Wilder Penfield, the Frontal Lobes and Psychosurgery
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HISTORICAL REVIEW COPYRIGHT © 2019 THE CANADIAN JOURNAL OF NEUROLOGICAL SCIENCES INC. Against the Current: Wilder Penfield, the Frontal Lobes and Psychosurgery Richard Leblanc ABSTRACT: Psychosurgery refers to the surgical interruption of the white matter fibres joining the frontal cortex to the remainder of the cortical mantle and to the thalamus, in an attempt to mitigate the manifestations of psychosis. It reached its heyday following World War Two and was abandoned with the introduction of major tranquilisers such as chlorpromazine. Wilder Penfield, unlike most of his contemporaries, had a jaundiced view of psychosurgery. This paper addresses Penfield’s early experience with experimental, penetrating brain trauma and with the surgical resection of frontal, epileptogenic lesions, which explain his antagonism towards psychosurgery. RÉSUMÉ: À contre-courant : Wilder Penfield, les lobes frontaux et la psychochirurgie. La psychochirurgie consiste notamment en l’interruption chirurgicale des fibres de la substance blanche reliant le cortex frontal au reste du manteau cortical et au thalamus, et ce, pour tenter d’atténuer les manifestations de la psychose. Cette technique a atteint son apogée à la suite de la Deuxième Guerre mondiale pour être ensuite délaissée avec l’introduction des principaux tranquillisants, par exemple la chlorpromazine. À la différence de la plupart de ses contemporains, Wilder Penfield ne voyait pas d’un très bon œil la psychochirurgie. Cet article entend aborder les premiers travaux expérimentaux de Penfield portant sur les traumatismes cérébraux par pénétration et sur la résection chirurgicale de lésions frontales épileptogènes, ce qui expliquerait son opposition à l’égard de la psychochirurgie. Keywords: Penfield, Frontal lobes, Psychosurgery, Lobotomy doi:10.1017/cjn.2019.48 Can J Neurol Sci. 2019; 46: 585–590 INTRODUCTION Penfield arrived in Montreal in November 1928 to head In a series of experiments that began in 1924 at Columbia Neurosurgery at the Royal Victoria Hospital of McGill University. One of his first patients was his own sister, who had suffered from University in New York, and which ended in the laboratory of Pio 4 del Río-Hortega in Madrid in 1927, Wilder Penfield discovered headaches and focal motor seizures of the left arm for many years. that penetrating trauma to the brain results in the formation of a These had worsened and her left hand had weakened, as her complex scar, to which he referred as the meningocerebral headaches became more severe and she began to have bouts of ’ cicatrix.1,2 This lesion is composed of reactive astrocytes and vomiting. Colin Russel, the Royal Victoria s Neurologist-in-Chief, astrocytic fibrils, collagen fibres and a newly created vascular examined her when she was 43 years old. He found that she had fl plexus that anastomoses with arteries supplying the cortex around bilateral papilledema and hyperactive, left deep tendon re exes. A fi the scar. The meningocerebral cicatrix, Penfield believed, was the skull x-ray revealed calci cations within the right frontal lobe, and fi cause of post-traumatic epilepsy. He also discovered that the the diagnosis of a partially calci ed brain tumour was made. fi clean, meticulously atraumatic resection of such a lesion resulted Pen eld performed a right frontal craniotomy under local in a simple gliotic reaction at the resection margin, which was not anaesthesia in December 1928 and found a hypervascular epileptogenic. These discoveries provided the rationale for the tumour. Electrocortical stimulation around the tumour produced ’ fi surgical treatment of focal, post-traumatic seizures. the patient s usual seizure, and this allowed Pen eld to identify Penfield’s earliest experiences with the surgical treatment of the motor strip, which had been displaced posteriorly by the mass post-traumatic epilepsy revealed that scars sometimes involved effect of the lesion. He performed an extensive resection of the most of a lobe. In such cases, he observed, “cerebral lobectomies tumour and of the cerebral tissue behind it. The resection thus even though involving large amounts of brain substance was extended from just anterior to the motor strip to the frontal pole, fl followed by surprisingly little disturbance of function.”3 One from the lateral cortex to the midline and to the oor of the fi exception, however, was the extensive resection of a lesion anterior fossa (Figure 1). This resection completed, Pen eld “ within a frontal lobe, which sometimes produced placidity, the observed that the neoplasm had passed into the opposite hemi- ”4 inability to organise one’s activities and lack of initiative. I sphere. Removal of this portion was not attempted. Thus, the propose that this experience, early in his career, was at the origin of Penfield’s antagonism towards psychosurgery. From the Department of Neurology and Neurosurgery, Montreal Neurological Institute – and McGill University, Montreal, Canada Frontal Lobectomy, 1928 1935 RECEIVED JANUARY 24, 2019. FINAL REVISIONS SUBMITTED APRIL 6, 2019. DATE OF – It may be urged that to destroy a delicate instrument is not ACCEPTANCE APRIL 8, 2019. 3 Correspondence to: Richard Leblanc, MD, Montreal Neurological Institute, 3801 the best way to study its function University Street. Montreal, QC, H3A 2B4, Canada. Email: [email protected] THE CANADIAN JOURNAL OF NEUROLOGICAL SCIENCES 585 Downloaded from https://www.cambridge.org/core. IP address: 170.106.33.19, on 29 Sep 2021 at 01:35:27, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/cjn.2019.48 THE CANADIAN JOURNAL OF NEUROLOGICAL SCIENCES been, and which cured W.B.’s seizures. His clinical examination upon follow-up did not reveal any indication of “ abnormality,” and he had “no complaints to make regarding his ability to live and behave in a normal way.”3 W.B. felt “much more controlled” when facing situations for which he had been “very antagonistic” in the past. Nonetheless, his father, who had been his sole employer, asserted that since the cranio-cerebral trauma his son “never had a job that I didn’t get for him.” Penfield concluded from this that W.B. “has lost initiative: not all of it, but much of it.”3 It was also noted that W.B. had difficulty with simple mental arithmetic, which Penfield attributed to difficulty thinking. Penfield also reported the cases of two other patients who had undergone frontal resections with no apparent cognitive or behavioural consequences. Penfield concluded from these four cases that extensive frontal Figure 1: Drawing of the right frontal resection that Penfield performed lobectomies “are followed by surprisingly little disturbance of on his sister. The convolution at the posterior margin of the resection is function, and that those that do occur are limited to “thinking and the motor strip. The left cingulate gyrus, the pericalossal branch of the initiative.” One might also add placidity, exemplified by W.B.’s left anterior cerebral artery and the genu of the corpus callosum are seen 3 at the medial aspect of the resection cavity. Note that the tumour had post-operative behaviour, to the effects of frontal lobe resection. invaded the corpus callosum. Source: Penfield archives, Osler Library of Placidity and lack of initiative would later be appreciated as the the History of Medicine, McGill University. hallmarks of frontal lobotomy.6 Penfield published three of these cases in a paper entitled “The tumour had invaded both frontal lobes, a fact which Penfield did frontal lobe in man: a clinical study of maximum removals,” in not mention in subsequent presentations of this case. Brain in March 1935.7 The paper brought the physiology of the Despite the length of the procedure – 6 hours – and a near fatal frontal lobe to the attention of an international audience, and it is intraoperative haemorrhage, the patient quickly recovered from considered a milestone of neurophysiology by no less an author- surgery, and her convalescence was uneventful. She had no ity than Donald Hebb.8 neurological deficits when she left the hospital and, as Penfield noted, she “discharged her duties as mother and wife.” There were The Second International Neurological Congress, 1935 no “immediate mental symptoms.” Penfield first presented her The Brain paper was published four months before the Second case in 1930 and attributed the absence of any frontal lobe deficits International Neurological Congress, held in London, England, to “the fact that other portions of the brain had taken over the from 29 July to 2 August 1935. Two special sessions are still function of this lobe during the very slow growth of the tumour.”4 relevant today: one on “The Epilepsies: Their Aetiology, Patho- Penfield returned to her case in 1932, in an address entitled genesis and Treatment,” and the other on “The Functions of the “Functional Effects Produced by Cerebral Lobectomies.”3 Penfield Frontal Lobe.” Penfield was invited to speak on “Epilepsy and now reported that since he had first presented her case, his sister Surgical Therapy,” but despite his previous reports on the physi- had undergone post-operative x-ray treatments, but to no avail: the ology of the frontal lobes, he was not asked to participate in the tumour had progressed. She had been referred to Harvey Cushing session addressing these structures.9 Nonetheless, most of his in Boston, who resected more of the tumour, but she died some two paper discussed the resection of epileptogenic lesions of the years after Penfield had first operated upon her. In the interval, frontal lobes. Its purpose was to illustrate the effectiveness of Penfield had come to realise that his sister had not been “mentally surgery in arresting epileptic attacks and the safety of this form of up to her own standard in looking after household arrangements,” treatment when performed under local anaesthesia with the aid due to “a lack of capacity for planned administration.” Penfield of cortical mapping.