selected
parts of frontal lobe cortex is carried out.
(f) Cingulectomy.in which the anterior part
of the cingulate gyrus is removed by subpial
suction.
(g) Thalamotomy in which the fronto-
thalamic connections are interrupted at the level
of the thalamus (dorso-medial nucleus) by elec-
trocoagulation using stereotaxic techniques.
It is important to remember that the surge of
enthusiasm for psychosurgical treatment during
the 1940's was motivated by ineffectual psychi¬
atric therapy, particularly that available for the
treatment of patients with intractable and
distressing mental disorders. From this group,
the patients were selected for the more than
30,000* lobotomy operations that subsequently
were done.
A study project into the treatment of mental
disorder by lobotomy was organized against this
background. This communication describes the
last stage of this clinical study.
Early in 1948, the Department of Psychiatry of
the University of Toronto (headed by Professor
A. B. Stokes) and the Neurosurgical Department
of the Toronto General Hospital (headed by Dr.
K. G. McKenzie) developed a collaborative pro¬
ject to study the clinical effects of prefrontal
lobotomy. A plan of study was prepared, which
focused on: (1) the development of clinical
criteria for the selection of patients; (2) the
assessment of clinical, physiological, psycho¬
logical and physical characteristicsandof the pa¬
tient before and after lobotomy; (3) the
evaluation of the postoperative social and
personality adjustment of the patient over a
period of years by means of regular follow-up
studies.
The detail of this plan of study was as follows:
(a) Patients with chronic mental disorders un¬
responsive to an adequate range of appropriate
therapeutic methods (available at that time)
would be selected from the Ontario Mental Hos¬
pitals population, and referred to the Depart¬
ment of Psychiatry at the Toronto Psychiatric
Hospital.
(b) A detailed medical, psychological and
psychiatric investigation, including electro-
?This figure is an estimate and is probably much lower
than the actual number.
Canad. Med. Ass. J.
April 15, 1967, vol. 96
encephalogram and biochemical studies, was to
be carried out on each patient.
(c) Each patient would be presented to a
special staff clinical conference, including psy¬
chiatric and neurosurgical staff members, for
clinical and diagnostic evaluation, assessment of
prognosis (without lobotomy), decision for or
against operation, and prediction of response to
prefrontal lobotomy.
(d) A point rating scale was devised.to
assess the level of social, vocational and person¬
ality functioning (see Table I). Each patient
was to be rated on this scale both preoperatively
and postoperatively when an assessment relevant
to this study was made.
(e) A standard operative procedure would be
used on all patients: prefrontal lobotomy as
devised by Dr. K. G. McKenzie, which severs
the fibres of the frontothalamic projection
anterior to the lateral ventricles, by introducing
a leukotome through burr holes in the skull.
(f) A follow-up assessment would be made
at six months, one year, two years, four years,
five years and 10 years postoperatively.
The project was started in the spring of 1948.
By mid 1952, 150 patients had been treated with
prefrontal lobotomy according to the plan of
study. It should be mentioned that many more
than 150 had been studied during the period
1948-1952, but a number were rejected either
because methods of treatment other than lob¬
otomy were indicated or because the patient's
clinical picture was one which was considered
unlikely to respond beneficially to lobotomy. As
the project proceeded, it became evident to the
study group that patients with emotional
"flattening", marked social withdrawal and ex¬
tensive loss of reality-contact were usually poor
candidates for prefrontal lobotomy, but patients
with prominent symptoms of anxiety, fear and
tension, associated with ideas of self-recrimina-
tion and concern, responded well to the opera¬
tion.
During 1952 and 1953, the data for the first
150 patients treated with prefrontal lobotomy
were collected by examination of the case files
and by my personal interviews with all patients
who could be reached either in hospital or at
home. A monograph,1 "Lobotomy.A Clinical
Study", was published in 1954. This monograph
provided details of the format of the clinical
study, a description of the neurosurgical tech¬
nique, and analysis of biochemical, psychological
and electroencephalographic investigations that
were carried out. Follow-up assessments of 147
patients (three patients could not be located),
using a point rating scale (Table I) as an index
Canad. Med. Ass. J.
April 15, 1967, vol. 96
of response to prefrontal lobotomy in terms of
social and personal adjustment, were included.
It was noted also that 55% of treated patients
were out of hospital, the mortality rate was 2%,
and the incidence of postoperative epilepsy was
6%. The analyses of psychological, electro-
encephalographic and biochemical investigations
provided little significant data relevant to the
clinical picture.
Subsequent to this follow-up study in 1952,
there were 10 years of research inactivity. In
1962 the final stage of the lobotomy study was
started, using the same format as in 1952. This
consisted of personally visiting and interviewing
every patient who was still available and also
collecting information about the patient's adjust¬
ment through personal discussion with members
of hospital staffs, social agencies and family.
Method of Study
The first problem in the 1962 follow-up study
was to locate and contact as many patients as
possible who had belonged to this project. After
extensive correspondence, searching of hospital
records and examining vital statistics data, 116
patients were located, living in hospital
home. A questionnaire was sent to each patient
asking for information about present and past
health, whether living alone, with family or
friends, their opinions about the quality of
domestic relationships, the type, level and sta¬
bility of jobs since operation, and the range and
type of social and avocational activities. In addi¬
tion, information concerning the quality of pa¬
tient's health, functioning and adjustment was
obtained, when possible, from relevant sources.
family, friends, social workers, doctors, nurses
and rehabilitation workers. Appointments were
then scheduled to interview each patient.
A profile was prepared for each patient, which
brought together the data considered significant
TABLE I Point Rating Scale*
10 points each for.Intellectually normal \
Emotionally normal r Compared to
Socially normal i prepsychotic state
Working normally /
?This scale was devised to measure level of personal, social and vocational func¬
tioning. It was arbitrarily agreed, when the scale was devised, that scores of 0 30
inclusive would indicate that the patient required hospital care, whereas scores of
40 -100 indicated degrees of improvement (in terms of the patient's premorbid
state) sufficient to allow him to live out of hospital.
Miller: Lobotomy 1097
from the clinical material available in the 1952
and 1962 follow-up studies. The point rating
scale (Table I), which had been used to rate
the patient's preoperative and postoperative level
of functioning, was again applied in the 1962
follow-up to measure the patient's social, voca¬
tional and personality adjustment.
Clinical Data Dertved from 1962
Follow-up Study
1. Analysis of Patient Population
In the 1952 follow-up study, 147 of the
original 150 patients treated with prefrontal
lobotomy from 1948 to 1952 provided the ma¬
terial for the report that followed.1 In the 1962
follow-up study, 116 patients were available for
interviews. Seventeen had died (three had died
as a result of postoperative complication before
1952 and in the remaining 14 the causes of the
deaths could not be determined); 14 could not
be located.
TABLE II..Age Range of Patients in 1962
or at
36 29 21
As noted in Table II, there were 32 males
and 84 females. The majority were in the age
range 35 to 60, the mean age being 50 years. (In
the 1952 study,1 the mean age of the total group
of 150 patients was 41.6 years.)
The standard prefrontal lobotomy technique
had been used in all 116 patients. However, in
nine patients only one side of the brain was
lobotomized (unilateral lobotomy), while the
remaining 107 had bilateral operations.
The patients fell into a wide range of diag¬
nostic categories, the majority (73%) belong¬
ing to the category of schizophrenic disorders
(Table III), the rest to the broad categories of
affective disorders, psychoneuroses, and person¬
ality disorders.
2. Comparison of Postoperative Response
The first point of interest in looking at the
clinical data was the level of adjustment (as
measured by social and personal functioning)
which each patient had demonstrated from the
time of operative treatment to the interview
assessment in 1962. The time span ranged from a
minimum of 10 years to a maximum of 14 years.
-
Since each patient had been rated, using the
point rating scale (Table I), preoperatively and
1098 Miller: Lobotomy Canad. Med. Ass. J.
April 15, 1967, vol. 96

TABLE III..Diagnostic Categories

Schizophrenia
Catatonic. 18
Paranoid. 20
Schizo-affective. 7
Undifferentiated. 40
Total. 85
Affective disorders
Manic-depressive psychosis.
Involutional depression. 7
12
Psychotic depression. 1
With organic features. 1
Total. 21
Psychoneurosis
Chronic neurosis. 4
Neurotic depression. 1
Obsessive-compulsive. 1
Total. 6
Other
Psychosis with mental defect. 1
Behaviour disorder. 1
Immature personality with chronic anxiety.
1
Psychopathic personality (drug addiction). 1
Total. 4
Total No. of patients. 116
Preoperative Post Operative
again stages postoperatively (up to
at various Fig. 1..Graph of mean point ratings for 116 lobotomy
and including the 1962 follow-up assessment), patients preoperatively and postoperatively.
a profile which had been prepared for each pa¬
tient provided quantitative measures throughout ratings for each patient throughout the period of
the period of study. From Table IV it can be the lobotomy study were compared. It was found
seen that the majority of patients have tended
to maintain a steady level of adjustment over the
that a consistent pattern could be distinguished.
10 years (from 1952 to 1962 follow-up study). By plotting mean ratings (Fig. 1) the following
This is demonstrated by the fact that 69 patients pattern emerged: (1) The clinical reaction likely
(60%) were rated the same in 1952 and 1962, to occur in response to prefrontal lobotomy
while 26 patients (22%) improved in point would usually be apparent in the first six months
rating, and 21 patients (18%) were rated lower. postoperatively. (2) The clinical pattern seen at
six months postoperatively tends to remain rela¬
However, it is evident that for the majority of
those patients whose rating changed, the range tively constant, though a slow increment up to
was quite narrow.i.e. usually within 20 points. two years can occur. After this, little change in
the effects from lobotomy is likely to take place.
TABLE IV..Comparative Assessment of Patient 4. Index of Therapeutic Response to Lobotomy
Adjustment Using Point Rating Scale Between 1952
and 1962 as Measured by Hospital Stay
Patients with no change. 69 All patients in this follow-up study had been
Patients showing point improvement. 26 treated in mental hospitals for prolonged periods
20 points 20 =

40 points 4
= before referral to lobotomy project. The data
60 points 2
= from the 1952 study1 report that the average
Patients showing point loss. 21
20 points 16 = length of illness was 9.6 years and the average
40 points 4
=
length of time in a mental hospital was five
60 points
= 1 years (before operation).
Total. 116 In the present (1962) study we were interested
in determining: (1) how many patients recorded
as discharged from hospital at the time of the
3. Pattern of Postoperative Response 1952 study had
In order to assess the pattern of clinical re¬
subsequently required further
action to prefrontal lobotomy, the point scale
hospitalization, (2) how many patients who
and
continued in mental hospital postoperatively at
Canad. Med. ass. J.
April 15, 1967, vol. 96
the time of the 1952 study had improved suffi¬
ciently to be discharged.
The follow-up study of 116 patients provided
the following information:
Sixty-eight patients (60%) from the present
group of 116 patients had been discharged from
mental hospitals in 1952. Three patients subse¬
quently needed permanent hospital care, while
22 patients (about one-third of the discharged
patients) required short periods of hospitaliza¬
tion (one to three months).some once, others
several times.
TABLE V..Incidence of Hospitalization During Postoperative Period.in Various Diagnostic Categroies
1952
Patients Patients continuously in and required No. requiring
in out of
Diagnosis hospital hospital postoperatively hospitalization hospitalization continuously
37
7
4
Total. 48
Forty-eight of the 116 patients in the present
follow-up study were in hospital in 1952. During
the 10-year period since 1952, 10 of these im¬
proved sufficiently to live outside hospital.
However, only five patients remained well
enough to stay out of hospital continuously; the
other five developed recurrences of disabling
psychotic symptoms and behaviour rather
quickly (within three months) and were still in
hospital at the time of the 1962 follow-up. Thus,
in 1962 it was found that 70 patients (61%) were
living out of hospital and 46 (39%) still re¬
quired mental hospital care.
The incidence of hospitalization in terms of
diagnostic groupings was analyzed (Table V).
There were 85 patients with schizophrenic ill¬
ness in the follow-up group. Forty-eight (56%)
had been discharged from hospital in 1952, and
during the period 1952-1962 eight more patients
were able to leave hospital. Thus there was a
total of 56 (66%) patients who were able to
live out of hospital postoperatively.
In 1962 it was found that 33 (39%) of this
group had been living out of hospital continu¬
ously since their discharge, while 23 had re¬
quired further hospitalization. However, only
five of the 23 patients who had relapsed have
required continuous hospitalization, while the
remaining 18 have been treated for short
periods (one to three months) in hospital and
Miller: Lobotomy 1099
then improved sufficiently so that they were
able to function in the community.
Twenty-one patients in the follow-up group
had been diagnosed as having affective disorders
(Table III). Fourteen had been discharged from
hospital following prefrontal lobotomy, and were
living in the community at the time of the 1952
study. Subsequently, one more patient was dis¬
charged, increasing the total to 15. In 1962, 11
of this group have remained out of hospital,
while four have required further hospital treat¬
ment, two intermittently and the other two con-
1962
Patients wholeft hospital postoperatively
1962 (A) (B) (O
Patients No. who relapsed
No. out of
hospital continuous intermittent hospital
68 38 22 48
tinuously. The remaining 10 patients in the study
group belonged to a variety of diagnostic
categories, mainly psychoneurotic and person¬
ality disorders (Table III). Six had been dis¬
charged from hospital in 1952, and by 1962 this
number had increased to seven. Of this number,
three had relapsed and required hospital care.
two intermittently and one continuously.
In summary, the above data reveal that 78
(67%) out of 116 patients in the follow-up study
had improved sufficiently postoperatively to be
discharged from mental hospital. However, 30
of this number suffered relapses and required
further treatment in mental hospital, although
only in eight was this necessary on a continuing
basis. Further, the data in this study showed
only moderate differences in the incidence of
discharge from hospital, and relapse rates in the
diagnostic categories schizophrenia, affective
.
disorders, and other psychiatric categories, al¬
though the category of schizophrenia tended to
show slightly poorer postoperative results
(Table V).
5. Subsequent Psychiatric Treatment for
Lobotomized Patients
The follow-up study revealed that 45 of the
116 patients had required further psychiatric
treatment. This group included (a) those pa¬
tients who showed little or no improvement after
 1100 Miller: Lobotomy Canad. Med. Ass. J.
April 15, 1967, vol. 96

prefrontal lobotomy, and (b) those who had localizing lesion was not found by neurological
improved but subsequently relapsed. All of the examination. Anticonvulsant medications have
patients receiving treatment were in hospital or adequately controlled seizures in every case.
had been at the time treatment was started. The increase in the number of patients with
The type of specific psychiatric treatment epilepsy clearly indicates that the figure of 6%
prescribed was (for the incidence of epilepsy following pre¬
pharmacological, electrotherapy, frontal
or operative (lobotomy).in addition to psycho¬ lobotomy) given in the 1952 study3 was
therapy and milieu therapy (including occupa- much too low. It is also clear that epileptic
tional-vocational and recreational therapy). symptoms do develop as long as nine years after
Thirty-four patients were treated with psycho- operation, perhaps even longer.
tropic drugs, mainly phenothiazines.such as On the basis of the data from the present
chlorpromazine, perphenazine trifluoperazine.
or follow-up, the incidence of epilepsy after pre¬
There was significant relief of symptoms in frontal lobotomy is at least 12%. Taking into
10 patients, who have stayed out of hospital account the 28 patients who were not available
on maintenance doses of phenothiazine medica¬ to the present study, one could estimate the
tion with good results. The remaining patients
24 incidence of epilepsy to be about 14%.
showed little or moderate improvement on
phenothiazine therapy and are still being treated 7. Physical Health of 116 Lobotomized
in hospital. Patients
Ten patients were treated with a course of The physical health of these patients was
electrotherapy (ECT), but in only patients reasonably good. The physical problems and dis¬
two
was there a significant remission with relief of eases recognized in these 116 patients are noted
depressive symptoms. in Table VI.
One patient who had improved temporarily,
following a bilateral prefrontal lobotomy, be¬ TABLE VI..Incidence of Physical Disability in
came extremely disturbed and difficult to 116 Lobotomized Patients
manage. A second bilateral lobotomy was done, Marked obesity. 10
with the operative cut posterior to the original Cardiac disease. 3
one (based on the view that interruption of Gynecological diseases. 3
closer the Variety of organic diseases. 9
frontothalamic fibres at point
a to (renal, liver, gastrointestinal, pulmonary, skin, eye
thalamus would reduce assaultive behaviour). Metabolic and hematological)
diseases. 3
However, the second operation again proved to (diabetes, hyperthyroidism)
be of little value. Total. 28
6. Incidenceof Postoperative Complications
The results of this follow-up indicate that, Considering that the majority of these patients
except for epileptic symptoms, there were no
were middle-aged or older, the incidence of
significant organic postoperative complications physical disorders among them was not regarded
as unusual, except perhaps the relatively high
in addition to those noted in the 1952 study. incidence of obesity. Ageing and obesity did not
In that study1 the incidence of complications seem to predispose to cardiac disease in many
was as follows: postoperative hemorrhage, 3%; of these lobotomized patients.
brain abscess, 5%; dementia, 5%; epilepsy,
6%; and mortality rate, 2%. 8. Analysis of the Domestic Patterns of Living
In the 1962 study it was found that patients In evaluating the social adjustment of these
with postoperative epilepsy were well controlled 116 patients, we examined each patient's
with anticonvulsant medication. In two, grand domestic arrangements. Table VII shows the
mai seizures occurred when the patients tempo¬
rarily discontinued medication. living arrangements of non-hospitalized and
In the present study (1962), five out of nine
hospitalized patients, according to the broad
diagnostic categories. The great majority of pa¬
patients who had developed postoperative epi¬ tients were living in a group situation, and this
lepsy were available for interview, and these is obviously necessary for optimal functioning.
were still continuing on anticonvulsant medica- Indeed, stimuli from the environment which
tions. It was discovered that after a span from came through close interpersonal relationships
three to nine years postoperatively an additional frequently provided the important catalyst for
nine patients had suffered seizures. In all cases a productive living.
Canad. Med. Ass. J.
April 15, 1967, vol. 96
TABLE VII..Trends in Living Arrangements
9. Productive Capacity of Lobotomized
Patients as Measured by Work Efficiency
Hospitalized and non-hospitalized patients
were assessed in terms of their capacity to work.
Table VIII shows the kinds of work being done
by these patients, compared under the broad
diagnostic categories. It will be noted that a
significantly high proportion of lobotomized pa¬
tients were able to function productively. Actu¬
ally only 29 (eight from non-hospitalized and 21
from the hospitalized group) were unable to
perform any kind of work. Of the rest, 44 were
engaged in effective, productive and gainful
daily work equivalent to that of their peer group.
Forty-three were able to work productively with
varying degrees of competence, although usually
in a sheltered environment.
General Clinical Impressions
This study of 116 patients treated with pre¬
frontal lobotomy revealed that 67% had im¬
proved to a degree which made it possible to
Miller: Lobotomy 1101
live in the community with family and friends,
and in many cases to work productively and be
self-sufBcient and to engage in social activity.
Furthermore, 41% of these patients have held
these gains continuously up to 14 years while
living in essentially the same environment where
the illness developed. The remaining 26% of
improved patients have generally had a fluctuat-
ing course, with periodic return of symptoms.
Of the lobotomized patients, 33% showed
little or no improvement and have required con¬
tinuous hospital care. Even in this group, there
were a number who showed some improvement,
so that their adjustment in hospital was better.
The significance of this improvement was par¬
ticularly important in those patients who had
presented severe problems in management be¬
cause of destructive and impulsive behaviour.
The conclusions reached 14 years after the
start of the lobotomy study are almost identical
with those reported after a four-year follow-up1
in 1952. These are as follows:
1. Symptoms of persistent anxiety, fear, ten¬
sion and marked preoccupation with inner con¬
flict concerned with guilt, inadequacy, failure,
self-destructive wishes are usually relieved by
prefrontal lobotomy.
2. Symptoms of marked autism, fragmented
thinking, emotional "flattening", bizarre ideation
and mannerisms are not significantly influenced
by prefrontal lobotomy.
3. Because of the high incidence of postopera¬
tive dementia, the presence of brain pathology,
particularly cortical damage, is a contraindica¬
tion to prefrontal lobotomy.
4. The relief of incapacitating psychiatric
symptoms, such as morbid fears and self-con-
cern, allows the release of intellectual, emotional
and personality resources for productive living.
A noteworthy clinical finding in this study of
116 patients was the frequency of significant
personality defects. Only in nine patients was
it not possible to recognize signs of personality
defect. The defects were expressed in the pa¬
tient's limited capacity for new learning, the
restriction in the ability for positive planning,
and a lack of flexibility in dealing with situations
that required a shift in thinking or action. The
consequence of this defect was a narrowing in
the capacity to adapt to changing life situations.
Thus, even those patients who were functioning
extremely well in terms of relationship with
people, regular work and social activities, did
so as long as conditions were stable and sup¬
portive relationships constant. It was the clinical
impression that the reason for this restriction in
personality function was an impairment in the
 1102 Miller : Lobotomy
capacity for abstract thinking. Whether this was
primarily due to the patient's mental disorder or
the result of prefrontal lobotomy is not clear.
Discussion
What can one say about the results of this
long follow-up study? If it is examined within
the framework of psychiatric thought in the
1940's (when the problem of treating over¬
whelming numbers of chronic psychiatric pa¬
tients was a major issue), then the results in this
report of a 67% improvement after treatment
with lobotomy could be regarded as a significant
achievement. Reports of long-term studies of
lobotomized patients.such as that by Tooth
and Newton,2 who examined 10,365 patients
treated by leukotomy in England and Wales be¬
tween 1942 and 1954 and found that 46% were
able to function satisfactorily out of hospital; or
that by Freeman,3 who followed 787 lobotom¬
ized patients and found that 44% were out of
hospital five years postoperatively.suggest a
rather consistent figure (of close to 50%) of.
patients who improved after lobotomy. It is true
that some reports have shown much poorer re¬
sults.such as that by Vosburg,4 who found that
only 19% of lobotomized patients had been dis¬
charged from hospital.
It is evident from the above reports and
others5'1114 that there is considerable variation
in the clinical response to lobotomy as experi¬
enced by different investigators. To a large ex¬
tent, this reflects the clinical criteria used in the
selection of cases for operation. The importance
of establishing basic criteria for the selection of
patients for lobotomy was recognized early by
the investigators engaged in the lobotomy proj¬
ect reported here. For example, it became evi¬
dent that chronicity in itself was of little im¬
portance as compared to the presence of clinical
features (such as anxiety, tension and depres¬
sion) in the selection of
patients for lobotomy.
Tooth and Newton2 also make the point that the
improvement rate in lobotomized patients was
much higher (70%) in those with symptoms of
tension, obsessional thinking and persistent de¬
pression than in the other types of patients.
Again, Pippard5 found that patients with symp¬
toms of severe obsessional symptoms, persistent
tension and anxiety, and/or chronic intractable
depression were likely to be helped by lobotomy.
It is true that the use of psychosurgical pro¬
cedures since 1954, by those who still regard
it as useful, has tended to be much more selec¬
tive than in the past. Sykes and Tredgold6
treated a series of 144 patients with orbital
undercutting, of which 123 had affective dis¬
Canad. Med. Ass. J.
April 15, 1967, vol. 96
orders, and found that 68% of chronic depres-
sives were greatly improved. Tredgold7 de¬
fended his position regarding the value of
neurosurgical treatment against Smith,8 who
questioned the value of leukotomy as a method
that could significantly influence the rate of
remission of mental illness, by emphasizing the
significantly beneficial clinical response to lobo¬
tomy in properly selected patients. In an im¬
portant controlled study involving a five-year
follow-up study, McKenzie and Kaczanowski9
compared the results of 183 patients suffering
from psychotic illnesses and treated with pre¬
frontal leukotomy with a control group, and
found that there was no significant difference
in the remission rates as measured by the dis¬
charge rate from hospital. In 1964, an editorial
in The Canadian Medical Association Journal10
criticized the use of lobotomy, because of the
absence of adequate experimental design, the
paucity of controlled studies, the "chaotic lack
of agreement" about the value and "the disquiet
about its efficacy". This editorial points to the
results of the controlled study by McKenzie and
Kraczanowski9 as providing a solid basis for
abandoning lobotomy as a method of treatment
for mental disorder.
It is evident that in 1966 there still exists
controversy with respect to the value of lobo¬
tomy. This is so, because, even with the enor-
mous success of psychopharmacological drugs
(introduced in 1952), and the significant con¬
tribution of the insights provided by social
psychiatry, the psychiatrist still has patients who
are extremely resistant to treatment. The ques¬
tion arises whether lobotomy should still be
considered for some of these patients. A study
reported in the British Journal of Psychiatry,
August 1966, by Marks, Birley and Gelder11
concludes that "modified leukotomy* produced
more useful sustained improvement in patients
with long standing and severe agoraphobia and
anxiety than any other forms of treatment". This
study consisted of 22 patients with anxiety and
severe agoraphobia, who had been treated with
a modified leukotomy and compared with
matched controls over a period of five years. It
was found that the leukotomy patients were
"significantly better" than controls with respect
to symptom relief and work adjustment. From
this study it is clear that lobotomy is still re¬
garded not only as a method of treatment that
should be retained, but also as one that may be
the only therapeutic approach available for the
relief of intolerable distress and dysfunction in
?Modified leukotomy is synonymous with bimedial leuk¬
otomy.
Canad. Med. Ass. J.
April 15, 1967, vol. 96
some patients. Pippard5 expressed the opinion
that lobotomy is not a highly desirable method
of treatment for mental disorder but, on the
other hand, it should not be completely dis-
carded.
It would be my observation that the clinician
who has worked closely with patients treated by
lobotomy can identify certain patients who have
responded dramatically to lobotomy when all
other treatment failed. An example of this from
personal experience was the case of a 67-year-
old widow hospitalized more than 10 times over
a period of three years for intense anxiety and
agitation, and tormented ideas of guilt and re-
morse. She was treated with psychopharmaco-
logical and psychotherapeutic methods with
never more than slight and transient improve-
ment. Now, 18 months after a bimedial lobo-
tomy, she has been continuously out of hospital
and runs her home efficiently for herself and
two daughters. She is comfortable, energetic and
able to enjoy life-without the need of any other
therapy. In this particular case, I am convinced
that lobotomy ultimately was the treatment of
choice and, without it, the pattern of suffering
and disabiliy would have continued.
Thus, it seems reasonable to conclude that the
"lobotomy era", which had a dramatic and
powerful introduction 30 years ago, has virtually
come to a standstill. Its value as a treatment
method in psychiatry is clearly limited. But
perhaps it has found its proper place as a thera-
peutic method capable still of relieving un-
remitting and severe mental distress in a patient
unresponsive to all other modes of treatment. If
it can serve that purpose, we must retain it as a
valuable and useful therapeutic tool.
CONCLUSIONS
A long-term follow-up study was carried out
in 1962-63 of patients who underwent lobotomy
between the years 1948 and 1952 for chronic
mental illness that did not respond to other
forms of treatment. This study is a continuation
of the Lobotomy Research Project organized by
the Departments of Psychiatry and Neurosurgery
at the University of Toronto.
This follow-up was based on personal inter-
views with patients by the author who had made
a similar study in 1952. In 1962, 133 of the
original 150 patients who had had a lobotomy
were traced. Seventeen had died, leaving 116
patients for the present follow-up. Analysis of
the follow-up findings reveals that: Sixty-one
per cent of these patients who had lobotomy be-
fore 1952 were living and working in the com-
munity in 1962. Nineteen per cent required a
MILLER: LOBOTOMY 1103
period of hospital treatment after operation but
in 1962 had been discharged from hospital.
Thirty-nine per cent did not benefit sufficiently
from lobotomy to live out of hospital. Patients
who had been severe management problems
became significantly more tractable and better
adjusted in the hospital environment. In this
sample, patients with a diagnosis of schizo-
phrenia responded to lobotomy as well as those
in other diagnostic categories. Seventy-five per
cent were able to work productively, and in 38%o
this work was of high calibre.
Thirty-eight per cent of patients subsequently
had drug or electroconvulsive therapy and about
one-quarter showed a significant response.
The only significant postlobotomy complica-
tion was epilepsy, occurring in from 6% in the
1952 follow-up to 12% in 1962.
Personality defects could be recognized clini-
cally in 91%c. However, it is not known whether
these defects reflect the effect of lobotomy and/
or persistent residual mental pathology.
This study (and others) seen in the perspec-
tive of current methods of psychiatric treatment
suggests that: (a) in certain chronic, intractable,
distressing psychiatric conditions lobotomy can
be a useful therapeutic technique, and (b) treat-
ment with lobotomy can relieve severe incapaci-
tating psychiatric symptoms and thereby enable
the patient to attain a relatively healthy, reward-
ing and effective life.
I wish to express my appreciation to Professor A. B.
Stokes for his advice and guidance, to the Department
of Psychiatry, University of Toronto, the Departments of
Health of Ontario and of the Federal Government for
their support and aid in this Research Follow-up Study,
and to the superintendents and staffs of those Ontario
Hospitals who were helpful in facilitating the arrange-
ments of this study. I would also like to thank Mr.
Douglas Quirk, M.A., for his invaluable assistance with
statistics and graphs, and especially Mrs. Helen Beetham
for her secretarial assistance.
REFERENCES
1. MILLER, A.: Lobotomy, a clinical study, Monograph
No. 1, Ontario Department of Health, Queen's
Printer, Toronto, 1954.
2. TOOTH, G. C. AND NEWTON, M. P.: Leucotomy in
England
Health
and Wales, 1942-1954, Reports on Public
and Medical Subjects, No. 104, Her
Majesty's Stationery Office, London, 1961.
3. FREEMAN, W.: J. A. M. A., 181: 1134, 1962.
4. VOSBURG, R. L.: Amer. J. Psychiat., 119: 503, 1962.
5. PIPPARD, J.: J. Ment. Sci., 108: 249, 1962.
6. SYKES, M. K. AND TREDGOLD, R. F.: Brit. J. Psychiat.,
110: 609, 1964.
7. TREDGOLD, R. F.: Lancet, 1: 1016, 1965.
8. SMITH, A.: Ibid., 1: 765, 1965.
9. MCKENZIE, K. G. AND KACZANOWSKI, G.: Canad. Med.
Ass. J., 91: 1193, 1964.
10. EDITORIAL: Ibid., 91: 1228, 1964.
11. MARKS, I. M., BIRLEY, J. L. T. AND GELDER, M. G.:
Brit. J. Psychiat., 112: 757, 1966.
12. TUCKER, W. I.: J. Neuropsychiat., 2: 153, 1961.
13. GREENBLATT, M.: Amer. J. Psychiat., 116: 193, 1959.
14. Leading Article: Lancet, 2: 1037, 1962.