Man is a restless animal. He is not satisfied to settle down after his day's work and merely curl up and go to sleep. He has to find some way of exercising his talents for his own enjoyment and for those with whom he associates. When we inquire into the recreational activities of lobotomized patients, we find that there is a certain simplicity in their existence. A wife may find absolutely nothing wrong with her husband. She will insist that he is a good provider, a steady worker, sober, industrious, polite, agreeable, friendly, and everything else. The only difference she may be able to notice is that he likes to go to bed at nine o'clock at night. Now there is nothing particularly wrong with going to bed at nine o'clock at night, but it seems that this is about the period in the evening when wives are sometimes feeling their gayest, and with their evening chores completed, wish to express themselves in music, bridge-playing, reading, or what not.
Patients who have been operated upon for a distressing mental disorder do not experience the same need for recreation that normal, healthy people do. They prefer to take their sports sitting down and will attend ball games, movies and other spectacles rather than participate in more active sports. They enjoy the radio and keep up with the news, but they can hardly be called students of current affairs. Few of them read the editorials or listen to discussions and debates that go on over the radio. If they do go to a gymnasium or to the Y or a bowling alley, or swimming in summer or skating in winter, it is usually in company with somebody else who takes them along, rather than upon their own initiative. They enjoy the games, but the spirit of the contest doesn't mean much to them, and when they get tired they drop out of the game with little regard to the wishes of others. Their endurance may be very considerable, but their persistence in a task once they have lost interest is limited. As one lady said of her brother (Case 320): "He plays ping-pong just as well is he used to, but he doesn't go after the hard ones."
People who have been operated upon prefer the simpler games. A boy wonder in chess (Case 463), for instance, could play chess as soon as he got home after operation although he hadn't touched the board for eight years. His attack and defense were both carried out rather well but definitely below his former standard. Furthermore, he was likely to become diverted from the game by something happening in his vicinity, lose interest and get up from the table while the opponent was pondering a move. Other patients can play contract bridge satisfactorily, but no matter how many honors they hold will not initiate a bid. They will follow along satisfactorily, but their plan of attack is rather limited and they do not get much of a kick out of the game. Since three other people are dependent upon the interest and enthusiasm of the patient, this sometimes proves rather disappointing. Gin rummy is more their speed, a game that goes along in desultory fashion; partner and opponent being the same individual, it doesn't matter much whether the patient wins or loses.
Reading tends to sink to a somewhat lower level. People who previous to operation had been absorbed in their studies of philosophy, psychology, world affairs, medieval history, and so on, find that their preference turns to action stories, murder mysteries, the sports page and the comics. One lady (Case 382), who reads a great deal, completed "Gone with the Wind" five times in the course of a year. People who were formerly assiduous readers of the Bible tend to continue reading the same, but for shorter periods of time, and they admit to a falling off in their interest and absorption in the Book. Many of these people write letters, and sometimes long ones, but nevertheless on a somewhat superficial level, describing events rather than penetrating beneath the surface and interesting themselves in motives and their own reactions to them. Their procrastination in the matter of writing letters when we ask them for news of themselves in the years after operation is sometimes provoking. Their good intentions are certainly there, but they put it off, and even when invited to telephone and reverse the charges they often put that off, too. Nevertheless when we get them on the telephone, they are quite cheerful and cordial, answer questions without embarrassment and promise to do better next time.
When patients are asked about their activities, they will stress for the most part the day-to-day events — where they have been, what movies they have seen, and so on, but their recreations are for the most part few and simple, of the spectator type, and they do not go in at all for hobbies. There are a few exceptions to this rule, such as Case 215 who devoted a good deal of care and attention to a first-class garden, even when she didn't have to. As a rule it is the other person who applies the motive power.
People who have undergone prefrontal lobotomy and have become adjusted in society get along quite satisfactorily without feeling the necessity for advancing the welfare of the community. They tend to take things as they come, and while they may attend meetings of the citizens association or the lodge or the parent-teacher organization, or the church, as a rule they do not have much to say where planning is concerned, and they do not take part in campaigns of one sort and another that are meat and drink to so many socially-conscious individuals. They would rather go to movies than to lectures, and if they do take courses in interior decorating or the modern American novel, it is usually at the behest of some member of the family rather than their own urge for betterment. They are cheerful extraverts who do not take life or themselves too seriously. When the motivation is sufficient and somebody gets behind them and really pushes them into doing something, they will cooperate quite satisfactorily. But they don't look around to see what needs doing; they don't marshal their forces, get other people interested, sit down at the telephone or at the typewriter, address envelopes or collect money for the schoolboy patrol or the local Democratic party or for the repair of the organ at the church. It is not that they are diffident, or that they are lacking in energy, or that they are surly and disagreeable and unwilling to help out where a need is shown. It is just that they lack the spark that sets normal people to doing things for the betterment of the community.
What has been said in this regard applies to the great majority of people, but once in a while a person whose psychosis has not been of great duration or severely disorganizing is able to rise in the social scale to a point of leadership in the community which is almost to be expected of these sensitive and gifted individuals. That such activities are possible, even in the presence of major damage to the frontal lobes, is shown in the following case, which is quoted in some detail.
Summary. A 28 year old mother of three children underwent prefrontal lobotomy because of an intense suicidal drive, and the further obsession that only prefrontal lobotomy could relieve it. After six weeks of hospitalization and brief shock therapy with no improvement, prefrontal lobotomy was performed September 16, 1938. The patient was not disoriented and rapidly recovered her alertness. She soon resumed her interest in the household, and later on in community activities.
Comment. Here is a woman who has time and energy not only to run a nice home and keep her husband and three children interested, but also to expand her activities outside of the home and enter the sphere of recreational, social and religious activities. According to her husband, she is more normal now than he has ever known her although there was a period of two or three years following operation when she was rather hasty, undiplomatic and outspoken, as she herself well recognized. She also states that she tends to take things more calmly and without the ups-and-downs, the emotional storms, the ecstacies and the moody desperations that she experienced in early life. She thinks she has grown up to take the world for what it is and to carry out her part toward its betterment. It is impossible to detect any lowering of social effectiveness in this particular person, and she has been followed rather carefully for a period of ten years. Her complete demoralization during the period of her psychosis and later progressive reintegration bring up the interesting question of morale in relation to the frontal lobes, which deserves some consideration before going on to the question of the highest achievements of man in regard to creative capacity.
Satisfaction spells stagnation — this has been the phenomenon too often present in our operated patients. We like a certain dissatisfaction with things as they are. We would specify, however, that it be a healthy dissatisfaction rather than an unhealthy one. A healthy dissatisfaction concerns external things that need improvement; an unhealthy dissatisfaction concerns the self and tends to become obsessive.
A great deal has been heard in recent years concerning morale and demoralization, particularly in connection with the armed services. We think that something may be gained by examining morale from the standpoint of personality functions as detailed in these frontal lobe investigations.
As we conceive it, morale is that quality of the human individual that places group interest above self interest. It might be termed that holos function of the human being, the social function as opposed to the ego function which is so definitely related to the frontal lobes. Morale is one of the most elevated of the personality functions. It is late in developing, is subject to marked fluctuations in states of health and disease, and it tends to recede with advancing years. It requires vigorous health for its maintenance. The child doesn't have it, nor does the old man, nor does the sick man, nor does the bored man. When a person is afflicted with a mental disorder, it is among the first of the functions to be abolished. Whether the individual is suffering from a mild anxiety neurosis that prevents him from putting forth the little extra effort that is necessary to accompany his wife to a parent-teacher meeting or whether it is a profound disturbance in personality function that develops either along the lines of intractable hypochondriasis or an elaborate system of paranoid beliefs, the individual who allows the attitude toward himself to take precedence over his duty to society is in some measure suffering from demoralization.
Morale is that quality which makes an individual lay down his life if necessary in order that his organization shall survive. It is not mere aggressiveness against a mutual enemy; it is not mere unfaltering toleration of discomfort, pain, deprivation; it is not even a conviction that Heaven is the reward of unstinted devotion. There is something active about morale, something vivifying, energizing. It makes the organization something more than a collection of individuals. It makes it a unit of itself — a social unit with the individual components competing to find better ways of doing things for the benefit of the whole. It consists of seeing what ought to be done for the betterment of the unit — the organization. Morale reaches its highest pitch in combat with a seasoned, alert and implacable enemy. In fact, it is necessary to survival both of the individual and of the organization. Then, if ever, each individual of the organization is employing his faculties to the limit of his capacity to foresee probable moves of the enemy, as well as of his own unit, in order to be prepared to take his part in the struggle for existence. Disregarding his own danger, he thinks only in the terms of danger to the organization of which he is a member.
Fluctuations in morale are inevitable and to be expected. Anything that takes the attention of the individual away from his unit and focuses it upon himself causes a drop in morale; in fact, it is demoralization. Consider the member of the combat team who suffers a minor injury. If his morale is sufficiently high, he rejects the suggestion that he return to the rear and have it attended to, but if his morale is not quite high enough he accepts this suggestion. The same situation is met with in varying degrees in connection with other discomforts. Fatigue, hunger, exposure, loss of sleep, thirst and pain — all these have a straining effect upon morale, and the worst of them is anxiety. Fear of external happenings — apprehension, that is — is compatible with high morale. Any soldier is expected to be afraid of death or injury. But anxiety — the fear that wells up from within — is destructive to morale. Here there is a blend of anticipation of the future and consciousness of the self powered by an emotional toning that destroys the effectiveness of the individual for the unit of which he is a member. He becomes helpless in the coils of doubt and indecision, incapable of action, a liability — even a menace — to his fellows. Such demoralization is contagious, and the morale of the organization receives a setback even from the presence of such an individual. Fortunately, such demoralization is usually of only temporary character. It is rather obvious that in patients presenting a varied array of symptoms there is a concentration of the attention upon the functions of the body which ordinarily pass unnoticed by the individual in good health. Furthermore, the patient is inclined to interpret the symptoms in relation to future consequences. Both of these aspects of human existence, the self and the future, are very personal, very unpredictable, very variable, and consequently are associated with an affective toning that may result in preoccupation with fixation.
The exposure of an individual to a situation will leave certain physical changes in his nervous system which remain latent until some unaccustomed strain acts as a developing agent, bringing to light a constellation of symptoms. This may remain vague and unclear if the strain is relieved, or it may fade back into obscurity if the exposure is accompanied by increasing tolerance. However, if some precipitating factor, bearing an affective charge, occurs at the critical time, the constellation of symptoms emerges in bold relief and neither rest nor explanation nor further exposure to the situation can be expected to dull the image. All of the functional disorders — the hysterias, the neuroses, the psychoneuroses, the obsessive states, the hypochondriases, and also the schizophrenias, the paranoias, and the various tension states, have the same egocentric signature, the same personal attitude that is characteristic of demoralization. They also have the same abnormal preoccupation with the future, preserved and strengthened by a strong affective toning. We believe that the ideas in regard to the self and the future are elaborated by the frontal lobes but kept in operation by the emotional components applied by the thalamus.
Severing the connections between the thalamus and the frontal lobes abolishes the emotional component, makes the individual no longer interested in the subjective experiences that were so absorbing to him previous to operation. Prefrontal lobotomy also does away with concern for the future, especially as regards the individual himself in contrast to appreciation of the future in impersonal terms. This is subtle distinction. The patient has enough foresight to carry out effective work in order to gain his livelihood, but he is definitely not concerned over the possibility of personal failure, of disease, death and damnation — effects which might have loomed large in his consciousness previous to operation. Furthermore, the pathologic elaborations in the form of hallucinations, delusions, and especially visceral sensations, undergo immediate or gradual extinction. It is as though the fires of emotion that have kept these ideas glowing have become extinguished and the ideas reverted to psychological ashes.
Eliminating the affective components supplied by the thalamus does away with preoccupation with the self and the future, and consequently abolishes the demoralization that is synonymous with psychosis or neurosis. However, it must not be concluded that prefrontal lobotomy restores morale. The individual who has to undergo prefrontal lobotomy for the relief of his demoralization must usually sacrifice some of the holos functions of the personality that were mentioned earlier. Such an individual is concerned only to a limited degree with the advancement of members of his family or organization. He takes a practical interest in the group, does his share of the work but little of the thinking. He is incapable of engineering a long-range plan for the betterment of his associates. He goes through the forms of social and religious observance, but without the deep emotional conviction that characterized him before his illness. He makes his decisions along practical lines, finishing up his thinking on a rather immature basis and seizing upon immediate conclusions rather than looking beneath the surface to estimate the implications in terms of advancement of the whole group. He may be capable of prolonged thought, but he is lacking in the ability to express the deeper side of his nature. Creative work, as in writing, music, painting, poetry, is a relative impossibility, and social service is apt to be foreign to his ways of thinking. He approaches a problem in a direct and practical manner, without considering beforehand the social implications. A devious and considerate approach to the situation involved in winning the esteem of a loved one is apt to be beyond his capacity. He is usually rather ingenuous, light-hearted, undiplomatic and immature in his interpersonal relations. He cannot worry. Self-sacrifice, altruism, reverence, patriotism, contemplation and introspection no longer interest him. He may be tolerant and reserved and dignified in his dealings with other members of the family or society in general. He often maintains an excellent social manner, free from any embarrassment or self-consciousness, but it is this very fact that reveals a certain shallowness of the personality. Something of value has been lost in the process of prefrontal lobotomy, something which Bianchi called attention to many years ago as the "social sense," something that we might speak of as the holos function of the personality as opposed to the ego function.
Morale is such a vital factor in success in the armed forces that very few patients can make a successful adjustment there after prefrontal lobotomy. Quite a number of our patients have been turned down when they tried to enlist, although others were quite helpful during the war in civilian capacities. One of our patients (Case 15) succeeded in his efforts to get into the service and was assigned to the military police. He was an unstable psychopath with alcoholic tendencies before operation in December 1936. After a number of years of varying adjustment he entered the Army and throughout the training course enjoyed excellent health and freedom from his alcoholic indulgences. Just before his unit was to be sent overseas he was detached from it, however, and kept on this side, and trouble shortly developed. After the first and second courts-martial he was referred for psychiatric study, but only on the third occasion was the psychiatrist able to make his diagnosis stick, with the result that the patient received a medical discharge. Since then his adjustment has improved, rather than regressed, and his dissipations have practically ceased. Here again we can thank Alcoholics Anonymous for a major contribution to stabilization of this erratic individual.
Case 69 is a good example of satisfactory adjustment under war conditions following prefrontal lobotomy.
Comment. This man presented an anxiety neurosis of fifteen years' duration with disability, practically complete, of four years' duration. Following the relief of the anxiety, he manifested a certain indolence and tactlessness but this was not sufficient to keep him from functioning satisfactorily in his employment and taking his part in the war effort. When last seen he had service ribbons for the Atlantic, Near East and pre-Pearl Harbor and a star for a ship sunk by enemy action. His career has been an outstanding one among those who have undergone prefrontal lobotomy.
Morale is dependent upon harmonious functioning of the frontal lobes. Powered by an affective charge from the thalamus, it is in delicate balance and can be lowered rather easily by adverse circumstances in susceptible individuals. Demoralization is the keynote of mental disorders and is found also in a great variety of physical disorders accompanied by bodily discomfort or pain of various sorts that focus the attention of the individual upon himself rather than upon the unit of which he is a member. Prefrontal lobotomy, in abolishing preoccupation with self, does away with this type of demoralization. Yet patients who have undergone prefrontal lobotomy are somewhat lowered in their capacity to function as leaders in the group. They have exchanged an egocentric attitude for an egotistical one and are a bit too content with things as they find them and lacking in the imagination to see things as they ought to be. Furthermore, they do not experience the thrill and the drive toward execution, performance, perfection, that they might have had in their earlier days before the vicissitudes of life and surgery.
The two examples we have cited in which morale has returned to a high level have been patients who were never seriously disorganized by a psychosis. They had suffered rather from anxiety and emotional tension, without the devastating effects upon the personality as a whole that comes from long-continued lapse into psychosis. We believe that morale is a function of the frontal lobes but is very easily perverted by a psychosis and seldom restored to its pristine glory. The fact that some individuals after a disabling neurosis or psychosis and a major operation on the brain have regained this function speaks well for the healthy organization of the personality beneath its super-structure of neurosis. At the same time, the efforts of family and friends in the restoration of the operated individual to effective living must be recognized. It is all too easy to cultivate in the patient who has undergone operation, an attitude of passive acceptance of support, of indolence and procrastination that is harmful to adjustment at the highest levels of the social individual. The holos functions can be cultivated in these patients, just as they can in the youthful individual, by friendliness, firmness, consideration, and an attitude that fosters the self-esteem of the individual in assuming a useful place in society.
There is little to be said on this subject. We have not infrequently operated upon patients who have experienced religious exaltation and others too numerous to mention who have considered themselves endowed with mystic powers or under the influence, beneficent or malign, of unexplained spiritual forces. These tend to disappear after operation, and their place is taken by rather matter-of-fact mode of religious observance to which they have been accustomed but without deep conviction or enthusiasm. A successful wife of a successful minister (Case 228) does everything that her husband could expect of her, including piano teaching and accompanying at evensong service. In most instances — beyond attending church and singing with the congregation or in the choir — the externals appear to be sufficient. These patients are direct, practical and uninspired. Their beliefs are somewhat childlike, are seldom spoken of and are passed over, when direct inquiries are made, as of no particular importance. It is readily perceived that the spiritual life is gravely affected by prefrontal lobotomy.