The white cut: Egas Moniz, lobotomy, and the Nobel prize

In 1949 the Nobel prize was awarded to Egas Moniz, the neurologist who carried out the first lobotomy, a procedure that caused severe physical and psychological impairment. Seye Abimbola investigates the ongoing debate.

The closest most medical students get to learning about lobotomy is during their psychiatry or possibly neurosurgery rotations, although there is more chance for those who do an elective in medical history. However, the story of Egas Moniz and lobotomy exemplifies some of the important events and contemporary issues of social relevance in the history of medicine.

In the beginning

Egas Moniz, an outstanding neurologist who had been nominated twice for the Nobel prize for his development of the cranial angiogram with his surgical associate, Almeida Lima, performed the first lobotomy in 1935. Lobotomy means “the incision of a lobe,” but in this context it is simply the destruction or removal of the prefrontal lobes of the cortex of the brain, an option of last resort used to treat some forms of mental disorder that did not respond to other treatments. He wasn’t a trained surgeon, and since his hands were deformed by gout he did not often do the surgery himself.¹ “However, there is no doubt that it really was Moniz who initiated and managed to inspire enthusiasm for the importance of prefrontal leucotomy in the treatment of certain psychoses,” wrote his contemporary, the psychiatrist Bengt Jansson.²

Within months, prefrontal leucotomies (leucotomy, meaning “white cut,” is an old name for lobotomy) were being done all over the world. As another contemporary said, “Seldom in the history of medicine has an experimental procedure been so promptly adapted to the treatment of patients everywhere.”³ Moniz received several honours and was finally awarded the Nobel prize in 1949. “It might turn out that his thinking was not very sophisticated,” said science historian Zbigniew Kotowicz, “but the curious thing was that he got it ‘right’ in that no one appreciably improved on his results.”¹

The lobotomy era

Walter Freeman, an American neurosurgeon, did what soon became the largest series of such operations in the world. He enthusiastically adopted Moniz’s procedure and, dissatisfied with its length and messiness, developed a much quicker and simpler transorbital approach to the frontal lobe. For this he used a tool commonly used to break ice, which could be inserted by tapping it with a rubber hammer and making an opening in the roof of the eye orbits. Freeman called it the “ice pick lobotomy,” an operation he performed, according to Ole Enersen, “with a recklessness bordering on lunacy, touring the country like a travelling evangelist. In most cases,” Enersen continued, “this procedure was nothing more than a gross and unwarranted mutilation carried out by a self righteous zealot.”³

Within 10 years, Freeman alone had lobotomised about 2400 patients.³In the 1940s and 1950s more than 50000 patients had lobotomies in the United States, mostly based on scanty and flimsy evidence for its scientific basis.⁴

The fall of lobotomy

It soon became clear that although prefrontal lobotomy curtailed severely agitated and violent behaviour and therefore becalmed psychotic patients, it had many undesirable effects. It produced apathetic “zombies” and led to severe intellectual impairment, reduced drive, disinhibition, emotional lability, incontinence, obesity, and epilepsy in many patients. It left a long trail of victims, including well known personalities such as Hollywood actress Frances Farmer and the sisters of American president John F Kennedy and writer Tennessee Williams.⁴

Protests came from many quarters, but mostly it was the writers and film makers who got across to the public the full horror of “carving up the human brain like a Thanksgiving turkey.”⁵ Tennessee Williams’s 1958 play Suddenly Last Summer was inspired by the experience of his sister’s lobotomy. Ken Kesey won a Pulitzer prize in 1962 for One Flew Over the Cuckoo’s Nest, in which the hero McMurphy, a loud and charismatic psychiatric patient, is lobotomised as a punishment by the manipulative and domineering Nurse Ratched, who simply couldn’t stand McMurphy’s unruly behaviour as he engaged her in an endless battle for control of the ward.

With increasing acceptance of electroconvulsive and insulin shock therapies and the appearance of effective drugs for treatment of anxiety, depression, and psychoses in the 1950s, the popularity of lobotomy began to decline. Evidence of its widespread abuse (in many instances lobotomy was not used as a last resort but was used to treat problem children, rebel adolescents, and political opponents) and collateral effects added to it’s decline. By 1975, when the Oscar winning film adaptation of One Flew Over the Cuckoo’s Nest was made, lobotomy had finally become history.⁴

NARA
Folks, do not try this at home!

The Nobel controversy

The award of the Nobel prize to Moniz has been widely criticised. Torsten Wiesel, fellow Nobel laureate in medicine, says Moniz’s 1949 prize “was a terrible mistake that caused permanent damage to thousands of patients.”⁶

A handful of lobotomised patients and their families, particularly their children and grandchildren, have recently begun to speak out. “It’s like we were all supposed to slink into the shadows, as if it never happened, as if doctors never cut into the brains of people we loved,” says Christine Johnson, a medical librarian in New York, whose late grandmother was lobotomised in 1954. She hosts a website devoted to the memory of people who underwent the procedure and through which she has been leading a campaign for Moniz’s Nobel prize to be rescinded. In a letter criticising the Nobel committee she said it “has never taken responsibility for the fact that they awarded a prize for an operation that was a total failure and without any scientific merit. Through the committee’s actions,” she continued, “they endorsed this brutal operation and provided justification for thousands of more operations.”6 Sue Kemsley, another campaigner says: “It would be nice if the Nobel prize committee would admit to their error, de-Nobelise Egas Moniz, and dedicate his prize instead to the victims of psycho­surgery.”⁴

However, in an essay displayed on the Nobel site Bengt Jansson writes: “I see no reason for indignation at what was done in the 1940s as at that time there were no other alternatives.”² And this raises an important question: was lobotomy made popular in the face of better alternatives? How widely discredited had the procedure become by the time the Swedish Academy recognised Moniz?

Conclusion

Although the prize had the effect of making lobotomy a respectable procedure, it wasn’t the single factor in popularising the operation. Moniz was already internationally respected and had been nominated for the Nobel prize in 1928 and 1933 for his work on cerebral angiography. Also, Walter Freeman’s evangelising zeal in America played some part.

It remains to be asked whether it really was the effect of the Nobel prize that resulted in more lobotomies being performed in the three years after August 1949 than in the previous 13 years. And how could Moniz have been awarded the Nobel prize for a procedure that failed to cure an angry lobotomised patient who rendered Moniz paraplegic from a shot fired at his spine 10 years before he was awarded the prize?³

I don’t think it makes sense to withdraw a prize awarded over half a century ago. It would be good if the World Health Organization could dedicate a day to remember the tragedy of lobotomy. And following the example of Norway, which has awarded compensation to all surviving lobotomy patients,⁴ nothing stops the Swedish Academy from recognising the negative impact of lobotomy on the lives of thousands of patients and their families around the world. My suspicion is that prefrontal lobotomy was just an excuse to award Moniz the deserved prize for cranial angiography he repeatedly missed in 1928 and 1933.

I agree with psychiatrist V W Swayze II, who says: “If we learn nothing else from that era, it should be recognised that more rigorous, prospective long term studies of psychiatric outcome are essential to assess the long term outcomes of our treatment methods.”⁷ I would add not only psychiatric outcomes. Thankfully, the practice of evidence based medicine, “the white cut” we had always needed, is now helping to separate the wheat from the chaff in the choice of treatment modalities accepted for clinical practice.

national library of medicine/spl
Egaz Moniz, Portugese neurologist

1. Janson-Smith D. The unkind cut. Wellcome News 2002;Q2: 24-5.
2. Jansson B. Controversial psychosurgery resulted in a Nobel prize. www.nobelprize.org/medicine/articles/moniz/index.html
3. Enersen OD. Antonio Caetano de Abreu Freire Egas Moniz. www.whonamedit.com/azlist.cfm/a.html
4. Kemsley S. Why Nobel should rescind the prize. www.psychosurgery.org/index_files/Page2836.htm <
5. Sutherland J. Should they de-Nobel Moniz? Guardian 2004 August 2. www.guardian.co.uk/Columnists/column/0,5673,127800.html
6. Johnson C. The first psychosurgeon. www.psychosurgery.org/index_files/Page627.htm
7. Swayze II VW. Frontal leukotomy and related psychosurgical procedures in the era before antipsychotics (1935-1954): a historical overview. Am J Psychiatry 1995;152:505-15.

       

           

	EDUCATION The white cut: Egas Moniz, lobotomy, and the Nobel prize       Seye Abimbola,Obafemi Awolowo (January 2006)
	Manuel Correia (March 14th, 2006)       N/A , Portugal mccorreia@sapo.pt
	I agree in general with de expressed purpose of the author, but I suggest to correct in future texts concerning this matter the following: - Moniz was nominated for the Nobel Prize in 1928 and in 1933, as the author mentions, but also in 1937, 1944 and finally, in 1949. Cerebral Angiography was always referred to by his evaluators. Of course from 1937 onwards, prefrontal leucotomy turned to be also an object of nomination. The reason for the refusal of awarding him for angiography, even when he got the prize in 1949, was the belief that Cerebral Ventriculography performed by Walter Dandy was a best diagnosis technique. - There is no evidence that the patient who shut Moniz in 1939 had underwent any previous surgery. If you can refer to some text mentioning it, I would be greatly interested in the reference. For the rest, thank you for your article.