Prefrontal Lobotomy in the Treatment of Mental Disorders (GWU, 1942)
[Narrator:] A review of the landmarks on the skull and the more significant structures in the frontal lobe will give one a clearer impression of the nature of the operation. On the prepared skull, at a 0.13 centimeters behind the glabella, the coronal suture is outlined. Six centimeters above the zygoma in the coronal suture, the opening is made. This corresponds to a point close to the sphenoidal ridge on the interior of the skull. The coronal suture on the inside of the skull is observed. Note again the sphenoidal ridge behind which the operator must not penetrate for fear of lacerating arteries. Turning now to the brain, the frontal lobe is bounded by the Sylvian fissure and the Rolandic fissure. The point of entrance of the knife is shown. Here is the Sylvian fissure with its large vessels. On the mesial aspect of the hemisphere, the genu of the corpus callosum lies here. Sectioning the brain in approximately the plane of the coronal suture allows us to expose certain vital points. Observe first the corpus callosum and the association pathways. Next, the fascicular singuli and the anterior limb of the internal capsule. After dissection of the brain, these structures are more clearly seen. The fascicular singuli skirts the corpus callosum, and runs down into the temporal lobe. The plane of the lobotomy incision lies just anterior to the head of the caudate nucleus. When the head of the caudate nucleus is removed, the fibers radiating forward from the thalamus are seen. Note the thalamus with its radiation into the temporal and the occipital regions, and its anterior radiation into the frontal lobe. […] [Narrator:] The patient is lying on the table with his head shaved back as far as the vertex. The first mark is made three centimeters behind the lateral rim of the orbit, and then a cross-mark is made six centimeters above the zygoma. Another mark is made in the midline, 13 centimeters from the glabella. These points are joined by a line leading over the vertex, following as accurately as possible, the coronal suture. Midline is similarly indicated. Operations can be performed under local anesthesia if the patient is sufficiently cooperative. An incision through the scalp along the indicated line exposes the coronal suture. The periosteum is scraped off and markings are made with a chisel. The wound edges are then retracted with a self-retaining mastoid retractor. A bore hole is placed in the coronal suture by means of successive drills. The opening is then enlarged in the line of the coronal suture by a rongeur to give greater play for the knife. The dura is opened, and the cortex is punctured in an avascular area, following which the leucotome and the nasal septum periosteal elevator are introduced. A similar opening is then made on the opposite side. In the following procedure, the surgeon inserts the leucotome into the brain. He is guided by the neurologist in order to keep the brain incision constantly in the plane of the coronal suture. His first move is to penetrate directly through the brain from one opening in the skull to the other. [The surgeon carefully follows the neurologist so that they can penetrate the skull correctly.] His second move is to locate the faults in the midline, always keeping in the plane of the coronal suture. The surgeon then clamps a hemostat on the blunt dissector, introduces it into the incision, and cuts to within one centimeter of the midline. The surgeon must be careful to avoid the anterior cerebral artery, laceration of which will lead to serious bleeding. He must also remain in front of the anterior perforated space with its many penetrating vessels. Still guided by the neurologist, the surgeon cuts the upper quadrant in the same way, always maintaining the instrument in the plane of the coronal suture, as indicated by the guiding neurologist. It seems to be of little importance whether or not the ventricle is entered. The incisions are irrigated out with normal saline in order to control hemorrhage. Usually there is very little bleeding, most of this coming from the superficial cortical vessels. The incisions are now deepened by radial stab incisions, which push the vessels before them, preventing further bleeding, and at the same time, interrupting more completely the fibers in the frontal lobe. It is when these remaining fibers are being severed that the patient often becomes disoriented. The surgeon starts on the second side, inserting the leucotome through the incision, where it can be seen coming out on the surface of the brain. This shows the delicacy and accuracy of the method. When the operation has been completed on both sides, the surgeon injects a few drops of iodized oil into the upper and lower extremities of the incision, in order to demonstrate by x-ray their exact location. [?] is important, since a failure of the operation can often be correlated with the erroneous placement of the incisions.