Antonio Egas Moniz: The man who perfected the lobotomy

Lobotomy. The word has come to inspire fear and loathing through its depictions in works such as Ken Kesey’s 1962 novel, and the 1975 movie, One Flew Over the Cuckoo’s Nest, and the 1982 biopic Frances, in which it was claimed the American actress Frances Farmer had been given the procedure against her will. And yet for much of the twentieth century the lobotomy was a legitimate treatment for serious mental illnesses such as schizophrenia and severe depression. Estimates of the number of operations performed in the US from the 1930s and into the 1980s range from 40,000 to 50,000. Further, neurologist Antonio Egas Moniz, the man credited with performing the first modern frontal lobotomy to treat mental illness, in 1935, shared the 1949 Nobel Prize for Physiology or Medicine, with Swiss physiologist Walter Rudolf Hess.

Moniz was born on 29 November 1874 in Avanca, Portugal. His early work in medical research was in developing angiograms – injecting fluids into patients’ brains, enabling doctors to visualise blood vessels so they could be scanned for anomalies.

A 2014 article in the Singapore Medical Journal says that by 1926 Moniz was able to produce a clear angiogram, “the first of its kind”.

“His work in this area subsequently led to the use of angiography in the detection of internal carotid artery occlusion, which was until then a frequently missed diagnosis,” it states. 

The idea of interfering with the brain to modify behaviour was not new in 1935. According to a 2001 article in the Journal of the History of the Neurosciences, “the first attempt at psychosurgery – intentional damage to the intact brain for the relief of mental illness – was undertaken in 1888 by Swiss psychiatrist Gottlieb Burckhardt”.

Its author, James Stone of the University of Illinois in the US, writes that six chronic schizophrenic patients underwent “localised cerebral cortical excisions. Most patients showed improvement and became easier to manage, although one died from the procedure and several had aphasia or seizures … Nevertheless, his approach had shocked the medical community as reckless and irresponsible. Burckhardt was ridiculed, his academic endeavours ceased and his surgical endeavor largely ignored.”

It is also suggested that Moniz was influenced by two American scientists, Carlyle Jacobsen and John Fulton, from Yale University, who in 1935 presented a paper in which they described how a chimpanzee with both frontal lobes removed became more co-operative and willing to accomplish tasks.

Moniz’s first procedures, according to the LiveScience website, involved cutting holes in the skull and injecting ethanol into the brain to destroy the fibres that connected the frontal lobe to other parts of the brain. He later introduced a surgical instrument called a leucotome, which contained a loop of wire that, when rotated, created a circular lesion in the brain.

An article in the United States Public Broadcasting System says Moniz in 1936 published “well-received” positive descriptions of his first 20 operations – he called the procedure a “leucotomy” – on patients who had suffered from anxiety, depression, and schizophrenia. 

His reporting was especially well received in the US, where neurology professor Walter Freeman went on to perform thousands of the operations. It was he who came up with the term “lobotomy”. In 1952 Freeman operated on 225 people in 12 days during a “lobotomy tour” of West Virginia, according to a Wall Street Journal report.

At first he used an ordinary ice pick, then later switched to an instrument called an orbitoclast, best described as a modified ice pick. This would be inserted through the patient’s eye socket using a hammer, and then moved side-to-side to separate the frontal lobes from the thalamus, the part of the brain that receives and relays sensory input.

With the advent of antipsychotic drugs, the practice of lobotomy ceased. Freeman performed his last two operations in a single day in 1967. One patient reportedly survived but the other died of a brain haemorrhage two days later.

By then, the father of the modern lobotomy, Moniz, was long dead. His first brush with death came in 1939 when he was shot several times by a schizophrenic patient. He survived, however, and although confined to a wheel chair lived until 1955, when he died of an internal haemorrhage.