António Egas Moniz: History of Lobotomies

Written By: Naomi

Trigger Warning: Racism, Violence Against Women, Graphic Descriptions of Medical Procedures

Background


António Caetano de Abreu Freire Egas Moniz was born on November 29th, 1874 in Portugal. Portugal was under monarch rule when Moniz was growing up, his entire family strongly supported the monarchy but Moniz believed in a republican government causing him to become an activist when he was a student and attend protests. Moniz was even jailed on two separate occasions for his participation in demonstrations. Moniz Studied medicine in University and graduated in 1899 but he stayed with the university for the next 12 years of his life teaching basic medical courses. He started his official political career in 1900 when he was elected into parliament. During WWI he was made the ambassador to Spain and continued to represent Portugal in the 1919 Portugal Peace Conference after the war. In 1911 he became a neurology professor at the University of Lisbon, it was during his time here that he was arrested a third time for his protesting efforts when he prevented the police from breaking up a student run protest. Moniz retired from his political career in 1926 to focus on his medical career, he continued to teach at Lisbon until his retirement in 1944.


It was not Moniz’s work in politics or as a professor that he was remembered for, often times his name is lost to history and disconnected entirely from what has lived on. The medical procedures he helped create have taken on a life and legacy of their own with many variations and affects on medical and mental health history. Moniz offered many advances in medicine that are still used today, but like anything else in the history of medicine, there were tests and trials to prove the procedures would yield results.


Procedures


Moniz developed the first cerebral angiogram, he theorized that if the blood vessels in the brain could be visualized with radiography, it would allow doctors to locate and isolate brain tumors. Moniz started his experiments on 3 human patients with suspected epilepsy, a tumor, and Parkinsonism which is the combination of mobility issues that comes with Parkinson's disease. He started by injecting them with radiopaque dyes like strontium and lithium bromide into arteries in their brains then x-raying to look for abnormalities. These trials yielded nothing useful, in fact, one patient died. Eventually he was able to succeed and find a combination of 25% sodium iodide and developed the cerebral angiogram still used today to find blood clots that can lead to strokes and check for aneurysms or brain tumors. This was Moniz’s positive contribution to medicine and earned him two Nobel Prize nominations. But there was another procedure Moniz created that was widely used and twisted into a tool of horror today.


Moniz had an interest in mental health as a neurologist and believed that mental illness had to have a somatic cause, a cause within the physical body. In the 1930’s he began to theorize mental illness was caused by abnormal neural connections in the frontal lobe, the synapses in the brain would fire repeatedly and cause fixations or, “predominant, obsessive ideas”. He supported his theory with observations of World War I soldiers who had their frontal lobes damaged in the war whose personalities and characters changed. At the Second International Congress of Neurology held in London in 1935 Moniz witnessed the results of an experiment done by psychologists at Yale named John Fulton and C.F. Jacobson where the frontal lobe of a chimpanzee was completely removed, making the animal more calm and cooperative when before they were described as emotional and would throw tantrums. Moniz was fascinated and asked the neuroscientists if the results could be replicated in humans with mental illness, to which Fulton was shocked and stated that the process might be possible but it was, “too formidable” to be done on human patients.



Moniz refined his idea and theorized that if he instead could surgically remove or break the connection between the synapses or “White fibres” in the frontal lobe, the patient’s mental health would improve since he was breaking that obsessive connection. He called the procedure, the prefrontal leucotomy, better known as a lobotomy today, this procedure was used as a means to replace various shock therapies. With the reinforcement of his cause and affect theory he began experiments just 3

Human brain that has undergone a leucotomy

months later on 20 patients with schizophrenia, anxiety, manic depression and bipolar disorder, 17 of these patients being women. Moniz could not perform the surgeries himself since he had extreme gout damage to his left hand and he had no training as a neurosurgeon despite teaching the subject at the university he was employed at, so he recruited one of his staff members to perform the procedures for him. The first 10 of these experiments were done by injecting pure alcohol into the frontal lobes of the patients to kill the tissue before Moniz and his assistant developed a technique with a tool called a leucotome that is a hollow needle was inserted into the brain with a wire loop at the end that could be retracted after it looped around brain material and sever it or rotated to destroy tissue.


Moniz determined that the first 40 patients who received the treatment were a success and that the treatment was simple, “always safe” and that the side effects were outweighed by the benefits. Moniz notes though that those with “deterioration” due to mental illness could not be helped by the procedure as they wouldn't benefit much from it. The usefulness of this procedure was questioned by the sometimes severe complications and risks that would come with the treatment, lobotomies were shown to be improving or eliminating symptoms rather than the mental illness itself while also causing sometimes serious impairments to the patient’s life in their intellect and personalities. The operation worked in treating symptoms by damaging the brain to lower self-awareness, self-control, responsiveness, and spontaneity through emotional blunting and restricting the intellectual range through brain damage. Complications with the procedure killed patients and the lasting effects would cause others to commit suicide months later making the mortality rate 5% in the 1940’s while those who survived were often left with disabilities and emotional or intellectual deficits. Seizures and becoming dependent on others immediately after the surgery was common and the treatment focused on “training” patients after a procedure. The treatment was popular in western culture and increased dramatically in use into the 1950’s with around 20,000 performed in the United States on mainly female patients, a study in 1951 found that in 60% of lobotomy patients were female in America and 74% were female in Canada. There was a very obvious preference to perform this procedure on women, this also reflects the belief that psychosis was tied to the female gender.


In the biography of Walter Freeman, M.D., who assisted in the development of the lobotomy titled The Lobotomist there was evidence that race and gender were taken into consideration for who should receive the treatment, picking mainly black women as candidates. The rational used to justify the choice was that families of color were more likely to care for their family members post lobotomy. This population was also picked due to the side effects of the lobotomy making individuals docile, citing in particular a visitation of a group of 20 individuals post operation where 15 of them were outside with only one guard required to oversee them. Additionally, the use of the lobotomy technique was suggested for use on black patients in Tuskegee, Alabama in 1951 when the already extremely unethical Tuskegee Syphilis study was taking place.


This practice slowed in frequency into the 1950’s when medicines to treat mental illnesses were being developed and lobotomies are reflected upon as a barbaric treatment that is another instance of medical professionals not respecting the rights of their patients. Moniz was accused of being aware of the side effects and complications of the procedure but providing inadequate documentation of the trials and surgery as well as not following up with patients after their procedures.




Despite the cruelty of the treatment, Moniz was awarded the Nobel Prize in Physiology or Medicine in 1949 for the, “discovery of the therapeutic value of leucotomy in certain psychoses”.



Contribution to Current Ethics


Many professionals who look back on this procedure feel that the surgery and it’s after effects were not researched enough to justify its use on human patients. The treatment was risky and unethical since the neurosurgeons and neurologists were doing more harm to their patients than good for the sake of making their symptoms more manageable for caretakers and the general public without consideration for the patient. An investigation in 1977 by the National Committee for the Protection of Human Subjects of Biomedical and Behavioral Research looked into allegations that lobotomies and other psychosurgeries were used as a form of reproductive abuse to control people of color and further restrain the individual’s rights. It was decided that psychosurgery could have positive effects if performed correctly but it is only the case in limited situations at that time. This decision though did not have much gravity as the procedure was not being used as often and medication to treat mental illnesses were more common.


The testimonies made by those who have been through this procedure or those whose loved ones had been lobotomized describe the surgery being offered to them as a small outpatient procedure that would assist them with their mental health. The true nature or side affects of the procedure were not disclosed to the patient or their family. The needs of the patients were never considered which directly violates the American Association of Neurological Surgeons code of ethics, the needs of the patients have been shifted to the forefront of most provider’s minds now due to establishment and reinforcement of ethical codes for every branch of the medical profession.


As professionals we are not to harm our clients and the targeting of women and people of color enforces an ongoing narrative of systematic oppression and a distrust of medical professionals. This shows how much harder we have to work and why the distrust is deserved in some communities or cultures.


There have been great improvements in mental health treatments and the field is focused on the client’s needs. Professionals want to be transparent about their credentials, what services they can provide, and what to expect from therapy which is a stark contrast and growth from the barbaric treatment of patients in the past. Laws to protect the rights of patients have been made and enforced but there are still areas that require additional growth in order to provide equal service for people of color and women who had been historically targets for malpractice. Though lobotomy as a procedure was incredibly damaging, it was considered groundbreaking for its time. There have been improvements to the treatment and the cases that were a success have been studied to better our understanding of mental illnesses and how they can be treated through medicine. The field continues to grow as research is done but it is important to put the client’s needs, safety, and health first.

References


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