The Vital Probe: My Life as a Brain Surgeon
In a work that is still regarded as a classic of clarity of writing and astuteness of observation, James Parkinson (1775-1824) was the first to describe “an evil from the domination of which the victim had no prospect of escape.” This was paralysis agitans, the shaking palsy that Charcot renamed “Parkinson’s disease.” It is marked by a wide variety of motor disorders of which the most conspicuous is uncontrollable tremor, sometimes accompanied by local muscular rigidity and by a characteristic rigidity of the muscles of facial expression leading to the set expression known as the “parkinsonian mask.” For well over a hundred years the disease remained a complete mystery so far as concerned interpretation and treatment.
I.S. Cooper’s very substantial claim to fame is founded on his having devised a neurosurgical treatment for parkinsonism which could relieve the tremors and the rigidities without causing damage on its own account. This is indeed a gift of life because parkinsonism can be very long lasting. Macdonald Critchley, one of the world’s leading neurologists, has described a pensioner whose mild symptoms of parkinsonism had lasted from the age of 65 until his death at 105.
Cooper devised his operation by ordinary scientific procedures extraordinarily well worked out; that is, he built upon his own hunches or on clues already available (Russell Meyers had already made a significant contribution which Cooper acknowledges) and he seized astutely and perceptively upon any informative conjunction of events thrown up by chance (through that which Bacon described as “the casual felicity of particular events”); in due course by a characteristically scientific flash of imaginative insight he hit upon a hypothesis about the control of parkinsonism of which a surgical operation would be the empirical test.
Apart from the surgical strategy, Cooper raised stereotactic surgery to a specially high degree of proficiency. Stereotactic surgery is a system of surgery in which the surgeon’s hands and the various instruments (scalpels, probes, forceps, etc.) that represent functional extensions of the hands are guided with geometrical precision to the part of the brain that is to be the subject of a surgical procedure. Stereotaxy is specially valuable in the surgery of the brain. If a surgeon has to conduct a surgical operation on the contents of the perivisceral coelom (known to laymen as the “insides”) he can rummage around inside until he finds the part he is seeking, pushing tubes and pipes aside now this way and now that; they can be even partially externalized provided they are kept moist. There is no record in the history of medicine of any surgeon’s forgetting to spoon them back in again. If any such procedure were applied to the brain the patient would end as a human vegetable, for functions and faculties are to so high a degree localized in the brain that every brain surgeon operates in the anxiety that his operative procedures cause functional damage as great as or even worse than that which he is seeking to relieve.
In addition to needing technical proficiency, then, the brain surgeon must be a man with strong nerve, resolution, and strength of character, and must have in specially full measure that sanguine temperament which is a precondition of success in all forms of surgery from chiropody upward. In addition to these specialized endowments a surgeon intent upon using new operations must have an inventive brain and must also be a good man in a moral sense. When the time comes to decide upon whether or not to undertake an operation, Cooper writes
…though approval may come from a committee of professors or professional peers in the hospital, and appeals to do so may come from the patient and family, it is impossible not to ask, “Do I have the right? Can I bear responsibility if I am wrong?” One may have the technical skill of Harvey Cushing, but the motivation and morals of a whore. Motivation and morals may play the principal role in deciding what one should do.
A second technique that Cooper developed and improved upon was that of cryosurgery, the destruction or functional inactivation of tissues by the use of extreme cold (around 196 degrees below zero Celsius). This was a stroke of genius in brain surgery because of the extreme importance of avoiding any procedures likely to give rise to hemorrhage or the inflammation that follows tissue damage.
Parkinsonian tremors consequent upon encephalitic infections are not the only motor disabilities Cooper has alleviated by neurosurgery. He has relieved the symptoms of about 150 cases of dystonia musculorum deformans (DMD)—a quite dreadful disease that may afflict the young of both sexes. It is marked by uncontrollable muscular tremors combined with sometimes grotesque postural fixations resulting from the simultaneous contraction of antagonistic muscles. Cooper himself has given a moving nontechnical account of this disability in his The Victim Is Always the Same (1973).1 Not the least of the disabilities suffered by many of the victims of DMD is the incompetent misdiagnosis of psychoanalysts, many of whom contrive to weave around the victim of DMD the kind of tailored myth that ostensibly explains their symptoms and at the same time, unhappily, demonstrates the uselessness of attempting their surgical alleviation.
Cooper is probably the world’s greatest authority on the treatment of disorders of movement, of which in his principal professional work2 he remarks,
…disorders of movement are not clearcut entities but rather constitute a spectrum of abnormal postures, states of muscle tone and movements varying from hypotonic flaccidity to bone-breaking muscular contractions, from akinesia to relentless, violent movements capable of producing exhaustion and death.
Psychoanalytic dogmas and other such obfuscations were not the only ones Cooper had to put up with, for when he began his work in the early Fifties conventional opinion had it that cerebral surgery could cure tremor only by substituting paralysis for it and that tremor could only be abolished by a procedure that inactivated the source or interrupted the conduction of the motor nerve impulses that arise in the “precentral gyrus” and are conducted down the great corticospinal (pyramidal) tract. Cooper’s work confuted many of these dogmas and I can easily imagine that he was not as grovelingly tactful as a man of about thirty ought to be when, in a very authoritarian profession, he challenges the opinion of his seniors.
Cooper began his great work on parkinsonism at Bellevue Hospital and University Hospital. In the first twelve cases in which he tried to relieve the shaking palsy by surgical intervention, seven were markedly improved, four were not, and one died. Nevertheless there were grounds for encouragement and Cooper was invited to tell a meeting of the American Neurological Association in June 1953 what these were.
Cooper woke at 2 AM on the day of the meeting and delivered his address from memory to the bathroom mirror in order to be able to speak without notes—in my opinion a form of showing off that does not produce anything like such a good impression as the lecturer believes it will. He had high hopes of the meeting and of the effect he thought his contribution to it would produce, but in the outcome he was bitterly disappointed: having said his piece and shown a film to an interested minority of the audience he returned to the lecture hall and found himself the subject of unfavorable comment. He learned he had not followed up his cases long enough—and that even hypnotism could allay the tremors of parkinsonism. How then could Cooper attribute his cures to his own surgical skill? Worse still, Cooper’s claims became front-page news in an article in The New York Times by its famous science editor, David Lawrence. The reporting in newspapers of disputed or not yet published scientific or medical findings was then an unforgivable medical and scientific solecism—Cooper was accused of being responsible, though he had never before met Mr. Lawrence or spoken to him. Cooper was thereupon labeled “controversial” and the label, being pejorative, stuck.
During the golden age of surgery—the days of W.S. Halsted of Johns Hopkins and Berkeley George Moynihan, Lord Moynihan of Leeds, when the vast improvements of anaesthesia and asepsis had made possible abdominal surgery of until then unimaginable audacity and therapeutic effectiveness, the surgeons were mostly successful in a medical sense, but physicians in the days before antibiotics and, effectively, before vitamins, hormones, and electrolyte balances, etc., were not. This was an inequality of accomplishment which surgeons (remembering all those sneers about surgery having been an accomplishment of barbers) did not allow their physician colleagues to forget.
So began the tension that still exists between physicians—the patricians of medicine, as they imagine themselves to be—and surgeons, dismissed as high-grade manual workers; and in no branch of medicine was this antipathy more strongly marked than in neurology—for clearly cognate reasons. In the main neurologists are very skilled at interpretation and diagnosis—so much so that sometimes one gets the impression that neurology is more an intellectual than a practical pursuit. Where medical neurology fails is in treatment and cure, for so many neurological injuries have irreversible consequences, as the victims of strokes and of peripheral nerve injuries learn to their dismay.
Neurosurgeons, however, were sometimes able to do good and gave reason enough, therefore, for jealousy. Even the great British surgeon Victor Horsley, whom Cooper (and, more significantly, Gilbert Horrax, Harvey Cushing’s assistant for twenty years) describes as the father of modern neurosurgery, was looked down upon by his physician colleagues. Horsley, soured by his failure to relieve his teenage son of epilepsy, became aggressively more sharp and critical with his colleagues, with the effect that, according to Cooper’s account of the matter, he was never allocated beds of his own at the National Hospital for Nervous Diseases in Queen Square in London; and in the First World War, while Harvey Cushing was commissioned as a brain surgeon, Horsley was relegated to Mesopotamia (now Iraq), where he died of a tropical fever.
Irving Cooper, it may be observed, is both a physician and a surgeon, for he is a diplomate of the American boards of neurology and psychiatry as well as of neurological surgery. His qualifications were not high enough, unfortunately, to protect him from the campaign of depreciation amounting sometimes to vilification of which he became the victim. It is as true in the world of medicine and science as it is in the world of letters that any very notable accomplishment by a young man—particularly if there is a suspicion that it is due to a real superiority of skill of hand or mind—arouses an extreme envy or resentment. Professor Adrian Upton, MD, who introduces this volume in a wise and temperate foreword, writes:
…a young physician can expect nothing but trouble from an important and original discovery made early in his career. Such an individual would be wise to attribute his discovery to luck rather than ability. An even more cynical thought is that a pioneer should develop some physical handicap (a limp, a stutter, or an eyepatch)….
See P.B. Medawar, "Victims of Psychiatry," New York Review of Books, January 23, 1975.↩
I.S. Cooper, Involuntary Movement Disorders (Hoeber Medical Division, Harper and Row, 1969).↩