1. 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

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

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

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

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

6. 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

7. Orbitofrontal Cortex
On examination
Anosmia. 7

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

9. 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

10. Medial Prefrontal Cortex
On exam
Lower extremity weakness. 10

11. 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!

12. 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

13. 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

14. 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

15. 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

17. 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