António Egas Moniz

Portuguese neurosurgeon

• Born: November 29, 1874
• Birthplace: Avança, Portugal
• Died: December 13, 1955
• Place of death: Lisbon, Portugal

Egas Moniz made two major contributions to the field of neurology during the 1920’s and 1930’s. He developed cerebral angiography and later developed the prefrontal lobotomy, for which he received the Nobel Prize in 1949.

Early Life

António Caetano de Abreu Freire was baptized with the added honorary name of Egas Moniz (AY-gahs moh-NEEZ). He attended boarding schools operated by the Jesuit Order or lived with his uncle, Abadelde, a priest. It was his uncle who carefully supervised his education. The family was land-rich but income-poor. Thus, when Egas Moniz’s father died, the ancestral home had to be sold. His uncle purchased it for Egas Moniz and also assumed the cost of his education. In 1891, Egas Moniz entered the University of Coimbra, where he excelled academically, was elected president of Tuna Academica, the most prestigious student organization, and wrote political pamphlets for liberal republicans who were struggling to overthrow the Portuguese monarchy.

During Egas Moniz’s senior year, he decided to study medicine. Two years after graduation from the medical school, he accepted an appointment to the medical faculty at Coimbra and married Elvira de Macedo Dias. Her dowry and inheritance relieved Egas Moniz of all financial concerns. Within a few years, he was also receiving a steady income from a series of books on sexual behavior and physiology. Periodically, he traveled to France and studied neurology at Bordeaux and later at Paris. His Parisian mentor, Jean Sicard, encouraged him to begin research on cerebral angiography. In 1910, Egas Moniz was appointed professor in the newly formed Department of Neurology at the University of Lisbon, a position he held until his retirement in 1945. In addition, he served as director of the Institute of Neurology for Scientific Investigation in that city.

Egas Moniz was also politically active. For fifteen years, he was repeatedly elected to the Portuguese parliament as a deputy from Estarreja, a district that included Avança. As a leading liberal activist, Egas Moniz was deeply involved in the nation’s political reconstruction after the monarchy fell in 1910. By 1917, he was named ambassador to Spain. The next year, he was appointed minister for external affairs and was Portugal’s representative at the Paris Peace Conference, where he signed the Treaty of Versailles. In 1926, the dictator António de Oliveira Salazar gained control of the government, and Egas Moniz abandoned politics. During this early period, he accomplished little in neurology, although he did publish A neurologia na guerra (1917; neurology of war), which summarized his studies of head injuries during the war.

Life’s Work

Childless, embittered by his lack of success in politics, and perhaps dissatisfied with his accomplishments, Egas Moniz began to concentrate on neurology. Like many in the profession, he was frustrated by the lack of techniques available for studying the living human brain. Since the brain had uniform density, no individual structures could be distinguished by X ray. Following up on Sicard’s suggestion and work, Egas Moniz devoted himself to angiography the science of visualizing blood vessels in the brain. He perfected the only two substances that proved opaque to X rays without damaging the nervous system. In 1927, Egas Moniz traveled to Paris to announce that he had successfully developed cerebral angiography. Within the next seven years, he published a total of two books and 112 articles, and lectured in Brazil on the subject. Cerebral angiography established Egas Moniz as a leading neurologist.

He appeared to want the Nobel Prize in Physiology or Medicine long before he actually received it. In 1928, the Nobel Prize Committee received two very brief letters nominating Egas Moniz perhaps sent in fulfillment of obligations owed him. Yet the committee, noting the various complications associated with the procedure, declined to award the prize to him. Within the next three years, Egas Moniz developed the first X-ray phlebography (picture of veins) of the brain. Again, in 1933, two brief letters of nomination were sent to the Nobel Prize Committee, and again the committee declined.

Since the early 1900’s, psychiatrists had regarded mental and emotional disturbances as diseases of the mind. Most attempted to treat them through various forms of psychoanalysis. Yet some neurologists in the 1920’s and 1930’s believed that psychological problems were caused by diseases of the brain and searched for physical cures for mental illnesses. In 1935, Egas Moniz, then sixty-one, attended the International Neurological Conference in London, where the American neurophysiologists John Fulton and Carlyle Jacobsen presented their study of two monkeys from which they had removed most of the prefrontal lobe (directly behind the forehead) of the brain. They reported that, after the experimental procedure, the monkeys no longer became upset if they made mistakes while performing complex tasks they had learned. Egas Moniz raised the question: Was the procedure feasible to use on humans to relieve anxiety states? It appeared that the report inspired him to do research in this area. Yet later, in response to critics, he insisted that he had been thinking of such a procedure for several years prior to the conference.

Earlier somatic treatments for mental disorders were diverse, often extreme, and unsuccessful. Hospital stays were prolonged. Large state institutions, operating on limited budgets, were often overcrowded and understaffed. Shock therapy rarely cured hospitalized patients, but it did make them docile and easier to handle. In this climate, the drastic surgery offered by Egas Moniz appeared to offer hope.

Egas Moniz moved ahead on an essentially experimental course. Only three months following the conference he began the operation that he called “leucotomy” (from the Greek word for white), because the prefrontal lobes were not severed, only the white matter; that is, neuronal-association fibers connecting the lobes to other parts of the brain were cut. Having had gout since the age of twenty-four, he was too disabled to perform the surgery himself. Thus, the first procedures were performed under his direction by his colleague Almeida Lima, a professor of neurosurgery. Initially, Egas Moniz and Lima used alcohol injections to destroy a portion of the frontal lobes. Soon, however, the technique was modified to the cutting of nerve fibers with a surgical leucotome. Four months after he began his operations, he presented a report on all twenty patients selected: Seven of the patients were cured; eight seemed improved; and five were unchanged. The operation also appeared to relieve patients suffering from intractable pain.

The theory behind his procedure was flimsy at best. He seemed unusually willing to take risks, appeared unconcerned about very troubling side effects, and was much too optimistic in interpreting the clinical results. The report was done too soon postoperatively to be complete or accurate. However, Egas Moniz published his results in 1936 and presented them before the Medical Psychological Society in Paris the following year. He admitted the procedure was exceedingly bold but added that the results vindicated his daring. A few months later, he reported on eighteen additional patients treated and on several modifications to the procedures.

In the process of developing the surgery, Egas Moniz introduced two innovations. He invented the leucotome, a hollow needle that carried within it a razor-sharp wire as a cutting blade. He cut only one centimeter of white matter in the lobes but did not remove it. It was left free in the cavity to undergo autolysis, or self-digestion. In his writings about the procedure, Egas Moniz first coined the word psychosurgery. Lobotomy, as the procedure came to be known, never became common in Portugal; Egas Moniz and his associates performed no more than one hundred such operations. The procedure had its critics, including many psychiatrists who favored less drastic treatments for mental illness.

Despite growing protests from psychologists, psychiatrists, and neurologists, the number of lobotomies performed worldwide over the years increased. Between 1949 and 1952, thousands of lobotomies were performed annually. By 1960, however, the use of the procedure was drastically curtailed when it was realized that these operations were producing brain-damaged people.

Near the end of his life, Egas Moniz was awarded the 1949 Nobel Prize in Physiology or Medicine “for his discovery of the therapeutic value of prefrontal leucotomy in certain psychoses.” He shared the prize with Walter R. Hess, who used precise surgical and electrical techniques to investigate functions of the hypothalamus. In 1945, Egas Moniz had retired to his ancestral home in Avança and was unable to attend the awards ceremony. He died in 1955 at the age of eighty-one.

Significance

Egas Moniz was an ambitious man, the last survivor of a long and distinguished line of Portuguese aristocrats. He was a natural leader, politically astute, and able to maintain a prominent place in Portuguese politics despite frequent changes in government. He was instrumental in reestablishing diplomatic relations between Portugal and the Vatican. Throughout his life, Egas Moniz appeared to need some motivation in the form of an important practical problem to solve. In the field of neurology, cerebral angiography and, later, prefrontal lobotomy provided the answer. By 1934, he had won great praise and many honors for his work. A man who avoided sharing the credit with others, he was persistent, with keen observational powers and the ability to persuade others to join him in developing and extending basic techniques. He is credited with starting a new chapter in the area of brain surgery.

Egas Moniz was known worldwide as a man of many interests. He wrote several biographies of Portuguese heroes and scientists, a history of playing cards, and a number of neurological publications. He held memberships in the Royal Academy of Sciences in Lisbon, the American Society of Neurology, the Brazilian Academy of Letters, and the Brazilian Academy of Medicine. In addition to the Nobel Prize, he received the Grand Cross of Public Instruction, the Grand Cross of Isabella the Catholic of Spain, and honorary degrees from the Universities of Bordeaux, Toulouse, and Lyons.

Bibliography

El-Hai, Jack. The Lobotomist: A Maverick Medical Genius and His Tragic Quest to Rid the World of Mental Illness. Hoboken, N.J.: J. Wiley, 2005. This biography, although of physician Walter Freeman, includes good information about Egas Moniz.

Glaser, Hugo. The Road to Modern Surgery: The Advances in Medicine and Surgery During the Past Hundred Years. Translated by Maurice Michael. New York: Dutton, 1962. The seven chapters of the book, designed for the average reader, describe the research done on vitamins, hormones, viruses, and in the areas of childbirth and old age. Chapter 6 presents a general history followed by a brief description of Egas Moniz’s leucotomy procedure.

Koskoff, Yale David, and Richard Goldhurst. The Dark Side of the House. New York: Dial Press, 1968. This is the story of Millard Wright, who in 1949 became the first patient to be lobotomized without brain damage. Three pages in the prologue mention Egas Moniz and are confined mainly to his 1936 leucotomy procedure. Very brief mention is made of his work in cerebral angiography.

Sackler, Arthur M., et al., eds. The Great Physiodynamic Therapies in Psychiatry: An Historical Reappraisal. New York: Hoeber-Harper Books, 1956. The articles in this work originally appeared in the Journal of Clinical and Experimental Psychopathology and the Quarterly Review of Psychiatry and Neurology. Chapter 6 presents Egas Moniz’s article “How I Succeeded in Performing Prefrontal Leukotomy.” At the end of the book, there is a brief one-page biography with a picture.

Stevenson, Lloyd G. Nobel Prize Winners in Medicine and Physiology, 1901-1950. New York: Henry Schuman, 1953. This work is part of the Pathfinders in Twentieth Century Science series, written for young adults. Provides brief biographies and explanations of why each of the Nobel laureates became involved in his or her research.

Valenstein, Elliot S. Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness. New York: Basic Books, 1986. This book contains some of the most complete information about Egas Moniz. Traces the history of psychosurgery from the late nineteenth century. Three chapters are devoted to Egas Moniz’s life, theories, and work. Presents a detailed description of his various procedures and requires a strong knowledge of neurology.