Egas Moniz Develops the Prefrontal Lobotomy

Date November-December, 1935

António Egas Moniz pioneered the surgical treatment of psychiatric disorders, giving impetus to the widespread practice of lobotomy.

Locale Lisbon, Portugal

Key Figures

• António Egas Moniz (1874-1955), Portuguese neurologist
• Pedro Almeida Lima (b. 1903), neurosurgeon who performed the first prefrontal lobotomy under Moniz’s direction
• Walter Jackson Freeman (1895-1972), American neuropathologist and neuropsychiatrist

Summary of Event

In the early twentieth century, no consensus existed in the medical community concerning the treatment of mental illness. In part, this lack of consensus reflected opposition between two broad approaches to human development. One stressed the biological determinants of behavior, whereas the other stressed the role of environment and experience in shaping the psyche. (This division was mimed by the professional rivalry between neurologists and psychiatrists.) More fundamentally, however, this lack of consensus simply reflected a lack of knowledge.

As the number of patients admitted to hospitals for psychiatric treatment steadily increased (by 1938, according to an article in the New England Journal of Medicine, there was “one bed for mental disease for each bed for all other diseases in America”), the demand for effective treatment increased proportionately. The issues at stake were not only humanitarian—many psychiatric patients, especially those in state institutions, were condemned to live in utter misery with no hope of relief—but also financial, for the costs of maintaining such patients for years and even decades were enormous. This was the climate that encouraged the development and acceptance, in the 1930s, of such radical therapies as shock treatment (using drugs or electric shock to induce coma or convulsions) and lobotomy.

António Egas Moniz, the pioneer of lobotomy, was an extremely ambitious and multitalented man, with many interests outside his career in neurology. Prior to the development of lobotomy, he was best known for his work in cerebral angiography, which permits the visualization of the blood vessels in the brain after the injection of a radiopaque substance. He had hoped to receive a Nobel Prize for this work, which was done in the late 1920s, and he was very disappointed when it became apparent that such recognition was not forthcoming.

In August, 1935, Egas Moniz traveled to London for the Second International Congress of Neurology. There, he attended a symposium on the frontal lobes of the brain, including a presentation by Yale University researchers John Fulton and Carlyle Jacobsen on the effects of removing much of the frontal lobes of two chimpanzees. Egas Moniz himself later asserted that this presentation was not decisive in the development of lobotomy, which, he said, he had been considering for some time. Contemporary observers, however, noted that Egas Moniz seemed to be deeply impressed by the fact that the surgery had a calming effect on one of the chimpanzees, which had previously been subject to fits of temper and other disturbances.

As Elliot S. Valenstein has shown, Egas Moniz’s interpretation of the Fulton-Jacobsen study was selective and deeply flawed, yet this misreading entered medical folklore and was even perpetuated by the Nobel Prize Committee in its citation of Egas Moniz in 1949. Egas Moniz ignored the fact that, although one of the subjects was indeed less agitated after the surgery, the other chimpanzee was affected in the opposite way, becoming much more temperamental and uncooperative postsurgery. This latter result did not accord with the presuppositions that Egas Moniz brought to the London congress. He believed that many psychiatric disorders were caused by “abnormal adhesion” between nerve cells, as a result of which neural impulses “keep following the same path . . . constantly giving rise to the same morbid ideas, which are reproduced over and over again.” This hypothesis of “fixed ideas” was sheer speculation, but the lack of evidence did not deter Egas Moniz. He interpreted the Fulton-Jacobsen study as a confirmation of his belief that if the nerve fibers in which the pernicious “fixed ideas” were conducted could be destroyed, the patient might experience significant improvement. Thus, in November, 1935, only three months after the London congress, Egas Moniz made his first attempts at psychosurgery.

Long crippled by gout, Egas Moniz himself did not perform the operations; rather, he directed his younger colleague, the neurosurgeon Pedro Almeida Lima. Initially, Egas Moniz used injections of alcohol to destroy nerve fibers in the frontal lobes. The first operation took place on November 12, 1935. The patient was a sixty-three-year-old woman with a long history of mental illness. Two holes were drilled in the top of her skull and injections were made on both sides of the brain in the prefrontal area. In the following weeks, Egas Moniz and Almeida Lima repeated this procedure with six more patients, steadily increasing the amount of alcohol injected. With his eighth psychosurgical patient, however, Egas Moniz adopted a new method, cutting (or, at first, crushing) the nerve fibers. This surgery, performed on December 27, 1935, may be called the first lobotomy.

Egas Moniz himself did not employ the term “lobotomy,” which was first used in 1936 by his American disciple Walter Jackson Freeman and became the standard designation for the operation in the United States. The term that Egas Moniz coined for the operation was “leucotomy,” from the Greek word for white (because the nerve fibers are white matter, as opposed to gray matter, which contains nerve cell bodies); accordingly, the surgical instrument he employed was called the “leucotome.” This instrument, the design of which was refined and modified by Egas Moniz and others, contained a retractable wire loop. After the leucotome had been inserted into the brain, this wire loop was extended and the instrument was rotated. In the first leucotomy, one such rotation (or “core,” as Egas Moniz termed it) was made on each side of the brain; in subsequent operations, as many as six cores were made on each side of the brain.

In 1936, Egas Moniz published a monograph in which he reported on the outcome of psychosurgery for the first twenty patients he treated (including those treated with the alcohol-injection method). These patients suffered from a variety of disorders, ranging from disabling anxiety and depression to chronic schizophrenia. Egas Moniz reported that of the twenty patients, seven had been cured as a result of the surgery and seven had improved; six were said to be unchanged. Despite the fact that Egas Moniz’s claims could not bear scrutiny (he overestimated improvement, underestimated postoperative difficulties, and failed to conduct adequate follow-up, basing most of his analyses on observations made within days of the operation), his monograph was widely hailed as persuasive evidence for the potential benefits of psychosurgery.

Significance

The impacts of Egas Moniz’s radical and well-publicized use of brain surgery to treat psychiatric disorders were both immediate and lasting. Within three months of the publication of Egas Moniz’s 1936 monograph, prefrontal lobotomies had been performed as far afield as Italy, Romania, Cuba, and Brazil, as well as in the United States, where the acceptance of lobotomy owed much to Freeman’s advocacy.

Freeman, a superb lecturer and a man of seemingly inexhaustible energy, was head of the neurology department at George Washington University when, in 1936, he read Egas Moniz’s monograph. Soon thereafter, assisted by a colleague, James Winston Watts, Freeman performed his first lobotomy; by the end of the year, he and Watts had performed twenty lobotomies. In 1942, Freeman and Watts published Psychosurgery: Intelligence, Emotion, and Social Behavior Following Prefrontal Lobotomy for Mental Disorders. The book was extremely influential, not only in the United States but also abroad. In the immediate postwar years, there was a dramatic increase in the number of lobotomies performed worldwide; in the United States, lobotomies increased from approximately five hundred per year in 1946 to five thousand in 1949. When Egas Moniz received the Nobel Prize in Physiology or Medicine in 1949 for the development of the prefrontal lobotomy (he shared the award with Walter Rudolf Hess, a Swiss researcher recognized for his discovery of the function of the middle brain), the credibility of psychosurgery was further enhanced.

Within only a few years, however, by the mid-1950s, the number of lobotomies performed annually began to decline steeply. There were two reasons for this sudden turnabout: First, tranquilizing drugs such as Thorazine had been developed, and their widespread use was sufficient by itself to restrict lobotomy to exceptional cases; second, serious concerns about the validity of lobotomy were being expressed in the medical community. Some physicians had been opposed to lobotomy from the beginning, but as more long-term studies of lobotomized patients became available, it became evident that proponents of lobotomy, like Egas Moniz before them, had not been objective in assessing the consequences of such surgery. Although the operation as performed by Freeman and his colleagues became something quite different from Egas Moniz’s early attempts, lobotomy always involved radical injury to the frontal lobes. Lobotomized patients frequently lost their abilities to plan ahead, to think abstractly, and to perform other vital functions. In many cases, particularly in the treatment of patients suffering from schizophrenia, lobotomy was not only excessively costly in psychic terms but also generally ineffective.

In the 1960s and 1970s, growing public awareness of ties between the government and science and a new appreciation of the threat of various kinds of mind control led to the placement of further limitations on the use of psychosurgery, including some legislative restrictions. Psychosurgery is still practiced in the United States on a small scale, with greater precision than ever before, thanks to technological advances and significant improvements in knowledge concerning the brain’s circuitry. Despite such advances, resistance to psychosurgery remains high, both within the medical profession and among the general public.

Bibliography

El-Hai, Jack. The Lobotomist: A Maverick Medical Genius and His Tragic Quest to Rid the World of Mental Illness. New York: Wiley, 2005. Print.

Freeman, Walter, and James W. Watts. Psychosurgery: Intelligence, Emotion, and Social Behavior Following Prefrontal Lobotomy for Mental Disorders. 2d ed. Springfield Thomas, 1950. Print.

Fulton, John F. Frontal Lobotomy and Affective Behavior: A Neuropsychological Analysis. New York: Norton, 1951. Print.

Johnson, Jenell. "Thinking with the Thalamus: Lobotomy and the Rhetoric of Emotional Impairment." Journ. of Literary & Cultural Disability Studies 5.2 (2011): 185–200. Print.

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Raz, Mical. "Interpreting Lobotomy—The Patients' Stories." Psychologist 27.1 (2014): 56–58. Print.

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Valenstein, Elliot S. Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness. New York: Basic, 1986. Print.