When prefrontal lobotomy has been carried out in the plane of the coronal suture, there is little interference with motor function. For a few days there is apt to be some masking of the face, plateau speech and urinary incontinence, but even as early as the day after operation the patient is able to sit up, feed himself, read the newspaper, and walk, although a bit unsteadily. He can write with pencil or pen in his normal script, can manage buttons and tie knots, smoke cigarettes and manipulate the parts of a picture puzzle. Reflexes are usually normal, the Babinski sign is flexor, and only the abdominal reflexes may be absent. By the end of a week even these minimal signs clear up and nothing in the way of motor disturbance is noted.
Patients who have been operated upon behind the plane of the suture show more marked and prolonged pathologic signs. We have a sufficient number of these now to be able to form some conclusions as to the parts of the frontal lobe that are necessary for dexterity in performing some of the complicated acts that have previously been habitual with patients. In estimating these we have been obliged to eliminate some patients in whom the incisions were incomplete, and others in whom the incisions were complicated by arterial lacerations, infected wounds or pre-existing organic brain disease. Furthermore, there is some doubt about the validity of certain tests in patients who have been catatonic for a prolonged period.
The following cases illustrate that when the lobotomy is performed more than 15 mm. behind the coronal suture impairment of motor skill is severe and persistent. In the course of our investigations of prefrontal lobotomy we found that we cannot trespass behind this plane without causing disability, whether the incisions are in the upper or lower quadrants. Posterior incisions in the upper quadrants are apparently useless as well as injurious.
The case in which the most posterior incisions were made was a 41 year old woman (Case 88) who had responded temporarily to a standard lobotomy (Fig. 77). This patient was completely incapacitated after the second operation. She could chew but not swallow for three weeks, could not speak a word but could utter peculiar inarticulate cries. When a sheet was placed between her teeth, she clamped her jaws upon it and would not let it go (bulldog reflex) (Fig. 78). She would turn her head and eyes in following an object but not upon command. There were no spasmodic laughing or crying spells, nor was there a startle reaction. Upper and lower limbs were hypertonic with perseveration and reflex grasping. The Babinski sign was positive and remained so. Edema and trophic disturbances were absent. Recovery from the disability was very incomplete. After two years the patient was able to walk only with support, she could not feed, bathe or clothe herself, she could not articulate distinctly, but continued to make loud cries on many occasions. She was remarkable chiefly because of the range and volume of her expectoration; six to ten feet was observed on a number of occasions, and her accuracy was remarkable. The "wind-up" was a bit deliberate, and she often succeeded in turning her head at the appropriate moment so that the spittle avoided the handkerchief held by the nurse and reached its mark on her husband or elsewhere. This patient could neither sit down nor get up out of a chair. She could not manipulate buttons or strings, could not use scissors or pencil. To the end she showed marked reflex grasping with both hands and a clutch reaction in the toes. Reflexes were increased generally with plantar extension. She was incontinent of urine and feces.
Incisions were made far posterior to the coronal suture in a 41 year old catatonic individual (Case 219) who had been sick off and on since 1918 but who had known a brief period of normality following insulin shock in 1937. He was operated upon twice in January 1944. After the second lobotomy, 2 cm. behind the plane of the coronal suture (Fig. 79) there was profound depression of all activity, so much so that pulmonary atelectasis developed, but he survived in a badly dilapidated condition. Edema developed in the lower limbs. Recovery of motor functions was slow, and with a great deal of inertia, apart from the catatonia which disappeared. Three years after operation he could walk, run, skip, hop on either foot, throw and catch a ball, feed himself with proper utensils, manipulate buttons and zippers but not shoelaces. He could smoke cigarettes but let a pipe or a cigar go out. He could shake hands, kiss his wife, move parts of a picture puzzle about but not fit them together accurately. He could deal cards, pick up his hand and play the cards but without regard to suit or even color. He could not dance nor play the piano nor use a typewriter, and his former skill at pocket billiards was gone, although he held the cue correctly. His speech consisted of a few names, usually repeated only after considerable urging, although he could write somewhat better to dictation and in his usual script. He still showed some hypertonus and perseveration, with a hint of reflex grasping on the left, and a persistence of pill-rolling tremors that had been present for years preceding operation. For a long time after operation he had to be pulled out of his chair and backed into it, but he recovered these abilities, being able to get up a year or so sooner than being able to sit down. Also he was for a long time unable to stoop down and pick up something from the floor. He still has very incomplete control over his sphincters, and recently for the first time has achieved success in the rather complex act of masturbation. His facial mimicry is decidedly less than normal although much less strained than it was during the catatonic period. A peculiar shaking of the head with high-pitched tittering or crowing sound is his chief accomplishment in the matter of interpersonal communication. When he does speak, it is often with repetition of syllables: yes-yes-yes-yes-yes.
Permanent neurologic residuals are even fewer in Case 221 whose operation was performed in March 1944 after a schizophrenic psychosis of almost 20 years' duration. The first operation failed to relieve the disturbed behavior, so a second one was performed 1.5 cm. behind the coronal suture (Fig. 80). Severe inertia developed with edema of the lower limbs that was slow in clearing up. This patient can dress and bathe herself but cannot fix her hair. She can talk connectedly and coherently although rather briefly. She can play the piano, knit, sew, embroider and crochet, write quite legibly in her former script, with adequate expression. She can play table tennis, dance to music, can tend to her garden. Aside from a certain stiffness in her walk and fixity of facial expression she might be considered neurologically normal. She has regained control of her sphincters.
Case 255, also a schizophrenic of long duration who has been out of the hospital for six years following operation (Fig. 81) can enjoy dancing, fishing, horseback riding, skating and driving her car. She shows no masking of the face or rigidity or slowness of movement aside from inertia that is still present, and her voice is pleasantly modulated. Reflexes are normal and the plantars are flexor in type.
In Case 144, a schizophrenic of twelve years' duration, the plane of the lobotomy deviated from the coronal suture, going 8 mm. anterior to the sphenoidal ridge below and 2 cm. behind the coronal suture above (Fig. 82). The chief neurologic abnormality in this case is incontinence that still continues after five years. Otherwise the patient has regained her motor skills.
Comparisons of the roentgenograms of these cases indicates the cortical regions that are apparently concerned with dexterity and manipulation. In all of them the motor disorders were very severe in the period directly after operation and receded slowly. In Case 88 the necropsy disclosed lesions affecting Area 6, with severe degeneration in the lateral as well as the medial nuclei of the thalamus (See Chapter XV). Since the lesions in a lobotomy performed in the plane of the coronal suture although still within the frontal agranular field show little involvement of the lateral group of nuclei, it must be concluded that the frontal agranular field is concerned with motor skills. Furthermore, with sections made progressively farther backward, more and more of these motor skills are permanently abolished. On the other hand, it is remarkable how much motor skill is preserved in spite of incisions that would seem to cut through the head of the caudate nuclei. That the cortex and not the caudate in concerned, however, is indicated by the fact that the caudate nuclei were only slightly involved in Case 88 where the incisions extended merely to the ventricle.
Edema and trophic disturbances in the lower limbs have occurred more notably in cases in which the lower portions of the frontal lobe have been incised posterior to the sphenoidal ridge even though the lesions in the upper quadrants were in the plane of the coronal suture. Cases 484 and 328 (Fig. 43, Chapter VII) are examples of this. This inertia was not accompanied by permanent loss of motor skill. Due to certain technical difficulties we have not attempted operation behind the sphenoidal ridge from the lateral approach. We mistrust our ability to control the plane of section with sufficient accuracy; and in this region a deviation of 5 mm. too far posteriorly may cause death, as in Case 46.
The use of a contrast medium to show where the surgical incisions have actually been made has rendered it possible to correlate these incisions with disturbances in motor function. Without roentgenographic verification we would often have been in the dark as to the cause of such complications.