Medicine Studies (2009) 1:367–378
DOI 10.1007/s12376-009-0031-7
ORIGINAL PAPER
A Dark History: Memories of Lobotomy in the New Era
of Psychosurgery
Jenell Johnson
Received: 14 April 2009 / Accepted: 12 November 2009 / Published online: 9 December 2009

Springer Science+Business Media B.V. 2009
Abstract Deep brain stimulation has recently been
identified as the ‘‘new frontier’’ in the surgical
treatment of major depressive disorder. Powerful
memories of the lobotomy era, however, pose a
rhetorical challenge to clinical researchers who wish
to make a case for its therapeutic future. For DBS
advocates, establishing the relationship between these
two treatments is not just a matter of telling a history; it
also requires crafting persuasive arguments for the
lineage of DBS that relate the new psychosurgery in
some way to the old. Working from a rhetorical
perspective, this article identifies and analyzes three
strategies employed by DBS advocates to manage the
memory of lobotomy, which it terms evolutionary,
genealogical, and semantic. In conclusion, this article
suggests that a rhetorical perspective might be brought
to bear on the frequent calls for dialogue with regard to
psychosurgery, which are meaningless without atten-
tion to the persuasive dynamics such dialogue entails.
Keywords Psychosurgery
Lobotomy

History
Collective memory

Deep brain stimulation
Rhetoric
J. Johnson (&)
Louisiana State University, 260 Allen Hall, Baton Rouge,
LA 70803, USA
e-mail: jjohn@lsu.edu
Lobotomy is remembered as one of the most
spectacular failures in the history of medicine. During
the first half of the twentieth century, an untold
number of men, women, and children were subjected
to the procedure, which sought to alleviate the
emotional symptoms of mental illnesses by partially
separating the frontal lobes from the rest of the brain.
Originally developed in 1935 by Portuguese neurol-
ogist Egas Moniz under the name ‘‘leucotomy,’’
lobotomy was in use as a mainstream psychiatric
treatment in many countries until the early 1960s.
Although Moniz was honored with the Nobel Prize in
1949, it is American neurologist Walter Freeman who
is most frequently associated with the procedure and
who, with his surgical partner James Watts, changed
the operation’s name from ‘‘leucotomy’’ to ‘‘lobot-
omy’’ when they introduced the operation to the
United States in 1936. Freeman became something of
a medical superstar in mid-century America, promot-
ing the operation on trips across the country, fre-
quently attracting (and often seeking) the attention of
the popular press, who lauded lobotomy as a miracle
cure. The ‘‘transorbital’’ version of lobotomy pro-
moted by Freeman used electroconvulsive shocks to
render the patient unconscious, and accessed the brain
by thrusting a leucotome, an icepick-like instrument,
through the patient’s eye socket. Freeman hoped
transorbital lobotomy would find a place in psychiatry
‘‘somewhere between shock therapy and major frontal
lobotomy’’; the ‘‘simple,’’ ‘‘safe,’’ and ‘‘quick’’ pro-
cedure, Freeman maintained, was a perfect fit for state
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hospitals short on doctors, beds, and financial
resources (1954, p. 261).1 Although patient outcomes
post-lobotomy varied widely—there were a number
of patients who reported that lobotomy provided them
with significant benefit—it was clear that lobotomy
took something from each of its patients, even if it was
difficult to describe exactly what that ‘‘something’’
was.2 After lobotomy was shifted out of the psychi-
atric armamentarium in the mid-1950s in the wake of
chlorpromazine’s rapid rise, it found new life as a
trope in fiction and films such as Suddenly, Last
Summer, One Flew Over the Cuckoo’s Nest, Planet of
the Apes, and Frances, in which the once-miracle
operation represented the ultimate authoritarian threat
to individuality. In recent years, a number of horror
movies have resurrected the lobotomist as a blood-
thirsty monster who haunts abandoned asylums,
armed in one film with a two-foot leucotome in each
hand (Asylum). In the public imagination, the terms
‘‘lobotomy’’ and ‘‘psychosurgery’’ evoke frightful
images of sadistic doctors, zombie patients, mind
control, and institutional brutality. For many in the
medical profession, the terms ‘‘lobotomy’’ and ‘‘psy-
chosurgery’’ also bring to mind the era before
institutional review boards, controlled clinical trials,
and codified biomedical ethics.
Although the specific practice of lobotomy has
disappeared, the general practice of psychosurgery
was never entirely abandoned as a ‘‘last resort’’
therapy for mental illness. Bilateral cingulotomy, for
example, is an option for patients with obsessive-
compulsive disorder, and amygdalotomy may be
1
Freeman and Watts differed in their opinions on transorbital
lobotomy, a disagreement that ‘‘strained’’ their relationship
(Pressman 1998, p. 337) and contributed to their professional
split. See also Freeman and Watts 1950, pp. 51–61, for a
discussion of their disagreement about transorbital lobotomy’s
stature as a ‘‘minor’’ or a ‘‘major’’ surgical operation.
2
One 1949 letter to The New England Journal of Medicine
describes what was lost in these patients:
Even in consideration of a certain general vagueness
concerning just what constitutes a soul, some observers have
described post-lobotomy patients as persons who had lost this
ill defined but apparently indispensable part of their individ-
uality. Perhaps it would be more acceptable to say that many of
them had lost the vital spark of their personality, or the
particular spiritual value compounded of the emotions and the
reasons, and consisting of the ability to know sorrow and
happiness, peace and anxiety, compassion and understanding
that puts the final touches on the human being (p. 249).
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J. Johnson
recommended for patients whose behavior is classi-
fied as pathologically violent or aggressive. While
these forms of ablative psychosurgery are rare, deep
brain stimulation (DBS), a procedure that uses
implanted electrodes to directly stimulate targets in
the brain, is heralded by many as the ‘‘new frontier’’
in the treatment of major depressive disorder
(MDD).3 The first published reports of DBS for
MDD appeared in 2005 (Mayberg et al.), and
citations rapidly have swelled to well over two
hundred. Although it is difficult to know the actual
number of patients receiving this procedure, the
extant literature suggests that ‘‘the pace of DBS in
neuropsychiatric disorders is accelerating and the day
in which DBS will be more widely available for
clinical use is not far off’’ (Goodman and Insel 2009,
p. 263).
Lobotomy frequently appears in discourse sur-
rounding DBS in both biomedical literature and the
popular press. According to a recent editorial in
Biological Psychiatry, ‘‘commentaries on the subject
of DBS in neuropsychiatry seem incomplete without
some discussion of the lessons to be learned from the
excesses and abuses of its distant predecessor, frontal
lobotomy,’’ a discussion the editors believe should
not be limited to the biomedical profession. As this
next ‘‘wave in psychiatric neurosurgery is ushered in
by DBS, the clinical and scientific community must
assure the public that the kind of mistakes made
before are not repeated’’ (Goodman and Insel 2009, p.
263). If advocates for DBS, then, are to convince
their audiences that a new form of psychosurgery is
scientifically, technically, and ethically sound, it is
imperative that they answer the lobotomy ‘‘question’’
that hangs over psychosurgery in such a way that
leaves no doubt that the ‘‘new era’’ is not repeating its
‘‘dark history.’’ For DBS advocates, establishing the
relationship between these two treatments is not just a
matter of telling a history; it involves crafting
persuasive arguments for the lineage of DBS that
address, in some way, the powerful memory of
lobotomy. This article identifies and analyzes those
rhetorical strategies.
3
There is considerable disagreement about whether DBS
ought to be classified as ‘‘psychosurgery,’’ a question that I
believe should be answered in the affirmative. I address this
issue later in the article, and give reasons for my position in the
conclusion.
A Dark History
The term ‘‘rhetoric’’ is familiar to most people as
the derisive antonym of ‘‘reality,’’ a legacy with roots
in Plato’s denunciation of the sophists. For rhetorical
theorists and critics, however, ‘‘rhetoric’’ is a neutral
term that describes the suasory elements of discourse
(Bryant 1973). To subject a discourse to rhetorical
analysis is to offer an ‘‘account’’ of that suasory
element (Segal 2005, p. 5) in order to understand how
particular discourses ‘‘[control] and [structure] infor-
mation and the valuative mindsets that form the bases
of others’ thoughts and actions’’ (Gronbeck 1998, p.
50). To approach a text with a rhetorical perspective
focuses our attention on questions of persuasion and
power. Who is persuading whom of what and for
which reasons? What tropes, figurative language,
definitions, appeals, images, or arguments are
employed for which audiences? What is included,
and what is left out? As a mode of inquiry that
emphasizes the power of language to shape attitudes
and direct action, rhetoric offers medicine studies
unique insight into the role persuasive discourse plays
in biomedical development. In this article, for
example, a rhetorical perspective allows us to move
away from ontological questions about whether DBS
is ‘‘really’’ psychosurgery in order to focus on more
important questions. What’s at stake in this distinc-
tion? Why is it persuasive? And, importantly, whose
interests does it serve?
The arguments I analyze in this article are taken
from medical and nonmedical discourse for a number
of reasons. Mass media frequently present biomedical
developments to a public audience hungry for infor-
mation about the latest breakthroughs in science and
medicine, and DBS has frequently attracted the
attention of the popular press. Yet the flow of
information and influence is not unidirectional from
biomedicine to the public (Lewenstein 1995): public
interest may transform into public concern, which
may be transformed into political action and govern-
mental regulation. It was public concern, for example,
that fomented federal investigation into the ‘‘second
wave’’ of psychosurgery in early 1970s America.4
4
The rise of psychosurgery in the early 1970s is one of the
reasons cited for the formation of the US National Commission
for the Protection of Human Subjects of Biomedical and
Behavioral Research. Psychosurgery was included ‘‘in
response to widespread public concern’’ (Quality…1973,
26318; United States 1977).
369
Public perceptions of biomedicine, therefore, can
have a significant impact on medical research and
clinical practice. In addition, the line between bio-
medicine and the ‘‘general’’ public is a permeable
boundary: doctors and research scientists are not
excluded from the ‘‘general’’ public. Medical profes-
sionals read the same newspapers, books, and mag-
azines, watch the same films, and live in the same
communities as the general public, even as they have a
more specialized knowledge about certain medical
matters (cf. Condit 1996). As we shall see shortly,
biomedical and public arguments for DBS exhibit
similar strategies of memory management, even as
they differ in terminology and emphasis for their
respective audiences.
Finally, a note about this article’s geographic
scope. The DBS arguments I analyze are almost
exclusively drawn from American medicine and
media. Although in a globalized and networked
world, discourse knows no national boundary, the
collective memory I describe in this article should be
read as American collective memory. The legacy of
Walter Freeman and the recurrent trope of lobotomy
in American popular culture, combined with psycho-
surgery’s imbrication in US Cold War anxieties in the
early 1950s and early 1970s, has contributed to a
particularly strong memory of lobotomy in the United
States. However, it is important to note that lobotomy
was an international procedure from its inception to
its extinction, and it was practiced in hospitals from
Japan to Brazil. Whether the memory I describe here
is distinctly American or not is an open question I
hope a later comparative study might be able to
answer.
In what follows, I first provide a brief introduction
to the concept of collective memory and then show
how it may be observed in rhetorical assumptions
about an audience’s evaluation of past events. I then
analyze a number of arguments that advocate for the
use of DBS for psychiatric disorders, which I group
according to strategies they use to construct its
lineage in relationship to the lobotomy era. At a time
when there has been much hand-waving about the
value of dialogue in biomedicine, a rhetorical
perspective provides insight into the metaphorical
dialogue between past and present, and also speaks to
ways in which this relationship is mobilized persua-
sively in public and professional dialogues about the
future of biomedicine.
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Collective Memory
The origin of the term ‘‘collective memory’’ is
generally attributed to sociologist Maurice Halbw-
achs (1980), who attested that individual memory is
constructed in relationship with a particular social
environment. At present, there are perhaps as many
definitions of ‘‘collective memory’’ as there are
scholars who use the term, and almost as many
arguments that attempt to decisively articulate col-
lective memory’s relationship to history (see Klein
2000 for an acerbic critique). Some scholars have
suggested that collective memory has been subju-
gated by history (Foucault and Bouchard 1977; Nora
1989), while others have argued that history itself is a
kind of collective memory (Geary 1994; Ricouer
2006). Others maintain that collective memory and
academic history may serve as complementary
accounts of the past (Assmann 2006). These distinc-
tions extend beyond the scope of this article, which is
concerned not with how memories are formed,
preserved, or contested, but with how collective
memory is invoked in arguments as an implicit or
explicit assumption about an audience’s judgment of
the past.
It hardly bears mention that the interpretation of
the past events has a powerful effect on the present.
Disputes over how we remember historical events are
deeply political struggles. As Susan Reverby (2001)
writes in her analysis of African–American memories
of the Tuskegee syphilis study, collective memory
‘‘exists in the liminal area of historical fog and fact,
available as a set of experiences to be used by those
who wish to tell differing tales, make various political
points, and remember in discordant ways’’ (p. 23).
Bolstered by representations of Tuskegee in popular
media, collective memories of the study hold fast to
the idea that test subjects were deliberately infected
with syphilis, an account that conflicts with ‘‘official’’
histories of the study (which deny that deliberate
infection took place). When professionals in history
and medicine dismiss collective memories of Tuske-
gee as inaccurate, Reverby argues, and therefore
unworthy of serious consideration, they miss an
opportunity to engage in potentially productive
dialogue about Black experiences of medicine. This
disengagement has a significant consequence: collec-
tive memory of the Tuskegee study is often cited as a
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J. Johnson
factor in the widespread distrust of public health
authorities in African-American communities (Tho-
mas and Quinn 1991).
Collective memory is more than just a vernacular
account of the past; it is also a judgment on the past
enabled by a present set of values. Aristotle provides
one way to think about this valuative aspect of
collective memory. Rhetoric, Aristotle suggests, can
be classified into three ‘‘species’’ of discourse:
forensic, deliberative, and epideictic. Forensic rhet-
oric is devoted to the past, concerns the question of
what happened, and is exemplified by speeches in
the courtroom. Deliberative rhetoric is devoted to the
future, concerns the question what should we do and
is exemplified by speeches in the political assembly.
Although it obviously concerns the past, and, as I
will explain shortly, also guides deliberation about
future action, collective memory might best be
thought of as a kind of epideictic rhetoric (Gronbeck
1998), which is devoted to the present, addressed to
questions of what we value, and exemplified by the
funeral oration. Epideictic, writes Judy Segal, ‘‘is a
culture’s most telling rhetoric, because, in general,
we praise people for embodying what we value and
we blame them for embodying what we deplore’’
(2005, p. 61). Heroes can be tarnished and villains
redeemed by later generations, a matter vividly
illustrated in medicine by the controversial figure of
J. Marion Sims, the 19th century American surgeon
often referred to as the ‘‘father’’ of modern gynecol-
ogy. Initially lauded for his pioneering work on
fistula surgery and the development of the speculum,
Sims became a site of argument when it was revealed
that much of his research was obtained by operating,
without anesthesia, on enslaved Black women. The
historical facts of Sims’ research are not disputed; for
critics, the point of contention centers on the
question of whether present or past ethical standards
should be used to evaluate his contribution to
medicine (Barker-Benfield 1999; Sartin 2004;
O’Leary 2004). Should we praise or blame J. Marion
Sims? What eulogy should we write, and what form
should it take? The answers to these questions reveal
more about what we value than they reveal about
who Sims was or what he did. In this way, the past
‘‘can guide the present, but the present also is
reconfiguring the past; therefore, through evocation
of collective memories, past and present live in
A Dark History
constant dialogue, even in a hermeneutic circle
where neither can be comprehended without the
other’’ (Gronbeck 1998, p. 57).
The case of J. Marion Sims exhibits a struggle
over the formation of collective memory. However,
although collective memory is clearly contextual
and subject to change, once established as memory,
it forms a common ground with which groups
construct a visible identity for themselves and others
(Assmann 1995). If there is a collective biomedical
identity, it is shaped, like any other group, by shared
interpretations of its past. Biomedicine erects phys-
ical and linguistic monuments to commemorate the
names of its heroes (Jonas Salk; Thomas Hodgkins;
Louis Pasteur); textbooks recount the therapeutic
courage of Christiaan Barnard and the barrier-
breaking career of Elizabeth Blackwell. Heroes
and heroines of medicine are remembered not
simply for their technical contributions to the
profession, but also because they embody values
that medical professionals would do well to emulate.
Collective memory therefore also serves a normative
function (Assmann 1995): persons, actions, and
events are selectively recalled, praised or blamed
in order to inculcate values that ought to direct
future action. In this regard, memories of failure are
particularly resonant, and they are woven into a
recursive narrative of medical development. Just as
a nation negatively constructs the virtue of patriot-
ism by remembering its traitors, biomedicine devel-
ops ethics in sharp relief to its Mengeles,
thalidomides and lobotomies. Rather than forget
these people and events in service of a mythic tale
of unblemished medical progress, by remembering
heroes and villains, successes and failures, medicine
develops a reflective attitude toward its past and
present in order to craft an ethical orientation
toward its future.
Although the collective memory I’ve described
above takes an explicit form in textbooks, landmarks,
and commemorative discourse, collective memory
can also be observed in arguments that implicitly
assume an audience’s judgment about the past. For
example, in the previous paragraph, I clearly assume
that as a reader interested in medicine, you are
familiar with Josef Mengele’s experiments at Ausch-
witz-Birkenau, and I also assume you share the
judgment that he acted unethically, or at the very
least, that you know his actions are remembered in
371
this way. The stronger a memory is, the less it needs
to be articulated explicitly.5 In the arguments for
DBS I will analyze in the next section, the collective
memory of lobotomy emerges in the argument as an
assumption that the audience knows something about
lobotomy and this something, to put it very simply, is
that lobotomy was bad.6
Managing the Memory of Lobotomy
The strategies employed by DBS advocates to relate
the new era of psychosurgery to the old take a
number of forms and they are not mutually exclusive.
Arguments often employ multiple strategies in the
same paragraph, and sometimes in the same sentence.
What characterizes each of these strategies is the way
they answer the lobotomy question. I identify three
such strategies in this section, which I have organized
according to the lineage they argue for DBS: the
evolutionary strategy, in which DBS is characterized
as an improved version of lobotomy, the genealogical
strategy, in which the neurological, not psychiatric,
lineage of DBS is emphasized, and the semantic
strategy, which argues that DBS is not a form of
psychosurgery in an attempt to rhetorically sever the
lineage with lobotomy altogether.
The evolutionary strategy reflects an idealized
vision of medical progress as the continuous refine-
ment of biomedical knowledge, technique, technol-
ogy and ethics in order to maximize human health
5
In rhetoric, assumptions in argument are often discussed as a
form of enthymeme, a kind of truncated syllogism that
assumes, rather than expresses, one of its premises. To use
the famous example, a syllogism looks like this:
All men are mortal.
Socrates is a man.
Socrates is mortal.
An enthymeme, in contrast, might look like this: ‘‘Socrates is
a man. Therefore, Socrates is a mortal,’’ which suppresses the
common knowledge that ‘‘all men are mortal.’’
6
This assumed evaluation is characterized well in a comment
by psychiatrists Daniel Stewart and Kenneth Davis in The
American Journal of Psychiatry: ‘‘If someone today were to
suggest a frontal lobotomy as a means of relieving mental
anguish, the responses might include sardonic laughter,
revulsion, or even outrage’’ (2008, p. 457).
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372
and minimize human suffering. In arguments that
employ an evolutionary strategy, the audience’s
memory of the lobotomy era is explicitly or implicitly
referenced in order to show the extent to which
contemporary psychosurgery has evolved from its
notorious predecessor. One article, for example,
states the evolutionary strategy in direct terms:
‘‘psychosurgery has a complex and controversial
history dating back to antiquity, and continues to
evolve in the present era of neurosurgery’’ (Mashour
et al. 2004, p. 216). Other arguments express the
evolutionary strategy through comparison. For exam-
ple, the article ‘‘Biological Basis for the Surgical
Treatment of Depression’’ (Abosch and Cosgrove
2008), advocates for DBS using new models of
depression as a systems-level disorder. The article
emphasizes the scientific grounding for today’s
techniques by presenting a litany of improvements
in contemporary psychosurgery:
Although the field of psychosurgery has its
roots in anecdotal experience as opposed to
hypothesis-driven experimentation assessed
with validated outcome measures, a new era is
fortunately emerging. Advances in the field of
neuroimaging have allowed the use of human
participants for testing hypotheses about the
mechanisms that underlie these disorders. In
addition to higher expectations and greater
scrutiny placed on investigations in this arena,
the advent of DBS technology has provided
investigators with a tool that is nondestructive,
modifiable, capable of being turned on or off,
and more focal in its effects (p. 1).
The ‘‘new era’’ of psychosurgery finds its ‘‘roots’’ in
the psychosurgeries of the past, and the authors
suggest that contemporary psychosurgery is superior
at every point of comparison: more rigorous testing
based on controlled experimentation; better theories
of mental illness using the observational power of
neuroimaging; greater regulations and oversight; less
destruction; reversibility; refined precision. Contem-
porary psychosurgery is thus argued to be an
improvement on its ‘‘root’’ in nearly every way.
Note that the history of psychosurgery is not told in
this article; it is referenced indirectly. The lobotomy
era is mobilized purely for its rhetorical force; no
history is written for lobotomy because that history is
obvious. A history is told because the audience needs
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J. Johnson
to know. Collective memory provides a reference
point for something the audience already believes.
There is no need to tell this story, nor to make an
extended evaluative argument about why psychosur-
geries’ past were erroneous or subject to ‘‘appropriate
public and governmental concern’’ (p. 2) because
the authors can count on the audience’s judgment—
their collective memory of lobotomy—to assist their
argument. To close the article, the authors state their
wish for properly regulated and controlled clinical
studies ‘‘so as not to repeat the errors of the past’’
(p. 8). In the last phrase, lobotomy is invoked as an
‘‘error,’’ a lesson that must be learned. This sentiment
is echoed by Mashour et al., who call DBS psycho-
surgery’s ‘‘new frontier,’’ and explain that ‘‘it is
critical that clinicians and ethicists alike maintain a
clear perspective on surgical intervention for psychi-
atric disorders so that the dark history of psychosur-
gery does not repeat itself’’ (p. 416).
In the evolutionary strategy, it is not only scientific
knowledge, technology and technique that have
improved since the days of the lobotomy, but also
the ethical environment in which DBS is researched
and therapeutically applied. As the arguments above
suggest, the ethical failures of lobotomy (an assump-
tion problematized by Pressman 1998) may be
remedied by today’s more stringent codes of bio-
medical conduct. An article from Psychiatric News
brings ethicists Joseph Fins and Benjamin Greenberg
together to claim that the ‘‘appreciation of the
importance of informed consent and other ethical
considerations—make the current environment vastly
different and more conducive to safe investigation’’
(Moran 2004). Informed consent is immediately
familiar as one of the hallmarks of biomedical ethics,
and its need in DBS research is echoed by Goodman
and Insel: ‘‘researchers need to ensure that a process
is followed that protects human subjects’’ (2009, p.
265). Additional ethical issues pertinent to DBS,
another article suggests, ‘‘include patient selection,
patients’ rights, adverse event reporting, and a
commitment to long-term care’’ (Hardesty and Sack-
heim 2007, p. 834).
In recent years, it is been proposed that a new field
of ethics is required in order to address the unique
ethical issues raised by developments in neuroscience
like DBS. Although still in the initial stages of
theoretical development, neuroethics focuses on two
related sets of issues laid out by Roskies (2002). The
A Dark History
ethics of neuroscience addresses familiar bioethical
concerns with neuroscience research design, as well
as the impact of that research on ‘‘existing social,
ethical, and legal structures.’’ The neuroscience of
ethics addresses the impact that a neurological
substrate of morality has upon traditional notions of
ethics (pp. 21–22). Although these two strands of
inquiry are clearly related (which raises questions
about the logic of their division) they both find
exigency in psychosurgery, which raises traditional
concerns about ethical research and treatment and
also provokes larger issues, such as what ethical
behavior means if it can be modified by the flick of a
knife or the flip of a switch. In an article in
Neurosurgical Focus (2008), which investigates the
impact of neuroethics on contemporary psychosur-
gery, Joshua Wind and Douglass Anderson reference
the lobotomy era a number of times, most strikingly
in the conclusion:
In retrospect, it is interesting to ponder whether
Egas Moniz would have traveled down the road
of the leucotomy had he known the implications
of his actions. If Moniz had known that he
was not simply searching for a treatment for
psychosis, but rather traveling towards technol-
ogy that could shake the concept of human
personhood, would he have continued? One can
only speculate. But the questions left to be
answered, the therapies still to be developed,
and the ethical lines yet to be drawn will be
some of the great challenges of medicine in the
near future (p. 4).
In the neuroethics literature, the collective memory of
lobotomy justifies the existence of the new field,
which presents itself as an improved ethical environ-
ment in which contemporary psychosurgery might
take shape.
Neuroethics was brought to the American public’s
attention in 2002 by a New York Times editorial
written by conservative columnist William Safire. In
‘‘The But-What-If Factor,’’ Safire worries about the
dangers of ‘‘unbridled science’’ that accompany ‘‘the
benefits and dangers of treating and manipulating our
minds.’’ Because questions raised by neurotechnolo-
gies have such wide-ranging social implications,
Safire writes, neuroethics should not be confined to
the pages of medical journals; this ‘‘soul-searching
debate,’’ he writes, should ‘‘get out of the ivory
373
tower, onto the floor, onto the tube and into print until
it penetrates every sentient being’s consciousness.’’
The Economist published an article with similar
concerns that same year, arguing that developments
in neurotechnology raise ‘‘ethical and legal questions
of the same nature and gravity as advances in
genetics’’ (‘‘Open Your Mind’’).
Not surprisingly, the popular press have reported on
DBS with gusto, often taking an explicitly positive
stance on the surgery, and the evolutionary strategy is
mobilized in these arguments as well. In an interview
with the Washington Post, ethicist Joseph Fins claims
that ‘‘today’s [psychosurgery] is far more discreet, less
toxic and easier to study than its predecessor’’ (Stein
2004). An article in Slate comments that DBS is a ‘‘far
cry from the days when lobotomies robbed patients of
the ability to feel emotions like love and compassion’’
(Richards 2008). Time uses the history of lobotomy in
much the same way: ‘‘the practice of psychosurgery
has long been dormant—tarnished by the notorious
brain-scrambling lobotomies of the 1940s and 1950s—
but it has recently reclaimed a bit of its luster, thanks to
a relatively new and much more benign technique
called deep-brain stimulation’’ (Song 2006). When
compared to psychosurgery of the past, the era of
neurostimulation finds validation. ‘‘New’’ psychosur-
gery is ‘‘much more benign.’’ Changes are ‘‘dramatic.’’
The regulative environment is ‘‘vastly different’’ and
‘‘safer’’ than that of the days of the lobotomy. These
stories invoke the collective memory of lobotomy as a
comforting touchstone of medical progress.
One doesn’t often see newspaper articles that
worry about the removal of a tumor or severing of the
corpus callosum in epilepsy patients on principle.
Safire, for example, bluntly states, ‘‘no ethical
problem exists with a pacemaker to protect the
heart.’’ Although there are clearly ethical issues
surrounding pacemakers, what we might take Safire
to mean is that the ethical issues raised by surgery for
functional psychiatric disorders provoke (Safire
might say ‘‘merit’’) public attention in a way that
surgery for organic neurological disorders does not
(and the battle over ‘‘organic’’ and ‘‘functional’’
disorders rarely plays out in the opinion section). ‘‘If
[deep brain stimulation] was only restricted to
neurological disorders, it would not be a topic of
ethical debate,’’ astutely observes one neuropyschia-
trist (Sachdev 2008, p. 68). If anything, neurosurgery
is hailed in the popular imagination as the apex of
123
374
medical achievement, and neurosurgeons are viewed
with the kind of awe reserved for that echelon of
super-human that includes fighter pilots and the
summiters of Everest. There is something about
surgical intervention into psychiatric disorders, how-
ever, that pricks immediate ethical concern—an
admixture of the public’s trust in neurosurgery, its
perpetual wariness of psychiatry, and the persistent
memory of the lobotomy era. If we revere neurosur-
geons as demigods, we revile the lobotomists as their
monstrous counterparts—a perversion of everything
we value about surgery on the brain.7 Another
effective strategy to manage memories of the lobot-
omy era, then, is to redraw DBS’s family tree in order
to highlight its respectable ancestors (neurosurgery
for neurological disorders) and favorable relatives
(cardiac pacemakers) while downplaying its lineage
in the lobotomy era, a strategy I suggest might best be
termed genealogical.
Nearly every discussion of DBS in biomedical and
popular literature references its initial development to
control Parkinsonian tremor. In most biomedical
discourse about DBS, this genealogy is stated briefly
at the start before moving into the current applica-
tions for psychiatric disorders. Discussions of DBS in
the popular press spend much more time describing
its neurological lineage. In an interview with Time
(2006), neurologist Michael Okun explains, ‘‘we can
thank the patients with Parkinson’s disease for
helping us develop these therapies because what we
learned from them we’re applying to other disor-
ders.’’ In the genealogical strategy, the progenitors of
DBS patients are not lobotomy patients but Parkin-
son’s patients, the difference between Ken Kesey’s
Cuckoo’s Nest and Oliver Sacks’ Awakenings. This
article also provides a brief narrative common to
many popular articles about DBS:
Deep-brain stimulation (DBS) was first devel-
oped in France in 1987 and evolved out of the
so-called ablative, or lesioning, surgeries in
which doctors use heat probes to burn and
permanently damage small regions of the
brain—in the case of Parkinson’s, regions
7
This ‘‘monster’’ rhetoric is displayed most notably in
discourse surrounding Walter Freeman, recently the subject
of a biography by Jack El-Hai (2005) who comments, ‘‘aside
from the Nazi doctor Josef Mengele, Walter Freeman ranks as
the most scorned physician in the twentieth century’’ (p. 1).
123
J. Johnson
where patients’ tremors and quakes are known
to arise. These same brain areas are targeted
with DBS, but instead of destroying tissue,
doctors implant slender electrodes that pump
steady pulses of electricity—think of it as a sort
of pacemaker for the brain (Song).
The article’s description of DBS as a ‘‘sort of’’
pacemaker for the brain is one of the most frequent
ways in which neurostimulation is rhetorically con-
nected to nonpsychiatric conditions. This analogy has
become so commonplace in discourse surrounding
neurostimulation technology, in fact, that it often
loses its analogical quality: it is not like a pacemaker.
It is a pacemaker. The analogy is rhetorically
effective for a number of reasons. First, the pace-
maker is a device well known to a nonspecialist
audience, and it is likely that many people know at
least one person with a cardiac pacemaker personally.
Second, as William Safire has told us, the cardiac
pacemaker is a prime example of a noncontroversial
medical technology. In an interview with the Cleve-
land Plain Dealer, Ali Rezai, head of the Cleveland
Clinic’s Center for Neurological Restoration, com-
pares DBS’s medical moment to
where heart pacemakers were in the 1950s.
Back then, you would tell someone, ‘I’m having
a pacemaker put in,’ and people would go,
‘What’s that?’ Now everyone knows what a
heart pacemaker is. I think that it will be a
similar situation for brain pacemakers in 10 or
20 years (Hall 2001).
Rezai is quoted in another article about DBS in
Discovery Magazine entitled ‘‘Brain Pacemakers
Tackle Depression,’’ a headline in which the anal-
ogy-invoking quotation marks are dropped (Neergaard
2008). An article about DBS in Wired magazine, of all
places, claims in its headline that the ‘‘Brain ‘Pace-
maker’ Tickles Your Happy Nerve’’ (Graham 2007).
The Washington Post writes: ‘‘modeled on heart
pacemakers routinely implanted in people’s chests to
automatically regulate heart rhythms, brain pacemak-
ers were first developed in the late 1980s to treat
Parkinson’s, a devastating brain disorder in which
victims inexorably lose control of their muscles’’
(Stein 2004). And perhaps most striking, the Cleveland
Clinic and the US Department of Health and Human
Services Office on Disability recently co-sponsored a
A Dark History
conference on DBS in May 2008 using the analogy as
the title: ‘‘Brain Pacemakers: A Promising Approach
and a New Era of Hope for Neurological Disorders.’’
Emphasizing the initial use of DBS for neurolog-
ical conditions rhetorically sites the surgery’s devel-
opment in a medical lineage less likely to provoke an
ethical maelstrom. The ‘‘pacemaker’’ analogy works
by associating something the audience doesn’t know
with something they do know and which, importantly,
is ethically neutral. I must point out that by examining
these two strategies as rhetorical is not to suggest there
is something fallacious or specious about these
claims, but to emphasize a potential effect on the
audience. It is true that DBS was developed to treat
Parkinson’s, and the stimulator clearly resembles the
cardiac pacemaker in many respects. There’s nothing
less truthful about calling a neurostimulator a brain
pacemaker, or more truthful about calling DBS a form
of psychosurgery. What matters here is not the
procedure, per se, but the language used to shape
the audience’s knowledge about and attitudes toward
the procedure: the making-present of one lineage, the
making-absent of another.
The final strategy this article will examine is the
argument made by DBS advocates to aband on the
term ‘‘psychosurgery,’’ which I call the semantic
strategy. ‘‘Perhaps no other word in the field of
neurosurgery, or medicine for that matter,’’ writes
surgeon Paul Larson, ‘‘conjures up a more negative
connotation than the word ‘psychosurgery’’’ (2008, p.
50). Faced with a collective memory of lobotomy too
strong to be effectively managed by the strategies
above, some advocates have argued that the field
should replace the term ‘‘psychosurgery’’ with ‘‘psy-
chiatric neurosurgery,’’ ‘‘neurosurgery for psychiatric
disorders,’’ ‘‘neurosurgery for mental disorders,’’ or
‘‘limbic system surgery.’’ Although ‘‘limbic system
surgery’’ denotes the same class of procedures as
‘‘psychosurgery’’ (and it must be noted that lobot-
omy, too, was ‘‘limbic system surgery’’) it simply
does not bear its connotative weight. To put it another
way, we do not remember ‘‘limbic system surgery.’’
There might be a history of limbic system surgery
familiar to a few surgeons and historians of medicine,
of course, but there is no collective memory of the
term ‘‘limbic system surgery,’’ and this is precisely
why the term is preferred.
Sachdev and Chen (2008) argue that the name
change is warranted because there is a categorical
375
distinction between ‘‘psychosurgery’’ and neurosti-
mulation: ‘‘DBS is not ‘psychosurgery’ even though
it involves neurosurgery for the treatment of psychi-
atric illness. This is because no brain lesion is
created, except for any inadvertent damage produced
by the insertion of electrodes’’ (p. 28). For Sachdev
and Chen, the distinction between psychosurgery and
DBS lies in the function of ablation. Although the
authors admit that tissue damage is part of every
operation, they do not classify DBS as ‘‘psychosur-
gery’’ because the ultimate purpose of tissue damage
is to insert the electrode; any damage to brain tissue is
only a means to a continually stimulating end, not an
end in itself (as is the case in ablative surgeries like
lobotomy and amygdalotomy). To further their argu-
ment, Sachdev and Chen turn to the familiar pace-
maker analogy: ‘‘the insertion of a cardiac pacemaker
is not ‘cardiac surgery.’ Although this may be a
trivial distinction, it is important so as not to tar DBS
with the lobotomy brush’’ (p. 8). Interestingly, the
authors note the difference between ablation-as-ends
and ablation-as-means is ‘‘trivial’’: what is ‘‘impor-
tant’’ in the name change is not semantic precision,
but the rhetorical management of memory—a clear
anxiety that DBS, if regarded as psychosurgery, will
be ‘‘tarred with the lobotomy brush.’’
Sachdev (2008) speaks directly to these concerns in
a second article, in which he argues that ‘‘psychosur-
gery’’ should be abandoned because of ‘‘the emotive
nature of the term… The bad press for psychosurgery
originated from the period of ‘lobotomy,’ which
involved the removing or lesioning of large parts of
the frontal lobes and which is thankfully behind us’’ (p.
97). Although Sachdev again focuses his attention on
the different functions of ablation in order to make the
case for the name change, he also makes it clear that the
primary reason driving the name change is not a
difference in technique, but the ‘‘pejorative connota-
tions’’ psychosurgery received during the lobotomy
era. He ultimately recommends that the term ‘‘psy-
chosurgery’’ be ‘‘firmly replaced by ‘neurosurgery for
psychiatric disorders’’’ (p. 98). The name change is not
just advocated for DBS. Rosenfeld and Lloyd (1999)
also write strongly in favor of a name change for
ablative psychosurgery as well: ‘‘the term psychosur-
gery is imprecise and is burdened with the connotation
of destructive lobotomy operations. The term should be
replaced with the phrase ‘Neurosurgery for Mental
Disorder’ (NMD); ‘Limbic System Surgery’ is another
123
376 J. Johnson

alternative’’ (p. 106). Again, the authors express granted that words, especially scientific terms
concern that the term ‘‘psychosurgery’’ is ‘‘imprecise’’; and terms used in legal statutes and government
however, the primary motivation underlying the name regulations, have an objective meaning. On the
change is to unload the ‘‘burden’’ of connotation. other hand, it is often assumed that when there
Whether DBS is termed ‘‘psychosurgery’’ or ‘‘neu- are verbal disputes about the definitions of
rosurgery for psychiatric disorders’’ seems to have words, that such disputes are relatively trivial,
little impact in the day-to-day treatment of patients. and can easily be resolved by simply clarifying
Where the name matters a great deal, however, is in the the meanings of the words (p. 117).
public and political perception of the surgery. ‘‘Words
There is no objective meaning of ‘‘psychosurgery’’
can have great power,’’ Sachdev observes, and
that can be appealed to in this debate; ‘‘psychosur-
‘‘…because of the prohibition on psychosurgery in
gery’’ finds meaning, as Wittgenstein reminds us, by
many jurisdictions, the development of DBS as a new
how it is used in the language. Whether DBS is
therapeutic technique would be severely thwarted’’
‘‘really’’ psychosurgery is not a matter to be resolved
(p. 98). In other words, in areas where psychosurgery
by an appeal to objective reality or the dictionary,
is specifically prohibited, what is recommended is not
although the Oxford English Dictionary, I might note,
to petition officials to create an exemption for DBS, but
does not support Sachdev’s case. ‘‘Psychosurgery’’ is
to change the name in order to avoid any hindrance to
defined broadly as ‘‘neurosurgery performed to treat
programs of research or clinical application.
mental illness and alter behaviour.’’ If the definitional
It bears mention that the distinction of ablation-as-
issue turns on the meaning of ‘‘surgery,’’ even this
means and ablation-as-end is already written into a
definition does little to clear things up, for ‘‘surgery’’
number of regulations about psychosurgery. An
is defined as ‘‘the art or practice of treating injuries,
Oregon statute against psychosurgery, for example,
deformities, and other disorders by manual operation
defines ‘‘psychosurgery’’ as ‘‘any operation designed
or instrumental appliances.’’ What is deep brain
to irreversibly lesion or destroy brain tissue for the
stimulation if not the use of an instrumental appliance
primary purpose of altering the thoughts, emotions or
to treat a disorder? Ultimately, debates over a word’s
behavior of a human being. ‘Psychosurgery’ does not
‘‘real’’ meaning are unproductive, for what a word
include procedures which may irreversibly lesion or
means will always come back to how it is used. From
destroy brain tissues when undertaken to cure well
a rhetorical perspective, far more interesting than
defined disease states such as a brain tumor, epileptic
whether DBS is ‘‘really’’ psychosurgery is the ques-
foci and certain chronic pain syndromes’’ (Oregon
tion of why this question matters, to whom, and for
1973, my emphasis). The language of the Oregon
what effect. The semantic strategy is a rhetorical issue
statute is also cited by the Psychosurgery Review
that goes far beyond ‘‘mere semantics.’’ As Sachdev
Board in Melbourne, Australia, the country in which
points out, if DBS is called ‘‘psychosurgery’’ in
Sachdev practices. Given this distinction, which
certain jurisdictions, regulations will prohibit its
clearly uses the purpose of ablation to delimit
research and clinical use. For clinical researchers
psychosurgery, it would seem as though regulations
who believe strongly in the therapeutic potential of
like these would already make an exception for
DBS, as Sachdev clearly does, a ‘‘careless approach
procedures like DBS. The chief concern, then,
with our terminology can have adverse conse-
appears to be the public perception of DBS.
quences’’ on the lives of people suffering deeply from
As rhetorical scholars have argued for millennia,
intractable forms of depression (2008, p. 98).
all definitions are persuasive. All language is bur-
dened with connotations and implicit values, and any
definition of a term involves ‘‘claims of ‘ought’
Conclusion
instead of ‘is’’’ (Schiappa 2003, p. 5). Writes
philosopher Douglas N. Walton (2001),
In this article, I have argued that the collective memory
popular opinions tend to take certain assump- of lobotomy era requires advocates of deep brain
tions about definitions for granted, without stimulation to engage in a variety of rhetorical
reflecting on them too deeply. It is taken for strategies in order to persuasively articulate its lineage.

123
A Dark History
In many of these arguments, lobotomy is a productive
ghost: its memory is marshaled as a touchstone by
which contemporary forms of psychosurgery can be
evaluated. Although some stimulation advocates wish
to avoid its constraints, it is clear that a significant
number also use the powerful collective memory of
lobotomy as an impetus to engage in reflection about
psychosurgery’s past, present, and future, a move
echoed by a number of histories of psychosurgery that
have appeared in the medical literature in recent years
(Feldman and Goodrich 2001; Koppell and Rezai
2003; Mashour et al. 2004; Fins et al. 2006; Stone
2008; Wind and Anderson 2008). Fins et al. (2006)
praise this renewed interest in psychosurgery’s history,
because it provides
a good opportunity for us to reflect on the
legacy of psychosurgery and its modern itera-
tion under the guise of neuromodulation. The
seriousness of their scholarship allow a dia-
logue for which all readers of this journal
should be appreciative, whether or not one
agrees with the piece. In consideration of the
complexity of the topic, a diversity of views
should be welcomed and open debate encour-
aged. Nothing less will provide the ethical
justification for achieving a therapeutic future
for neuromodulation (p. 713).
While Rezai et al.’s call for more debate about
psychosurgery is laudable, it is also important that the
dialogue they encourage not be limited to members of
the biomedical professions. In this article, I have
attempted to show what a rhetorical perspective
might bring to this discussion by arguing that any
invocation of medicine’s past involves an element of
persuasion. The rhetorical dynamics of collective
memory also leads us to ask questions about the
dialogue between patients/companions and physi-
cians that leads to decision making about DBS as a
treatment option (or electroconvulsive therapy which,
like psychosurgery, is also burdened with a ‘‘dark’’
history). How do clinicians address questions gener-
ated by collective memory? Are they dismissed or
used as a point of departure to engage in dialogue
about patient concerns? If these memories are
engaged, how are they managed rhetorically, and
for what reasons? What rhetoric brings to the
interdisciplinary table of medicine studies is an
emphasis on the power of language to shape our
377
attitudes and actions. If biomedicine truly valorizes
dialogue that extends beyond the pages of its
journals, it is essential to examine its persuasive
communication practices and to investigate the
different forms that this persuasion may take. To
simply call for dialogue without asking how it
operates risks replacing meaningful dialogue with
an empty word.
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