Foreshadowings

To the Editors:

In his review of I.S. Cooper’s book The Vital Probe: My Life as a Brain Surgeon [NYR, January 21], Medawar states that Cooper’s very substantial claim to fame is founded on his having developed a neurosurgical treatment for parkinsonism which could relieve the tremors and rigidities without causing damage on its own account. It should be noted that at the meeting of the American Neurological Association (1953) in which Cooper reported the relief of tremor and rigidity of Parkinson’s disease by ligature of the anterior choroidal artery, Spiegel and Wycis described their method of producing lesions of the fibers emitted by the globus pallidus by stereotactic approach, i.e. by an electrode or other instrument inserted by use of a guiding apparatus, and of relieving the above named parkinsonian symptoms. This method, used as early as 1873 in Ludwig’s laboratory and perfected by Horsley and Clarke for work in cats and monkeys (1908), was introduced by Spiegel and Wycis for neurosurgery of the human brain (Science 106.349.1947). After abandoning his ligature of the anterior choroidal artery on account of the variability of the area supplied by this artery, Cooper inserted a cannula directed by a simplified guiding device in order to inject fluids into the pallidum; in other words, he employed a stereotactic technique. He first injected alcohol, a method previously reported by Spiegel and Wycis for treatment of some choreatic movements (Transact. Amer. Neurol. Ass. 75.234.1950), but abandoned by them on account of the irregularity of spread of the fluid. The priority of Spiegel and Wycis in initiating the treatment of Parkinson’s disease by stereotactic procedures was unequivocally recognized in recent books: Stereotaxis in Parkinson Syndrome, by R. Hassler, F. Mundinger, and T. Riechert (1979) and Stereotactic Operations, by T. Riechert (1980).

The second great advance attributed to Cooper is the introduction of cryosurgery, the application of low temperature for elimination of central structures. Two advantages of this method are claimed: production of reversible depression of function by moderate cooling preceding the destruction of a structure by freezing and absence of hemorrhages. It should be recalled that reversible depression of function by cooling was studied in animal experiments on the motor cortex by Trendelenburg (Pflügers Archiv für die ges. Physiologie 133.305.1910) and by the Nobel laureate Bárány for cerebellar localization in human patients (Deutsche med. Wochenschrift 39.637.1913). As to the absence of hemorrhages on use of cryosurgery, Mark of Harvard demonstrated on cerebral cortical vessels the occurrence of hemorrhages accompanying freezing (Confinia Neurol. 26.178.1965).

These data presented in the interest of historical fairness are not intended to diminish Dr. Cooper’s merits as a skillful surgeon and as a diligent promoter of stereotactic procedures on the basal ganglia in Parkinson’s disease. Fairness also dictates mentioning that the operative treatment of this disease relieves chiefly two symptoms: tremor and rigor, but not the akinesis (slowing and diminution or loss of spontaneous movements). The latter symptom is favorably influenced by Dopa, whose use is based on the work of Hornykiewicz and of Cotzias.

Ernest A. Spiegel, M.D.

Philadelphia, Pennsylvania

P.B Medawar replies:

Cooper’s text is remarkably free from extravagant claims of priority in the introduction of the precedures he used. Indeed, any such errors of judgment should be attributed to my review rather than to Cooper’s text, so I am glad to have Dr. Spiegel’s footnote—Cooper himself is much too familiar with the scientific process not to realize that premonitions or foreshadowings of pretty well every scientific or medical discovery can be found by people intent upon seeking them out.