Egas Moniz, the lobotomy and Portugal's first Nobel Prize

In late June 1927, in Lisbon, a young neurosurgeon named Pedro Almeida Lima exposed the carotid artery in the neck of a 20-year-old man with a tumour of the pituitary gland. The method, as it was later published, was to clamp the artery for a moment and inject five or six cubic centimetres of a freshly made 25 per cent solution of sodium iodide, taking X-ray plates as fast as possible while the liquid was still going in.4 sources

The man in charge, the professor of neurology António Egas Moniz, could not do the injections himself; gout had left his hands badly deformed. On the film the arteries of the brain showed up through the bone, bent out of their usual course by the tumour. It was the first time angiography had shown a lesion inside a living patient's skull. The Casa-Museu Egas Moniz and a 2017 review date the success to 28 June 1927; a 2020 history gives 18 June.3 sources

Twenty-two years later, on 27 October 1949, the Karolinska Institute in Stockholm announced that Moniz had won the Nobel Prize in Physiology or Medicine. It was not for the angiogram. It was for an operation he had devised in 1935, which cut into the frontal lobes of psychiatric patients and which the world came to know as the lobotomy.3 sources

He was born António Caetano de Abreu Freire on 29 November 1874 in Avanca, a village near Estarreja in the district of Aveiro. His godfather, an uncle who was a priest and gave him his first lessons, had him take the name Egas Moniz, after a hero of Portugal's twelfth-century wars against the Moors.3 sources

He studied medicine at Coimbra, graduating in 1899, and trained in neurology in Bordeaux and Paris under Babinski, Dejerine and Pierre Marie. He became a lecturer at Coimbra in 1902. In 1911 the new Republic created a chair of neurology at Lisbon, the first in the country, and gave it to him.3 sources

Politics took up as much of his energy as medicine. A republican under the monarchy, he was jailed in 1908 for his part in a plot against the dictatorship of João Franco, and sat as a deputy in several parliaments from 1903. In 1917 he founded the Centrist Republican Party, which wanted the president to have the power to dissolve parliament.3 sources

His Centrists backed Sidónio Pais, the army officer who seized power in December 1917. Moniz presented his credentials in Madrid as Portugal's envoy on 16 March 1918, and on 8 October 1918 became foreign minister. He was named head of the Portuguese delegation to the peace conference in Paris, but on 16 March 1919, three months after Sidónio's assassination, Afonso Costa replaced him.2 sources

After 1919 he went back to his clinic. The First Republic ended with a military coup in May 1926, and the dictatorship that followed became António de Oliveira Salazar's Estado Novo (New State). Moniz left public life disillusioned and, at 52, gave himself to research.4 sources

In the 1920s neurologists could not see a brain tumour on an X-ray. The best method was the American surgeon Walter Dandy's pneumoencephalography, which injected air into the brain's cavities and looked for distortions. Moniz had seen Jean-Athanase Sicard in Paris use an iodised oil to diagnose compression of the spinal cord, and wondered whether the brain's arteries could be made opaque instead.2 sources

He worked through dogs, rabbits and heads from the anatomy department, testing lithium bromide, strontium bromide and sodium iodide. On living patients the first attempts failed. One patient, injected with a bromide solution, died about eight hours later of a stroke caused by a clot in the carotid artery. “This accident … was a great shock to us,” the Lisbon team wrote, and Moniz stopped for a time before switching to sodium iodide.2 sources

On 7 July 1927 he presented the result to the Neurological Society in Paris. His conclusion was short.2 sources

He kept refining it. From 1931 he used Thorotrast, a thorium dioxide suspension that gave sharper pictures; years later it was found to cause liver disease and leukaemia because the radioactive thorium stayed in the body. He showed that angiography could reveal a blocked internal carotid artery, and named the carotid siphon, a bend of the artery inside the skull. In 1942 the thousandth angiography was performed at Lisbon's Hospital de Santa Marta.3 sources

Lisbon colleagues nominated him for the Nobel Prize for angiography in 1928 and 1933, and again in 1937, when the leucotomy was also mentioned. Writing in Neurosurgery in 1998, B. Lee Ligon reported from the Nobel documents that on two occasions his nominations were assessed by Hans Christian Jacobaeus, a Karolinska Institute professor and member of the Nobel committee, who advised against an award. Until computed tomography arrived in the 1970s, angiography was the main way to see the brain's blood vessels.4 sources

In August 1935 Moniz attended the second International Neurological Congress in London. There the American physiologist John Fulton and his colleague Carlyle Jacobsen described two chimpanzees whose frontal lobes had been removed. Afterwards the animals no longer flew into rages when they failed at a task. Many have seen this, as Bengt Jansson notes in an essay for the Nobel organisation, as the trigger for Moniz's “bold step”.3 sources

His idea, as the 1949 presentation speech later put it, was that mental illnesses accompanied by emotional tension might be relieved by destroying the frontal lobes or their connections with the rest of the brain. He chose to cut the connections, which run through the white matter, hence the name leucotomy, “the white cut”. Moniz thought some psychoses were sustained by fixed, obsessive patterns of thought, which he blamed on a “fixation” of the connections between nerve cells, and that cutting these fibres might break them.4 sources

He moved fast. In November 1935, only months after London, Almeida Lima began operating at Moniz's direction, under general anaesthetic, first by injecting alcohol into the white matter of the frontal lobes to destroy it. The patients came from Lisbon's Bombarda mental hospital, whose director, Sobral Cid, supplied them. From 27 December they used a leucotome Moniz designed: a thin cannula with a retractable wire loop, later replaced by a steel band, which was pushed into the brain and rotated to cut small cores of white matter in each frontal lobe.4 sources

On 3 March 1936 Moniz presented the first 20 cases in Paris, and a monograph followed that year. By his own count seven patients were cured, seven improved and six unchanged, and none died. Of the seven with schizophrenia, only two improved. Vomiting, incontinence, apathy and disorientation followed almost every operation, but he described them as temporary.3 sources

In 1937 he reported a second series of 18 patients, all with schizophrenia, of whom three were almost cured and two much better. He admitted that patients whose illness had already worn them down gained little.1 source

Critics have found the evidence thin. The neuroscientist Elliot Valenstein argued that Moniz proposed the operation with little theoretical or experimental basis and quickly declared many patients cured, and that his peers did not question him because of the standing angiography had given him. Moniz has also been accused of playing down complications, keeping poor records and following patients up poorly.3 sources

The medical historians Dominik Gross and Gereon Schäfer, who went back to Moniz's Portuguese and French papers, found his first assessments were made days or weeks after surgery, with no follow-up over months or years. The patients' own wishes were not taken into account. By modern standards, they concluded, the first series gave no evidence at all that the operation worked.1 source

Moniz's reputation carried the operation abroad, to Brazil, Italy and above all the United States. There the neurologist Walter Freeman and the neurosurgeon James Watts began operating in 1936, soon developed their own “closed” technique, and performed about 600 operations with it. The operation became known as lobotomy. In 1944 Freeman nominated Moniz for the Nobel Prize.3 sources

Freeman then simplified it further. His transorbital lobotomy drove an instrument like an ice pick through the thin bone above the eye socket, often under local anaesthesia or with the patient sedated after electroconvulsive therapy. He taught it to psychiatrists and travelled from hospital to hospital demonstrating it. Watts broke with him over the lack of sterile technique. Counts of Freeman's own operations vary: more than 3,000 lobotomies of both kinds in one review, more than 3,500 transorbital ones alone in another, over 4,000 in a third.3 sources

Asylums were full and nothing else seemed to work. In the United States about 10,000 operations had been done by August 1949. In England and Wales, 10,365 people had a single leucotomy between 1942 and 1954, and 762 more were operated on more than once. One estimate puts the total for the United States and Europe between 1936 and 1956 at about 60,000.2 sources

The cost showed early. Many patients became dull, apathetic and childlike, without drive or initiative. At a conference in 1953, reported death rates from the operation ranged from 0.8 to 2.5 per cent, and about one patient in ten developed epilepsy. In 1971 Freeman published a follow-up of 707 people with schizophrenia, four to 30 years after surgery. He reported that most had improved, yet 73 per cent were still in hospital or living at home in “a state of idle dependency”.2 sources

By 1949 Moniz was 74 and retired: he had left his chair on reaching 70 in November 1944. On 14 March 1939 a patient had shot him in his consulting room. Accounts of his injuries differ. The NobelPrize.org essay says he was hit in the leg and spent the rest of his life in a wheelchair; a 2017 review says he was left paraplegic. What is clear is that he went on working: he kept his chair for five more years and a private practice until his death.3 sources

That year the archive records nine nominations for him: five from professors in Lisbon, three from São Paulo and one from E. Busch, a professor of neurosurgery in Copenhagen. All gave the same reasons, the surgical treatment of mental disorders and the diagnosis of brain tumours by angiography. On 27 October the Karolinska Institute decided to split the prize between Moniz and Walter Rudolf Hess of Zurich.4 sources

Both prizes were for work on how the brain is organised. Hess had mapped centres deep in the brain by stimulating them with fine wires in cats. Presenting the award, Professor Herbert Olivecrona of the Karolinska Institute said the leucotomy worked best for depression and obsessions and less well for schizophrenia, and that in less favourable cases nursing was simpler because the patient could be kept in a “quiet” ward. He acknowledged that the personality changed.2 sources

Moniz did not go to Stockholm. At the ceremony the Crown Prince handed his prize to Portugal's chargé d'affaires, a Mr Patricio. On 3 January 1950 the Swedish minister in Lisbon, Gustaf Weidel, delivered the prize to Moniz, and Estarreja, his home municipality, had already honoured him on 23 December.2 sources

The prize came after the operation's best years. In 1952 two Frenchmen, Delay and Deniker, introduced chlorpromazine, the first drug with a definite effect on schizophrenia. By the mid-1950s antipsychotic drugs had largely replaced surgery, and the procedure and the people who practised it fell into disrepute. After 1954, Jansson notes, the number of operations fell steadily.2 sources

Moniz saw the turn. On 20 May 1954 he spoke to the Lisbon Academy of Sciences on “A leucotomia está em causa”, “Leucotomy is in question”. He died in Lisbon on 13 December 1955, aged 81. The British doctor Sir Geoffrey Jefferson wrote in The Lancet that his name would live for his “two great contributions to medicine”.3 sources

Psychosurgery did not disappear altogether. Since the 1970s a few patients with severe anxiety or obsessive-compulsive disorder that resists every other treatment have had small, precisely placed lesions made with stereotactic methods. Sweden, Jansson wrote in 1998, performed about five such operations a year.2 sources

Freeman, the operation's great promoter, lost his standing as the drugs took over. Norway later reckoned with the damage: in 1996 it agreed to compensate people who had been lobotomised.2 sources

Some have called for Moniz to be stripped of the prize. In 2004 the campaign was led by Christine Johnson, who had a close relative harmed by lobotomy, through the website psychosurgery.org. That July the Nobel Foundation wrote to her declining to withdraw the award, while saying it was relieved that “the medical profession can today offer much more humane and effective therapies for the severely mentally ill patients”.1 source

The Nobel organisation's own website carries an essay on the controversy, published in 1998 by Bengt Jansson, a professor of psychiatry at the Karolinska Institutet who had sat on the Nobel Assembly. He argued that the 1940s had no alternative for the sickest patients and that the operation made some lives more bearable, and concluded: “I think there is no doubt that Moniz deserved the Nobel Prize.”1 source

Others disagree. The neuroscientist Torsten Wiesel, himself a Nobel laureate in medicine, has been quoted as calling the 1949 award “a terrible mistake that caused permanent damage to thousands of patients.” Some take a middle line: the authors of a 2017 tribute in Frontiers in Neuroanatomy wrote that angiography, not the leucotomy, would have deserved the prize, while asking readers to judge the operation in the context of its time.2 sources

In Portugal Moniz is honoured as a scientist. In 1989 the Banco de Portugal put him on a 10,000-escudo banknote, and several stamps have marked the first cerebral arteriogram. The museum in Avanca presents him as the precursor of modern brain imaging and of psychosurgery. The next Nobel laureate born in Portugal was José Saramago, who won the prize for literature in 1998. Moniz is still the country's only laureate in the sciences.5 sources

The angiogram he fought for has lasted. Doctors now usually image vessels first with CT or MR angiography, but catheter angiography of the brain is still used to confirm aneurysms and malformations and to investigate subarachnoid haemorrhage and stroke.3 sources