Talk:Lobotomy

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Talk: Lobotomy/ Archive 1

Historical Context

This section needs development on: 1. Medical paternalism and culture, especially in relation to therapy and patient consent (to what extent was patient consent seen as necessary in any medical field). Psychiatric patients and diminished responsibility. Dehumanisation of psychiatric patients (particularly in the context of large public asylums). 2. Growth of asylum populations from the 19th to the early mid 20th century. Problems associated with this. Also, eugenics and psychiatric populations. 3. Population of "chronic" patients in psychiatric hospitals. 4. Licence for radical therapies was granted due to perceived inevitable terminal degeneration of patients diagnosed as schizophrenics. If such a patient was likely to end their days as a dement, according to the medical opinions of the day, then radical interventions (as with General Paralysis of the Insane and Fever Therapy) were seen as justified. 5. Association of these interventions, seen, at least, in the popular press as "cures" (rather than as, at best, treating certain symptoms) with modern medicine and positive developments. 6. Desire of psychiatrists to reintegrate with mainstream medicine. "Heroic therapies" - were seen as potential routes to this reintegration. Freekra (talk) 16:21, 25 November 2009 (UTC)

Excellent efforts, Freeka, toward improving an abysmal article on an important subject. However, there's a real problem with any section that opens (as it currently does), "Properly considered in its historical context..." This implies there are multiple ways to consider the context, a particular one of which is being offered by the article as the proper one. Also, I completely understand the argument that severe mental illness had at the time few treatments, and that some of those few were almost as scary-seeming as lobotomy, so lobotomy wasn't such a big jump as it might otherwise sound --- but there must be some way to get that across without all the detail about Metrazol and so on --- there's way too much detail on earlier treatments and the physicians that developed them --- this stuff belongs in other articles on those specific topics, linked from here. (And why does it matter which doctors were Jewish, or Nazis?) Please don't let this discourage you — I commend you for taking on the very difficult task of improviong the mess that is this article. But it will be, well, difficult work. One last point: if you know how to archive the Talk page so far (I don't) I think it would be a good idea to do that and start fresh --- it's an even bigger mess than the article itself. EEng (talk) 05:16, 26 November 2009 (UTC)

Thanks for your comments EEng, they're very apposite. OK. I'll see about severely condensing down that first paragraph on historical context and the development of heroic psychiatric treatments. Also points about Jewish doctors and Nazi sympathesisers are well made. Thanks again and if you have any time to pop in occassionally and make other useful observations I'd much appreciate it. Unfortunately, I don't know how to archive I talk page, but I'll look into it.Freekra (talk) 10:49, 26 November 2009 (UTC)

Eventually figured out how to archive talk page. See the link above for the archive. I've kept this section as the only existing current discussion. Freekra (talk) 11:46, 26 November 2009 (UTC)

I see now I've been spelling your nom de plume incorrectly. Sorry, Freera Freekra! Article looks much better already! EEng (talk) 21:35, 26 November 2009 (UTC)

Freaky. Thanks again EEng ;) Freekra (talk) 22:06, 26 November 2009 (UTC)

Freekra, apparently I still couldn't get your name right (now corrected above) --- long day. I counsel you not to feel you have to take on all the tasks you list (below) on your own, or you may burn out. I would be very careful using The Lobotomist, which is specifically on Freeman's life and work, shouldn't be considered a comprehensive source on lobotomy in general --- not saying don't use it, but bear its limitations in mind. There's been amazingly little in the way of book-length treatments in the last few decades; you'll certainly need to include Valenstein and Shutts but you're probably going to need to bring in journal articles as well. Re "patients' points of view" sooner or later you'll run into Dully, My Lobotomy, but again it's just one experience. Like I said, this is going to be a big, big job. EEng (talk) 09:04, 27 November 2009 (UTC)

The major reason I'd like someone to have a look at El Hai's book is so that some statements about Freeman can be accorded a proper citation with page numbers. It would be easier to rewrite the section on Freeman if it could be ascertained what is currently factual in the text. In regard to doing everything myself, I was hoping that by putting up a to-do list I might encourage other editors to participate. I'm not quite sure about the process of recruiting other people to help. For myself, I have a deadline looming so I might have to leave this article as it stands for a week or so. In regard to other sources, it is easier for me to locate journal articles, at the moment, than books. So, if someone else has access to Valenstein and Shutts that would be wonderful. Patient experiences are a major problem. Dully is exceptional as he was a child when he had his lobotomy performed and was able to recover in a way that most adult survivors would not have been able to. First place to start, I guess, is with the psychiatric literature on side-effects, critiques of the procedure, etc. Thanks again for your comments EEnd Freekra (talk) 09:32, 27 November 2009 (UTC)

It's EEng, if you don't mind, Mr. or Ms. Freaky. For recruiting, well, just see who shows up; there's no deadline for getting this done. I advise avoiding the term lobotomy survivor because it's implicitly critical of the procedure. For comprehensive evaluations of the safety and effectiveness (or otherwise) of the procedure, retrospective papers of the last 30 years at the earliest will be the only ones, I suspect, with sufficient distance (earlier sources, of course, might be used to illustrate early enthusiasm, later debates, and then growing criticism as lobotomy began to fall from grace, as those happened). I'd use Kotowicz with caution, it being a mix of cited fact and uncited assertion. For example, he states (without futher discussion, or even citation that I can see) that soon after Moniz' Nobel Prize the USSR banned lobotomy, presumably for the protection of its citizens. Given the substantial evidence that psychiatry was abused for political purposes in the USSR, and the well-known disconnect there between lofty legislation and daily reality, such a naked statement is problematic. EEng (talk) 20:14, 28 November 2009 (UTC)

Suggested To-Do List

I'm going to keep plugging away at this article but any help in editing the article with sourced and non-biased material would be appreciated. Whatever one's feelings about the procedure there should be no need to say that it is "barbaric" etc. Simply describing the procedure, its history and outcomes should be sufficient to allow the reader to make up their own minds.

I've already made some changes - inserting the Historical Context, dividing the history of the procedure into the contributions of Buckhardt, Moniz, Freeman and a Reaction Section. The latter should probably moved into a separate section and extensively re-edited. I don't think Norbert Weiner's reaction is particularly relevant. There were plenty of other critical reactions from parties more closely related to the subject. I've also expanded the section on Buckhardt and begun editing the section on Moniz.

Proposed To-do list.

• Introduction Removal of sentence: "There is significant evidence that the procedure was used as a means of controlling persons whose behavior (such as "moodiness" or "youthful defiance") was considered annoying or embarassing, often without the patient's informed consent in the modern sense." I think that this sentence could be removed. The most frequent application of lobotomy was in a asylum setting. In regard to inappropriate usage this was mostly directed at patients who were considered to be management issues. There are plenty of cases where social prejudice and clear abuse of medical power impacted on the use of the procedure but I think that this would need to find better support in the main body of the text. At the moment I don't see major support for the contention in the article itself.
• Moniz An elucidation of theoretical basis for his procedure.
• Freeman El-Hai, Jack (2005). The Lobotomist. Wiley. ISBN 0471232920. This is the major source for this paragraph as it stands. I don't have access to this book currently. If anyone does they might add page numbers to the citation - particularly with reference to Freeman practicing transorbital lobotomy on grapefruit (from memory - unreliable - I think this is true?).
• Reaction Needs development. I think also some consideration of reviews of the treatment in the medical literature, reported side effects, etc, would be most useful.
• Patient Experiences Not sure what sources to use, but I think that a section attempting to recount the procedure from the patient's point of view would be worthwhile.

Any comments, help, etc, would be much appreciated. Freekra (talk) 12:48, 26 November 2009 (UTC) It might also be an idea to have a section outlining the varous types and techniques used. Freekra (talk) 13:06, 26 November 2009 (UTC)

"The most frequent application of lobotomy was in a asylum setting" - Actually this appears not to have been the case, at least in regard to those procedures performed by Freeman and Watts pre 1943Freekra (talk) 15:19, 26 November 2009 (UTC)

Moniz section now expanded and almost finished. Need a bit on how his leucotomies were initially received. Freekra (talk) 04:05, 27 November 2009 (UTC)

Images

Apart from some more images of icepicks and hammers used by Freeman for the transorbital lobotomies, I haven't been able to find any non-copyrighted images to cover the other aspects of the procedure and I have no experience in sourcing such items. What I'd really like to use are the images from the following article which is public access but still under copyright: Bilateral Frontal Lobe Leucotomy in the Treatment of Mental Disease This article has some excellent images - particularly Fig. 2 which visually demonstrates the conception of mental processes at that time which supported the procedure. Does anyone know if it's even possible to get a release on such images? Freekra (talk) 21:48, 26 November 2009 (UTC)

You would have to get written permission from the publisher. Looie496 (talk) 19:27, 27 November 2009 (UTC)

Does anyone have any experience of doing this? What's the likelihood of the publisher granting a release on an article that was published in the late 1940s? Freekra (talk) 19:34, 27 November 2009 (UTC)

There are editors who have a knack for finding useable (in terms of permissions) images for various articles. I suggest you mention desired images here on Talk, and concentrate on the text (on which you contiue to do an excellent job, by the way). Images are fun and eyecatching, but they should have a purpose directly related to the article. Portraits of doctors and pts belong in articles on those people; but the photo of Freeman and Watts "in action" seems right on point, and something like the "Fig. 2" you mention sounds like it would as well (though I doubt you could get permission for it --- see below). Re "icepicks and hammers," lots of surgical instruments look like refugees from a torture chamber, but articles on other procedures don't usually illustrate tham; including such photos here plays into the sensationalist angle and I don't see what they add to the understanding of the subject.

One way around your "Fig. 2" permissions problem would be to describe what the reader will see in the figure then link to the paper itself (which as you point out, is luckily open-access); but this is awkward and the figure in question better be really, really worth the reader's trouble. (By the way, the McKenzie paper you link to gives one of the weirdest illustrative examples I've ever seen, whether in a medical context or any other: "When both [frontal lobes] are removed, the individual...could operate a simple boat. He would require his frontal lobes, however, to be taught anything more than the rudiments of sailing." So maybe it works this way: zero frontal lobes = rowboat; 1 frontal lobe = sailboat; 2 frontal lobes = ocean-going yacht?) EEng (talk) 20:14, 28 November 2009 (UTC)

Point taken re photos of doctors etc. I guess I was just looking for anything visually I could include and really that's all there is available. If you disagree with any current photos or any textual changes I've made delete/rewrite without compunction. I actually hadn't read the maritime analogy in the article until you brought it up. I wonder how many frontal lobes McKenzie would think that it takes to change a lightbulb? It's bizarre.Freekra (talk) 02:17, 29 November 2009 (UTC)

New Section: Medical Case Histories

Added this section and, while I personally think it might improve the article, I'm not sure if it's appropriate for an encyclopedic entry. Any feedback would be welcome.Freekra (talk) 00:38, 28 November 2009 (UTC)

Recitation of case histories weighs the article down, unless a particular case is especially enlightening on the subject of lobotomy; if the case is notable mostly because the patient is notable (e.g. Rosemary Kennedy) then the article on that patient is a better place for details (especially since the topic may be controversial and is best worked out in one place instead of two). Take a look at WP:MEDMOS which I think you'll find helpful in general. (In the case, it suggests a home for case histories outside the article.) EEng (talk) 20:14, 28 November 2009 (UTC)

I agree entirely with your pruning of the notable non-notables. Dully, I believe is mostly useful in terms of the info he provides regarding Freeman from the radio doc he did. That's now the source for the grapefruit story etc until I can get another written one. What I was wondering about, though, were the medical case histories I took from that journal article. Are they appropriate here or outside the article? I'm asking again cause I'm a little confused as to which section you're referring to in your comments above - the notable non-notables or to the medical case histories? Thanks again for all your help and "sage advice". :) Freekra (talk) 02:09, 29 November 2009 (UTC)

I meant the "medical case histories" --- jargon-filled, not sure what they tell the reader. I removed them. You can always get the text back (e.g. for use in Wikisource) from the article history. Re "notable non-notables," you'll notice I didn't (a few days ago, when I adjusted the "notable cases" section) remove any items, just cut down the detail, leaving it to articles on those individual persons to explain. BTW, I wonder if special attention should be given to Frances Farmer --- long before the film, it was a common idea that Farmer had been lobotomized --- so perhaps this issue should be discussed more prominently than in "cinematic/literary portrayals section" (maybe something like the way Phineas Gage is treated -- with details removed except to say that it was once reported, now there is serious reason to doubt etc etc, with link "see Frances Farmer" article for full discussion; there's similar text at Psychosurgery that ought to be similarly cut down and linked to Farmer article). EEng (talk) 12:45, 30 November 2009 (UTC)

You're probably right in that they're primary source and don't really belong here unless there's a secondary source to comment on them. Possibly same is true of 1970 dictionary entries which, as it stands at least, is a bit confusing in terms of what the article is saying. Freekra (talk) 13:52, 30 November 2009 (UTC)

Effects of lobotomy

It doesn't seem like there's a lot of empirical information here about the effects of lobotomy, either intended or unintended. Is the 1970 medical dictionary excerpt intended as an authoritative and still-current description of lobotomy's typical effects, or is it intended to be historical? This is especially important because the article does describe popular depictions of lobotomy, and it should comment on to what extent they are accurate.

It also doesn't have much information on what the experts actually concluded -- were lobotomies sometimes effective, but too damaging? Were they too often used inappropriately to justify cases where they helped? Were they (as a few sources in the article suggest, but do not support with evidence) completely destructive, but for a time therapists mistook the effects of brain damage for improved mental health? Or was the whole thing a monstrous fad that was built on nothing at all?

I apologize for asking these questions when I can do nothing to help answer them, but since this page seems to have a number of active editors, I thought I'd mention it. Inhumandecency (talk) 23:50, 29 November 2009 (UTC)

Please don't apologise they're all good questions. Empirical information is scant on the efficacy of the treatment although I will be inserting more material of fairly large studies drawn from the 1940s and 1950s. So far as I can ascertain there are no double-blind trials or any studies approaching contemporary standards in the medical literature from when the procedure was current. This is not that surprising as this was true of a lot of the production of medical knowledge it would seem until at least the 1950s (open to correction on that). Mostly these type of physical therapies were introduced with quite a bit of fanfare in the medical press claiming huge recovery rates. Other clinicians tried to reproduce this, rarely succeeding, but were at least pleased to get any therapy that might achieve recoveries over the average spontaneous remission rate. There doesn't appear to have been a lot of control for selection bias here (taking acute cases for insulin shock therapy etc). Once there was an international acceptance of the procedure as effective - on whatever grounds that actually stood - there was little incentive to challenge the therapy. Psychiatrists had a huge investment in procedures that held out the promise of a cure or alleviation of symptoms because they had so little else in their medical armoury. Moreover, cardiazol shock therapy, insulin coma therapy and surgical leucotomy (not the office procedure of Freeman who has a bit of the medical mountebank about him) were avenues for asylum doctors to attempt to reintegrate with the wider medical profession. Asylum doctors (as distinct from Psychoanalysts - although they too could embrace physical therapies by Freudianising their mode of action) had a huge investment and, as with the case of insulin in 1957, when good evidence was produced calling a procedure into question they fell back on the authority of their clinical experience to rebut it. Empirically they were right in any case with ECT, it would seem, and probably cardiazol too.

However, I'm sure there are later follow-up studies of lobotomy procedures. I haven't gone looking for them yet, but I will.

I wouldn't think it was built on nothing. Undoubtedly, in the context of large asylums especially, and from a management point of view some of the results were "positive". Difficult to manage patients could become much less of a drain on resources and that is made explicit in the literature, as are a lot of the more unpleasant side-effects (something is always lost of the person etc). However, these are mostly drawn from clinical observations rather than any robust statistical studies. Psychiatrists at this time were much more trained in reading and drawing inferences from case studies - and taught through that means - than through large statistical studies.

The 1970s dictionary is intended not as authority on the actual effects of lobotomy but of the contemporary medical understanding. I intend to supplement it with stuff drawn from each decade of the procedure's existence.

The short answer is that the article is not yet complete and I'll be looking to find as much authoritative info as possible on the actual impact of lobotomy. But I'll need a little time and any help would be appreciatedFreekra (talk) 01:19, 30 November 2009 (UTC)

'Ok. Got one follow-up study 2009 Longterm outcome of leucotomy on behaviour of people with schizophrenia from Journal of Social Psychiatry of 87 lobotomised schizophrenics, all army vets avg. age 71 yrs, who had had the procedure approx. 45 years previously. Study briefly goes through the historical medical literature on the subject. States that need for controlled trials wasn't recognised until 1000s of people had had the procedure. No contemporary objective assessment of cognitve or psychosocial outcomes. Little can be drawn from contemporary studies claiming positive outcomes: not robust studies. Strict criteria for surgery not applied - often indiscriminate usage. This study measured 87 lobotomised schizophrenics against one control of non-lobotomised schizophrenics and another control group with multiple othe diagnosis. Little significant difference between the two groups other than that the lobotomised group were somewhat more irritable. Study states one of the proposed impacts of the surgery was to reduce irritability - so a fail on that point. Concludes that long-term effects of chronic schizophrenia had more impact on them than long-term effects of leucotomy. Refers also four other studies on long-term effects of leucotomy which, it says, generally supports their results that re schizophrenia over the long haul having more impact that the lobotomy. Will track these studies down.

The truth, I suspect, is that you're not going to get a proper answer to how effective it was. The best you might be able to say is that the procedure was used on 1000s of people with no proper evaluation of its effects. Freekra (talk) 02:36, 30 November 2009 (UTC)

Relationship to Psyschosurgery article

There's naturally a lot of overlap of potential content between Lobotomy and Psychosurgery. Even now 'Psychosurgery' has lists of lobotomy pts, the Frances Farmer story, etc. Meanwhile, this article (Lobotomy) is getting quite long. Perhaps Psychosurgery should be thought of as a main article (not sure that's the right term) and lobotomy and certain other things as sub-articles to it. At the very least, discussion of work leading up to lobotomy could be moved out of here and into Psychosurgery (or into an "early work" sub-article to Psychosurgery). Also, discussion of opposition/concerns re lobotomy could be discussed with that re psychosurgery in general -- that would be another sub-article perhaps. Same for ethical/abuse issues, lists of pts and so on. This way Lobotomy article could be pretty narrowly on things about that procedure (that includes plenty -- Moniz, Freeman, Freeman's version of procedure, etc) with Pschosurgery containing material (or pointing to sub-articles) on historical context and all that other stuff, including modern versions. EEng (talk) 16:50, 30 November 2009 (UTC)

There's also the article History of psychosurgery in the United Kingdom. Some of it appears to be lifted straight from another website - as I point at Talk:history of psychosurgery in the United Kingdom - but if the rest wasn't lifted from somewhere (I do have my suspicions but perhaps its unfounded) it looks to be a good article with, again, a lot of overlap. But I agree, merger makes the most sense, with one long article on psychosurgery and related shorter articles. Freekra (talk) 23:33, 30 November 2009 (UTC)