Sunday, June 25, 2006

Egas Moniz, leucotomy, and the Nobel Prize

A movement developed in the USA proposed the withdrawal of the Nobel Prize given to Egas Moniz for his surgical approach to some psychiatric diseases. It seems that this movement is supported by relatives from patients operated with a modification of the method of Egas Moniz. Indeed the operation modified by Walter Freeman in the USA was called lobotomy and was a much cruder procedure than the one initiated by Egas Moniz, which was called leucotomy. Freeman used a tool for the severing of neural fibers, which removed a much larger proportion of white matter. Moreover the surgical approach was different, in leucotomy the penetration was made from the side of the skull (parietal prefrontal leucotomy), in lobotomy the approach was through the orbit (frontal lobotomy). It is not Egas Moniz’ fault if his method was modified and used in patients for whom there was no justification for a surgical intervention. The modified procedure (lobotomy) was used by others indiscriminately often with dramatic consequences for the patients.
"It wasn't just the intrusiveness of those more radical procedures of lobotomy that caused the outcry but also the applications that certain proponents seemed to favor. The neurosurgeons Vernon H. Mark and William H. Sweet and the psychiatrist Frank R. Ervin, for example, wrote a letter to the Journal of the American Medical Association in 1967 that implied that psychosurgery might help quell the urban riots then sweeping the nation (USA); if, in each city, there were a handful of troublemakers with abnormalities of the amygdala, the troubles might have a medical explanation. These physicians seemed ready to diagnose as surgically treatable derangements of the brain, the violent outbursts that many viewed as a complex social problem". (Melvin Konner in Sciences, the publication of the NY Academy of Sciences)

It is also true that many patients benefited from leucotomy. As illustrated in an extensive British report a significant number of patients benefited from leucotomy. The Board of Control for England and Wales published in 1947 a survey collected from 97 public and 11 private psychiatric Hospitals concerning the outcome of 1000 leucotomies performed in those Hospitals. Among patients that left the Hospital 248 were considered cured, 105 improved, and 6 showed no improvement. Among patients still in the Hospital 323 showed improvement, 248 were considered unimproved, and in 10 the situation had become more severe. There were 33 relapses among those that left the Hospital and 12 among those still in the Hospital. There were 60 reported deaths. The report concluded that prefrontal leucotomy is in general an operation easy to perform for the patient although not always easy for the surgeon. Complications are not frequent. The number of deaths cannot be considered high if one takes into account the gravity of the mental diseases one is facing.
A significant improvement is observed in a large number of cases with serious symptoms and a dismal prognosis where all other methods of treatment have failed. Many patients submitted to prefrontal leucotomy leave the Hospital and others, although unable to return to social life, become quieter and easier to handle.
One cannot be certain yet whether the results are obtained with the loss of the finest, subtler mental qualities. Further studies are required to ascertain this point. Prefrontal leucotomy should be executed after a detailed evaluation of each individual case by experienced psychiatrists, concluded the british report.

More recently a paper published in the Archives of General Psychiatry by I.C. Bernstein et al. (1975, 32:1041-7) reported that in 43 private psychiatric patients who underwent prefrontal lobotomies between 1948 and 1970, 35 were virtually free of symptoms that prompted the operation, 6 had some improvement, and 2 were unimproved. The authors commented that “There is general agreement that high social class is a favorable prognostic feature……The supportive social environment seen so often in a private patients population is, we suggest, an important factor in our relatively high rate of success as compared with series from state hospitals”. This shows the multiple variables that could influence the outcome. Since the technique was not standardized, the outcome depended also very much on the ability of the surgeon. Another difficulty concerned the diagnosis of the psychiatric condition, which is still difficult and was even more difficult at the time. There is a growing body of opinion that schizophrenia is an umbrella term covering several diseases of differing etiology. Moreover, until a few years ago a patient labeled schizophrenic in the U.S. would likely have been called manic-depressive or neurotic in England and delusional psychotic in France (Lynn Payer, Medicine and Culture, Viking Penguin).

When Egas Moniz died, Professor Sir Geoffrey Jefferson expressed in The Lancet from December 31, 1955 (page 1397) his warm appreciation for the work of the Portuguese scientist. He wrote: “His life was an unusually productive one, his name will live for his two great contributions to medicine. No one who was privileged to watch the development of Egas Moniz’s discoveries could help but admire the ways in which they were developed. Humanity has reason to pay its last respects and express its gratitude to another great Portuguese explorer".

There is an excellent site dedicated to Prof. Egas Moniz, it describes different aspects of his life, not only his scientific work. One can also visit the interior of his country home and birth place, which became a museum. All sort of references related to his daily life can be found at the site. The address is
http://museuegasmoniz.cm-estarreja.pt
The site is still in the making and new data will be added.

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