The Lobotomist

The adage has it that the road to hell is paved with good intentions. It is evident from this revealing portrait of neurologist Walter Freeman-the originator of the infamous "ice pick" lobotomy-that good intentions without sober analysis can indeed have hellish consequences.

This film by Barak Goodman and John Maggio chronicles the rise and fall of one of medicine's most exalted and reviled figures. Using a series of interviews, film clips, and historical photographs, The Lobotomist reveals the history and motivation behind Freeman's ill-fated-and arguably, shameful--misadventure in neurosurgery. The film leaves no doubt that Freeman began with the noblest of ideals: to reduce the suffering of thousands of severely impaired patients, warehoused in unspeakably inhumane asylums across the United States. Indeed, to the film's credit, Freeman is not depicted as a monster or a madman; rather, he comes across as a deeply flawed human being, blinded by his overweening sense of ambition and destiny. The film also highlights the deep complicity of orthodox medicine in permitting Freeman (and, initially, neurosurgeon James Watts) to carry out his work without systematic oversight or substantial challenge. (Psychoanalysts protested, but Freeman argued with some justification that they had nothing to offer to the types of patients he treated; the AMA belatedly condemned the procedure as destructive, but by then, thousands had undergone lobotomy.)

The film does a good job depicting the historical context of Freeman's efforts. For example, the apparently successful neurosurgical technique developed by Dr Egaz Moniz (who won a Nobel Prize for his work) helped convince Freeman that a brain defect of some sort was at work in severe mental illness. Freeman had also observed that certain frontal lobe injuries, such as those sustained by soldiers in combat, could result in docility. He was certainly right in viewing frontal-subcortical circuits as critical in the mediation of aberrant or violent behavior. Indeed, some of Freeman's severely impaired patients seem to have improved modestly, after sectioning of nerve tracts connecting the thalamus to the frontal lobes. But far too many of Freeman's lobotomized patients (victims?) wound up worse off than before the procedure, often in near-vegetative states.

Freeman is described at one point in the film as a tragic figure. But this characterization misses the mark. Genuinely tragic figures-Hamlet or Macbeth, for example-are riven by conflict and self-doubt. The film suggests that Freeman suffered from few overt doubts, probably because he refused to see the catastrophic results of his own misguided efforts. As another speaker in the film suggests, Freeman was really a messianic crusader. And we have seen throughout history that crusades of all stripes usually lead to calamity.

The film could have used more commentary by neuropsychiatrists and neurosurgeons and a bit less from nonclinical writers, gripping though their accounts may be. Specifically, it would have been helpful to place Freeman's primitive procedure in the context of more recent and promising developments in neurosurgery, such as the use of bilateral anterior cingulotomy for refractory obsessive-compulsive disorder.¹

Nonetheless, the film does an excellent job of documenting one of the saddest chapters in the history of neuropsychiatry. Particularly moving is the testimony of Howard Dully, a 58-year-old bus driver who underwent Freeman's procedure. The film also presents us with many cautionary lessons for our own time, such as the need for genuinely informed consent (it hardly existed in Freeman's day) and scrupulous analysis of outcomes for any medical procedure. In short, despite its limitations, this film-which airs January 21st on PBS as part of its "American Experience" series-should be required viewing for every neurologist and psychiatrist.

References:

1. Jung HH, Kim CH, Chang JH, et al. Bilateral anterior cingulotomy for refractory obsessive-compulsive disorder: long-term follow-up results. Stereotact Funct Neurosurg. 2006;84:184-189.