1949 Nobel Prize in Physiology or Medicine β Hess and Moniz: Two Approaches to the Brain
What You Will Learn
This article explores the reasons why Walter Hess, who meticulously mapped the functions of the hypothalamus in cats through precise brain stimulation, and Egas Moniz, who performed radical prefrontal lobotomies on severely mentally ill patients, shared the Nobel Prize in the same year. It examines the stark contrast between their approaches and the lessons we can learn from this dichotomy, both positive and cautionary. This is a candid look at one of the most controversial awards in Nobel Prize history.
Beyond Common Sense: Was the Nobel Prize Always Justified?
When discussing the Nobel Prize, we often implicitly assume that every award remains justifiable even today. While this assumption generally holds true, the 1949 prize presents a clear challenge to this notion.
In this year, the prize was divided equally between two individuals. One was Walter Hess, whose research continues to form a precise foundation for modern neurology. The other was Egas Moniz, whose procedure (prefrontal lobotomy) is now largely regarded by most psychiatrists as a crude and unethical intervention. The fact that these two individuals received the same award is a lasting irony in Nobel history.
In this article, we will address the stories of these two individuals honestly and together. Simply praising Hess and glossing over Moniz does not accurately convey the reality of this award. We will explore the differences in their approaches, why these approaches could be grouped together in that era, and what lessons we can learn from this contrast today.
If we were to express this contrast in terms of computer science, both individuals used "sudo" privileges on the brain. However, their usage was diametrically opposed. Hess performed precise API calls to activate specific functions, while Moniz indiscriminately deleted kernel modules. Both approaches required powerful privileges, but they differed drastically in terms of precision and irreversibility.
The Zeitgeist: An Era of Radical Intervention in Psychiatry
1949 was a year when the world was finding a new balance, and psychiatry was reaching the peak of radical interventionism.
In April, the North Atlantic Treaty Organization (NATO) was established. In August, the Soviet Union successfully tested its first atomic bomb. Nuclear parity became a new condition of the Cold War, and international politics for the next half-century would be shaped by this balance. In October, the People's Republic of China was founded. The political map of the Asian continent was fundamentally redrawn.
At this time, psychiatry was in an extremely challenging clinical situation. Effective medications for conditions we now know as schizophrenia were not yet available (chlorpromazine was only introduced in 1952). Antidepressants were also unavailable (the first tricyclic antidepressant, imipramine, was developed in 1957). Psychiatric wards in hospitals were essentially large-scale, long-term confinement facilities, and in the absence of effective treatments, doctors were often desperate.
This desperation led to the widespread adoption of several radical interventions, including insulin shock therapy (inducing hypoglycemic coma), electroconvulsive therapy (ECT), and prefrontal lobotomy. While many of these procedures are now considered overly aggressive interventions from today's perspective, clinicians at the time often felt that doing something was better than doing nothing. It is a perspective that we would later learn to re-evaluate.
It is important to remember that the Nobel Committee made its decision in this context. They were not fools. They believed that, given the prevailing understanding of the time, some clinical intervention for mental illness was necessary. This judgment was partially justified at the time, but it was later re-evaluated.
In the context of Korean history, 1949 was the year when Kim Koo was assassinated by Ahn Doo-hee in June. The tumultuous period of early South Korean politics reached its peak, and the prelude to the Korean War was already beginning. It was a time when radical interventions of various forms were being justified around the world.
Walter Hess: Discovering the Precise API
Walter Rudolf Hess was a Swiss physiologist. His life trajectory was unusual: he was originally an ophthalmologist but abandoned ophthalmology in 1912 at the age of 34 to pursue pure physiology. He then spent 40 years as a professor of physiology at the University of Zurich, dedicating more than 20 years to studying the function of the diencephalon in autonomic nervous system integration.
His methodology was crucial. He inserted extremely precise electrodes into the brains of anesthetized cats and, after they recovered, stimulated specific areas with the electrodes at different times. The precise location of the electrodes was confirmed by post-mortem dissection. Through this method, he was able to map, like an atlas, which specific areas of the diencephalon, when stimulated, elicited specific autonomic nervous responses.
The results were remarkably precise. Stimulating the anterior region of the hypothalamus caused a state of parasympathetic dominance (decreased heart rate, increased digestion, and induction of sleep). Stimulating the posterior region caused a state of sympathetic dominance (increased heart rate, pupil dilation, and defensive posture). Stimulating the lateral region induced appetite, and stimulating other specific points elicited precise fear responses (the cat's fur stood on end, and it arched its back and adopted a defensive posture).
These findings were significant for two reasons. First, they demonstrated that the autonomic nervous system is not simply a distributed system in the spinal cord and periphery, but is integratedly regulated by a central brain system. Previously, the autonomic nervous system was thought to function only reflexively. Second, it revealed that each autonomic function is mapped to a specific location on the brain. This map is the prototype for the map of hypothalamic functions in today's neurology textbooks.
If we were to summarize Hess's work in terms of computer science, it would be as follows: he precisely mapped the API endpoints of the brain. He established a relationship of "sending a signal to this address will yield this response." Precise location, precise stimulation intensity, precise response. This approach set a new standard for brain research, and today, its extensions form the basis for sophisticated neural modulation techniques such as deep brain stimulation (DBS), transcranial magnetic stimulation (TMS), and optogenetics.
The DBS electrode that is inserted into the subthalamic nucleus of patients with Parkinson's disease is, in principle, the same approach as Hess's cat experiments in the early 20th century β sending a precise signal to a specific API endpoint in the brain to elicit only the desired response.
Egas Moniz: The Temptation of Indiscriminate Kernel Deletion
AntΓ³nio Egas Moniz was a Portuguese neurologist and politician from the University of Lisbon. His background was completely different from Hess's. He was a Foreign Minister who attended the Paris Peace Conference in 1917, and he was also a neurologist who first developed cerebral angiography in 1927. He was an ambitious, politically active, and internationally renowned intellectual.
In 1935, he began a new procedure: leukotomy (later renamed lobotomy). The principle was extremely simple: make a hole in the skull, insert a special instrument, and sever the white matter (nerve fiber bundles) between the prefrontal cortex and the thalamus. He hoped that this section would alleviate the symptoms of severely mentally ill patients.
Why did he begin this radical procedure? To understand the context, it is necessary to look back. He attended the 1935 International Neurological Congress in London, where he heard presentations by two American scientists (Jacobson and Fulton). They reported that when they lesioned the prefrontal cortex of chimpanzees, their emotional responses were extremely attenuated. Moniz decided to extend this observation to human patients with mental illness. The first procedure was performed in November of that year at the Santa Marta Hospital in Lisbon. The subjects were patients with severe depression and anxiety.
The initial results were "successful" from his point of view. After the procedure, the patients' violent emotional reactions decreased, and he interpreted this as a therapeutic effect. He then published a report of his team's initial 40 cases, which was met with surprise and interest in the international scientific community.
This is when the procedure entered a completely different cycle. Walter Freeman, an American physician, took over the procedure and modified it into a much more radical form. Freeman's "icepick lobotomy" β a procedure in which a tool resembling an icepick was inserted under the upper eyelid and used to perform the procedure in a few minutes β was performed on more than 50,000 people in the United States during the 1940s and 1950s. During this period, many patients in American psychiatric hospitals underwent this procedure and experienced significant personality changes, cognitive impairment, and loss of autonomy.
By this point, the procedure had shifted from being a "treatment" to being a form of "control." From today's perspective, a large part of these procedures is now considered to be overly aggressive interventions, but in the case of the thousands of patients who underwent the procedure, the negative effects far outweigh the positive effects.
There is also a dark irony in Moniz's own life. In 1939, he was shot by a psychiatric patient in his office and became paraplegic. The contrast of him being a victim of a patient, who might have been a patient who underwent the procedure he developed, remains a lasting mark on his story.
CS Comparison of the Two Approaches
Let's summarize the way these two individuals approached the brain in terms of computer science.
Hess's approach: Treating the brain as a system with an API that has not yet been documented, observing the responses by applying precise stimulation to specific locations, and creating the documentation. The stimulation was completely reversible (the response returned to normal when the electrical stimulation was stopped). An approach of observing and understanding the system.
Moniz's approach: Treating the brain as a problematic system that is malfunctioning, and stopping the operation by deleting the suspected problematic module as a whole. The deletion was completely irreversible (the severed white matter did not regrow). An approach of intervening and manipulating the system.
This contrast is a fundamental dichotomy that is often repeated in systems engineering: whether to prioritize observation and understanding or intervention and control. The answer depends on the situation. In a crisis, intervention may be a priority, while in a stable situation, observation may be a priority. However, the degree of irreversibility of the intervention is a critical factor to consider. Reversible interventions can be experimented with, but irreversible interventions must be considered with extreme caution.
The main reason why Moniz's lobotomy is being re-evaluated today is at this point: that he performed irreversible interventions without fully understanding the degree of irreversibility. This is a major lesson that later psychiatry has learned, and this lesson has led to today's clinical principles of drug treatment first, integration of psychotherapy, and extremely limited use of neurosurgery.
Neurosurgery is not completely abandoned today. Precise procedures such as capsulotomy or DBS, which are performed in extreme cases of obsessive-compulsive disorder, are descendants of Hess's approach, but they are performed only under very strict review and with the patient's explicit consent. In other words, today we are continuing to develop precise API calls and minimizing indiscriminate kernel deletions.
Why it Matters
The insight that the 1949 award leaves us with is that "the justification for medical intervention should be judged by the precision and reversibility of the intervention."
The contrast between the two approaches to the brain has become a compass for the direction in which psychiatry has evolved over the past half-century. Today, the flow of psychiatric treatment is becoming more sophisticated in the order of medication β psychotherapy β precise neural modulation, and irreversible, indiscriminate interventions are allowed only in extremely exceptional cases. This flow is based on the heavy lessons of the 1949 award.
Another insight is that "science is a self-correcting system, but this self-correction takes time, and there are victims in the meantime." Lobotomy was eventually re-evaluated and moved towards abandonment, but in the meantime, tens of thousands of patients underwent irreversible procedures. This case shows that the mere existence of a self-correcting system is not enough, and how quickly this correction works is critical.
Today, we are facing several new medical interventions. Gene editing, brain-machine interfaces, and various bio-implants. Each has a different degree of irreversibility and a different target population. What the 1949 award asks of us is to assess the precision and reversibility of each intervention as accurately as possible before the intervention, and to make decisions about irreversible interventions as late as possible.
The Nobel Committee's decision to award the prize to these two individuals was the best decision at the time, but from today's perspective, it is only partially justified. And the fact that this award leaves us with some regrets is also evidence that science has the ability to re-examine itself. A perfect system does not exist; what matters is a system that can recognize its own errors.
1949 Hess-Moniz Summary: Hess precisely mapped the functions of the hypothalamus by stimulating the brain in cats, and Moniz introduced lobotomy, which involved severing the white matter of the prefrontal cortex in severely mentally ill patients. The stark contrast between their approaches became a compass for psychiatry to learn how to differentiate between precise and indiscriminate interventions. It remains one of the most controversial awards in Nobel history.
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