Antonio Caetano de Abreu Freire Egas Moniz

Egas Moniz, considered the father of modern psycho-surgery, is chiefly remembered as the originator of lobotomy. In 1949 he shared the Nobel Prize for Physiology or Medicine with Walter Rudolf Hess, Switzerland (1881-1973).

Hess (Zurich University) won the prize "for his discovery of the functional organization of the interbrain as a coordinator of the activities of the internal organs".

Egas Moniz (University of Lisbon, Neurological Institute) won the prize "for his discovery of the therapeutic value of leucotomy in certain psychoses".

In the name of a hero
Egas Moniz' real name was Antonio Caetano de Abreu Freire. He was born on the family farm in Avancha in northern Portugal, the son of Fernando de Pina Rezende Abreu and Maria do Rosario de Almeida e Sousa. His godfather named him Egas Moniz after the hero of the Portuguese resistance against the Moors.

Egaz Moniz received his first education from his uncle Abbé Caetano de Pina Rezende Abreu Sa Freire, before entering the University of Coimbra. He studied mathematics and considered a career in engineering before joining the Faculty of Medicine at Coimbra University. He received his doctor’s degree in medicine in 1899. Selecting neurology as his specialty, Egas Moniz went to Paris and Bordeaux to study with the leading figures in neurology and psychiatry, such as Joseph Jules François Félix Babinski (1857-1932), Joseph Jules Dejerine (1849-1917), Pierre Marie (1853-1940) and Jean Athanase Sicard (1872-1929).

In 1902 Egas Moniz became professor at Coimbra and married Elvira de Macedo Dias. He was appointed to the chair of neurology at the new University of Lisbon in 1911, a position he held until his retirement in 1945. He also worked for a time as a physician in the Hospital of Santa Maria, Lisbon.

A doctor at Versaille
As a young man Egas Moniz became strongly involved in politics. In the period between 1903 and 1917 he served several times in the Portuguese chamber of deputies and was Portuguese ambassador to Spain 1917-1918 after the overthrow of the monarchy. Later in 1917 he was appointed Minister for Foreign Affairs and at the end of World War I he led the Portuguese delegation at the Paris peace conference in 1918 (1918-1919) and was Portugal's signatory to the Treaty of Versailles, which was signed on June 28, 1919. He retired from politics in 1919 after a political quarrel involved him in a duel.

Cerebral angiography
Although Egas Moniz had written a book on the physiology and pathology of sex, and after World War I also a book on neurology in war, it was only after his party had been deposed that he returned to the University of Lisbon. Here he redirected his attention to neurological research and in the years from 1927 to 1937 introduced and developed the idea of utilizing X-rays as a method of making visible the blood vessels of the brain, and to locate brain tumors.

When he entered neurology, the method by which physicians attempted to use the still new technique of X-raying to locate intracranial tumors was the one developed by the American neurosurgeon Walter Edward Dandy (1886-1946), involving the injection of air into the brain cavities. Seeking a more exact as well as a less hazardous technique, Egas Moniz began a series of cadaver experiments in which he injected various radiopaque solutions, most references are to sodium iodide, into the brain’s arteries. After mapping the normal distribution of the intracranial blood vessels, he introduced his method clinically 1927, outlining with X rays the location and size of a patient’s brain tumor by the tumor’s displacement of injected arteries.

Egas Moniz and his colleagues published over 200 papers and monographs on normal and abnormal cerebral angiography, and the technique has been refined and elaborated for the localisation of tumors and vascular disorders throughout the body. His technique, later refined by German and Swedish scientists, has proved to be of considerable value in the diagnosis of intracranial diseases.

Prefrontal leucotomy - lobotomy
However, what has made Egas Moniz famous, some would rather say infamous, is his introduction of leukotomy, later renamed lobotomy by Walter Freeman (1895-1972) and James Winston Watts.

Early in his career Egas Moniz had worked with F. Regis on the problem of toxic psychoses and had become convinced that «only by an organic orientation can psychiatry make real progress.»

In 1935, at the Second International Neurological Congress in London, he heard the physiologist John Farquhar Fulton (1899-1960) and the animal physiologist Carlyle Jacobsen discuss the effects of frontal leucotomy (surgical division of the nerves connecting the frontal lobes to the rest of the brain) on the behaviour of two chimpanzees: the animals remained friendly, alert, and intelligent but were no longer subject to temper tantrums or other symptoms of the experimental neuroses that had been successfully induced prior to surgery.

Egas Moniz realized that certain psychoses, particularly degenerated schizophrenia and severe paranoia, involve recurrent thought patterns that dominate normal psychological processes. He reasoned that, severing the nerve fibres between the frontal lobes, known to be closely associated with psychological responses, and the thalamus, might force a transformation of existing thought patterns to more normal ones, allowing a more normal life for the psychotic.

Prefrontal leucotomy - lobotomy - was first performed in Lissabon by Egas Moniz and his surgical associate, Almeida Lima, on November 12, 1935. Using local anesthetics Egas Moniz and Almeida Lima drilled several holes in the patient's skull, first injecting adrenalin and novocain, then pure alcohol. The object had been, not to destroy the actual frontal lobes, but rather to destroy the fibers, the white matter, or leukos, which connect the frontal lobes – the area they believed to be most immediately concerned with social behaviour. Their patient was a female asylum inmate. This operation is the first example of the use of brain surgery for the treatment of a psychological disorder.

When the patient awaked she was less agitated and paranoid than she had been before, and she certainly had no worries about her hair. Two months later the patient was observed by a young physician who did not find any of the old symptoms present. Egas had invented the prefrontal lobotomy.

Unfortunately for Egas Moniz (but maybe fortunately for the patients), the director of the asylum was suffering twinges of professional jealousy and was unwilling to supply any more surgical subjects. Quite apart from this, he was, as Lima put it, experiencing "doctrinal and ethical" doubts about the nature of the operation. In order to maintain his flow of patients, therefore, Egas Moniz not only had to exercise his considerable powers of charm, but began to withhold the results of his work that suggested it was less than perfect, so that it appeared that the operation was already a success, and was so simple that it could be applied quickly on a wide, public basis.

Egas Moniz and Almeida Lima started a comprehensive project of 20 operations. The procedure was carried out on 13 patients with agitated depression, of whom a majority were reported to be "clearly improved," and on 7 patients with schizophrenia, of whom only 2 improved. However, both the first and several other patients who underwent the same procedure were also, Egas Moniz admitted, somewhat more apathetic and frankly duller than he had hoped. In addition they suffered from nausea, sphincter disorders, sluggishness and disorientation. Still, Egas Moniz interpreted the result of his first operation as the patient being cured.

Injecting alcohol did not, however, prove sufficiently effective, and after seven operations he started using a special knife called the leucotome. The leucotome was inserted into the brain substance. With a few sideways movements, the fibers were severed and the patient could recover.

His method was "trial and error", the following up of his patients was inadequate, and no observations stretched over a period longer than two months after the operation. The lack of symptoms was seen as complete resolution, and Moniz maintained that nobody had become worse.

The report of their first clinical trials on mental hospital patients - no operative deaths and fourteen out of twenty patients «cured» or «improved» - created worldwide interest and debate over the possibility that mental illness could be corrected by operating on brains that are not organically diseased.

Egas Moniz published his successful results with "the white cut" in six countries simultaneously. And, as one contemporary said, "Seldom in the history of medicine has an experimental procedure been so promptly adapted to the treatment of patients everywhere."

"The white cut" certainly proved to be less than perfect, but unfortunately it culd be applied quickly on a wide, public basis. And was it! One of the most avid readers of his first report must have been Walter Freeman, chief of neurology, and James Watts, chief of surgery, both at George Washington University, who undertook what soon became the largest series of such operations in the world. Freeman was later to develop lobotomy with a recklessness bordering on lunacy, touring the country like a travelling evangelist, literally using an icepick to crush through the bony orbit above each eye to produce brain lesions. Between 1948 and 1957, he alone lobotomized 2400 patients. In most cases this procedure was nothing more than a gross and unwarrented mutilation carried out by a self-righteous zealot.

"The white cut" certainly proved to be less than perfect, but unfortunately it culd be applied quickly on a wide, public basis. And was it! One of the most avid readers of his first report must have been Walter Freeman, chief of neurology, and James Watts, chief of surgery, both at George Washington University, who undertook what soon became the largest series of such operations in the world.

Their first patient was a 63-year-old woman from Kansas, the type of agitated, depressed and fearful personality that Moniz had experimented on. Faced with the choice of a mental institution or surgery, she and her husband opted for the knife. On the operating table, she had second thoughts when she was about to be shaved, and she would loose the curls she was proud of. Freeman assured her that her curls would be saved; this was not the case, but after the operation, as Freeman himself noted, "She no loner cared".

The operation was carried out on September 14, 1936. Freeman and Watts had altered Moniz's prescribed technique since the first leukotomy, and six holes were were now cut in the patient's head. When she had stitched together and had woken from the anaesthetic, the sense of calm she exuded in contrast with her former terror was striking. When asked by Freeman if she could remember why she had previously been so upset, she could only say: "I don't know, I seem to have forgotten. It doesn't seem important now". Freeman and Watts were thrilled.

A week after surgery, the woman began to behave strangely. She talked incoherently, becoming stuck on certain syllables, repeating them endlessly and hopelessly jumbling up her sentences. She could no longer recite the days of the week, and when she was asked to write, the same repetitions and sad, nonsensical constructions occurred on paper. A few days later, her speech had largely returned and she went placidly home, showing neither eagerness nor apprehension.

Freeman was later to develop lobotomy with a recklessness bordering on lunacy, touring the country like a travelling evangelist, literally using an icepick to crush through the bony orbit above each eye to produce brain lesions. Between 1948 and 1957, he alone lobotomized 2400 patients. In most cases this procedure was nothing more than a gross and unwarrented mutilation carried out by a self-righteous zealot.

At the Nobel presentations in 1949, Herbert Olivecrona captured the significance of Egas Moniz’ work when he said:

«Frontal leucotomy, despite certain limitations of the operative method, must be considered one of the most important discoveries ever made in psychiatrics, because through its use a great number of suffering people and total invalids have recovered and have been socially rehabilitated.»

Considering the patient's state of mind after the operation, the Nobe Peace Prize may seem more appropriate. Egas Moniz probably would have deserved the prize as much for his contribution to radiology.

Norway early
Norway was one of the first countries to use lobotomy, after Portugal, Italy and the U.S. The method was introduced to Norway by the director of Gaustad sykehus, Ørnulf Ødegård, who performed his first operation shortly before christmas in 1941. Within a few years the method was firmly established as a common treatment. This situation remained even long after the appearance of scientific reports indicating that the operation has no merit as a cure for mental disorders. Patients who have been lobotomized have suffered from side-effects, often basic disturbances of their psychological behaviour, and risked a reduction of their intellectual capacity.

Honours
Moniz received the Gran-Cruz da Instrução e Benemerência (Portugal) and the Gran-Cruz de Izabella Catolica (Spain): he was appointed Grand Officier de la Couronne d'Italie, and Commandeur de la Légion d'Honneur (France). He was Doctor, honoris causa, of the Universities of Bordeaux and Lyon; Membre de Mérite, and President at various times, of the Academy of Sciences, Lisbon; Member of the Academy of Medicine, Paris; of the Academy of Medicine, Madrid; of the Society of British Neurological Surgeons; Honorary Member of the Royal Society of Medicine, London; of the Académie Nationale de Médecine de Rio de Janeiro; of the American Society of Neurology; and of several South American institutions among many others. A 1937 Portugual stamp commemorates the first cerebral arteriogram, performed by Egas Moniz in 1927.

A bon vivant
Besides his scientific achievements and his contributions to politics, Egas Moniz was an accomplished historian, literary critic, and composer. He authored several works, including an autobiography. He was an urbane man who enjoyed good living and suffered from gout. At 65 he was shot in his office by one of his schizophrenic patients, but recovered to die peacefully at 82 on the farm on which he was born (Internet: he became paraplegic).

A brief prehistry of lobotomy
Lobotomy, later to be much of a tragedy, probably originated with an accident in America in 1847. A manual worker named Phineas Gage was involved in a rock-blasting operation, when, during an uncontrolled explosion, an iron bar was driven clean through the front part of his head. To everybody's surprise, he survives the removal of the protruding bar. As he recovers, however, it is observed that his personality has dramatically changed, though his memory and intelligence remain apparently unaffected. In 1868, a physician named Harlow from Boston writes about him:
"His equilibrium, or balance, so to speak, between his intellectual faculties and animal propensities seems to have been destroyed. He is fitful, irreverent, indulging in the grossest profanity, which was not previously his custom, manifesting but little deference for his fellows, impatient of restraint or advice when it conflicts with his desires." The now extremely rude Phineas Gage is an object of immense medical interest, for it seems clear, from his somewhat crude experience of psychosurgery, that one can alter the social behaviour of the human animal by physically interfering with the frontal lobes of the brain.
The German physiologist Friedrich Leopold Goltz (1834-1902), doing experiments with the surgical ablation of neocortex in dogs, reported that when the temporal lobe were removed, animals were more tame and calmer than the unoperated ones.
This inspired Gottlieb Burkhardt (1836-1907), a physician and supervisor of the insane asylum Préfargier in Canton Neuenburg, Switzerland. In 1890 he drilled holes in the heads of six severely agitated patients and extracted sections of the frontal lobes. Some of his patients actually became calmer after the surgery, two of them too much so, as they died.
His surgery was considered morally reprehensible at the time, so that very few psychosurgeries of this kind were carried out in the next 40 years or so. But his work is not forgotten. Phineas and his iron bar have started a train of thought that win come to a strange and tragic fruition in the next century.

• G. Burckhardt:
  Ueber Rindenexcisionen, als Beitrag zur operativen Therapie der Psychosen.
  Allgemeine Zeitschrift für Psychiatrie, Berlin, 1891, 47: 463-548.

• A vida sexual (fisiologia e patologia). Coimbra, 1901.
  (Physiological and pathological aspects of sex life).
• Novas ideias sobre o hipnotismo. Lisbon, 1914.
• A neurologia na guerra.
  Lisboa, Livr. Ferreira, 1917. (Neurology in war).
• Um ano de politico. Lisbon, 1920. (A year of politics).
• Júlio Diniz e a sua obra
  (Julio Denis and his works), 6 editions, Lisbon, 1924.
• O Padre Faria na história do hipnotismo. Lisbon, 1925.
  (Abbé Faria in the history of hypnotism)
• L’encéphalographie artérielle, son importance dans la localisation des tumeurs cérébrales.
  Revue neurologique, Paris, 1927, 2: 72-90.
  Introduction of cerebral arteriography.
• Injections intracarotidiennes et substances injectables opaques aux rayons X.
  Presse médicale, Paris, 1927, 35: 969-971.
  Carotid arteriography.
• Diagnostic des tumeurs cérébrales et épreuve de l’encéphalographie artérielle. Paris, Masson, 1931.
  (Diagnostics of cerebral tumours and application of arterial encephalography).
• L’angiographie cérébral, ses applications et résultats en anatomie, physiologie et clinique. Paris, 1934.
  (Cerebral angiography, its applications and results in anatomy, physiology, and clinic).
  This work on cerebral angiography is one of the best known of more than a hundred books and articles published on the subject by Egas Moniz.
• Essai d’un traitement chirurgical de certaines psychoses.
  Bulletin de l’Académie de médecine, Paris, 1936, 115: 385-392.
  Prefrontal leucotomy.
  Translation in Journal of Neurosurgery, Baltimore, 1964, 21: 1110-1114.
• Tentatives opératoires dans le traitement de certaines psychoses.
  Paris, Masson, 1936.
  (Tentative methods in the treatment of certain psychoses).
• La leucotomie préfrontale. Traitement chirurgical de certaines psychoses.
  Torino, 1937.
  (Prefrontal leucotomy. Surgical treatment of certain psychoses)
• Clinica dell'angiografia cerebrale.
  Torino, 1938. (Clinical cerebral angiography).
• Ao lado da medicina. Lisboa, 1940. (On the side of medicine).
• Die cerebrale Arteriographie und Phlebographie. Berlin, 1940.
  (Cerebral arteriography and phlebography),
• Trombosis y otras obstrucciones de las carótidas.
  Barcelona, 1941.
  (Thrombosis and other obstructions of the carotids).
• História das cartas de jogar.
  Lisbon, 1942. (History of playing-cards).
• Como cheguei a realizar a leucotomia pré-frontal.
  Lisbon, 1948.
  (How I came to perform leucotomy).
• Mein Weg zur Leukotomie.
  Deutsche medizinsche Wochenschrift, Stuttgart, 1948, 73: 581-583.
• Die präfrontale Leukotomie (Prefrontal leucotomy).
  Archiv für Psychiatrie und Nervenkrankheiten, Berlin, 1949. Obituaries
• Antonio Egas Moniz, M. D. The Lancet, London, 1955; 2: 1345.
• R. Perino:
  Egas Moniz, 1874-1955.
  Journal of the International College of Surgeons, 1961; 36: 261-271. Biographical:
• Egas Moniz:
  Confidencias de un investigador cientifico. Lisboa, Ed. Atica, 1949.
• Kolle, editor:
  Grosse Nervenärzte.
  Volume 1. Stuttgart, Thieme, 1966, pp. 187-199. (Barahona Fernandes).
• Anonymous:
  Journal of the American Medical Association, Chicago, 1967, 206: 368-369.