No Title

Abstract

From the above findings and discussion, the following conclusions seem to be justified: 1. Restricted orbital undercutting, as described, is a precise operation, and is consistent in reducing the emotional tension of anxiety states, depressive states of any kind, and obsessional states. 2. This reduction of tension varies in degree, but is generally considerable and at once evident to the patient and to the clinician, and is demonstrable by psychometric tests. 3. There is some blunting of emotional tone, and some reduction of standards, which is beneficial if they were previously abnormally high. 4. The subsequent progress varies greatly: some patients show steady progress to full clinical recovery and full capacity for work; some reach a rather lower standard, but can still leave medical care and can work at almost full capacity. These groups between them form about half the total of the two series of cases studied from 11 years' work. Others, though clinically improved, still need medical care and have greater impairment of capacity for work. Others show improvement, and then relapse, though of these 55 per cent. recover again. Just over 3 per cent. showed no improvement at any time. But nearly all patients had ceased before operation to respond to other forms of treatment. 5. This subsequent progress depends on various factors: ( i ) The diagnostic category: the great majority of recurrent (endogenous) depressions recover, and have no more attacks. Reactive and involutional depressions are mostly freed of medical care, though some still need it and others relapse. Anxiety and obsessional states nearly all improve, but most still need care, and relapse is commoner. Schizophrenias with marked tension derive benefit, but others are not improved. ( ii ) Previous personality: those with schizoid and paranoid trends are unlikely to benefit; those with severe obsessional trends may benefit, but are unlikely to reach full recovery. Inadequate personalities will be unchanged, but those with emotional instability or marked tension may benefit from a decreased sensitivity to stress, enough to work usefully and without medical supervision. ( iii ) Duration of illness: more than 5 years' previous illness is associated with a lower recovery rate in depressives and anxiety states. ( iv ) Circumstances after the operation: the sense of support at home is of prime importance, especially in the reactive depressives, anxiety and obsessional states. A job to go to is of considerable value. 6. The operation produces in some a release of hostility; this is by no means necessarily harmful, being often a step towards recovery, but if handled unsatisfactorily can be damaging. Lack of consideration and blunting of affect also need help—and re-education. How well this can be done depends partly on the factors in the environment listed above. If anti-social habits, such as alcoholism, are allowed to develop, the prognosis is poor. 7. In a few patients in whom symptoms persist, this can be attributed either to the original disease or to the effects of previous treatment; the latter was not common. Both must clearly be considered when facing a decision to operate at once or to try other means of treatment first. 8. A decision to operate must take careful note of the symptoms, especially the degree of tension, of the diagnostic category, and of the duration of the illness; and must weigh up these against the factors in the environment that the patient will go to, and the help he will get, and also consider his chances of major improvement by any other treatment. 9. But certain risks must also be remembered. In this series: ( i ) Death from operation occurred in some 1.5 per cent. of cases; ( ii ) Epileptic fits in some 16 per cent. No evidence has been found here to throw light on the reasons for either, but the latter was seldom of great significance; ( iii ) Adverse behaviour changes may occur as a result of the operation, and not be influenced by after-care; but the risk of this appears to be of the order of some 5 per cent. This is very considerably less than findings reported for the results of other operations.