In a passage in “Bread and Freedom” Camus expresses his revulsion at the way in which, in political arguments, one atrocity may be bartered for another: if one protests at some enormity of the communists, three American negroes are “thrown in one’s face.” In any such disgusting attempt at outbidding, Camus says, one thing does not change—the victim, freedom. It is this reflection that gives Irving Cooper’s book its title: the victim is the patient, and the aptness of the Camus quotation becomes very clear as the book goes on.
The subject of Dr. Cooper’s book is the treatment of a rare and unqualifiedly dreadful neuromuscular disease of stealthy onset known as dystonia musculorum deformans (DMD), in which the limbs and extremities of the victims are locked firmly into grotesquely functionless attitudes by the simultaneous contraction of antagonistic muscles, and in addition victims may suffer mad-looking tremors. It is a disease of the kind that makes even the most devout question the existence of a benevolent deity. Although Lewis Carroll himself thought “Anglo-Saxon attitudes” a sufficient diagnosis, I put it to Mr. Martin Gardner1 that the White King’s looking-glass messenger Haigha, whose extraordinary movements and postures caused Alice so much surprise, was in reality the victim of DMD.
Janet, the patient whose treatment Dr. Cooper describes in the greatest detail, contracted the disease at the age of six when she was a reasonably bright girl who weighed about fifty pounds. Five years later on admission to Dr. Cooper’s clinic, she weighed only thirty-seven pounds. Her back was arched in such a way as to force her rib cage and stomach forward; the right leg stuck out like a ramrod, with the toes coiled under the sole of the foot, and her left leg was doubled back so that the foot pressed against the buttock. Attempts to move her arms produced clonic contractions, i.e., contractions not sustained but compulsively repeated. Clinical examination was made almost impossible by the fact that Janet screamed with pain at any attempt to move her limbs and her back arched so much that her head almost touched her buttocks. Her undernourishment was fairly typical and when, as with Janet, the disease follows a chronic and progressive course patients become bedfast and die eventually from inanition or from bedsores.
Although conventional wisdom had long had it that neurosurgery could only substitute paralysis for involuntary muscular contraction Cooper had assembled enough circumstantial evidence to justify the audacious hypothesis that DMD could be meliorated without paralysis by the inactivation through freezing of a group of cells deep in the thalamus, the part of the brain through which sensory impulses pass on their way to the cerebral cortex and which has important motor connections with the cortex.
The operation requires that the head should be kept absolutely still so that a freezing probe, mounted on a stereotactic apparatus, should be guided into the appropriate region of the thalamus. The operation has to be carried out on the conscious patient so that the behavior of the limbs can give direct evidence of the area of the brain affected (the brain itself does not “feel pain”). The degree of refrigeration achieved, with liquid nitrogen used as refrigerant (-196°), could be very exactly controlled. The use of refrigeration was a brilliant idea of Dr. Cooper’s, for it is a procedure less likely than most others to cause a traumatic inflammation which might set up a whole sequence of undesirable side effects. Cooper is one of the pioneers of cryosurgery and a world famous master of the use of stereotactic apparatus in the surgery of the brain.
Janet’s series of operations had satisfactory results, and most of the book is devoted to her case, but there are three subplots: those of David, Donald, and Susan. All three stories have it in common that the unhappy patients first fell into the hands of the psychoanalysts—men whose glib and self-assured interpretations of their illness did much to impede diagnosis and treatment. With various refinements all three were judged hysterical. David’s affliction was such that when he walked his pelvis was alternately thrust forward and withdrawn, like a caricature of a pop star; clearly exhibitionism, the psychoanalysts opined, and in this case complicated by an extreme neurotic fear of touching his own penis. The psychiatrist’s memorandum on David’s discharge from the psychiatric ward ended: “Diagnosis on discharge: psychoneurosis, conversion hysteria. Condition on discharge: Improved.”
After his discharge David got steadily worse and it seems to have been only by coincidence that DMD was eventually diagnosed and treated.
The psychoanalysts’ efforts to get at the secret deformities of Janet’s psyche included some searching interrogations into her having shared a bath tub with her brother at age seven; she too was labeled a conversion hysteric until a neurologist who saw her later recognized DMD (“there is no question in my mind—a case right out of the book”)—equally self-assured, no doubt, but with this important difference: the neurologist was right.
Susan was judged to be writhing and contorting herself in order to attract attention and her treatment, which so far as it concerned herself was inhumanly cruel, was eventually extended to include her parents—a procedure which nearly broke up their marriage.
It all makes sorry reading, yet Cooper is much more charitable to the psychoanalysts than his readers are likely to be: indeed, he includes a long Fontenelle-like dialogue with Janet in which he explains that it is sometimes genuinely difficult to distinguish psychogenic from physical disorders and that surgeons had sometimes conducted operations to relieve or ascertain the causes of pains of hysterical origin. The overall impression, however, is overwhelmingly condemnatory, and no wonder.
In his wise and temperate foreword Macdonald Critchley, one of the world’s leading neurologists, says of DMD, “It is not surprising that the suspicion that the disability is not an organic one can be legitimately entertained for a while. There is no excuse, however, for persisting obstinately in this error, and a note of horror is struck as one reads of the tribulations of Susan and Janet until they eventually received the correct diagnostic appraisal at the hands of neurologists who were belatedly consulted. One likes to think that such a fate could never again befall these victims.”
People more affected by manner than by matter will find much to complain of in the style of Cooper’s book: he refers to himself throughout in the third person (“…his glance rested on the rooftops which obscured Montefiore Hospital”). His style shows more evidence of concern and personal involvement than is traditionally associated with clinical reporting—but why not? I can think of one good reason: it will make Cooper just a little bit more vulnerable to the kind of whispering depreciation that is to be expected from those fashionable psychiatrists (mainly English) who have made such a good thing out of writing imaginative literature on the psyche. Such men use their literary skill not for the advancement of learning but to create a kind of Gothic caricature of psychiatrists who attempt physical remedies: a caricature that typically depicts a man intent upon using powerful psychotropic drugs of unknown action upon a psyche already bruised by electrical convulsions, a man often in collusion with a neurosurgeon whose lobotomies are remedies hardly more discriminating or sounder in principle than kicking a television set to make it work or stop it from flickering.
Alas for them, Cooper is not a good subject for this caricature. His sense of concern and involvement are apparent everywhere and he makes no such general case against them as they will undoubtedly try to make against him. Indeed, the impression the reader will form of Irving Cooper after reading this book is of a skillful and courageous man who in addition to high surgical skill was brilliantly able to take advantage of that felicitous and unpremeditated conjunction of ideas which, following Horace Walpole, has come to be called “serendipity.”
“Serendipity” is not a good word for Cooper’s discoveries (although Macdonald Critchley uses it) because it has too strong a connotation of “accidental” and not enough of felicity and of the amalgamation of ideas which in a different context would be called wit. However, it should be emphasized that Cooper is a neurologist and physiologist as well as a surgeon and the hypothesis which led him to devise an operation for the relief of DMD is an almost perfect example of what Karl Popper described in a purely methodological sense as a “risky” hypothesis—the kind of hypothesis which could so very easily be wrong and which for that very reason increases our confidence in its validity when it stands up to empirical trial.
Cooper explicitly says that anybody interpreting his book as a general criticism of psychiatry would be mistaken; but perhaps he is being too generous—for psychoanalysts will continue to perpetrate the most ghastly blunders just so long as they persevere in their impudent and intellectually disabling belief that they enjoy a “privileged access to the truth.”2 The opinion is gaining ground that doctrinaire psychoanalytic theory is the most stupendous intellectual confidence trick of the twentieth century: and a terminal product as well—something akin to a dinosaur or a zeppelin in the history of ideas, a vast structure of radically unsound design and with no posterity.
January 23, 1975