In a famous incident in 1848, Mr Phineas Gage, a 25-year-old railroad worker, sustained severe damage to his frontal lobes when a metal tamping rod was blasted through his head after a freak accident... Gage`s accidental frontal lobotomy laid some of the groundwork for the surgical procedure of frontal (prefrontal) lobotomy... This operation became popular in the mid-twentieth century; it was done extensively over a period of years not only for psychosis but also for neurosis and depression... recommended for “difficult children”. 1

The Frontal Lobes: An approach Mark Keezer R4 Neurology Dec 1, 2010

Multiple Divisions of the Frontal Lobe Motor cortex Premotor & Supplementary Motor cortex Apraxia Frontal Eye Fields Broca’s Area. 3 3

The Remainder Prefrontal Cortex Orbitofrontal Cortex (OFC) Medial Prefrontal Cortex (MPC) Dorsolateral Prefrontal Cortex (DLPFC). 4

To begin with... Sustained Attention Digit span (7 forward, 4 backward) Serial 7’s WORLD Months/days of the week backwards. 5

Orbitofrontal Cortex Disorder of Social Conduct (right hemisphere) Dis-inhibited, impulsive behaviour Poor hygiene, promiscuity, spending money Poor judgement and insight Emotional lability Euphoria Witzelsucht (transl: joke addiction) Facetiousness, inappropriate levity and senseless joking. 6

Orbitofrontal Cortex On examination Anosmia. 7

Working Memory (perhaps more OFC) Verbal & spatial working memory. 8

Medial Prefrontal Cortex (including Cingulate Cortex) Akinetic/apathetic/abulic syndrome Paucity of spontaneous movement and gesture Sparse verbal output Repetition may be preserved Urinary (& fecal) incontinence Micturition centre. 9

Medial Prefrontal Cortex On exam Lower extremity weakness. 10

Frontal Gait Disorder (perhaps more MPC) “...the disorder represents a loss of integration, at the cortical and basal ganglionic levels, of the essential instinctual elements of stance and locomotion that are acquired in infancy...” Short-stride, shuffling, hesitant steps Magnetic gait Ignition apraxia Turning by small steps with one foot, the other planted as a pivot Retropulsion. Alien hand syndrome as well!

Dorsolateral Prefrontal Cortex Dysexecutive syndrome Ability to plan, monitor, and carry out an activity to achieve a goal Poor judgement Indifference (almost “la belle…”). 12

Dorsolateral Prefrontal Cortex On exam Abstract thought (orange & apple, chair & table, watch & ruler, tree & ant) Judgment “You arrive in Vancouver, you’ve lost your friend’s phone number and they are not listed in the phone book. How do you find them?” Executive function Perseveration due to difficulty abandoning the initial pattern of responses. 13

Executive Function G L A S T C Go-no-go (inhibitory control; 1=2, 2=0) Conflicting instructions (sensitivity to interference; 1=2, 2=1) Louria sequences (fist, edge, palm) Lexical fluency (>11 words in 1 minute = normal) Trails Clock drawing Stroop test String of M’s and N’s Applause sign. G L A S T C Lexical fluency more left hemisphere 14

Frontal Release Signs (perhaps more DLPFC) Palmar grasp Don’t warn them, just lay their hands down and touch then and see if they hold your hands spontaneously Glabellar tap (Meyerson’s sign) Palmomental reflex (the only with localization value) Snout reflex Rooting reflex Utilization behaviour Echolalia & Echopraxia. 15

A popular procedure was the “ice- pick” lobotomy in which an ice pick was inserted above the eye and pounded through the orbital roof with a mallet, then swept to and fro... The primary proponent of this technique used a gold-plated ice pick and kept speed records for the procedure. A lobotomy was once done on an eccentric actress who had no mental illness... The procedure has been abandoned. 17