[P&S; Medical Review:Fall 1998, Vol.5, No.2]

BILATERAL FRACTIONAL RESECTION OF FRONTAL CORTEX FOR THE TREATMENT OF PSYCHOSES^$

Robert G. Heath, M.D. and J. Lawrence Pool, M.D.
From the Department of Neurological Surgery

( Read before the American Academy of Neurological Surgery, Colorado Springs, Colorado, October 1947)

Since October, 1946, we have been treating psychotic patients with bilateral ablation of specific parts of the frontal cortex. Although the series is now quite large, only 4 have been followed for longer than eight months. We shall, therefore, confine this preliminary report to these cases. The aim of the procedure was to obtain improved behavior by a specific, limited removal of cerebral cortex which, it was hoped, would avoid the risk of certain complications, such as deleterious alterations of behavior and persistent incontinence, that sometimes follow prefrontal leucotomy or lobotomy.

No report of a case bilateral cortical extirpation except for removal of specific cellular pathology is to be found in the literature. Our decision to remove a circumscribed cortical area was based on the animal experiments of Richter and Hines, and of Mettler. This work suggested to us that bilateral removal of analogous areas from the cortex of psychotic patients might well result in specific behavior changes which would be of benefit to the patient. Therefore an effort was made to resect bifrontally a segment of cortex containing at least the rostral portion (the larger part) of each Brodmann's area no. 9. No attempt was made in this series to ablate area 9 in its entirety owing to the proximity of its caudal margins to the motor and speech areas. The method of cortical resection in the 4 reported patients may be described as follows:

(1) Anesthesia: Preoperative medication: Morphine sulphate, 0.015 gm.; scopalamine, 0.0004 gm. (by hypodermic). Anesthesia: sodium pentothal, intravenously, supplemented by local infiltration of the scalp with 1% novacain. An intratracheal tube was passed on each patient to provide for the administration of nitrous-oxide-oxygen, by which anesthesia was maintained for the major part of each operation.

(2) Surgical Technique: In one stage, a bifrontal coronal scalp flap was reflected anteriorly, based along the supra-orbital ridge, and crossing the vertex at the coronal suture line. Bifrontal bone flaps, hinged on each temporal muscle, were then turned and carried as far anteriorly as the extent of the frontal air sinuses would permit. The bone overlying the superior longitudinal sinus was left intact. The dura on each side of the midline was then reflected in a medial direction, and cortico-dural vessels were divided between silver clips or lightly cauterized with the electrocautery. The boundaries of the proposed cortical resections were indicated by a black silk thread laid upon the exposed surface of the cortex. Anatomical landmarks, such as the three frontal gyri, the precentral sulcus, etc., served as guides for the placement of the thread markers. After hemostasis along the designated line by means of silk ligatures or silver clips, the desired segment of cortex was removed after sharp dissection with a No. 11 scalpel blade cutting at right angles to the surface of the brain, to the depth of the underlying sulci; that is, to the fullest extent of the gray matter but no further. As indicated in the accompanying diagrams (Figs. 1-4), the resected cortical segments were not identical in configuration or site, although all of them included, approximately, the rostral third of the superior frontal gyrus and an adjacent portion of the middle frontal gyrus. The medial or parasagittal portion of the superior frontal gyrus was always included in each block of resected tissue. The approximate shape and site of each removal, as judged by measurements, inspection at operation, photographs, and postoperative x-ray studies, are indicated on the accompanying diagrams (Figs. 1-4).

In Cases 1 and 2 the electrocautery was not applied to any portion of the brain at any time, hemostasis being achieved entirely by means of silver clips, ligatures and the supplementary use of absorbable oxidized cellulose ("Hemopak," Johnson and Johnson, New Brunswick, N.J.). In Cases 3 and 4, however, hemostasis and resection were in part accomplished with the aid of electrocautery. In every case, penicillin solution 1:1000 was introduced into the cerebral wound in 5.0 cc. amounts on each side before dural closure. The dura, periostium, muscle, galea and scalp were finally closed in layers with interrupted black silk sutures. Small rubber drains were used in 2 cases and removed 24 hours postoperatively. During each operation, 500 cc. blood and 1000 cc. 10% glucose solution were administered intravenously. The average duration of these procedures was five and one-half hours. During operation no significant variations in pulse or respiratory rates, color or blood pressure were observed.

Case 1.The first case was a 58-year-old white female, suffering from manic depressive psychosis for 28 years. Hospitalization was necessary throughout this period as she seldom stabilized. Surgery was recommended because she had become a difficult problem in management. The referring physician noted:"She is often destructive, displays abnormal erotic trends and is careless in her toilet habits."...

At the time of admission she was hypomanic, displaying increased ideation and flight of ideas. There was an abundance of affect apropos of rapidly changing moods. During the initial interview she was mildly elated. She dramatically pleaded for freedom, advancing many reasons why she should be discharged. She insisted that she was all right and pleaded for an opportunity to visit spots of interest in the city. Emotions were shallow and she quickly changed from an inane euphoria to tears and dejection. Vague persecutory ideas were apparent; she condemned every doctor who had cared for her in the past and insisted that she had been institutionalized unjustly. On one or two occasions she had attempted to instigate legal proceedings against the offenders....

Her husband was 17 years her senior and she stated, "We never had strong emotional feelings for one another. We were like long-time companions." She became tearful in complaining of his neglect. Frequently she asked if sexual matters were important in one's emotional life. The sensorium was clear but judgment was markedly impaired. Insight was lacking. Dramatically moving her arms, she dismissed the story of 26 years of illness by saying, "I'm sound as a dollarin the past there was a little manic depressive illness in the family. We're the sort of people that keep the world moving, up one minute and down the next."

This patient was operated on Oct. 22, 1946. The next morning she was alert, responsive, and much more tractable than she had been the previous day. Her memory was intact for recent and remote events. The interview was much more productive than any of the preoperative sessions. She was forthright and displayed none of the evasiveness and emotional lability so outstanding before operation. She asked why she had not been informed ahead of time that she was to be operated on, adding that it was all right since she had complete faith in her physicians. Insight was increased as indicated by the fact that she readily accepted the explanation that her judgment was faulty at the time....

After two weeks of hospitalization she was transferred to a convalescent home. She was cheerful, frank and uninhibited. Preoperative egocentricity was displaced by concern for others and an interest in things outside herself. At that time her physical condition was excellent. Careful neurological examinations by several examiners were negative throughout the postoperative period.

During two months at the convalescent home her adjustment was excellent. There was little change in the mental picture. During several trips to a nearby village she behaved well and displayed good judgment. Further institutionalization was deemed unnecessary. However, since members of her family were unable to care for her, arrangements for her board at a convalescent home were made.

Twelve months postoperatively a follow-up report from the superintendent of the home stated that the patient "has been doing very well in every respect. She is inclined to become tired unless she watches her activities closely. Mentally she is in first class condition. We are rather pleased with the result attained by the procedure."...

Case 2This patient was a 42-year-old Hebrew housewife operated on January 27, 1947. Surgery was recommended after electroshock therapy proved ineffective and institutional management became difficult. The diagnosis was schizophrenia and the presenting symptoms were persecutory delusions, auditory hallucinations, confusion and periods of marked overactivity with destructiveness alternating with inertia. The first psychotic episode in 1936 lasted five months and during it she displayed inertia and was very confused. She then made a marginal social adjustment until January, 1943, when she became obstreperous and demanding, appeared wild and excited and was hallucinatory. She was obsessed with the idea of killing her husband and stated he failed to satisfy her sexually....

On admission the patient was quite disturbed and assumed bizarre dramatic postures, at times looking to heaven with arms outstretched. She frequently made dramatic gestures with her hands. Regularly she threw herself to the floor, sometimes with sufficient violence to bruise herself. She crawled to the feet of the examiner and pulled herself up by his trouser legs, looking longingly into his eyes and fondling his wearing apparel. There were frequent impulsive changes in behavior in which she suddenly retreated as if ashamed, clamped her thumb and finger about her nose, and said, "I stink! Do you smell me?" Occasionally objects on her dresser were forcefully thrown to the floor. Her facial expressions ran the gamut of all emotions and there was usually a distant, dazed look in her eyes. Her hair was unkempt and streamed over her eyes.

She was often boisterous and rambling, very talkative, speaking alternately in English and Yiddish. The examiner was often referred to as her lover; appeals were frequently made to the deity. Her speech reflected ideas that she might be harmed by poisonous food, that she emitted offensive odors, etc. Considerable affect was present but was completely inappropriate. Persecutory delusions were apparent. She was hallucinating in the auditory and olfactory sphere. Frequently she listened and answered voices. Delusions of impending harm were evident from her conversation. Memory and recall could not be evaluated because of her disoriented state. There was no insight....

The patient was operated on January 27, 1947. Twelve hours following operation she was bright and responsive, called the doctors by name, and inquired as to their health. By evening she again appeared somewhat dazed and confused. The confusion and disorientation persisted for 10 days. When one of the doctors first entered the room she gave signs of momentary recognition, but then again would stare into space with vacuous eyes, express delusions, and occasionally complain of olfactory hallucinations. At times she perseverated and usually she was much distracted by objects in her environment. At no time did she show any of the intense agitation so outstanding before operation.

After ten days the marked disorientation and confusion began to subside. She became somewhat euphoric, garrulous and very distractible. Following are excerpts from a conversation on the 11th postoperative day. She asked how she looked with her head shaved, but did not appear to be concerned about it. She mentioned several times that she now had five hats. Frequently she showed considerable abandon and lack of inhibition: "You are very sweet, I like you. I am fond of you for many reasons." When asked to list them, she was unable to give specific reasons: "Dr.........is very sweet. He dropped in for a minute and said he had a big operation, and left. He is always so nice."...

On one occasion, about two weeks after the operation, the patient was incontinent of feces after taking a laxative. She spoke of this quite openly without embarrassment.

Auditory hallucinations disappeared after the operation. During the third postoperative week the distractibility and garrulity began to subside. For several days before discharge, on the 26th postoperative day, the patient discussed with insight the nature of her delusions....

When seen two weeks after her discharge (five and one-half weeks after operation) it was apparent that the patient had improved greatly. The husband stated that she was making a satisfactory adjustment to her home. He felt that she was more distractible than before her illness and that it was necessary to push her somewhat to get her to complete any given task. On several occasions the patient went shopping by herself, showed good judgment in the items which she purchased, and had them charged as she customarily did. He complained that she occasionally woke him up at night when she desired to go to the bathroom. Otherwise her behavior seemed much the same as it was before her illness began. She conversed freely with her friends and recognized most of the people that she knew in her local community prior to the onset of her illness. Her sense of humor had returned and she was already taking over some of the household duties. She did most of the cooking, was meticulously neat in her dress, bathed frequently, and kept her house clean and orderly.(A housekeeper was then employed to help her with the housework .) ...

About three weeks after going home the patient assumed complete charge of her home and the housekeeper was discharged. She performed efficiently in all spheres except that her planning was defective. In cooking she was unable to time things so that the different foods finished cooking at the same time. A roast was either burned before the first course was finished or else was raw when the other food were overcooked.

The extraversion and marked garrulity so apparent in the early post-operative period gradually lessened markedly and her abilities as a conversationalist improved. Her libido increased markedly, but there was no promiscuity. She showed none of the tensions suffered by others concerning world affairs. In some ways her affect was more appropriate than it had been preoperatively. Before operation she showed no interest in attending memorial services for her father and did so only under pressure and with little expression of sorrow. She expressed interest in attending a recent service and during it wept and at times sobbed aloud. The emotion was fleeting, however, and she became cheerful as soon as the environment changed....

When last seen, 12 months after operation, she was resuming work as an antique dealer in addition to her housekeeping. The marked defects in integration, present in the immediate postoperative period, have largely disappeared. The sister, who is a very keen observer, feels she is no different than she was before the psychosis began. No defect is evident in learning. Eight months following operation she learned to play mah jong without difficulty or delay. On close study, vague schizoid tendencies, apparently present all her life, are evident.

Case 3This patient was a 32-year-old single Jewish male, a salesman. He was a catatonic schizophrenic who was referred for lobotomy because he had become a difficult problem in hospital management. Periodically he became excited and was assaultive, obstreperous and destructive at such times. Psychotic manifestations appeared gradually during several years preceding his first commitment in 1941 (six years ago) and persisted without complete remission....

Overt psychotic symptoms developed after he was rejected by the draft board as a constitutional psychopathic inferior. He became grandiose, excited and obstreperous. Electric shock, metrazol, and insulin treatments were given at several institutions with little benefit....

The patient was operated on March 17, 1947. From a physical standpoint the postoperative course was uneventful. The wound healed by first intention. The mental picture underwent frequent changes. The hallucinations which were apparent before operation seemed to disappear. Three of four days after the operation he showed signs of clearing. For one or two days he was sociable. Blocking was less apparent. The schizophrenic pattern was, however, still much in evidence in his productions. He then became alternatively negativistic and excited. Usually he lay silently on his back, occasionally muttering to himself. When approached or touched he developed a look of anger and breathed heavily. When the examiner stepped away he would again become quiet.

In the last week of his convalescence this picture changed for a few days and he became more friendly. However, he was still very preoccupied and refused to talk, muttering only a few words in a very hostile manner. At times, during the last few days of his stay, he was very agitated and paced back and forth in his room. At no time was he assaultive. There was no incontinence. Facilities at the hospital were such that long-term observation was not possible and he was therefore transferred back to the sanitarium, essentially unimproved....

Case 4A 22-year-old Jewish male, diagnosed as hebephrenic schizophrenic, was recommended for lobotomy when he became so disturbed as to constitute a difficult problem in institutional management. He was confused, hostile, assaultive, untidy in dress and habits, smeared his feces and was coprophagous. He was delusional and hallucinating and segregation was necessary.

As early as 1941 he expressed ideas of being followed and became more seclusive. Overt psychotic manifestations, making institutionalization imperative, first appeared in May, 1943, when he was given a medical discharge from the Army after two weeks of service. Electric shock was administered with little benefit on several occasions. The family removed him from the institution two or three times but could not care for him longer than two or three weeks because of his assaultiveness and incontinence and his antisocial behavior....

On mental examination at admission he was retarded, almost stuporous, looked dazed and perplexed. There was considerable blocking and affect was flat. The few times that he spoke he was quite incoherent and the content had little meaning.

Occasionally he smiled as if responding to hallucinations. Memory and recall were poor and he had no insight.

The patient was operated on April 25, 1947. During the first two days following operation he was slightly tractable but productions were limited to simple responses to direct questions. He then became very excited, obstreperous, and assaultive, so that restraint was necessary. Attendants and doctors were accused of being perverts and ideas of persecution were expressed by the patient at this time.

Bowel and urinary incontinence continued as they had been preoperatively and he masturbated frequently. He was hospitalized for 18 days after operation. During the last week of his stay there were short periods of excitement and between these he was much the same as preoperatively; that is, unproductive and almost in a stupor. Immediately following operation the auditory hallucinations stopped. The patient was disappointed and stated that he liked the voices because they were encouraging. Under sodium amytal, 12 days postoperatively, he became more talkative and stated that his greatest fear was of going home because he lived in terror that his father would strike him down. At discharge he was considered unimproved, but the family disregarded advice to the contrary and took him home....

To quote the brother, six months after operation:" He is now easy to manage and does what we ask of him, although there is occasionally a delay. We have him on a leash. Basically he's probably the same, but we can handle him."...

Other authors have commented on the complications of lobotomy and some have made attempts to eliminate them by altering the procedure. Kinderall and Cleveland, incommenting on fatalities with lobotomy, state that the largest number of deaths result from the severing of an artery. Ziegler and Osgood note the frequency of edema and trophic changes following lobotomy. Modified techniques have been used to eliminate these complications by Hofstatter, Smokik and Busch, who severed only the radiations from the orbital areas. Schwartz and also Scoville have atttempted to improve the procedure by cutting only the medial portion of the white matter and report good results with fewer complications.

The experimental work on which our procedure is based indicates that the specific beneficial effect achieved with lobotomy; viz., an alteration in affective responses, can be brought about by removal of parts of Brodmann's area 9 and 10 bilaterally.

Richter and Hines, in discussing changes following removal of area 9, state that "the increased activity may be regarded as a result of a release phenomenon, i.e., the removal of the inhibitory influence from the higher centers may permit external stimuli to pass on freely without hindrance or interference to lower reflex centers. Actually the animals did show a greatly heightened distractibility, responding to all kinds of stimuli." Mettler describes similar effects from removal of area 9:" Bilateral removal of area 9 results in the appearance of a monotonous, sustained, ambulatory pattern of mild intensity (mild spontaneous overactivity)." He indicates further that bilateral removal of areas 8, 10, 11 and 12 does not, by itself, result in notable physiological changes in his animals, but that the effects of area 9 removal may be enhanced by the additional ablation of one or more of these aforenamed areas.

We attribute the absence of complications with this circumscribed procedure to the fact that a large percentage of the radiations between cortex and lower centers remains intact. Until recently reports in the literature have indicated that bifrontal excision of cortical tissue produced a deleterious effect on behavior. Brickner; Nichols and Hersit; Mixter, Tillotson and Weiss. Freeman and Watts in 1942 stated:" No patient with bifrontal lobectomy has yet been able to work for a living." In all of these cases, however, there was cellular pathology with more extensive brain involvement than frontal cortex alone. In 1945, Hebb, in a follow-up report of a case operated on by Penfield in 1940 for removal of bifrontal cortical scarring, offered evidence to contradict this idea. His patient was not only successfully employed, without unusual behavior trends, but was, in fact, functioning on a considerably higher level than before operation.

The results in our cases, operated on because of incapacitating behavior patterns but without demonstrable cellular pathology, support Hebb's contention that tissue can be removed from the frontal cortex bilaterally without deleterious effect on behavior.

(1) Bilateral circumscribed extirpation of frontal cortex was done on 4 psychotic patients. Two made a social recovery. Of the other 2, who were deteriorated schizophrenics, one improved sufficiently to be at home under supervision and the other improved only temporarily.

(2) Complications frequently seen following lobotomy did not occur in this series.

(3) This is the first report of bilateral removal of cortical tissue in brains without gross cellular pathology. There were no deleterious effects on behavior.

(4) A more extensive report on a larger series of psychotic patients with circumscribed bilateral cortical ablation will be made shortly.

Freeman, W. and Watts, J.W.: Psychosurgery. Springfield, Ill.:Charles W. Thomas, 1942, p. 75.

Hofstatter, L., Smokik, E.A. and Busch, A.K.:Arch. Neurol. & Psychiat. 53: 125, 1945.

^$This is an excerpt of the original article which appeared in The Journal of Nervous and Mental Disease, 1948, vol 107, pp 411-429. Reproduced by copyright permission of Lippincott, Williams, and Wilkins. copyright ©, Columbia-Presbyterian Medical Center