In the years following the First World War, the idea that specific brain areas were responsible for particular mental functions and aspects of mental illness was undergoing a renaissance. In 1935, Carlyle Jacobsen and John Fulton ablated the prefrontal cortex in two chimpanzees called Becky and Lucy (Jacobsen, Wolfe & Jackson, 1935). Jacobsen used the term “experimental neurosis” to describe Becky’s frustration and anger at her mistakes and failure to achieve a reward during experiments. Lucy was less agitated at her errors, appearing more ‘laid back’ under experimental conditions. After cortical ablation, Becky became more passive and did not show the same responses to failure. However, Lucy displayed much more agitated and aggressive responses during the tests.
The traditional history of psychosurgery would accord that it was Fulton and Jacobsen’s presentation at the Second World Conference of Neurology in London which inspired the Portuguese neurologist Egas Moniz, to develop similar procedures in humans. Indeed, it is relatively certain that Moniz asked the question whether surgical ablation of the frontal lobes could treat anxiety states in humans, but it seems that Fulton, ever the cautious scientist, was cautious about such an extrapolation of his findings. However, it is difficult to see how contrasting responses to the same procedure in only two animals could be the sole justification for extending the procedure to humans. Indeed, Moniz subsequently reported that he had been considering such interventions prior to Fulton and Jacobsen’s reports. It is more likely that Moniz was more influenced by Brickner and Penfield’s presentations at the same all-day conference (also attended by Walter Freeman) when Brickner gave a detailed description of his famous case, Joe A., reporting that his psychic functions were affected quantitatively rather than qualitatively . MacMillan argues that this lead Moniz to conclude that frontal lobe damage had potentially non-significant, and transitory, effects on the individual (MacMillan, 2002).
Whatever the true inspiration for experiments in humans, at the end of 1935 Moniz teamed up with Almeida Lima, a neurosurgeon (who had trained under Hugh Cairns, England’s leading neurosurgeon) who agreed to perform the procedures under the direction of Moniz. After practising on a cadaver, they went on to treat 20 patients, seventy percent of who came from the Manicome Bombarda asylum. The first operation, lasting thirty minutes, was performed by Almeida Lima with the assistance of Ruy de Lacerda on 12 November 1935 at the Neurology Service of the Santa Marta Hospital. Although Moniz’s paper (1936) includes a note of thanks to Sobral Cid, the director of the asylum, Cid was apparently less than enthusiastic about Moniz’s activities. Whilst the first four patients had been selected by Cid, all the postoperative assessments of the patients were performed by a young psychiatrist called Barahona Fernandes, and Cid refused to provide any more cases. The patients had been institutionalised with a range of psychiatric illnesses characterised by severe anxiety, obsessional behaviour, and irrational fears. Thirty percent of the patients came from "other sources", and his cases were probably selected because of availability rather than other reasons (Valenstein, 1986, p. 105). A number of cases had schizophrenia. Subsequent analysis of Moniz’s results by Berrios (1997) reveals that three factors predicted a better outcome: older age; female sex; and affective (rather than non-affective) psychosis.
They started by injecting alcohol to cause the desired lesions, but this tended to track along the injection tracts causing extraneous damage, and after the seventh patient they switched to using a leucotome to cut the fibres connecting subcortical areas in the brain and the frontal lobes. The leucotome was a thin, cylindrical device with a retractable wire which allowed 'cores' of tissue to be created in the white matter. They initially created six lesions bilaterally, but would create additional lesions during later procedures if the patient did not respond.
Moniz’s patients were probably suffering from a mixture of depression, schizophrenia, or panic disorder. Although there were no objective data collected other than case reports, he reported that: 35% had “clinical recovery”; 35% enjoyed “ameliorations”; and 30% showed no improvement (Moniz, 1936). Moniz reported that, “none of the patients became worse after the intervention” and boldly stated that, “No deaths. The intervention is harmless.” They presented their results in Paris on 3 March 1936 and published their first paper shortly afterwards. So keen was Moniz to get to publication that the follow-up period for most patients was less than two months and for four of the ‘cures’ the last observation was less than eleven days after the operation.
Moniz was the first person to use the term ‘psychosurgery’ in 1936 (Moniz & Lima, 1936), and he went on to be jointly awarded the 1949 Nobel Prize for Physiology and Medicine for his work in establishing leucotomy for psychosis. It is likely that Moniz’s previous work (the development of cerebral angiography) contributed to the award, and along with Moniz’s desire for recognition, this may explain why Moniz’s tentative experiments received more attention than Burckhardt’s. Moniz had been nominated by a Brazilian delegation at the First International Congress of Psychosurgery in Lisbon, and the nomination letter was written by António Flores, a renowned neurologist at the University of Lisbon. Incidentally, it was before Flores that Moniz had been awarded the professorship of neurology at the University of Lisbon in 1911. With regard to the Nobel Prize, Gosta Rylander, the Swedish neurosurgeon, was on the selection panel and was one of those who signed the award (Valenstein, 1986, p. 225). It was not the first time that Moniz had been nominated for the Nobel Prize. In 1928, less than six months after the first cerebral angiogram had been performed, the Nobel Committee received two nomination letters from Moniz’s colleagues. He was nominated once more in 1933 for his work in cerebral angiography, again by colleagues from the University of Lisbon (Valenstein, 1986, p. 77).
Moniz had started his career in politics, rather than surgery. He had been christened António Caetano de Abreu Freire Egas and had added the name Moniz in honour of Egas Moniz de Ribadouro, a Portuguese patriot who had helped to defend Portugal from the Muslim invasion of the Iberian Peninsula in the 12th Century. Prior to his surgical career Moniz had served as a minister to Spain and was a signatory to the Treaty of Versailles. Later in his career, after a political shift in Portugal to a more right-wing government, Moniz ceased his psychosurgical activity and devoted his time again to cerebral angiography. Eventually, Moniz was shot and injured by a former psychiatric patient in 1939, and although many have claimed that this patient had undergone leucotomy under Moniz, this has not been substantiated. He ended his days incapacitated with gout, an illness that had affected him for most of his life.