There isn't any moral challenge involved. Lobotomies were bad science and plenty of countries recognized that they are NOT HELPING very soon.
Even the Soviet Union, not exactly a paragon of human rights, banned them.
People like Egas Moniz and Walter Freeman had to systematically ignore evidence that stared them in the face. Now, it is somewhat natural to ignore evidence that goes against your hopes and beliefs, but qualified doctors should have known better.
Well, "not helping" and "bad science" was the default mode for pretty much the entire history of medicine, something that (to an extent) changed surprisingly recently. "Qualified doctors" didn't mean much in those days.
If you were saying this about the 1830s, you would have been right. But this changed a lot after people like Robert Koch introduced scientific methods into medicine. This German school was very influential world-wide. By the 1930s and 1940s, there already was an understanding that treatments should have measurable results, and pharmacology wasn't that different from today, of course relative to the tools they had.
That said, in psychiatry, it is really hard to measure results.
This is probably the single most horrifying thing I've ever read, but I couldn't put it down. If you can't stand body horror, you do NOT want to read the details of how lobotomies were performed...
(and if you can't stand psychological horror, you definitely don't want to read the details of *why* lobotomies were performed...)
Agreed. I had to stop reading this excellent review halfway through. Somehow the horrors inflicted by people trying to do good are even more upsetting than those inflicted by those trying to do evil.
"Of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive. It would be better to live under robber barons than under omnipotent moral busybodies. The robber baron's cruelty may sometimes sleep, his cupidity may at some point be satiated; but those who torment us for our own good will torment us without end for they do so with the approval of their own conscience."
C.S. Lewis was too optimistic (or rather, selective in the evidence he accepted). There is not enough money in the world to give to people such as Elon Musk so that they stop dreaming about things like reducing help to the poorest (DOGE).
I think there are a lot of very excellent quintessential C.S. Lewis quotes like this. When I read him, I so often think something along the lines of "I don't think he's exactly right but damn is he so poetic about the good point he's making"
He is just a skilled propagandist whom other propagandists love to quote when their goals are aligned.
In this specific case he wanted a hammer to hit someone specific who talked about improving society, so he wrote a poetic version of how people who want to improve society are the real villains. Which is a poetic equivalent of "abolish police".
I think calling him "just" a skilled propagandist is pretty reductionist, obviously he was a lot more than that, but I do think he was at the very least a very talented rhetorician
Similarly, doctors in Slovakia do many c-sections, doctors in Austria do few, and the countries are next to each other (saying this to avoid speculations on different populations having different biology, which I have already heard as an excuse).
Yes, home birth is considered first line in the Netherlands, although not the most common; government statistics tell me it's 26.9% home births, 72.8% hospital births, so the bar for "heightened risk or complications" hospital recommendation is low enough to cover most births. I was surprised to learn that home births are non-standard and rare in most countries!
“Not as egregious” seems like a huge understatement to me. Induction of labor and C-sections differ in that they are generally safe and effective, even if in retrospect most people agree they were overused for a period of time. It's hard for me to imagine a world where accepted best practices for surgeries remain so constant over time that we never look back and say "we used that too much”; this seems to me like a vastly different kind of thing than a surgery whose efficacy was never established, and whose successful outcome was often a person left severely and permanently disabled.
Not even remotely comparable. Elective C-sections are a reasonable choice, arguably safer depending on your priorities, over vaginal birth even with no complications.
One uncertain thing is whether the *baby* is worse off, not having the initial "seed" of bacteria from mother's vagina. This was the natural way to obtain your original microbiome, and by "routing around", we might make things like allergies and autoimmune disease worse.
There are now obstetricians who will wipe a baby's face with a cloth that touched the vagina, in order to transfer the bacteria even if C-section was used.
I support women's right to choose elective C-section, but it is not arguably safer except in a few edge cases. It's more convenient in the short term, but misinformation about its safety makes planned C-sections overused, much like lobotomies.
Planned C-sections are about three times more dangerous than planned vaginal birth, even including how some planned vaginal births end in unplanned C-section, which is the most dangerous category.
"The planned cesarean group comprised 46,766 women v. 2,292,420 in the planned vaginal delivery group; overall rates of severe morbidity...were 27.3 and 9.0, respectively, per 1000 deliveries. The planned cesarean group had increased postpartum risks of cardiac arrest (adjusted odds ratio [OR] 5.1, 95% confidence interval [CI] 4.1–6.3), wound hematoma (OR 5.1, 95% CI 4.6–5.5), hysterectomy (OR 3.2, 95% CI 2.2–4.8), major puerperal infection (OR 3.0, 95% CI 2.7–3.4), anesthetic complications (OR 2.3, 95% CI 2.0–2.6), venous thromboembolism (OR 2.2, 95% CI 1.5–3.2) and hemorrhage requiring hysterectomy (OR 2.1, 95% CI 1.2–3.8), and stayed in hospital longer (adjusted mean difference 1.47 d, 95% CI 1.46–1.49 d) than those in the planned vaginal delivery group, but a lower risk of hemorrhage requiring blood transfusion (OR 0.4, 95% CI 0.2–0.8)."
*Unplanned* C-sections are also vastly overused, mainly because current hospital conditions such as restricted movement, restricted food, lack of continuous support, and overuse of induction and augmentation *cause* the fetal distress that makes many unplanned C-sections medically warranted.
Furthermore, there are medically *unwarranted* C-sections like those performed by impatient doctors wanting to end their shift soon rather than wait for labor to progress naturally. The WHO estimates that under current conditions, about 10-15% of births medically warrant C-sections. In the US, 32.4% of births are C-sections.
What's the difference between 32.4% of births and 10% of births, which we could reach if medically unwarranted C-sections were reduced and hospital conditions improved to stop causing so many medically warranted C-sections? 22.4% of births, which means 264,320 unnecessary C-sections averted per year in the US.
How many cases of severe morbidity would this avoid? Keeping in mind that C-sections also cause higher rates of maternal mortality, traumatic maternal-baby separation, postpartum psychiatric disorders, long-term musculoskeletal issues, etc. that are not reflected in the few statistics we're looking at now, and assuming that unplanned C-sections are as safe as planned ones (they're not), avoiding 264,320 C-sections per year in the US would avoid about 4,800 cases of severe morbidity per year, as a minimum estimate.
If there were 50,000 lobotomies in the US over maybe 15 years, about 3,333 per year, and 90% of recipients were significantly worse off than they would otherwise have been, that's 3,000 problematic lobotomies per year.
Although getting a C-section is far safer than getting a lobotomy per procedure, and a few of the "severe morbidity" risks of C-sections are less permanent than those of lobotomies, unnecessary C-sections still have major negative impacts on more people per year than lobotomies did, and they still exist for some of the same reasons. So it's a cause that's worth noting.
Thanks for correcting me, and apologies, I shouldn't have written my previous comment so hastily. You're right that elective C-sections are associated with higher risks of severe mortality - I was previously only of the randomized controlled trials on the subject cited by your paper, which didn't find significant associations, but this study is bigger and does a reasonable job controlling for confounders. (Notably, it still wasn't large enough to detect any increase in material mortality: it found 0 deaths in the C-section group and 41 deaths in the much larger vaginal birth group).
However, I still stand by my position. By "arguably safer depending on your priorities" I was referring to the fact that vaginal births are associated with *common* complications that are low severity, but can have high QOL impacts. Notably, pelvic floor dysfunction and (ironically) emergency C-section, which in extreme cases has lead to women being cut open without anesthesia, and in median cases is still often traumatizing. The fact that many mothers choose a tiny absolute increase in risk of severe morbidity over a large decrease in the risk of some common complications and, in your words, convenience, shouldn't be considered overuse. It may simply be a reflection of the patients' legitimately held priorities which differ from your own.
I'd also like a citation on the claim that C-sections from "impatient doctors wanting to end their shift soon" happens at any meaningful scale. As far as I am aware, this claim is largely made based on C-sections happening in the evenings, but there are legitimate reasons for this.
Theranos was mentioned, but I don't think it's very similar. While it went on long enough to suck up a lot of money, hardly any patients were affected.
> It is harder to run clinical trials with high statistical power for new surgeries than for new drugs, and it somehow seems more dubious to do ‘sham’ (i.e., fake) surgeries on real patients in order to have adequate controls
If "the placebo effect" is really just regression to the mean https://westhunt.wordpress.com/2016/03/31/medicine-as-a-pseudoscience/ then it might not be so necessary to have sham treatments, and instead just double-blind measurement patients who did vs didn't receive any treatment. I suppose that is trickier for psychological treatments where you might be asking patients questions rather than just measuring something more objective.
Unfortunately placebo effect is a combination of real placebo and regression to the mean. Some surgical trials do include "sham surgeries" where they cut the body open and then don't do anything, and these seem to be surprisingly helpful, especially for pain.
What about vertobloplasty as a present analogue? No better than placebo outcomes, sold to patients that are in immense distress and desperate for anything that will help, and with severe side-effects that are often worse than what’s being treated.
I started working in 1978 at a state psychiatric hospital. Even though it was after deinstitutionalisation there were almost a thousand patients left from a peak of 3000 in 1958. (It is now a 150-bed hospital, for context, even though the population of the state is 3x.) There were patients who had been there since the 30's, undischargeable because of violence or helplessness. Including readmissions from deinstitutionalized patients who had gone to quarter or halfway houses, I once estimated that I had treated fifty patients who had had either lobotomies or deep insulin shock. I worked with staff who had known them before the brain interventions.
I believe all of this. Some of those patients were undischargeable BECAUSE of the desperate interventions. Ruined brains. But it is easy to say "this never should have happened...how could they do this...psychiatry was so evil..." I read those histories, back to the beginning. I knew them, less violent but still dangerous after psychosurgery. Here is what is left out in such retellings. These patients were not just difficult and unwell. Some of them were beating the shit out of other patients and putting staff in the hospital. We had one (Ivy League educated, BTW) who ran away from a walk group, broke into an apartment and drowned an old woman who was in her bathtub. Shy eighteen year-olds were terrorised on the unit by patients who were already brain-injured when they got to the hospital. The word "desperate" seems inadequate.
Low medical and hiring standards, sure. Believing dangerous charlatans and false authorities, yes - I knew some of those people, dammit. Even this book does not seem to fully capture what all of society was up against once we had decided that letting people starve by banishment or neglect, or even quietly killing them, was not acceptable.
Hearing people talk about the body horror aspect has made me think back to the way I was before medical school (I’m in my fourth year). I think the images in this article probably would have bothered me at least somewhat then, but I didn’t even think about that aspect now. I’m not going to be a surgeon, but the dissections, trauma cases, chronic wounds, and surgeries I have seen and participated in over the years have nearly removed my reactions to images alone, even if seeing the most horrible looking things in real life still bothers me.
Great review. Bit repetitive in places, could have been editorialized - but a great review.
The part about lobotomy as a cost-cutting measure, of course, reminds me of countless euthanasia debates about how euthanasia, too, would inevitably be pushed as a cost-cutting measure - and euthanasia supporter arguments frequently seem just like "No it won't" or "We'll put in safeguards to make sure it doesn't" (considering that there were positive cases of lobotomy, would it have been prudent to just put together sufficient safeguards for lobotomy to ensure that only the positive cases happen or negative don't", with an occasional "Well, but it *would* cut costs, wouldn't it..."
No, euthanasia (in the context of we're discussing here) is almost always done with informed consent. I have no problem whatsoever with people choosing to die; the right to die is a fundamental human right.
The reality is nobody knows how often these things happen because the data one would need is virtually never collected. Oregon has essentially no reporting requirements for its assisted suicide regime.
You do realize this is about the most biased source possible on the topic, and if the claims are true those actions would be illegal (there is a court case directly mentioned in the first link)?
> How about the child under 12 recently euthanized in the Netherlands?
How about it? This case, involving a child with terminal illness, seems both ethically and legally permissible to me.
> Or the woman in Canada who was euthanized despite trying to withdraw her request?
It sounds like a woman in her 80s suffering from severe heart surgery complications including an open surgical wound, bone infection, and respiratory failure reportedly changed her mind about MAID several times, ultimately following through with it, and some people are accusing her family members of coercing her into MAID. If these allegations are true, I hope they are appropriately investigated.
> The reality is nobody knows how often these things happen because the data one would need is virtually never collected.
If you want to stand on “we are killing the elderly and infirm, and that’s good” then ok, but that’s definitely not the same thing as “informed consent”.
Difference being that there were no such safeguards back then. Their model of the relationship between doctor and patient was very different from ours.
I thought this was great, but it badly needs a content warning at the top. I know folks with medical trauma that would really not want to go into this blind.
It is obvious to anyone who begins reading that they are soon going to be reading a description of a gruesome medical procedure. The horror ramps up gradually over the first few sentences. Seems to me that anyone who cannot tolerate descriptions of gruesome medical stuff will realize exactly what is coming and stop. If they do not, they lack common sense or a reasonable ability to look out for themselves. And, by the way, I myself have experienced 2 things I'd say are not at the border of medical trauma, but squarely in the middle. One them occurred when I was about 12, and left me with classic PTSD for a few months, with flashbacks, dreams of the event, and avoidance of the part of the neighborhood where it happened. Many people recover from PTSD. I did. I found the descriptions of lobotomy gruesome and disturbing, but probably not more so than the average reader does. Trauma is not a trump card, and does not relieve those who have suffered it from responsibility to show common sense and watch out for themselves.
Oh, for the love of Mike... AstralCodex readers are presumed to be reasonably mature and sensible. Surely you are past the age at which you need a content warning to protect you from unpleasant realities; if not, then a large proportion of the texts published here must give you nightmares...
You would think the opening paragraph should have been all the warning delicately nurtured persons would require: "Surgery for the soul required a sharp, eight-inch-long instrument—one time, an ice pick from the Uline Ice Company was used—and not much else. It did not require anesthesia or gloves, and the sharp instrument (either a leucotome or the sturdier orbitoclast) was not necessarily sterilized. It took less than ten minutes."
You are conflating the “delicately nurtured” as the whole category of persons who would benefit from such a warning. The horribly traumatized are also part of that category; for instance, a person with medical PTSD from waking up during an operation from improper anesthesia and being unable to move or talk for ten minutes while they feel people cutting them open and moving their organs around, others hands inside their chest cavity. Reading something like this might trigger a flashback to that.
The content warnings aren’t for you. It sounds like you don’t have the breadth of experience to understand how and why others might benefit from them other than being coddled.
The success rate as reported by the surgeon, which was also used as justification for the Nobel. I think the lesson to be learned is about the standards of evidence. To make the comparison, I think you’d need to make some argument about why our current standards of evidence are bad. I think it would have been possible to explain why “20 cases of success as reported by the surgeon” was not actually very good evidence, even contemporaneously.
I've heard this before and this is so implausibly low I flat out don't believe it. If it was 5-10% I'd believe it as evidence of something risky but net beneficial. Basically never, and lower than any other surgeries or medical intervention, is so wildly implausible you should immediately be suspicious.
Looking very slightly into it, it looks like the commonly stated claim is based on a meta study from 2021 (so most of the underlying studies would have been much earlier), when gender transition was far more rare and selected, and most of the underlying studies had several problems with participant drop out. The baseline of "compared with other major surgeries" is also not a great standard (other major surgeries are often more severe and can easily have massive side effects like lifelong incontinence). It had a fairly high bar for regret and almost certainly had selective dropout (even if you ignore the politics of the field, which are definitely going to sleep one direction). I don't think you can quite entirely dismiss these studies - this is some information, and these studies probably would have caught lobotomy or near lobotomy levels of damage - but it's not the last word either.
At least when we’re talking about minors, the whole concept of “choice” is pretty dubious - the lead lobotomy victim was signed up by his step-mom, just like many children who receive trans surgery.
Minors getting gender-affirming surgery is exceedingly rare, and would require agreement from the child AND parents AND multiple medical professionals.
And the administration of chemical castration to minors? Read WPATH’s own guidelines. Read the documents they were forced to turn over by Alabama’s AG.
Please comment “You are right. I explicitly said that many children receive trans surgery, which was actually completely false. Having conceded this point, I would like to pivot to a new argument.” Otherwise you are not worth engaging with.
If the number of children having trans surgery is so small it doesn’t matter, then why does it matter if the procedure is banned?
I believe trans surgery on minors is “rare” the same way I believe trans orbital lobotomies were “rare.” After all 10,000 cases wasn’t really that many, even in the 1940s.
We did. Sounds like maybe only 10,000 transorbital lobotomies were ever done, which is probably “very close to zero” if you consider the number of mental patients in the 1940s as the context. Am I supposed to feel better about medical barbarism just because it’s very rare? If so, what’s the point of the book and review?
This was exactly the cheap shot I was dreading when the relevance hook is introduced early on, of "what modern analogues might there possibly be?", and I did end up skimming to the end to reassure the anxious knot growing in my stomach. Props to the author for not doing the obvious bait. (Without commenting on whether it'd be a valid comparison or not - I just find the topic deeply tiresome, and it would've sucked to have a 30k or whatever word buildup just to beat that dead hobbyhorse with an Axe of Grinding.)
There is an obvious comparison to be drawn with sex reassignment shortly after birth for intersex babies. It kicked off in the 60s at the end of the lobotomy era, involved no patient consent, and demonstrably did a lot of harm. In some particularly egregious cases, fully male patients were given vaginas because they had a micropenis.
Given the reference to gender-affirming care, the ironic thing here is that medically unnecessary sex reassignment and follow-up HRT seem to create transgender adults, except they're chromosomal males living as men (or less often, females living as women). There must be a real horror to knowing one signature from a parent you (probably) love(d) caused you a lifetime of struggle.
Agreed, I think the author honestly wanted our mind to go to it but of course touching it would be a firestorm.
I can imagine 100 years from now something similarly graphic about constructing 'artificial penises', the complications of 'bottom surgery', mastectomies on children...
I think it would go as not-self-aware medication to culturally specific conditions
Like Russians in 1960s could self-medicate "terror by conscience" with vodka
It would start with extensive explanation that they felt gender/conscience as ever-present visceral feeling and it was not just a name for certain class of thoughts
Fascinating and horrifying! Semi-related, I found this documentary "Nuts" (2016) to be super entertaining. I went in with zero fore-knowledge which I'd recommend. Short version. There was an extremely famous doctor who emplanted goat testicles as a cure for impotence. If you don't already know this story I think you'll be shocked at how famous.
About the Howard substory, I'd put most of the blame not on the medical-lobotomy complex, but on his criminally wicked step-mother and the dereliction of parental duty from his father. Of course, if step-mom had gone to the police to frame the boy for whatever she'd have come up with, they'd have sniffed her out right away, so Freedman wasn't entirely blameless here. Hoel probably knows this, so I guess that's why it's not central to the main story.
I did happen to pattern-match to "huh, this has the same look and structure as The Dawn Of Everything review" before reading this comment, but it doesn't have the same magisterial level of polish, and the humour quotient is quite a bit lower. Perhaps that's due to the subject matter being quite grim though.
It's also entirely possible that Howard is lying, he really was as violent and uncontrollable as his stepmother said, and the memoir is a desperate attempt to blame his bad behavior on everyone except himself.
"By now, you’ve probably figured out what I’m going to say."
I promise I'm not one of "those people", but I was really expecting this to turn to comparing and contrasting this to transgender surgery. I see a lot of parallels, in that it's a controversial surgery, and could similarly be a story of something that is beneficial for some people, but gets too widely used by zealous doctors (with sometimes good, sometimes selfish intentions), isn't questioned enough by the media, and ends up being a net negative for some people, and we realize later we should have prevented it. I don't know if that story is true, but I'd find an exploration interesting.
Yes, and comparing "transgender surgery" or Ritalin to lobotomies is stupid for the same reason that comparing mainstream Democrats or Republicans to Nazis is.
There may be some ways in which your least favorite politician is like a Nazi - most pairs of things share at least one trait - but making the comparison contributes nothing beyond being provocative.
I was absolutely sure he was going to go there after this sentence:
> I can’t imagine much worse than being extremely mentally ill, and then having a bunch of random body parts removed.
But I was wrong. You can be forgiven for noticing the extremely strong subtext. I saw it 10 other places. Mostly it reminds me that a huge amount of what we currently know and accept will be shown to be wrong in the future. May our descendants judge us charitably.
I did not think of transgender surgery at all while reading this review. I suspect that "the extremely strong subtext" stems from your own priors rather than the text here.
You're right, that's a key difference. (I assume) These days surgeries aren't done without consent of the person they are being done to, unlike the story about the poor 12 year old in the review that made me physically queasy.
I think a key point of the article is that "the science" has done some pretty fucked up things that apparently seemed fine at the time.
It would seem that the "Managerial Society" or culture that developed since those days has had some benefits, though at some costs as well. Institutional controls are much stronger now.
A comparison to euthanasia matches well too, though I've read Scott's posts on that and agree that it isn't abused. I wonder if lomoboty, if Freeman never invented the transorbital lobotomy and stayed with Watts, would have reached a similar status to euthanasia, gender reassignment surgery, or ECT – something highly risky, but possibly worth it for specific intractable cases. At least before the invention of psychiatric drugs.
Gender reassignment is neither highly risky nor appropriate only for intractable cases. Anyone who wants it should try it out (in increments and starting with non-medical interventions, obviously, not scheduling every surgery immediately).
Some transhumanists I know that have transitioned had no mental health concerns at all, and pursued it as voluntary body modification, though this is less common than using transition to treat gender dysphoria.
Agreed, I think the author honestly wanted our mind to go to it but of course touching it would be a firestorm.
I can imagine 100 years from now something similarly graphic about constructing 'artificial penises', the complications of 'bottom surgery', mastectomies on children...
I didn’t enjoy this review for some kind of visceral way I also didn’t enjoy the game psychonauts. Let’s leave brains where they are and not pop them out.
I thought the review was fine and memorable but I didn’t really jive with the formatting - I like a beginning, middle, end, and a bit more of a relation to modern times.
It’s also missing a bit of the Joe shmoe micro humor to bring me along to why I care halfway through. I’m not sure what the hidden sauce is here, but I confused some of the characters, so I think they could have been caricatured a bit more. If one of them had a beard to his knees and smelled like cats, and the other one thumped his Bible every time he spoke, it might have helped. I know this is something Scott does well and we aren’t necessarily imitating Scott in writing these reviews, but it would have helped. If not with comedy, perhaps providing some summary statistics and comments about each guy early would help me anchor (ice pick man did 10,000 lobotomies, charged X for them, didn’t follow up. Dr #2 did 3,000 lobotomies, charged Y, did follow up).
A few other random ideas, could have gone over pop culture references to lobotomies in the beginning or end. And I expected a bit more discussion about the ethics. Should we try lobotomizing all permanent coma patients? Why or why not? What’s the most modern lobotomy? If not, when was the last one? Is there any modern take on why it (allegedly) helped some and hurt others?
Perhaps some of this in the review was in the article. I did read the whole thing but was also putting my son to sleep, watching celebrity jeopardy, brushing my teeth, and my phone kept losing my place so I had to refind it. For an article this long about one topic, maybe that’s why I wanted a bit more handholding than most of the geniuses that read this blog. Thanks for writing!
These potrayals of Freeman and Moniz smell strongly of narcissism (in the sense of personality disorder(or my layman inpression)). Do any psychiatrists want to comment on this?
Are there any treatments in common use today as obviously barbaric and damaging as lobotomies were? Yes. There's something called the "troubled teen industry" where "goons" (the actual job title) abduct children in the middle of the night and bring them to a camp the parents pay for to teach them discipline and ethics. About 1 in 300 US kids would be forced into these camps at some point in their life.
There are no regulations at all* about how the kids can be treated or what kind of infraction allows kids to be sent there. Although there might be some institutions that are ok, EXTREME abuse is the norm. For an online graphic novel about someone's experience, you can read https://elan.school
*(There was a law passed in 2024, the Stop Institutional Child Abuse act, but it just collects data and gives "recommendations" on "best practices" instead of allowing anyone to leave for any reason)
Oh, and if a temporary institution doesn't sound as awful as a permanent lobotomy because it's temporary, I'd like to point out that the suicide rate after them are extremely high. No good broad data is available, but I expect that the rate of suicide from people not being able to handle life afterwards is almost as high as the lobotomy death rate, and the chance of getting permanent psychological problems that prevent people from holding normal jobs and lives afterward is almost as high as the lobotomy rate. And this doesn't count lots of straight-up killings, some of which are well documented, like Phil Williams Jr being killed in "the ring" in 1982 (but the school continued for another 30 years and nobody has been arrested) And this is for a group of people which usually started off better than lobotomy patients did.
Also, the legal system has made it worse, and almost nobody has heard of this because people who buy media prefer innumerate stories that don't affect hundreds of thousands of people every year or uncritical positive stories about "rehabilitation not incarceration".
> No good broad data is available, but I expect that the rate of suicide from people not being able to handle life afterwards is almost as high as the lobotomy death rate, and the chance of getting permanent psychological problems that prevent people from holding normal jobs and lives afterward is almost as high as the lobotomy rate
WTF? How can you not get that your sense of certainty is functioning as your data? I do not doubt that the rate of staff mistreatment of residents is high in some of the many kinds of institutions that house troubled teens. It is high in virtually all settings where the vulnerable are housed unless there are well-enforced systems in place to train staff, monitor them, and punish and fire the abusive and neglectful ones. But if there is no good broad data on how the teens in question do post-institution, as compared to others with similar teen problems who were never sent to one of these places, youdo not know what impact the places have on suicide rates and later functioning, and you sure as shit do not know how it compares to lives post-lobotomy. I am a psychologist and know a fair amount about rates of this and that in different populations, yet I am often surprised by new data about how a certain group fares after a certain intervention or life event. I learn that my expectations were *wrong.*. If you don't understand that your views are valueless.
My data is not my "sense of certainty". I checked what I could!
When I read Joe vs. Elan School (the link) he mentioned several people he knew who wound up killing themselves. When I read a bunch of posts by other troubled teens on reddit and other places to see if a: this kind of thing actually regularly happens and b: how people report their lives are going, they often mentioned knowing a lot of people who suicided too. Also, the lobotomy death rate is well documented and is lower than most people expect. Freeman was extremely reckless and had about a 15% fatality rate, but overall it was mostly about 5%. I actually have well founded confidence that the suicide rate is not much lower than the lobotomy death rate, even if the ones from the worst institutions are the most active posters.
I am less confident in whether the psychological problems are permanent. After reading those, a few legal reports about the rare ones that shut down, and based on what I know about some other abusive situations, it's hard to imagine people NOT acquiring long-term psychosis from anything like what they described and mostly never fully recovering. This is mostly from my priors though, maybe people are more resilient than I expect.
If there were broad long-term studies I'd look at those but there aren't any. That doesn't mean we should ignore the data we have.
I'm not sure what sources you'd find most credible, but a simple search gives tons of results: Legal documents, news articles, the official websites of many places calling themselves boarding schools or something, there are tons of stories in r/troubledteens, and so on.
(It didn't used to be in the news, but then Paris Hilton put it into the overton window by describing her experiences a few years ago)
Sorry, big ones don't exist yet. This one, https://www.proquest.com/openview/c00ead86d038c1e648b144b826c9047b/1?pq-origsite=gscholar&cbl=44156 , checked people of an average age of 41.3 years old, and "Over two thirds of participants indicated they have a current, professionally-obtained mental health diagnosis (n = 21)" and it has more detail about severity, which might indicate long-term major psychological problems at similar rates as lobotomies, but as the small n would imply there aren't a whole lot of people in the study. (Also, I didn't read the whole 246 page monster thesis, I just searched for a few terms like PTSD and age)
Wow, thanks for stealing away my entire Sunday to read that. The first half is one of the wildest and upsetting non-fiction stories I've ever read. The second half is a stoner travelogue with a bunch of crazy anecdotes that is quite a bit less compelling but still fun.
A solid and generally well-written review giving details of a medical scandal most of us will have heard of, however vaguely, but are unlikely to have known much about. Among the best I've read so far (missed it earlier), it could have done with some brisk editing - tended to go a little flat and repetitious in the final fifth or so.
Psychosurgery framed as "surgery for the soul" is the cleanest version of the lobotomy story I have read. The book-review-contest format keeps these honest.
It isn't perfect -- some of the sections seem to repeat the content of others, and the comparison to ECT seems weak to me -- but overall this was an incredible review. Goes beyond "makes me want to read the book" into "I feel like I just *did* read the book". Not that those are mutually exclusive; if the rest of the book is half as interesting as the selected quotes, it'd be well worth reading the rest.
My worry for #12 was actually the reverse - I think we're more likely to overcorrect than under correct for big famous failures like lobotomies (and broadly, I think society has way overcorrected against the "you can just do things" spirit of the early 20th century). But given I believe that, it was good for me to read something like this to remind me that this overcorrection had some pretty good reasons for happening.
I can’t help but be concerned that ECT and the forms of psychosurgery that are performed today at academic centers may be underutilized relative to their evidence base due to the backlash to the abuse of mid century lobotomy and convulsion therapies.
The subject matter was fascinating and well chosen, but ultimately this review was a slog to read. The two culprits here are the elephantine size of the review itself and the overuse of extensive quotes from the book. Both could have been easily resolved by a willingness on the part of the author to just paraphrase more and save the quotes for its most striking moments.
It gets to a point where it's hard to even call this a review when half of it is taken straight from the book and it's dominated overall by summary rather than analysis.
Ask yourself, would you want to read Great And Desperate Cures after having its entire guts laid bare before you like this?
This blog has an idiosyncratic conception of what a "book review" is - shaped by Scott's own reviews, of course. My understanding is that the point is exactly that most blog readers wouldn't read the book itself, but Scott still wants to be able to lay out and later refer to its ideas, which necessitates an extensive summary.
Good enough for a like, although I don't think I'll end up voting for it. Fairly exhaustively cited and researched*, I do feel like I got a pretty good idea of what the book's about + relevant context to help put it in proper perspective. It probably says negative things about my content consumption habits that I felt numb to the brutality and gruesome depictions...might be good to read less horror writing. This stuff really happened, to real people in real life, with far-reaching consequences to the present (fuel for de-institutionalization more generally, an ongoing "shroud of disrepute" and cover for anti-psychiatry FUD that if anything seems to be getting worse, not better). Missing mood: it really ought to bother me more than it does.
Could have used one more editing pass to pare down on circuitous repetition. Sometimes it's just reusing of certain constructions, such as how many things end up being ironic(ally), or tons of (parentheticals). Other times it's straight-up copy-pasting of previous review sections. This works well as a conceit the first time, to emphasize that "hey I really mean this so I'm saying it twice", but ~all the later uses seem accidental more than intentional. E.g. the doubled comparison of Old and New Testaments. I get the impulse to remind readers of past ideas and overarching structure, but this wouldn't be as necessary in the first place if the length were lesser. There were also some weird tense lapses that left me confused - is "Carolyn W." still alive or not? I'm not sure! None of these made for insurmountable obstacles to comprehension, but they kept breaking my reading flow during an otherwise morbidly fascinating page-turner.
*although it's my understanding that the general consensus on ECT for depression is on firmer terra in 2026 than the review implies?
From what I remember of Scott's remarks, ECT is considered effective and underused relative to its risks due to past infamy, but the theoretical grounding is about as elusive as ever.
Yeah - I guess I thought it was a bit weird example, despite the parallelism with the rest of the review content. Antipsychotics are mentioned as the likely main change that spelled the end for psychosurgery...and even the widely used mental pill treatments of today, with serious-sounding names like Selective Serotonin Reuptake Inhibitor where we're damn sure we understand *what* it does...we still largely have no clue *why* it works! "That's worse, you know that's worse right?" The non-desperate cures are still grounded in consequentialism rather than neurochemistry theory!
The reviewer even admits elsewhere that we still "lack an adequate mechanistic understanding of most treatments". I felt just the sort of attitude from that ECT aside that's presumably driving the under-use that Scott lamented.
I sure hope there isn't a big cohort of tens of thousands of vulnerable people to whom the medical establishment has been and still is pushing irreversible medical and surgical intervention for reasons of desperation, economics, ideology, and individual esteem, in order to treat a psychological issue which in time we will consider far too nuanced to be treated by the blunt and brutal methods to which we currently find ourselves limited.
This seemed less in the spirit of a book review, and more just a (long) summary of the book. Of course you said the book itself is not easy to read, so there’s value in that. But next time don’t be shy about adding more of your original ideas throughout.
The brilliance of the lobotomy isn’t the damage done to victims, it’s the proof humans can live even thrive without the PFC’s simulation.
And it is an aspect of the illusion that language is paired with reason. The fact is logic, deduction, inductive reasoning is wholly separate from language.
Many commenters here fighting hard to avoid obvious comparisons to euthanasia and “gender affirming” surgery on minors by citing “informed consent.” Of course if you’d asked Freeman why he didn’t get informed consent for the kid who was lobotomized by his stepmother, he’d say the kid was a kid and the parent’s consent was what mattered. Just like with gender affirming surgery for teens - the parents signed off. And euthanasia is now freely administered to people in Canada and the Netherlands for whom the idea of meaningful informed consent is a joke. Literal children. Elderly people with advanced dementia.
Another example: could forget the last few New York Times articles about organ “donors” whose were prepped for harvesting while they were still alive? Of course, the pressure is still on to legalize the sale of organs, as if you won’t have people selling kidneys for crack.
And even if you don’t buy all of that, the fact remains that our public health and epidemiology “experts” tried to shut down the economy, schools, jails, and force us all to live online forever as part of a campaign to eradicate a virus that virtually everyone now ignores.
My trust in the medical profession has reached an all-time low over the last eight years. The idea that they should be a self-regulating profession is utter madness. They scream and cry about the rise of cranks like RFK, but have only themselves to blame. “Things are different these days” is the exact lie this review should have taught you NOT to believe.
> the fact remains that our public health and epidemiology “experts” tried to shut down the economy, schools, jails, and force us all to live online forever
I admit my first reaction was to check whether you are Wimbli's new account. So many "facts" thrown around freely...
Feel free to point out something I’m factually wrong about. San Francisco’s schools were closed for two years. Churches only reopened because the Supreme Court weighed in.
This was pretty interesting, but the application to the present day is shaky at best. I would appreciate some more discussion of how well this book's insight apply to modern medicine besides "remember that scandals happen nowadays".
Synopsis: Scientist meets family with 6yo daughter with genetic mutation leading to slow cognitive development, undertakes to develop gene editing therapy with funding from family, oversees mouse and monkey studies, then schedules surgery to inject trillions of viruses into spinal fluid of daughter in a one-off clinical trial, daughter dies one week later of complications predictable from monkey studies, meanwhile between surgery and death the scientist's Nature paper on the topic gets accepted for publication.
I couldn't finish this; it was incredibly long winded and seemed to be a summary without any analysis or review. At some point I started reading just the first two sentences of a paragraph and felt that nothing substantial was lost.
These book reviews are something I look forward to but I don't know what I'm supposed to do with this.
> consider the well-known case of Phineas Gage using more vulgar language, gambling, and being unable to hold down a job after a tamping rod destroyed a large chunk of his frontal lobes
Well-known but not well-established. In a case roughly the mirror of Moniz, the doctor who first diagnosed Gage exaggerated his symptoms greatly for attention and notoriety, and it remains unclear to this day how severe they got and how long they lasted. IIUC current best guess is that he was more vulgar for the rest of his life but much less so later, had trouble with anger issues likewise, and gambled excessively and lost jobs only in the first couple years. The job he held in Argentina as a stagecoach driver (IIRC, 5-10 years after the accident) was one that typically required being on very good terms with strangers and maintaining a reputation as polite and easy to work with.
I guess that in the 1930s and 40s if a group of surgeons went around reporting that they got good results from an operation, there wasn’t much to prevent them from spreading it far and wide, even if there was opposition and skepticism, as there was in this case. Especially if the target was a vulnerable population.
And maybe not today either, although one likes to think the scientific and legal scrutiny would be greater.
I recommend reading about Paolo Macchiarini, if you are interested in surgical scandals (a 21th century case).
Surprised that neither the post nor the comments mention unnecessary spine surgeries as a modern example. IIRC it's the most common unnecessary surgical procedure in the US.
Just FYI, regarding “ We have estimated that about 80% of the so-called functional type of mental disorders are due not only to infected teeth and tonsils” …
It’s an interesting fact that, at the same time that non-biologists are trying to make claims about “rational” medicine and biology, meaning dismissing claims that are “clearly crazy” like connections between infections in non-brain matter and brain ailments, actual biologists are trying very hard to clarify the many and non-obvious ways in which biology is not as simple as the mid-20th C model seemed to suggest. And these crazy linkages frequently *do* exist…
Philip Ball’s “How Life Works” is a good (albeit sometimes irritating) introduction to this subject.
I was expecting the author of this engaging review of the history of psycho surgery to say something about the relatively new noninvasive method in Transcranial Magnetic Stimulation (TMS) especially as a close alternative to ECT. Are there reasons to worry about TMS and is it as effective as its proponents claim?
Very nice review, but I'm confused by the following passage :
> Anecdotally, although ECT has gotten much safer (due to the aforementioned reduction in typical doses and frequencies of treatment), a physician told me that they saw a problematic pattern at the ECT center of a major university: the treatments were not very tailored. They would do one patient every few minutes, and not change the voltage dose for different patients. This is probably partly because they may not have had good evidence that tailoring the dose changed things much. But it still seems strange to me.
I'm curious why this would seem strange to the author / why this would be a problematic pattern?
What reasons would we have for thinking that ECT voltage should be different for different patients? I can imagine some analogue to mg/kg mass based dosing for drugs, or maybe normalizing for skin galvanic response or something? Is this established in the ECT literature ?
I'm... pretty sure the review also demonstrated that untreated mental illness is quite shit?
There isn't any moral challenge involved. Lobotomies were bad science and plenty of countries recognized that they are NOT HELPING very soon.
Even the Soviet Union, not exactly a paragon of human rights, banned them.
People like Egas Moniz and Walter Freeman had to systematically ignore evidence that stared them in the face. Now, it is somewhat natural to ignore evidence that goes against your hopes and beliefs, but qualified doctors should have known better.
Well, "not helping" and "bad science" was the default mode for pretty much the entire history of medicine, something that (to an extent) changed surprisingly recently. "Qualified doctors" didn't mean much in those days.
If you were saying this about the 1830s, you would have been right. But this changed a lot after people like Robert Koch introduced scientific methods into medicine. This German school was very influential world-wide. By the 1930s and 1940s, there already was an understanding that treatments should have measurable results, and pharmacology wasn't that different from today, of course relative to the tools they had.
That said, in psychiatry, it is really hard to measure results.
Excellent work and so informative… god damn
Hang on, why is this labelled Finalist #2? I can't see #1.
https://astralcodexten.substack.com/p/your-book-review-the-book-of-abraham
Here's the first one
Huh. Don't know how I missed it. Thanks!
This is probably the single most horrifying thing I've ever read, but I couldn't put it down. If you can't stand body horror, you do NOT want to read the details of how lobotomies were performed...
(and if you can't stand psychological horror, you definitely don't want to read the details of *why* lobotomies were performed...)
Agreed. I had to stop reading this excellent review halfway through. Somehow the horrors inflicted by people trying to do good are even more upsetting than those inflicted by those trying to do evil.
I, too, had to stop reading this review and ive actually read the book. I forgot how horrifying it all is.
>Somehow the horrors inflicted by people trying to do good are even more upsetting than those inflicted by those trying to do evil.
Well, the story of Unit 731 is pretty bad...
As C.S. Lewis famously said:
"Of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive. It would be better to live under robber barons than under omnipotent moral busybodies. The robber baron's cruelty may sometimes sleep, his cupidity may at some point be satiated; but those who torment us for our own good will torment us without end for they do so with the approval of their own conscience."
C.S. Lewis was too optimistic (or rather, selective in the evidence he accepted). There is not enough money in the world to give to people such as Elon Musk so that they stop dreaming about things like reducing help to the poorest (DOGE).
I think there are a lot of very excellent quintessential C.S. Lewis quotes like this. When I read him, I so often think something along the lines of "I don't think he's exactly right but damn is he so poetic about the good point he's making"
He is just a skilled propagandist whom other propagandists love to quote when their goals are aligned.
In this specific case he wanted a hammer to hit someone specific who talked about improving society, so he wrote a poetic version of how people who want to improve society are the real villains. Which is a poetic equivalent of "abolish police".
I think calling him "just" a skilled propagandist is pretty reductionist, obviously he was a lot more than that, but I do think he was at the very least a very talented rhetorician
Yeah came to comments to say, this is too horrifying, for me to read anymore. I'm like 10% in.
I couldn't make it past section 2, unfortunately. Fascinating topic, but too much for me.
"Forty years later, in 2026, how relevant are the factors Valenstein identified? Could anything like a lobotomy happen today?"
Not as egregious, but yes: overuse of induction of labor and C-sections. The latter especially in countries like Brazil and South Korea.
Similarly, doctors in Slovakia do many c-sections, doctors in Austria do few, and the countries are next to each other (saying this to avoid speculations on different populations having different biology, which I have already heard as an excuse).
Yes, home birth is considered first line in the Netherlands, although not the most common; government statistics tell me it's 26.9% home births, 72.8% hospital births, so the bar for "heightened risk or complications" hospital recommendation is low enough to cover most births. I was surprised to learn that home births are non-standard and rare in most countries!
“Not as egregious” seems like a huge understatement to me. Induction of labor and C-sections differ in that they are generally safe and effective, even if in retrospect most people agree they were overused for a period of time. It's hard for me to imagine a world where accepted best practices for surgeries remain so constant over time that we never look back and say "we used that too much”; this seems to me like a vastly different kind of thing than a surgery whose efficacy was never established, and whose successful outcome was often a person left severely and permanently disabled.
Stents.
https://www.verywellhealth.com/do-angioplasty-and-stents-prolong-life-4021221
Yes, we could and did cause excess mortality.
Not even remotely comparable. Elective C-sections are a reasonable choice, arguably safer depending on your priorities, over vaginal birth even with no complications.
One uncertain thing is whether the *baby* is worse off, not having the initial "seed" of bacteria from mother's vagina. This was the natural way to obtain your original microbiome, and by "routing around", we might make things like allergies and autoimmune disease worse.
There are now obstetricians who will wipe a baby's face with a cloth that touched the vagina, in order to transfer the bacteria even if C-section was used.
I support women's right to choose elective C-section, but it is not arguably safer except in a few edge cases. It's more convenient in the short term, but misinformation about its safety makes planned C-sections overused, much like lobotomies.
Planned C-sections are about three times more dangerous than planned vaginal birth, even including how some planned vaginal births end in unplanned C-section, which is the most dangerous category.
"The planned cesarean group comprised 46,766 women v. 2,292,420 in the planned vaginal delivery group; overall rates of severe morbidity...were 27.3 and 9.0, respectively, per 1000 deliveries. The planned cesarean group had increased postpartum risks of cardiac arrest (adjusted odds ratio [OR] 5.1, 95% confidence interval [CI] 4.1–6.3), wound hematoma (OR 5.1, 95% CI 4.6–5.5), hysterectomy (OR 3.2, 95% CI 2.2–4.8), major puerperal infection (OR 3.0, 95% CI 2.7–3.4), anesthetic complications (OR 2.3, 95% CI 2.0–2.6), venous thromboembolism (OR 2.2, 95% CI 1.5–3.2) and hemorrhage requiring hysterectomy (OR 2.1, 95% CI 1.2–3.8), and stayed in hospital longer (adjusted mean difference 1.47 d, 95% CI 1.46–1.49 d) than those in the planned vaginal delivery group, but a lower risk of hemorrhage requiring blood transfusion (OR 0.4, 95% CI 0.2–0.8)."
https://www.cmaj.ca/content/176/4/455.short
*Unplanned* C-sections are also vastly overused, mainly because current hospital conditions such as restricted movement, restricted food, lack of continuous support, and overuse of induction and augmentation *cause* the fetal distress that makes many unplanned C-sections medically warranted.
Furthermore, there are medically *unwarranted* C-sections like those performed by impatient doctors wanting to end their shift soon rather than wait for labor to progress naturally. The WHO estimates that under current conditions, about 10-15% of births medically warrant C-sections. In the US, 32.4% of births are C-sections.
What's the difference between 32.4% of births and 10% of births, which we could reach if medically unwarranted C-sections were reduced and hospital conditions improved to stop causing so many medically warranted C-sections? 22.4% of births, which means 264,320 unnecessary C-sections averted per year in the US.
How many cases of severe morbidity would this avoid? Keeping in mind that C-sections also cause higher rates of maternal mortality, traumatic maternal-baby separation, postpartum psychiatric disorders, long-term musculoskeletal issues, etc. that are not reflected in the few statistics we're looking at now, and assuming that unplanned C-sections are as safe as planned ones (they're not), avoiding 264,320 C-sections per year in the US would avoid about 4,800 cases of severe morbidity per year, as a minimum estimate.
If there were 50,000 lobotomies in the US over maybe 15 years, about 3,333 per year, and 90% of recipients were significantly worse off than they would otherwise have been, that's 3,000 problematic lobotomies per year.
Although getting a C-section is far safer than getting a lobotomy per procedure, and a few of the "severe morbidity" risks of C-sections are less permanent than those of lobotomies, unnecessary C-sections still have major negative impacts on more people per year than lobotomies did, and they still exist for some of the same reasons. So it's a cause that's worth noting.
Thanks for correcting me, and apologies, I shouldn't have written my previous comment so hastily. You're right that elective C-sections are associated with higher risks of severe mortality - I was previously only of the randomized controlled trials on the subject cited by your paper, which didn't find significant associations, but this study is bigger and does a reasonable job controlling for confounders. (Notably, it still wasn't large enough to detect any increase in material mortality: it found 0 deaths in the C-section group and 41 deaths in the much larger vaginal birth group).
However, I still stand by my position. By "arguably safer depending on your priorities" I was referring to the fact that vaginal births are associated with *common* complications that are low severity, but can have high QOL impacts. Notably, pelvic floor dysfunction and (ironically) emergency C-section, which in extreme cases has lead to women being cut open without anesthesia, and in median cases is still often traumatizing. The fact that many mothers choose a tiny absolute increase in risk of severe morbidity over a large decrease in the risk of some common complications and, in your words, convenience, shouldn't be considered overuse. It may simply be a reflection of the patients' legitimately held priorities which differ from your own.
Meta-review on pelvic floor dysfunction from vaginal birth: https://link.springer.com/article/10.1007/s00192-020-04550-8
OBGYN discussing pros/cons of elective C-section: https://www.reddit.com/r/medicine/comments/1qftktp/comment/o08j8ze/
I'd also like a citation on the claim that C-sections from "impatient doctors wanting to end their shift soon" happens at any meaningful scale. As far as I am aware, this claim is largely made based on C-sections happening in the evenings, but there are legitimate reasons for this.
Surgeons discussing C-section timing: https://www.reddit.com/r/medicine/comments/1p5qz1e/nyt_these_hospitals_figured_out_how_to_slash/
Well, historically speaking, over-prescription of psycho-active medication would seem to the primary candidate.
Theranos was mentioned, but I don't think it's very similar. While it went on long enough to suck up a lot of money, hardly any patients were affected.
And humans wonder why cats don't want to go to the vet!
Unfortunetly far too disturbing to read, for me. Might be my first ACX skip!
oh my god. That was a difficult opening section. But I had to keep going, as we are living through another era of great and desperate cures.
The cover art is the figure known as "the Damned Man" from Michelangelo's "The Last Judgment".
I would contrast Freud not with any of the doctors mentioned here, but instead Emil Kraepelin, whom I first heard about a couple years ago https://entitledtoanopinion.wordpress.com/2024/06/01/how-had-i-never-heard-of-emil-kraepelin-until-now/
> It is harder to run clinical trials with high statistical power for new surgeries than for new drugs, and it somehow seems more dubious to do ‘sham’ (i.e., fake) surgeries on real patients in order to have adequate controls
If "the placebo effect" is really just regression to the mean https://westhunt.wordpress.com/2016/03/31/medicine-as-a-pseudoscience/ then it might not be so necessary to have sham treatments, and instead just double-blind measurement patients who did vs didn't receive any treatment. I suppose that is trickier for psychological treatments where you might be asking patients questions rather than just measuring something more objective.
Unfortunately placebo effect is a combination of real placebo and regression to the mean. Some surgical trials do include "sham surgeries" where they cut the body open and then don't do anything, and these seem to be surprisingly helpful, especially for pain.
What studies have compared sham surgeries to regression-to-the-mean?
I suspect that acupuncture is helpful for pain patients for similar reasons.
What about vertobloplasty as a present analogue? No better than placebo outcomes, sold to patients that are in immense distress and desperate for anything that will help, and with severe side-effects that are often worse than what’s being treated.
I started working in 1978 at a state psychiatric hospital. Even though it was after deinstitutionalisation there were almost a thousand patients left from a peak of 3000 in 1958. (It is now a 150-bed hospital, for context, even though the population of the state is 3x.) There were patients who had been there since the 30's, undischargeable because of violence or helplessness. Including readmissions from deinstitutionalized patients who had gone to quarter or halfway houses, I once estimated that I had treated fifty patients who had had either lobotomies or deep insulin shock. I worked with staff who had known them before the brain interventions.
I believe all of this. Some of those patients were undischargeable BECAUSE of the desperate interventions. Ruined brains. But it is easy to say "this never should have happened...how could they do this...psychiatry was so evil..." I read those histories, back to the beginning. I knew them, less violent but still dangerous after psychosurgery. Here is what is left out in such retellings. These patients were not just difficult and unwell. Some of them were beating the shit out of other patients and putting staff in the hospital. We had one (Ivy League educated, BTW) who ran away from a walk group, broke into an apartment and drowned an old woman who was in her bathtub. Shy eighteen year-olds were terrorised on the unit by patients who were already brain-injured when they got to the hospital. The word "desperate" seems inadequate.
Low medical and hiring standards, sure. Believing dangerous charlatans and false authorities, yes - I knew some of those people, dammit. Even this book does not seem to fully capture what all of society was up against once we had decided that letting people starve by banishment or neglect, or even quietly killing them, was not acceptable.
Thanks for commenting. It’s not an angle one hears often.
I believe that a content warning would be helpful for this review, for body horror.
The images definitely don't help.
Yes, I really didn't need to see the image of someone getting stabbed in the eyes
Hearing people talk about the body horror aspect has made me think back to the way I was before medical school (I’m in my fourth year). I think the images in this article probably would have bothered me at least somewhat then, but I didn’t even think about that aspect now. I’m not going to be a surgeon, but the dissections, trauma cases, chronic wounds, and surgeries I have seen and participated in over the years have nearly removed my reactions to images alone, even if seeing the most horrible looking things in real life still bothers me.
I've added it.
Great review. Bit repetitive in places, could have been editorialized - but a great review.
The part about lobotomy as a cost-cutting measure, of course, reminds me of countless euthanasia debates about how euthanasia, too, would inevitably be pushed as a cost-cutting measure - and euthanasia supporter arguments frequently seem just like "No it won't" or "We'll put in safeguards to make sure it doesn't" (considering that there were positive cases of lobotomy, would it have been prudent to just put together sufficient safeguards for lobotomy to ensure that only the positive cases happen or negative don't", with an occasional "Well, but it *would* cut costs, wouldn't it..."
Lobotomy was often done without consent and possibly never with informed consent.
So is euthanasia.
No, euthanasia (in the context of we're discussing here) is almost always done with informed consent. I have no problem whatsoever with people choosing to die; the right to die is a fundamental human right.
How about the child under 12 recently euthanized in the Netherlands?
https://nypost.com/2026/06/24/world-news/netherlands-euthanizes-child-under-12-in-first-case-since-major-law-change-reports/
Or the woman in Canada who was euthanized despite trying to withdraw her request?
https://righttolife.org.uk/news/canada-woman-euthanised-against-her-will-after-requesting-palliative-care
The reality is nobody knows how often these things happen because the data one would need is virtually never collected. Oregon has essentially no reporting requirements for its assisted suicide regime.
You do realize this is about the most biased source possible on the topic, and if the claims are true those actions would be illegal (there is a court case directly mentioned in the first link)?
The Netherlands allowing the killing of children is documented in notorious far right sources such as the New York Times.
https://www.nytimes.com/2026/06/26/world/europe/assisted-death-child-netherlands.html
The first link in the R2L UK article is to an official Canadian government document.
Next up once we get past “it’s not happening” I’ll hear you tell me that it’s actually good.
> How about the child under 12 recently euthanized in the Netherlands?
How about it? This case, involving a child with terminal illness, seems both ethically and legally permissible to me.
> Or the woman in Canada who was euthanized despite trying to withdraw her request?
It sounds like a woman in her 80s suffering from severe heart surgery complications including an open surgical wound, bone infection, and respiratory failure reportedly changed her mind about MAID several times, ultimately following through with it, and some people are accusing her family members of coercing her into MAID. If these allegations are true, I hope they are appropriately investigated.
> The reality is nobody knows how often these things happen because the data one would need is virtually never collected.
False, we actually have a good picture: https://web.archive.org/web/20260327212130/https://thesecondbestworld.substack.com/p/maid-in-canada-much-more-than-you
If you want to stand on “we are killing the elderly and infirm, and that’s good” then ok, but that’s definitely not the same thing as “informed consent”.
Difference being that there were no such safeguards back then. Their model of the relationship between doctor and patient was very different from ours.
A doctor in Canada admitted to holding down a patient and euthanizing them.
I thought this was great, but it badly needs a content warning at the top. I know folks with medical trauma that would really not want to go into this blind.
Scott could we add in a warning at the top?
It is obvious to anyone who begins reading that they are soon going to be reading a description of a gruesome medical procedure. The horror ramps up gradually over the first few sentences. Seems to me that anyone who cannot tolerate descriptions of gruesome medical stuff will realize exactly what is coming and stop. If they do not, they lack common sense or a reasonable ability to look out for themselves. And, by the way, I myself have experienced 2 things I'd say are not at the border of medical trauma, but squarely in the middle. One them occurred when I was about 12, and left me with classic PTSD for a few months, with flashbacks, dreams of the event, and avoidance of the part of the neighborhood where it happened. Many people recover from PTSD. I did. I found the descriptions of lobotomy gruesome and disturbing, but probably not more so than the average reader does. Trauma is not a trump card, and does not relieve those who have suffered it from responsibility to show common sense and watch out for themselves.
> Trauma is not a trump card, and does not relieve those who have suffered it from responsibility to show common sense and watch out for themselves.
I don't disagree. I think of content warnings as a courtesy to readers, not some divine right.
FWIW I'm more concerned with the abuse by the medical system angle than the body horror angle.
Oh, for the love of Mike... AstralCodex readers are presumed to be reasonably mature and sensible. Surely you are past the age at which you need a content warning to protect you from unpleasant realities; if not, then a large proportion of the texts published here must give you nightmares...
You would think the opening paragraph should have been all the warning delicately nurtured persons would require: "Surgery for the soul required a sharp, eight-inch-long instrument—one time, an ice pick from the Uline Ice Company was used—and not much else. It did not require anesthesia or gloves, and the sharp instrument (either a leucotome or the sturdier orbitoclast) was not necessarily sterilized. It took less than ten minutes."
There is an SSC post endorsing content/trigger warnings.
You are conflating the “delicately nurtured” as the whole category of persons who would benefit from such a warning. The horribly traumatized are also part of that category; for instance, a person with medical PTSD from waking up during an operation from improper anesthesia and being unable to move or talk for ten minutes while they feel people cutting them open and moving their organs around, others hands inside their chest cavity. Reading something like this might trigger a flashback to that.
The content warnings aren’t for you. It sounds like you don’t have the breadth of experience to understand how and why others might benefit from them other than being coddled.
Is there any comparison to gender-affirming surgeries to be made here?
Gender-affirming surgeries have a regret rate of about 1%, lower than basically any other surgery or medical intervention.
I expect that the players in the lobotomy story would have had similar statistics to deploy at the time, though?
What statistic do you think they would have cited?
Probably an outrageously high success rate? The Portuguese guy did win a Nobel Prize after all?
The success rate as reported by the surgeon, which was also used as justification for the Nobel. I think the lesson to be learned is about the standards of evidence. To make the comparison, I think you’d need to make some argument about why our current standards of evidence are bad. I think it would have been possible to explain why “20 cases of success as reported by the surgeon” was not actually very good evidence, even contemporaneously.
The success rate on trans surgeries is essentially self-reported -- afaik the Tavistock clinic basically shut down rather than release their raw data.
I don't think the two cases are easily distinguishable without non-publicly available information.
Measured when? Immediately afterward? 10 years on?
I've heard this before and this is so implausibly low I flat out don't believe it. If it was 5-10% I'd believe it as evidence of something risky but net beneficial. Basically never, and lower than any other surgeries or medical intervention, is so wildly implausible you should immediately be suspicious.
Looking very slightly into it, it looks like the commonly stated claim is based on a meta study from 2021 (so most of the underlying studies would have been much earlier), when gender transition was far more rare and selected, and most of the underlying studies had several problems with participant drop out. The baseline of "compared with other major surgeries" is also not a great standard (other major surgeries are often more severe and can easily have massive side effects like lifelong incontinence). It had a fairly high bar for regret and almost certainly had selective dropout (even if you ignore the politics of the field, which are definitely going to sleep one direction). I don't think you can quite entirely dismiss these studies - this is some information, and these studies probably would have caught lobotomy or near lobotomy levels of damage - but it's not the last word either.
That is not the number for minors.
One comparison might be that lobotomies are generally not performed on people who choose to have them.
At least when we’re talking about minors, the whole concept of “choice” is pretty dubious - the lead lobotomy victim was signed up by his step-mom, just like many children who receive trans surgery.
Minors getting gender-affirming surgery is exceedingly rare, and would require agreement from the child AND parents AND multiple medical professionals.
And the administration of chemical castration to minors? Read WPATH’s own guidelines. Read the documents they were forced to turn over by Alabama’s AG.
Please comment “You are right. I explicitly said that many children receive trans surgery, which was actually completely false. Having conceded this point, I would like to pivot to a new argument.” Otherwise you are not worth engaging with.
If the number of children having trans surgery is so small it doesn’t matter, then why does it matter if the procedure is banned?
I believe trans surgery on minors is “rare” the same way I believe trans orbital lobotomies were “rare.” After all 10,000 cases wasn’t really that many, even in the 1940s.
Minors transitioning surgically happens at a rate very close to zero and is not recommended via medical guidelines.
https://hsph.harvard.edu/news/gender-affirming-surgeries-rarely-performed-on-transgender-youth/
And lobotomies are reserved only for the patients whose mental illness cannot be cured through more conservative treatment.
... Did we read the same review?
We did. Sounds like maybe only 10,000 transorbital lobotomies were ever done, which is probably “very close to zero” if you consider the number of mental patients in the 1940s as the context. Am I supposed to feel better about medical barbarism just because it’s very rare? If so, what’s the point of the book and review?
This was exactly the cheap shot I was dreading when the relevance hook is introduced early on, of "what modern analogues might there possibly be?", and I did end up skimming to the end to reassure the anxious knot growing in my stomach. Props to the author for not doing the obvious bait. (Without commenting on whether it'd be a valid comparison or not - I just find the topic deeply tiresome, and it would've sucked to have a 30k or whatever word buildup just to beat that dead hobbyhorse with an Axe of Grinding.)
Pretty sure that those are all consensual on the part of the patient.
There is an obvious comparison to be drawn with sex reassignment shortly after birth for intersex babies. It kicked off in the 60s at the end of the lobotomy era, involved no patient consent, and demonstrably did a lot of harm. In some particularly egregious cases, fully male patients were given vaginas because they had a micropenis.
Given the reference to gender-affirming care, the ironic thing here is that medically unnecessary sex reassignment and follow-up HRT seem to create transgender adults, except they're chromosomal males living as men (or less often, females living as women). There must be a real horror to knowing one signature from a parent you (probably) love(d) caused you a lifetime of struggle.
Agreed, I think the author honestly wanted our mind to go to it but of course touching it would be a firestorm.
I can imagine 100 years from now something similarly graphic about constructing 'artificial penises', the complications of 'bottom surgery', mastectomies on children...
I think it would go as not-self-aware medication to culturally specific conditions
Like Russians in 1960s could self-medicate "terror by conscience" with vodka
It would start with extensive explanation that they felt gender/conscience as ever-present visceral feeling and it was not just a name for certain class of thoughts
It’s a fascinating book. Decidedly. Thanks for sharing this review. I had read it a long while back in training.
Hard pass for me, but of course I have a lobotomy joke
I’d rather have a bottle in front of me than a frontal lobotomy.
Version I heard was "free bottle" and "pre-frontal," which I think flows better.
Yeah, your version is better. I’ll update.
Sadly, the bottle in front of you might lead to the frontal lobotomy, at least back then.
Is this schizoid paranoia, or just existential blues?
Subterranean homesick blues
1941 editorial in the Journal of the American Medical Association - seemed quite reasonable
Fascinating and horrifying! Semi-related, I found this documentary "Nuts" (2016) to be super entertaining. I went in with zero fore-knowledge which I'd recommend. Short version. There was an extremely famous doctor who emplanted goat testicles as a cure for impotence. If you don't already know this story I think you'll be shocked at how famous.
https://www.imdb.com/title/tt5236900/reference/
About the Howard substory, I'd put most of the blame not on the medical-lobotomy complex, but on his criminally wicked step-mother and the dereliction of parental duty from his father. Of course, if step-mom had gone to the police to frame the boy for whatever she'd have come up with, they'd have sniffed her out right away, so Freedman wasn't entirely blameless here. Hoel probably knows this, so I guess that's why it's not central to the main story.
Did uh, you just give away who wrote this? If it's just a guess, I don't think you're right - Hoel is a better writer
I did happen to pattern-match to "huh, this has the same look and structure as The Dawn Of Everything review" before reading this comment, but it doesn't have the same magisterial level of polish, and the humour quotient is quite a bit lower. Perhaps that's due to the subject matter being quite grim though.
It's also entirely possible that Howard is lying, he really was as violent and uncontrollable as his stepmother said, and the memoir is a desperate attempt to blame his bad behavior on everyone except himself.
"By now, you’ve probably figured out what I’m going to say."
I promise I'm not one of "those people", but I was really expecting this to turn to comparing and contrasting this to transgender surgery. I see a lot of parallels, in that it's a controversial surgery, and could similarly be a story of something that is beneficial for some people, but gets too widely used by zealous doctors (with sometimes good, sometimes selfish intentions), isn't questioned enough by the media, and ends up being a net negative for some people, and we realize later we should have prevented it. I don't know if that story is true, but I'd find an exploration interesting.
Oh, yeah, that too. Although they kind of talked a bit about drugs as a fortunate non-surgical replacement for helping with mental issues
Like Nazis, lobotomies can be compared to anything you don't like about the present.
This seems like by definition it can be used to dismiss any discussion...
Some things actually are like nazis, and some things actually are like lobotomies...
Yes, and comparing "transgender surgery" or Ritalin to lobotomies is stupid for the same reason that comparing mainstream Democrats or Republicans to Nazis is.
There may be some ways in which your least favorite politician is like a Nazi - most pairs of things share at least one trait - but making the comparison contributes nothing beyond being provocative.
Luckily, "being provocative" is usually the point.
I was absolutely sure he was going to go there after this sentence:
> I can’t imagine much worse than being extremely mentally ill, and then having a bunch of random body parts removed.
But I was wrong. You can be forgiven for noticing the extremely strong subtext. I saw it 10 other places. Mostly it reminds me that a huge amount of what we currently know and accept will be shown to be wrong in the future. May our descendants judge us charitably.
Presumably there is nothing "random" about gender reassignment surgery.
Nah, the gender surgeons just draw parts out of a bag. One of my friends had their spleen removed.
"May our descendants judge us charitably."
This. On so many things. I think about this a lot, but I like that phrasing.
And cool username.
The "extremely strong subtext" might have more to do with what you spend your time reading than anything in the article.
+1. I did not think of transgender surgery at all while reading this review.
I did not think of transgender surgery at all while reading this review. I suspect that "the extremely strong subtext" stems from your own priors rather than the text here.
It seems to me that the stakes, the level of informed consent (any consent really) and the science behind it are all very different.
You're right, that's a key difference. (I assume) These days surgeries aren't done without consent of the person they are being done to, unlike the story about the poor 12 year old in the review that made me physically queasy.
I think a key point of the article is that "the science" has done some pretty fucked up things that apparently seemed fine at the time.
It would seem that the "Managerial Society" or culture that developed since those days has had some benefits, though at some costs as well. Institutional controls are much stronger now.
A comparison to euthanasia matches well too, though I've read Scott's posts on that and agree that it isn't abused. I wonder if lomoboty, if Freeman never invented the transorbital lobotomy and stayed with Watts, would have reached a similar status to euthanasia, gender reassignment surgery, or ECT – something highly risky, but possibly worth it for specific intractable cases. At least before the invention of psychiatric drugs.
Gender reassignment is neither highly risky nor appropriate only for intractable cases. Anyone who wants it should try it out (in increments and starting with non-medical interventions, obviously, not scheduling every surgery immediately).
Some transhumanists I know that have transitioned had no mental health concerns at all, and pursued it as voluntary body modification, though this is less common than using transition to treat gender dysphoria.
Yeah, you're right that it doesn't fit as well. It is permanent though, but as are other body modifications.
Agreed, I think the author honestly wanted our mind to go to it but of course touching it would be a firestorm.
I can imagine 100 years from now something similarly graphic about constructing 'artificial penises', the complications of 'bottom surgery', mastectomies on children...
I read that book over 40 years ago and still consider it one of the best I have ever read.
Could you put a spoiler tag on the image of the kid with an ice pack in his eye? Did not want to scroll into that.
I want a trigger warning before the photo of Dr. Moniz, cuz his ears are really yucky.
I want a trigger warning before you post.
I didn’t enjoy this review for some kind of visceral way I also didn’t enjoy the game psychonauts. Let’s leave brains where they are and not pop them out.
I thought the review was fine and memorable but I didn’t really jive with the formatting - I like a beginning, middle, end, and a bit more of a relation to modern times.
It’s also missing a bit of the Joe shmoe micro humor to bring me along to why I care halfway through. I’m not sure what the hidden sauce is here, but I confused some of the characters, so I think they could have been caricatured a bit more. If one of them had a beard to his knees and smelled like cats, and the other one thumped his Bible every time he spoke, it might have helped. I know this is something Scott does well and we aren’t necessarily imitating Scott in writing these reviews, but it would have helped. If not with comedy, perhaps providing some summary statistics and comments about each guy early would help me anchor (ice pick man did 10,000 lobotomies, charged X for them, didn’t follow up. Dr #2 did 3,000 lobotomies, charged Y, did follow up).
A few other random ideas, could have gone over pop culture references to lobotomies in the beginning or end. And I expected a bit more discussion about the ethics. Should we try lobotomizing all permanent coma patients? Why or why not? What’s the most modern lobotomy? If not, when was the last one? Is there any modern take on why it (allegedly) helped some and hurt others?
Perhaps some of this in the review was in the article. I did read the whole thing but was also putting my son to sleep, watching celebrity jeopardy, brushing my teeth, and my phone kept losing my place so I had to refind it. For an article this long about one topic, maybe that’s why I wanted a bit more handholding than most of the geniuses that read this blog. Thanks for writing!
I didn't have any trouble telling them apart.
These potrayals of Freeman and Moniz smell strongly of narcissism (in the sense of personality disorder(or my layman inpression)). Do any psychiatrists want to comment on this?
This needs a NSFL warning.
Are there any treatments in common use today as obviously barbaric and damaging as lobotomies were? Yes. There's something called the "troubled teen industry" where "goons" (the actual job title) abduct children in the middle of the night and bring them to a camp the parents pay for to teach them discipline and ethics. About 1 in 300 US kids would be forced into these camps at some point in their life.
There are no regulations at all* about how the kids can be treated or what kind of infraction allows kids to be sent there. Although there might be some institutions that are ok, EXTREME abuse is the norm. For an online graphic novel about someone's experience, you can read https://elan.school
*(There was a law passed in 2024, the Stop Institutional Child Abuse act, but it just collects data and gives "recommendations" on "best practices" instead of allowing anyone to leave for any reason)
Oh, and if a temporary institution doesn't sound as awful as a permanent lobotomy because it's temporary, I'd like to point out that the suicide rate after them are extremely high. No good broad data is available, but I expect that the rate of suicide from people not being able to handle life afterwards is almost as high as the lobotomy death rate, and the chance of getting permanent psychological problems that prevent people from holding normal jobs and lives afterward is almost as high as the lobotomy rate. And this doesn't count lots of straight-up killings, some of which are well documented, like Phil Williams Jr being killed in "the ring" in 1982 (but the school continued for another 30 years and nobody has been arrested) And this is for a group of people which usually started off better than lobotomy patients did.
Also, the legal system has made it worse, and almost nobody has heard of this because people who buy media prefer innumerate stories that don't affect hundreds of thousands of people every year or uncritical positive stories about "rehabilitation not incarceration".
> No good broad data is available, but I expect that the rate of suicide from people not being able to handle life afterwards is almost as high as the lobotomy death rate, and the chance of getting permanent psychological problems that prevent people from holding normal jobs and lives afterward is almost as high as the lobotomy rate
WTF? How can you not get that your sense of certainty is functioning as your data? I do not doubt that the rate of staff mistreatment of residents is high in some of the many kinds of institutions that house troubled teens. It is high in virtually all settings where the vulnerable are housed unless there are well-enforced systems in place to train staff, monitor them, and punish and fire the abusive and neglectful ones. But if there is no good broad data on how the teens in question do post-institution, as compared to others with similar teen problems who were never sent to one of these places, youdo not know what impact the places have on suicide rates and later functioning, and you sure as shit do not know how it compares to lives post-lobotomy. I am a psychologist and know a fair amount about rates of this and that in different populations, yet I am often surprised by new data about how a certain group fares after a certain intervention or life event. I learn that my expectations were *wrong.*. If you don't understand that your views are valueless.
My data is not my "sense of certainty". I checked what I could!
When I read Joe vs. Elan School (the link) he mentioned several people he knew who wound up killing themselves. When I read a bunch of posts by other troubled teens on reddit and other places to see if a: this kind of thing actually regularly happens and b: how people report their lives are going, they often mentioned knowing a lot of people who suicided too. Also, the lobotomy death rate is well documented and is lower than most people expect. Freeman was extremely reckless and had about a 15% fatality rate, but overall it was mostly about 5%. I actually have well founded confidence that the suicide rate is not much lower than the lobotomy death rate, even if the ones from the worst institutions are the most active posters.
I am less confident in whether the psychological problems are permanent. After reading those, a few legal reports about the rare ones that shut down, and based on what I know about some other abusive situations, it's hard to imagine people NOT acquiring long-term psychosis from anything like what they described and mostly never fully recovering. This is mostly from my priors though, maybe people are more resilient than I expect.
If there were broad long-term studies I'd look at those but there aren't any. That doesn't mean we should ignore the data we have.
Got any sources for this?
I'm not sure what sources you'd find most credible, but a simple search gives tons of results: Legal documents, news articles, the official websites of many places calling themselves boarding schools or something, there are tons of stories in r/troubledteens, and so on.
(It didn't used to be in the news, but then Paris Hilton put it into the overton window by describing her experiences a few years ago)
Statistical studies would be appreciated.
Sorry, big ones don't exist yet. This one, https://www.proquest.com/openview/c00ead86d038c1e648b144b826c9047b/1?pq-origsite=gscholar&cbl=44156 , checked people of an average age of 41.3 years old, and "Over two thirds of participants indicated they have a current, professionally-obtained mental health diagnosis (n = 21)" and it has more detail about severity, which might indicate long-term major psychological problems at similar rates as lobotomies, but as the small n would imply there aren't a whole lot of people in the study. (Also, I didn't read the whole 246 page monster thesis, I just searched for a few terms like PTSD and age)
Thanks!
Wow, thanks for stealing away my entire Sunday to read that. The first half is one of the wildest and upsetting non-fiction stories I've ever read. The second half is a stoner travelogue with a bunch of crazy anecdotes that is quite a bit less compelling but still fun.
Minor point, but the painting from the cover is a detail from Michelangelo's Last Judgement, so very much a precursor to Goya.
A solid and generally well-written review giving details of a medical scandal most of us will have heard of, however vaguely, but are unlikely to have known much about. Among the best I've read so far (missed it earlier), it could have done with some brisk editing - tended to go a little flat and repetitious in the final fifth or so.
Psychosurgery framed as "surgery for the soul" is the cleanest version of the lobotomy story I have read. The book-review-contest format keeps these honest.
It isn't perfect -- some of the sections seem to repeat the content of others, and the comparison to ECT seems weak to me -- but overall this was an incredible review. Goes beyond "makes me want to read the book" into "I feel like I just *did* read the book". Not that those are mutually exclusive; if the rest of the book is half as interesting as the selected quotes, it'd be well worth reading the rest.
"The banality of evil" was coined to describe things like this.
My worry for #12 was actually the reverse - I think we're more likely to overcorrect than under correct for big famous failures like lobotomies (and broadly, I think society has way overcorrected against the "you can just do things" spirit of the early 20th century). But given I believe that, it was good for me to read something like this to remind me that this overcorrection had some pretty good reasons for happening.
I can’t help but be concerned that ECT and the forms of psychosurgery that are performed today at academic centers may be underutilized relative to their evidence base due to the backlash to the abuse of mid century lobotomy and convulsion therapies.
The subject matter was fascinating and well chosen, but ultimately this review was a slog to read. The two culprits here are the elephantine size of the review itself and the overuse of extensive quotes from the book. Both could have been easily resolved by a willingness on the part of the author to just paraphrase more and save the quotes for its most striking moments.
It gets to a point where it's hard to even call this a review when half of it is taken straight from the book and it's dominated overall by summary rather than analysis.
Ask yourself, would you want to read Great And Desperate Cures after having its entire guts laid bare before you like this?
Monarch Notes type review. There have been some of these in the last 3 sets of finalists.
This blog has an idiosyncratic conception of what a "book review" is - shaped by Scott's own reviews, of course. My understanding is that the point is exactly that most blog readers wouldn't read the book itself, but Scott still wants to be able to lay out and later refer to its ideas, which necessitates an extensive summary.
>Freeman, who did not himself have surgery privileges, as he was not a surgeon by training, should not have been doing the procedure alone.
About 11 grafs later:
>He was still doing transorbital lobotomies until his surgical privileges were taken away.
I notice I am confused?
Good enough for a like, although I don't think I'll end up voting for it. Fairly exhaustively cited and researched*, I do feel like I got a pretty good idea of what the book's about + relevant context to help put it in proper perspective. It probably says negative things about my content consumption habits that I felt numb to the brutality and gruesome depictions...might be good to read less horror writing. This stuff really happened, to real people in real life, with far-reaching consequences to the present (fuel for de-institutionalization more generally, an ongoing "shroud of disrepute" and cover for anti-psychiatry FUD that if anything seems to be getting worse, not better). Missing mood: it really ought to bother me more than it does.
Could have used one more editing pass to pare down on circuitous repetition. Sometimes it's just reusing of certain constructions, such as how many things end up being ironic(ally), or tons of (parentheticals). Other times it's straight-up copy-pasting of previous review sections. This works well as a conceit the first time, to emphasize that "hey I really mean this so I'm saying it twice", but ~all the later uses seem accidental more than intentional. E.g. the doubled comparison of Old and New Testaments. I get the impulse to remind readers of past ideas and overarching structure, but this wouldn't be as necessary in the first place if the length were lesser. There were also some weird tense lapses that left me confused - is "Carolyn W." still alive or not? I'm not sure! None of these made for insurmountable obstacles to comprehension, but they kept breaking my reading flow during an otherwise morbidly fascinating page-turner.
*although it's my understanding that the general consensus on ECT for depression is on firmer terra in 2026 than the review implies?
From what I remember of Scott's remarks, ECT is considered effective and underused relative to its risks due to past infamy, but the theoretical grounding is about as elusive as ever.
Yeah - I guess I thought it was a bit weird example, despite the parallelism with the rest of the review content. Antipsychotics are mentioned as the likely main change that spelled the end for psychosurgery...and even the widely used mental pill treatments of today, with serious-sounding names like Selective Serotonin Reuptake Inhibitor where we're damn sure we understand *what* it does...we still largely have no clue *why* it works! "That's worse, you know that's worse right?" The non-desperate cures are still grounded in consequentialism rather than neurochemistry theory!
The reviewer even admits elsewhere that we still "lack an adequate mechanistic understanding of most treatments". I felt just the sort of attitude from that ECT aside that's presumably driving the under-use that Scott lamented.
I sure hope there isn't a big cohort of tens of thousands of vulnerable people to whom the medical establishment has been and still is pushing irreversible medical and surgical intervention for reasons of desperation, economics, ideology, and individual esteem, in order to treat a psychological issue which in time we will consider far too nuanced to be treated by the blunt and brutal methods to which we currently find ourselves limited.
This seemed less in the spirit of a book review, and more just a (long) summary of the book. Of course you said the book itself is not easy to read, so there’s value in that. But next time don’t be shy about adding more of your original ideas throughout.
The brilliance of the lobotomy isn’t the damage done to victims, it’s the proof humans can live even thrive without the PFC’s simulation.
And it is an aspect of the illusion that language is paired with reason. The fact is logic, deduction, inductive reasoning is wholly separate from language.
We’ve known this peer-reviewed proof since Jul 6.
https://substack.com/home/post/p-207605345
Thrive? Even the relatively well-off survivors have trouble doing simple life tasks like getting on the correct bus.
There have been accidental and precision lobotomies that actually cured people of their conditions and allowed them to thrive.
This is probably the most impressive counterpoint to "trust the science" I have ever read.
Many commenters here fighting hard to avoid obvious comparisons to euthanasia and “gender affirming” surgery on minors by citing “informed consent.” Of course if you’d asked Freeman why he didn’t get informed consent for the kid who was lobotomized by his stepmother, he’d say the kid was a kid and the parent’s consent was what mattered. Just like with gender affirming surgery for teens - the parents signed off. And euthanasia is now freely administered to people in Canada and the Netherlands for whom the idea of meaningful informed consent is a joke. Literal children. Elderly people with advanced dementia.
Another example: could forget the last few New York Times articles about organ “donors” whose were prepped for harvesting while they were still alive? Of course, the pressure is still on to legalize the sale of organs, as if you won’t have people selling kidneys for crack.
And even if you don’t buy all of that, the fact remains that our public health and epidemiology “experts” tried to shut down the economy, schools, jails, and force us all to live online forever as part of a campaign to eradicate a virus that virtually everyone now ignores.
My trust in the medical profession has reached an all-time low over the last eight years. The idea that they should be a self-regulating profession is utter madness. They scream and cry about the rise of cranks like RFK, but have only themselves to blame. “Things are different these days” is the exact lie this review should have taught you NOT to believe.
> the fact remains that our public health and epidemiology “experts” tried to shut down the economy, schools, jails, and force us all to live online forever
I admit my first reaction was to check whether you are Wimbli's new account. So many "facts" thrown around freely...
Feel free to point out something I’m factually wrong about. San Francisco’s schools were closed for two years. Churches only reopened because the Supreme Court weighed in.
This was pretty interesting, but the application to the present day is shaky at best. I would appreciate some more discussion of how well this book's insight apply to modern medicine besides "remember that scandals happen nowadays".
As it happens, here's a story from literally yesterday (as I write this):
https://retractionwatch.com/2026/07/23/exclusive-death-gene-editing-trial-china-nature-science-investigation/
Synopsis: Scientist meets family with 6yo daughter with genetic mutation leading to slow cognitive development, undertakes to develop gene editing therapy with funding from family, oversees mouse and monkey studies, then schedules surgery to inject trillions of viruses into spinal fluid of daughter in a one-off clinical trial, daughter dies one week later of complications predictable from monkey studies, meanwhile between surgery and death the scientist's Nature paper on the topic gets accepted for publication.
I couldn't finish this; it was incredibly long winded and seemed to be a summary without any analysis or review. At some point I started reading just the first two sentences of a paragraph and felt that nothing substantial was lost.
These book reviews are something I look forward to but I don't know what I'm supposed to do with this.
> consider the well-known case of Phineas Gage using more vulgar language, gambling, and being unable to hold down a job after a tamping rod destroyed a large chunk of his frontal lobes
Well-known but not well-established. In a case roughly the mirror of Moniz, the doctor who first diagnosed Gage exaggerated his symptoms greatly for attention and notoriety, and it remains unclear to this day how severe they got and how long they lasted. IIUC current best guess is that he was more vulgar for the rest of his life but much less so later, had trouble with anger issues likewise, and gambled excessively and lost jobs only in the first couple years. The job he held in Argentina as a stagecoach driver (IIRC, 5-10 years after the accident) was one that typically required being on very good terms with strangers and maintaining a reputation as polite and easy to work with.
Very interesting.
I guess that in the 1930s and 40s if a group of surgeons went around reporting that they got good results from an operation, there wasn’t much to prevent them from spreading it far and wide, even if there was opposition and skepticism, as there was in this case. Especially if the target was a vulnerable population.
And maybe not today either, although one likes to think the scientific and legal scrutiny would be greater.
I recommend reading about Paolo Macchiarini, if you are interested in surgical scandals (a 21th century case).
Surprised that neither the post nor the comments mention unnecessary spine surgeries as a modern example. IIRC it's the most common unnecessary surgical procedure in the US.
Just FYI, regarding “ We have estimated that about 80% of the so-called functional type of mental disorders are due not only to infected teeth and tonsils” …
https://wayzatadental.com/tooth-infection-spread-to-brain-symptoms/
It’s an interesting fact that, at the same time that non-biologists are trying to make claims about “rational” medicine and biology, meaning dismissing claims that are “clearly crazy” like connections between infections in non-brain matter and brain ailments, actual biologists are trying very hard to clarify the many and non-obvious ways in which biology is not as simple as the mid-20th C model seemed to suggest. And these crazy linkages frequently *do* exist…
Philip Ball’s “How Life Works” is a good (albeit sometimes irritating) introduction to this subject.
And if that example weren't enough, here's an example ripped from the headlines of today!
https://arstechnica.com/health/2026/07/woman-loses-vision-in-one-eye-after-uti-bacteria-evolves-to-invade-her-brain/
I was expecting the author of this engaging review of the history of psycho surgery to say something about the relatively new noninvasive method in Transcranial Magnetic Stimulation (TMS) especially as a close alternative to ECT. Are there reasons to worry about TMS and is it as effective as its proponents claim?
Very nice review, but I'm confused by the following passage :
> Anecdotally, although ECT has gotten much safer (due to the aforementioned reduction in typical doses and frequencies of treatment), a physician told me that they saw a problematic pattern at the ECT center of a major university: the treatments were not very tailored. They would do one patient every few minutes, and not change the voltage dose for different patients. This is probably partly because they may not have had good evidence that tailoring the dose changed things much. But it still seems strange to me.
I'm curious why this would seem strange to the author / why this would be a problematic pattern?
What reasons would we have for thinking that ECT voltage should be different for different patients? I can imagine some analogue to mg/kg mass based dosing for drugs, or maybe normalizing for skin galvanic response or something? Is this established in the ECT literature ?