The effects of lesions of the frontal lobes were nicely divulged by Harlow’s famous case of Phineas Gage, published in 1868; it has been the subject of numerous monographs ever since. His patient was a capable foreman of a railroad gang who became irreverent, dissipated, irresponsible, and vacillating (he also confabulated freely) following an injury in which an explosion drove a large iron-tamping bar into his frontal lobes. In Harlow’s words, “he was no longer Gage.” Another similarly dramatic example was Dandy’s patient (the subject of a monograph by Brickner), who underwent a bilateral frontal lobotomy during the removal of a meningioma. Feuchtwanger, in a clinical study of 200 cases of frontal lobe injury, was impressed most with the lack of initiative, changes in mood (euphoria), and inattentiveness, without intellectual and memory deficits. Rylander, in a classic monograph, described similar changes in patients with unilateral and bilateral frontal lobectomies (see later). Kleist (1934), under the heading of alogia, stressed the importance of loss of capacity for abstract thought, as shown in tests of analogies, proverbs, definitions, etc. In chimpanzees, Jacobsen observed that the removal of the premotor parts of the frontal lobes led to social indifference, tameness, placidity, forgetfulness, and difficulty in problem solving, findings that led Egas Moniz, in 1936, to perform prefrontal lobotomies on psychotic patients (see Damasio). This operation and its successor, prefrontal leukotomy (undercutting of the prefrontal white matter) reached their height of popularity in the 1940s and (tragically) provided the opportunity to study the effects of a wide range of frontal lobe lesions in a large number of patients.
The findings in patients who underwent frontal leukotomy have been the subject of endless controversy. Some workers claimed that there were few or no discernible effects of the operation, even with bilateral lesions. Others insisted that if the proper tests were used, a series of predictable and diagnostic changes in cognition and behavior could be demonstrated. The arguments pro and con and the inadequacies of many of the studies, both in methods of testing and in anatomic verification of the lesions (the extent and location of the lesions varied considerably, and this influenced the clinical effects), have been well summarized by Walsh. Admittedly, in patients who underwent bilateral frontal lobotomy, there was little if any impairment of memory function or of cognitive function as measured by intelligence tests, and certainly no loss of alertness and orientation. And some patients who had been disabled by schizophrenia, anxious depression, obsessive–compulsive neurosis, or a chronic pain syndrome did improve with respect to their psychiatric and pain symptoms. However, many were left with changes in personality, much to the distress of their families. They were indifferent to the feelings of others; gave no thought to the effects of their conduct; were tactless, distractible, and socially inept; and were given to euphoria and emotional outbursts. El-Hai has written a fascinating historical account of the procedure in the United States and a portrait of its main proponent at the time, Dr. Walter Freeman. Although no longer undertaken, the procedure must be viewed in the context of the understanding of, and limited options for, psychiatric disease at that time.
Luria (1973) had another interesting conception of the role of the frontal lobes in intellectual activity. He postulated that problem solving of whatever type (perceptual, constructive, arithmetical, psycholinguistic, or logical, definable also as goal-related behavior) proceeds in four steps: (1) the specification of a problem (in other words, a goal is perceived and the conditions associated with it are set); (2) formulation of a plan of action or strategy, requiring that certain activities be initiated in orderly sequence; (3) execution, including implementation and control of the plan; and (4) checking or comparing the results against the original plan to see if it was adequate.