Dr. William B. Scoville, a Hartford, Conn., neurosurgeon, performed about 750 brain operations at two state hospitals in the 1950s, the heyday of the lobotomy era.
Today, Scoville does only seven or eight a year, all of them on suicidal or self-destructive private patients for whom, he says, all other therapies have failed. "For people condemned to the back wards of mental institutions, this can be a life-saving procedure," he says.
In 1980, Scoville is one of a handful of psychosurgeons who share the belief held by their predecessors of the 1940s and '50s that destruction of selected parts of the brain can favorably alter human behavior and cure mental illness.
One California neurosurgeon said in a recent interview he believes psychosurgery could cure violence-prone convicts. Scoville himself has suggested that drug addicts be lobotomized. A third in Mississippi has performed multiple operations on a 9-year-old boy he described as hyperactive and destructive.
Yet the operations today are relatively few. Somewhere between 200 and 500 are performed annually in the United States, compared with up to 5,000 a year in the late 1940s.
Though the methods of modern psychosurgery are far more sophisticated than those of 30 years ago, their use has provoked heated opposition from civil libertarians and some segments of the medical community.
The ensuing debate has encompassed not only the ethics of destroying healthy human brain tissue, but the proper limits of behavior control and the question of how far judges, lawyers and politicians should intrude into the relationship between doctors and their patients.
If a debate framed in large part, by the lobotomy era, the period between 1936 and 1960 when between 40,000 and 50,000 Americans underwent brain operations in a large-scale, popular effort to cure, or at least subdue, the nation's mentally ill.
The excesses of that era -- destructive side effects, lack of informed consent from patients, indiscriminate use of the operations -- have influenced some judges and state legislators to adopt restrictions that the modern psychosurgeons say have made their practice difficult if not impossible.
"In effect, patients are dying with their rights on," says California neurosurgeon M. Hunter Brown, who has advocated brain operations for willing convicts. Brown, who used to do at least a dozen operations a year, says he has done none since 1977, when California adopted a stringent law calling for judicial consent before operating on the brain of patients held legally incompetent.
"When families come to me, I send them to doctors in other states," Brown says. "I have to tell them the lights are out in California."
Modern psychosurgical techniques bear little direct resemblance to the "blind cut" lobotomies of the early psychosurgeons, many of whom indiscriminately severed large portions of nerves connecting the brain's front lobe to its center.
The new methods include "orbital undercutting," which gently removes a thin layer of white matter from the lobe without disturbing blood flow to the brain. Other surgeons have implanted tiny electrodes in the deepest recesses of the brain to burn out small precise areas of tissue.
The result, proponents contend, is an operation far more beneficial than the old lobotomy with few of the damaging side effects on personality.
Critics are far from convinced. Stephen L. Chorover, psychology professor at Massachusetts Institute of Technology, calls modern psychosurgery "bad sciene and bad medical practice" and compares the concept of destroying healthy brain tissue to the American military's destruction of the Vietnamese countryside "in order to save it."
For a brief period in the early 1970s, as psychiatry began to sour on massive use of tranquilizers on the mentally ill, proponents had hoped for "a renaissance of psychosurgery", as one scientist put it. Papers were published, conferences held and federal money began to flow.
Then almost as quickly as it started, the "renaissance" stopped, cut off in large part by vehement attacks from a few dissenters within the pyschiatric community.
The most vocal critic was Peter Breggin, a Bethesda psychiatrist who, after surveying more than a dozen noted neurosurgeons, decided the psychosurgery movement was on an alarming upswing. He wrote an article entitled "The Return of Lobotomy and Psychosurgery" but says that at first no medical journal would publish it.
"They told me (a) we're not interested, (b) you're full of .... and (c) we know these people and they're nice guys," Breggin recalls.
Breggin finally convinced then U.S. Rep. Cornelius E. Gallagher of New Jersey to insert the article in the Congressional Record in 1972.
The Breggin article linked modern psychosurgery to the early lobotomy movement, emphasized its harmful side-effects and condemned it as "mutilation of the mind." It provoked howls of protest from neurosurgeons as well as a series of Senate subcommittee hearings at which Breggin painted psychosurgery as a potential threat to democracy.
"If America ever falls to totalitarianism," Breggin warned, "the dictator will be a behavioral scientist and the secret police will be armed with lobotomy and psychosurgery."
Among Breggins's prime examples of the potential political applications of psychosurgery was an obscure letter from three Boston neurosurgeons to the Journal of the American Medical Association in 1967 at the height of the urban riots.
The doctors noted that social factors such as poverty, slum housing and poor education were important in understanding the riots, but added "the obviousness of these causes may have blinded us to the more subtle role of other possible factors, including brain dysfunction. . . ." mThey cited research showing the brain wave patterns of convicted murderers were often abnormal. Their conclusion:
"The real lesson of the urban rioting is that, besides the need to study the social fabric that creates the riot atmosphere, we need intensive research and clinical studies of the individuals committing the violence . . . to pinpoint, diagnose and treat these people with low violence thresholds before they contribute to ruther tragedies."
Since one of the letter's authors, Vernon H. Mark, director of neurosurgery at Boston City Hospital, had performed psychosurgery as a treat treatment of last resort, the implication was clear. Civil rights advocates with visions of black ghetto dwellers having their brains surgically altered, were particulary incensed to learn that the National Institute of Mental Health and the Law Enforcement Assistance Administration had granted about $600,000 to the three authors for brain research.
But the subcommittee's most bizarre testimony came from Orlando J. Andy of the University of Mississippi, who outlined his brain operations on difficult hyperactive children.
Among Andy's patients was a nine-year-old boy, called J. M., on whom, after a first operation failed, the neurosurgeon performed four more. Andy testified that J. M., now an adult, was relatively happy, functioning human being, even though a research report after the operations noted that "intellectually, however, the patient is deteriorating."
"Psychosurgery," Andy told the subcommittee, "is preferable to that of having a child with abnormal behavior continue under inadequate control during the formative and development years of his life."
Breggin argued that the real lesson of Andy's brain operations, which he performed on at least a dozen youngsters, was very different:
"It can be very difficult to control a child surgically but you can usually mutilate him repeatedly until he stops bothering anyone."
The testimony led to unsuccessful efforts in Congress to outlaw psychosurgery or put a two-year moratorium on its use. Instead, Congress directed the 11-member National Commission for the Protection of Human Subjects of Biomedical and Behavorioral Research to investigate psychosurgery and propose a national polcy on it.
But while Congress delayed judgement, a Michigan state court handed down a landmark ruling that held psychosurgery was too experimental a procedure to be performed on in voluntarily-held mental patients and convicts even with their consent.
In the case of Kaimowitz v. Department of Mental Health, an adult mental patient who had confessed to murder and rape consented to having a brain operation as part of a state-financed research project. His parents agreed as well.
But after hearing medical experts testify on both sides of the case, the three-judge panel ruled that "psychosurgery is clearly experimental, poses substantial danger to research subjects and accrues substantial unknown risks."
Their conclusion: "The state's interest in performing psychosurgery and the legal ability of the involuntarily detained mental patient to give consent must bow to the First Amendment, which protects the generation and free flow of ideas fron unwarranted interference with one's mental processes."
Although not legally binding outside of Michigan, the Kaimowitz decision has effectively eliminated virtually all psychosurgery in public mental institutions and prisons in the U.S., according to medical and legal experts. Despite denunciations from critics who contend the judges overemphasized psychosurgery's possible dangers, Gabe Kaimowitz, the Michigan Legal Aid lawyer who brought the suit, believes he could win a similar case anywhere in the country.
"They (the defendants) had everything -- a willing victim, the expert testimony -- and the point was that is didn't hold up in court," says Kaimowitz. "If I could get a plaintiff, I could win that case in my sleep."
In the back of a single drawer in a dusty gray file cabinet on the seventh floor of a state office building in downtown Portland, rests the entire output of Oregon's Psychosurgery Review Board.
In the six years since it was formed, the nine-member board has received only eight applications for psychosurgery and approved one. It has not met at all in the past 16 months for lack of business.
Although Oregon is the only state with a centralized board to review all psychosurgery cases whether at public or private institutions, at least four other states give patients an absolute right to refuse the operation, according to a 1978 survey by attorney Robert Plokin of the Washington-based Mental Health Law Project.
"Could an outbread of lobotomies legally happen again? I'd have to say yes," says Plotkin, who contends most state laws are weak when it comes to protecting confined mental patients from coercive or unproven treatments. "I'm not comfortable with the state of the law, but I would hope that there is so much more awareness even among doctors of patients' rights that an early alarm would go off in time to stop them."
But many doctors believe the law and the courts have already intruded too far into what they see as a medical question beween doctors and patients.
"Some of the legislation was passed in reponse to political pressures that have distorted the issues and the evidence," says neuropsychologist Elliot S. Valenstein of the University of Michigan. "I'm not a great admirer of psychosurgery but I do fear throwing every new medical procedure into the political arena."
Still others believe the entire psychosurgery debate has been overblown.
"There's been an awful lot of hysteria on both sides," says psychiatrist Willard Gaylin, president of the Hastings Institute in New York. "The greatest danger as far as mind control is concerned isn't from psychosurgery but from TV. It's a lot cheaper to control the population through the media than to plant electrodes in everybody's brain."
Still the lobotomy controversy refuses to die. The board of the American Pyschiatric Association, the largest professional body of psychiatrists in the U.S., was so divided that it refused to take a stand seven years ago on a report from a study group it had commissioned that advocated limited uses of psychosurgery.
Three years ago, the National Commission came out with its own long-awaited report that found psychosurgery a potentially effective therapy of last resort for victims of certain select mental illnesses, but proposed a set of federal restrictions so stringent that many surgeons contend they would all but eliminate use of the operation.
"The result is that there may be 200 people in the U.S. who could benefit enormously from psychosurgery but who cannot get it because of complex restrictions developed because of what have been abuses in the past," says John Lipkin, associate director of psychiatry for the Veterans Administration, whose strict guidelines have eliminated a lobotomy program that at its height involved nearly 3,000 patients between 1943 and 1951.
Others are happier to see the legal brakes on psychosurgery. Says Alan Stone, president of the America Psychiatric Association, "We still know so little about the brain and how it functions that to begin intentionally destroying normal brain tissue just can't be justified."