How The Brain Lost Its Mind E-Book

Allan Ropper

• Herausgeber: Atlantic Books
• Kategorie: Wissenschaft und neue Technologien
• Sprache: Englisch

Seitenzahl: 452

Veröffentlichungsjahr: 2020

Beschreibung

'Hugely entertaining' Guardian 'Fascinating' Mail on Sunday In 1882, Jean-Martin Charcot was the premiere physician in Paris, having just established a neurology clinic at the infamous Salpêtrière Hospital, a place that was called a 'grand asylum of human misery'. Assessing the dismal conditions, he quickly upgraded the facilities, and in doing so, revolutionized the treatment of mental illness. Many of Charcot's patients had neurosyphilis (the advanced form of syphilis), a disease of mad poets, novelists, painters, and musicians, and a driving force behind the overflow of patients in Europe's asylums. A sexually transmitted disease, it is known as 'the great imitator' since its symptoms resemble those of almost any biological disease or mental illness. It is also the perfect lens through which to peel back the layers to better understand the brain and the mind. Yet, Charcot's work took a bizarre turn when he brought mesmerism - hypnotism - into his clinic, abandoning his pursuit of the biological basis of illness in favour of the far sexier and theatrical treatment of female 'hysterics', whose symptoms mimic those seen in brain disease, but were elusive in origin. This and a general fear of contagion set the stage for Sigmund Freud, whose seductive theory, Freudian analysis, brought sex and hysteria onto the psychiatrist couch, leaving the brain behind. How The Brain Lost Its Mind tells this rich and compelling story, and raises a host of philosophical and practical questions. Are we any closer to understanding the difference between a sick mind and a sick brain? The real issue remains: where should neurology and psychiatry converge to explore not just the brain, but the nature of the human psyche?

Leseprobe

Praise for How the Brain Lost Its Mind

“This aptly titled book picks up where Oliver Sacks left off in examining the behavioral characteristics of neurobehavioral syndromes in an effort to span the gap that has historically separated the twin disciplines of the brain, neurology and psychiatry. In contrasting the organic (general paresis of the insane) with the ethereal (hysteria), this neuropsychiatric treatise brings the two divergent disciplines closer together without committing to their ultimate unification.”

—Jeffrey A. Lieberman, MD, chairman of psychiatry, Columbia University Vagelos College of Physicians and Surgeons; past president, American Psychiatric Association; and author of Shrinks: The Untold Story of Psychiatry

“Occasionally, a treatise arrives that challenges conventional reductionist notions that brain and mind can be unified through the neuroscience of the brain. Current brain analysis via brain scans, neural networks, genomic analysis, and psychopharmacology has not seduced Ropper and Burrell, who take the contrarian position that there is a subjective mental life that organizes itself. In an unusually readable and surprisingly lyrical account of syphilis, a surrogate for mental disorders caused by brain destruction, and hysteria, a stand-in for psychiatric disorders, they create a fascinating tension between neurology and psychiatry and offer thoughts on unifying the two fields of clinical medicine. Their original interpretations of Conrad’s Heart of Darkness and Thomas Mann’s Dr. Faustus alone make the book worth reading as literary criticism.”

—Joseph B. Martin, MD, PhD, dean emeritus, Harvard Medical School

“A sweeping narrative of how the concept of mental illness evolved in the context of culture, history, and science. How the Brain Lost Its Mind is written with wit and wisdom and filled with vividly depicted colorful characters—from Freud to Maupassant to the Marquis de Sade, from the physicians of nineteenth-century Europe to the public health commissioners of 1930s New York. Ropper and Burrell trace the riveting history of the science of the mind and brain, revealing how and why neurology and psychiatry split, and how the future of medicine depends on their reunification.”

—Aaron Berkowitz, MD, PhD, associate professor of neurology, Harvard Medical School; author of Clinical Neurology and Neuroanatomy and The Improvising Mind

“I have listened to, watched, and read Allan Ropper on subjects related to the brain for thirty years. He’s still my teacher, but I’ve never seen him teach like this. Along with his friend and gifted coauthor, Ropper takes us on a romp through centuries of cultural and scientific history. There’s a kicker: can that history clarify and crystallize through the lens of just one nasty disease? Yes. Read how in this page-turningly accessible and brilliant book.”

—Edison K. Miyawaki, MD, assistant professor of neurology, Harvard Medical School; author of The Frontal Brain and Language

“Through tales of eminent physicians and their suffering patients, replete with sex, drugs, and magnetically induced hypnotism, we learn how a bacterium that deprived countless souls of their reason also helped scientists discover a role for brain biology in mental illness.”

—Alan Jasanoff, author of The Biological Mind; professor of biological engineering, brain and cognitive sciences, and nuclear science and engineering

“It is remarkable how much influence syphilis has had on human history and how widespread the disease has been. Even today, the subject is generally off limits, which is why the story remains mostly unknown—and why How the Brain Lost Its Mind makes for compelling reading. Like all wellwritten histories—and this one is very well written—the narrative engages like a mystery novel. But the story is true, and replete with sometimes salacious, sometimes revelatory details. Ultimately, it is the story of the beginning and development of the modern scientific study of the brain and the mind: the false leads and great discoveries, the charlatans and the heroes. The question of what is a disease of the brain and what is an illness of the mind remains undetermined even in our knowledgeable and enlightened era. A fascinating and sophisticated read.”

—Avi Nelson, political commentator

Published by arrangement with Avery, an imprint of Penguin Random House LLC.

First published in hardback in Great Britain in 2020 by Atlantic Books, an imprint of Atlantic Books Ltd.

Copyright © Dr Allan H. Ropper and Brian David Burrell, 2019

The moral right of Dr Allan H. Ropper and Brian David Burrell to be identified as the authors of this work has been asserted by them in accordance with the Copyright, Designs and Patents Act of 1988.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of both the copyright owner and the above publisher of this book.

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A CIP catalogue record for this book is available from the British Library.

Hardback ISBN: 978-1-786-49180-0

Trade paperback ISBN: 978-1-786-49181-7

Paperback ISBN: 978-1-786-49183-1

E-book ISBN: 978-1-786-49182-4

Printed in Great Britain

Designed by Nancy Resnick

Frontispiece: Une Leçon Clinique à la Salpêtrière by André Brouillet 1887, FNAC 1133, Centre National des Arts Plastique. Copyright © Public domain/Centre National des Arts Plastique. Photo courtesy Musée d’Histoire de la Médecine, Paris.

Atlantic Books

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www.atlantic-books.co.uk

For Dr. Raymond D. Adams, master clinician and author of the definitive book on neurosyphilis, who taught that there was only one brain and it belonged to both neurology and psychiatry.—AHR

For Jennie Bujnievicz, who taught us for a while, allowed us to see particular things, and then sent us on.—BDB (via TRP Jr.)

CONTENTS

AUTHORS’ NOTE

INTRODUCTION

1. A CLINICAL LESSON

2. WHAT IS A DISEASE?

3. PYGMALION AND GALATEA

4. THE INVENTION OF HYSTERIA

5. THE PAPUAN IDOL

6. HEARTS OF DARKNESS

7. THE SOUL OF A NEW DISEASE

8. THE UNSETTLED TERRITORIES OF THE MIND

9. THE DIFFICULT CASE OF ANNA O.

10. THE DEVIL AND ADRIAN LEVERKÜHN

11. SEX AND THE NEW WOMAN

12. WINNING THE BATTLE AND LOSING THE WAR

13. THE PSYCHIC INTERPRETATION OF DISEASE

14. A BEAUTIFUL NAME FOR A HORRIBLE DISEASE

15. MEDICINAL LOBOTOMY: THE INVENTION OF THORAZINE

16. THE FEVERED DREAM OF A SCIENTIFIC PSYCHOLOGY

17. THE LESSONS OF NEUROSYPHILIS

NOTES

SELECTED BIBLIOGRAPHY

INDEX

AUTHORS’ NOTE

This book tells the story of a disease known for its uncanny ability to mimic the symptoms of almost any illness, mental or physical. Its root cause—syphilis—was the driving force behind five centuries of fear and loathing, and though now viewed with little cause for concern in the developed world, it is epidemic elsewhere. Neurosyphilis, or syphilis of the brain, first appeared in Europe in the late 1700s, and produced a rapidly expanding wave of debilitating insanity that filled asylums and cut lives short in a grotesque and frightening way. As traumatizing and destructive as AIDS proved to be two hundred years later, neurosyphilis cast a pall over the sexual lives of people from all walks of life for the better part of a century, while its cause and nature remained a mystery. Its shadow may no longer haunt us, but it is still with us today, although shunted into the neglected corners of medicine.

When a cure for syphilis was found and the threat of neurosyphilis receded, so did popular awareness of brain-based mental disorders. Into this conceptual vacuum a seductive new theory of the unconscious emerged emphasizing mind over brain. Sigmund Freud’s psychoanalytic system would dominate the treatment of mental disease for most of the twentieth century, and it still colors our conversations about the mind while largely ignoring the brain. We have written this book to redress this derailing of a coordinated neurological and psychiatric approach to mental illness.

How does a germ-borne venereal disease produce insanity? Do we really understand the difference between a sick brain and a sick mind? In setting out to write a book about neurosyphilis, we ended up with a book about sex, hysteria, psychosis, hypnotism, psychoanalysis, mind cures, synthetic dyes, sensation fiction, psychotropic drugs, genius, and madness. Which is to say, we ended up with a book about neurosyphilis—a far more expansive subject than we first imagined.

We have relied on the resources of many libraries and their staffs, notably the Countway Library of Medicine at Harvard Medical School and the Robert Frost Library of Amherst College. We greatly appreciate the invaluable assistance of Sandy Ropper, MLS, in providing extensive library research. Several of our colleagues provided essential assistance with our investigations, including Drs. Emily Stern, David Silbersweig, and Daniel Talmasov of Brigham and Women’s Hospital, Drs. Michael Fox and William Greenberg of Beth Israel Deaconess Medical Center, Dr. Paul McHugh of Johns Hopkins University School of Medicine, Dr. Thomas D. Sabin of Tufts Medical Center, and Dr. Joseph B. Martin of Harvard Medical School. Professor Hans Vaget of Smith College provided valuable insights into the life and works of Thomas Mann. Our sincere thanks go out to our editors at Avery Books, Megan Newman and Nina Shield, for their astute input and hard work; to our agent, John Thornton of the Spieler Agency, for kick-starting the project; and to Fran Shifman for reading early versions of the manuscript. We would also like to thank colleagues who led us to the stories of their patients, some of which appear here with identifying features altered to protect their privacy.

INTRODUCTION

I took special notice of Mr. M the moment he entered my field of vision. Anyone would have. A study in contrasts—tall, thin, and handsome, wearing crisply cuffed Brooks Brothers slacks, polished wing-tip shoes, and a shabby white T-shirt—he was pacing, as people tend to do in hospital corridors, deep in conversation, sometimes excitedly. Sans Bluetooth, oblivious to anyone around him, he was immersed in a heated argument with himself.

I had been called down to the psych ward to check on Mr. M, to see if he might be having seizures. He was not, but in our initial interview he insisted that the sugar in his coffee was the source of the voices he was hearing; it was poisoning not just him but everyone. His argument was articulate and intense, and as I later decided while contemplating a Danish pastry in the hospital café, unconvincing. I wondered why patients like him are admitted to a psych ward in the first place. They don’t belong there.

Twenty-seven years old, Mr. M has a degree from the Wharton School, a wide vocabulary, and a brain problem. He impressed me as being an intelligent, exceedingly perceptive, engaging man, yet completely psychotic. I noted many hints, some of them highly suggestive: involuntary grasping responses when I put my fingers in his palm, darting eyes, head tossing, lip smacking—what we call soft neurological signs. Yet every test we ran, every scan, no matter how sophisticated, ruled out many things, and ruled in nothing. He seemed to have a normal brain. I was sure he did not; I just couldn’t prove it.

To my dismay, I found his patient file dense with psychiatric jargon, as if he did not have a brain disease at all, as if the roots of his psychosis were wrapped up in the tangled filaments of his life experiences. By general agreement, he was insane. But the word itself means different things to different people. The identifiable mental illnesses, the bigticket items including bipolar illness and schizophrenia, are diseases of brain structure and function. Most neurologists believe this, as do most academic psychiatrists. Yet we do not have the irrefutable evidence to prove it. As a result, these conditions are treated clinically as mental illnesses rather than as brain diseases. Neurologists by and large have tacitly condoned this practice, and even abetted it, partly because we cannot nail down the structural or functional brain problems that produce most abnormal behaviors. This is a serious problem and a longstanding one.

In 1801, the pioneering French psychiatrist Philippe Pinel invented the term aliénation mentale as a catchall for all forms of insanity. Pinel meant alienation in the sense of loss, a state in which the patient has become estranged from reason. Pinel attributed it, as medicine had only recently begun to do, to the brain, but he also saw alienation as a disorder of sensibility (perception), of intelligence, and of the will, without associating those things with specific brain structures. In other words, insanity was also a problem of the mind.

Pinel’s classification efforts mark the very beginning of the practice of psychiatry and the first stirrings of my own profession, neurology. It was the dawn of a new era. Minds and brains took precedence over manners and morals. Specialists known as alienists were now charged with deciding whether persons detained for “reasons of madness” belonged in a hospital, in a prison, or back out on the street. Prior to Pinel, anyone exhibiting erratic behavior would have been dumped, somewhat indiscriminately, into an asylum or maison d’aliénés, chained to the wall and left to wallow in their own filth. Pinel would soon reform the asylums out of his sense of humanity, but also because he perceived differences of type, severity, and cause of insanity, and he believed many of his patients could be reclaimed through what he called “moral treatment.” He also hoped to put psychiatry on a par with biological science by establishing a classification scheme for all mental illnesses.

In Pinel’s time, my patient Mr. M would have been committed to an asylum and declared aliéné. The English word insane is not equivalent and would not be appropriate in his case. Unlike aliéné, insane defines a state of mind by what it is not, and glosses over our inability to distinguish the many categories and causes of bizarre thoughts and erratic behaviors. It is a declaration rather than a placeholder. As though in compensation, we now possess a wealth of subclassifications of insanity, including schizophrenia, bipolarity, psychosis, conversion disorder, and so on through the 947 pages and 297 descriptors catalogued in the Diagnostic and Statistical Manual of Mental Disorders. The sheer scope is impressive, but what the DSM fails to do is identify which disorders arise in specific brain pathology. This is because in most cases we still do not know.

In the early 1800s, no one had mustered a serious argument for the brain as a source of mental instability. Phrenology, the only viable theory of mind at the time, treated the brain as a muscle in need of toning, its faculties capable of being strengthened through exercise or repressed through restraint. The expert would feel the bumps on the skull, consult an atlas of the underlying brain, map the patient’s character and proclivities, and write out a detailed diagnosis and a prescription. As a logical and medically approved system for understanding the mind, it was very appealing, and most customers walked away contented. If insanity was the result of unfortunate deformations of the skull, the phrenologist could tailor his examinations to flatter his clients. If a cranium did not measure up to the ideal, he would provide the owner with helpful suggestions. Nothing was at stake because the theory could not be disproven. At least at first.

The seed of phrenology’s undoing was sown in 1822 when a medical student working in a French asylum published a thesis with an intriguing premise: Could a mental breakdown be caused by a disease of the brain? He found the evidence in a small cohort of patients in their thirties and forties who had died at the asylum after a period of florid insanity. Although he could not say how the affliction had come about, he accurately described its dramatic effects. In the months before their deaths, all of the patients had exhibited similar patterns of delusion, depression, mania, and later, paralysis. At autopsy, they displayed a consistent pattern of damage in their frontal lobes, seemingly caused by an inflammation of the brain’s outer lining. The idea that a physical disorder of the brain could produce insanity was unprecedented—and decidedly non-phrenological. An outside agent appeared to be invading these patients’ bodies and crippling their mental faculties. The medical establishment instantly rejected the notion.

The brain had long been conjectured to be the organ of the mind, but even the phrenologists could not provide a coherent explanation of how it worked. Clearly it controlled the muscles. Epileptic convulsions, for example, were assumed to indicate an underlying brain disorder, one affecting motor control, while unconnected to the thought process. Epilepsy did not alter personal identity. This new syndrome, on the other hand, vastly distorted the victim’s sense of self. How did it do that?

At first no one took the young student seriously, but as soon as the asylum superintendents recognized the advantages of a medical diagnosis for insanity, the idea caught on. Such a disease would establish their bona fides as real doctors, not merely as custodians relegated to the grimy back wards of medicine. The superintendents were also astute enough to recognize that the clinical details provided by the medical student matched a large proportion of the patients under their care. Within a few years, thousands of cases had been catalogued, all with the same pathology. Whatever it was, it seemed to have become epidemic, and it spurred the building of newer and larger asylums.

The disease soon acquired a name: general paralysis of the insane (today known as GPI). Its symptoms included colorful delusions of grandeur, psychosis, slurred speech, periods of deep melancholy, a gradual spread of paralysis, and death usually within a few years of onset. Although the diagnosis could be made with some precision, no one was entirely sure what caused it or what could be done about it. It was impossible to say whether it was a brain state or a mind state, germbased or hereditary, due to lifestyle or due to bad luck.

Today we know all about it. It is caused by syphilis, and it manifests itself as a mental illness. For that reason, it provides the ideal lens through which to view all forms of mental alienation. For a time it even bridged the gap between neurology and psychiatry. Perhaps it can bring them together once again.

Mrs. B sits in a wheelchair, clutching a leather-bound, jewel-encrusted Bible while a young man in a white lab coat excuses himself and steps into a conference room. He will be only a minute, he says. The room is full of young doctors and medical students, two dozen or so. This is the neurology group at Boston’s Brigham and Women’s Hospital. We have gathered for Chief’s Rounds, a weekly teaching exercise. Mrs. B has graciously agreed to participate.

The young man, who happens to be our senior neurological resident, sets the stage. Today’s patient is seventy-five years old, of Jamaican descent, and has been living in the Dorchester section of Boston for fifty years. She lives alone, but in the last few months has been unable to manage her affairs. Her walking has deteriorated. She falls frequently, especially in the dark. Her behavior has become increasingly bizarre and disorganized. She has stopped cooking. Family members describe her as “not who she is,” and her religious fervor has crescendoed to a euphoric pitch. She carries her Bible at all times, and speaks constantly of the end of the world and of her important role in it.

Once Mrs. B is wheeled into the room, the chief begins the classic neurological examination. She responds slowly and deliberately to his questions, and admits only to some vision problems. Wielding a penlight and moving his face to within inches of hers, the chief notices how her pupils fail to narrow in response to the light, yet they constrict when he asks her to focus on his thumb as he moves it closer. “Pupils accommodate,” he says, “but they don’t react to light.”

After she is wheeled out, the guessing game begins, starting with the medical students, then the residents in reverse order of seniority, and finally the academic faculty. Only the senior resident knows the results of her tests. The round table conjectures touch on every cause of premature dementia, as well as brain tumors, strokes, and ophthalmic problems, but nothing seems to fit her signs and symptoms, especially her recent mental decline, one too abrupt to qualify as an ordinary dementia. No one gets it right. In fact, no one in the room under the age of sixty-five has ever seen a case like hers. A century ago, almost everyone would have recognized it instantly. Even a country doctor would have seen it. Finally the chief weighs in: “What about syphilis?”

Most people do not realize that syphilis, a venereal disease, can invade a brain and quickly destroy the mind within, reducing the patient to a hopeless wreck. It can take two years or thirty, but in any case, if left untreated, it is unrelenting. Neurosyphilis is now uncommon, at least in the developed world, which explains why a roomful of doctors in a major teaching hospital failed to spot it. It is not on the list of usual suspects in cases of dementia. A blood test can identify it quickly, but before the first such test was developed, syphilis was extremely difficult to pin down. It could manifest itself as almost anything. It still does.

The senior resident put Mrs. B on a series of penicillin injections—our first line of defense. They would rid her body of the infection and rid her mind of its overblown religiosity, but fall short of producing a complete recovery. The neurological damage had been done.

Meanwhile, up on the neurology ward, Sara J, a nursing student—nineteen years old, the first in her family to go to college—lies on her side, salivating onto her pillow, clenching her teeth in obvious distress. Her family, all five of them, huddle at the foot of her bed. A week earlier, she had been preparing for final exams, acting “completely normal,” according to the roommate who brought her to the ER.

In cases involving neurological symptoms—convulsions, tremor, paralysis, numbness, coma, seizures, palsy, migraine, hallucinations, disorientation, catatonia, even blindness—I begin by ruling out the biggest threats. One of these is epilepsy. As my residents and I enter, Sara rolls over and it begins. Her muscles tense, her teeth gnash so violently she almost breaks her incisors. Arching her back in a half circle, supporting herself by only her heels and the back of her head, she goes into grand mal convulsions. Her mother, frantic, yells at us, “Can’t you stop this? Do something!”

The wires attached to the electrodes stuck to the young woman’s scalp lead to an electroencephalograph behind the bed, carrying signals from her brain activity during her frenzied behavior. There is nothing unusual in the waveforms of the electroencephalogram. She is not having a seizure; her spasms and convulsions do not look genuinely epileptic. Even so, she has no control over them, and for the first time in her life, it seems, her parents have no control over her. I ask the family to step out, but her brothers are emphatic that she can’t be left alone in a room with men, even with a doctor. “She is a virgin,” they say.

We have our theories. The overprotective family and their odd insistence that she is a virgin raise a few red flags. A social worker pays a visit, but neither the young woman nor her parents will give anyone a peek into their lives. The blood tests, along with a battery of other tests costing an astronomical sum, all come back negative. She does not have a disease we can identify, but Sara would have been quickly diagnosed by any nineteenth-century physician. He would have called it hysteria.

Three patients in the same week: one a case of general paralysis, also known as neurosyphilis, a disease of the brain; one a case of pseudoepileptic seizures, an affliction of the mind; and the third, Mr. M, fell somewhere in between. He seemed normal in many ways. He spoke in full sentences; he had no paralysis, blindness, or incoordination; yet his mind was a mess. The attending psychiatrist gave him Seroquel, an antipsychotic, and he became almost catatonic. When switched over to Valium, he began talking again—about good and evil, about righteousness. “If you had a choice between being on the right or the wrong side of evil,” he asked me, “and you could do it forever, which would you choose, Doc?” I had no answer. He was not confused, just crazy.

As a resident in the 1970s, I treated “crazy” patients with penicillin. We still had a lues clinic for the treatment of neurosyphilis (lues is a euphemism for syphilis). Every few months we took spinal taps to test whether the drug was working. We could see the white blood cells in the cerebrospinal fluid go from a count of about fifty down to one or two over the course of a year, a measure of the disappearance of the syphilis bacterium within the nervous system. The clinic is long gone, but the memory of it has stayed with me. We were curing mental illness by treating the body. Mr. M reminded me of the extent to which we have drifted away from that. Instead of curing his disease, we were merely moderating his symptoms.

A friend recently asked me, “You’re a neurologist, right? Why am I anxious and can’t focus? I can’t figure out what is making me feel this way. Nothing special has happened to me.” I could only shake my head. He’s wrong that being a neurologist would allow me to deduce the cause of his nervousness. My friend is anxious, he believes, because something in his brain is not functioning properly—perhaps a chemical imbalance. He is angling for a societally legitimized pseudo-medical diagnosis. Thanks to drug company advertising, every uncomfortable state of mind has morphed into a medical problem with a brain-based explanation. Freud took the opposite tack: he assumed that anxiety and neurosis are psychopathologies, not organic but experiential in origin. This assumption was still dominant when I started practicing medicine. Patients suffering from mental distress wanted to know what events in their lives had led to their feeling like this, and the medical profession was happy to oblige them. Now they want to know what events in their brain have brought them down.

Today we know a lot more about the brain than Freud and his contemporaries did. As for the mind, history has taken us on a circuitous journey, and what we think we know has outpaced what we really do know. Only in the last few decades have we doubled back, somewhat chagrined, to our original route, weighed down by the baggage we acquired along the way. The baggage goes by many names—Freudian, neo-Kraepelinian, Jungian, Pavlovian, Skinnerian, and so on—and it continues to divide neurology and psychiatry into opposing camps.

The causes of bipolar disorder, schizophrenia, depression, autism, alcoholism, attention deficit disorder, criminality, sociopathy, and neurosis, despite the optimistic pronouncements of popular scientists, remain out of reach. The question of what makes one person act ethically and reasonably while another becomes a thief and a liar has been relegated to the social sciences, where it remains highly speculative. Why someone becomes agitated and confused in the absence of a recognizable pathology is equally baffling. For a clinical neurologist like me, the situation is frustrating and somewhat absurd, much like the case of the blind men describing an elephant: their descriptions vary wildly depending on which part of the animal they latch onto. Mental illness is just such a beast. Neurologists and psychiatrists, each enamored of the part that makes the most sense to them, describe the pathology from their own vantage point, uncertain what the whole animal looks like. Instead of sharing our perspectives, we continually return to our comfort zones: mind versus brain. In order to begin the conversation anew, we could use some common ground: a disease of both mind and brain. Syphilis, for example.

When Sir William Osler, widely acknowledged as the greatest diagnostician ever to wield a stethoscope, declared that “he who knows syphilis knows medicine,” he elevated what had been considered a lowly disease, one treated mostly by dermatologists, into something all encompassing. Almost always sexually transmitted, it can attack any organ, usually starting with the genitals in the form of ugly lesions and dry ulcers known as chancres. From there it moves inward. The heart, liver, lungs, and spinal cord are at its mercy, as is the brain. Only careful examination can distinguish the true nature of syphilis from the many things it merely appears to be. For this reason, it was called the Great Imitator—not just an imitator of biological disease, but of almost any mental illness. This made it a crucial nexus of neurology and psychiatry.

Osler had it mostly right. Understand syphilis, and you will indeed understand all of medicine. He might have added that if you understand how a mental disturbance due to a brain disease differs from a purely psychological problem, you will gain a deeper understanding of disease in general. This book sets out to do just that.

CHAPTER 1

A CLINICAL LESSON

On a warm Paris afternoon in late spring, throngs of weary tourists swarm the narrow streets off the Boulevard Saint-Michel in search of a place to unwind after a day spent in the grueling pursuit of checklist tourism. Led around by docents and modern-day Baedekers, most of these vacationers have dashed through a handful of the city’s five-star attractions, waved selfie sticks while plugged into audio tours, and can now be seen flowing into the Place Saint-Michel in a movable feast fanning out across the sidewalks and down the clogged alleyways feeding into the Rue de la Huchette.

Just around the corner from this bustling warren of conviviality, one of the most historically significant artworks in the city goes unnoticed, unvisited, and unappreciated. Sheltered in a vestibule of a stately neoclassical building, it presides over an oasis of solitude and calm. Because none of the guidebooks mention it, very few people are even aware it exists. It is a large painting, and over the century and a quarter since it was painted, it has lost its notoriety but not its significance. To understand this one painting is to understand everything that went wrong in the modern concept of mind and brain. It portrays nothing less than the original sin of neurology and psychiatry, one from which we are still trying to recover.

The colonnaded building housing the painting is perched on the Rue de l’École-de-Médecine, a two-minute walk from the bustle of the Place Saint-Michel. It is the home of Paris Descartes University, a satellite of the Sorbonne. Among other things it contains a museum of medical history: a cabinet of gruesome curiosities including an amputation kit used at the Battle of Waterloo, crude-looking instruments once used to remove bladder stones, and boxes of glass eyes. Admission costs three euros, but the painting can be viewed for free. At nine and a half by fourteen feet, it is too big for the museum’s limited wall space and has been accommodated just outside of the main gallery, as if in an afterthought, in a skylighted foyer where, on a sunny day, the glare makes it difficult to take in as a whole. As a further indignity, it is unframed and almost casually hung, a sad fate for a work once hailed as “the success of the Salon of 1887.”

The painting is by André Brouillet, a journeyman artist who studied with the great Jean-Léon Gérôme, had a moment of passing fame, and then slid back into obscurity. He titled the work Une Leçon Clinique à la Salpêtrière (A Clinical Lesson at the Salpêtrière Hospital), and at the Salon des Beaux Arts of 1887, an annual showcase of established and aspiring academically trained artists, it stood out by virtue of its striking subject. Rather than drawing upon the distant past, Brouillet chose to depict a contemporary event, one very much of the moment. The setting is a window-lit room in a hospital. A medical demonstration is in progress before a male audience. At first glance, it appears to be a group portrait of thirty finely rendered individuals. The center of attention is a young woman in a state of semiconsciousness and semi-undress. The scene is highly sexualized and frankly voyeuristic, hardly unusual in the world of academic painting. Two of its more obvious points of reference include a scandalous canvas by Gérôme entitled The Slave Market in Rome, featuring a nude young woman standing on an auction block as buyers frantically make their bids. The other, a more subdued work, depicts Philippe Pinel, the aforementioned pioneer in the humane treatment of the insane, as he orders the unshackling of the madwomen at an asylum. Stripped of all context, the subjects of these works are young, vulnerable, exposed, unseeing or semiconscious women under the complete control and watchful eyes of men. In each case the historical moment trumps the sensational content, allowing the paintings to be peddled as art rather than as pornography.

A salon-goer of 1887, unlike the viewer of today, would have known exactly what was going on in Brouillet’s canvas. A young woman under hypnosis will be induced to act out a series of seemingly unexplainable physical and mental tasks, during which needles will be passed through her hand with no sensation of pain, paralyses will appear on one side of her body, only to switch sides after the application of a magnet, and her perception, having become sensitized, will allow her to read thoughts and exhibit astounding feats of clairvoyance. Finally, as the pièce de résistance, she will respond to a series of random suggestions from her handlers, ranging from the banal—“You are smelling a flower,” “You see a snake”—to the fantastic—“You have survived a violent train crash,” “You are Kutuzov at the Battle of Borodino.” In response to each suggestion she will act out a series of tableaux vivants, all in service of advancing knowledge of one of the most baffling forms of neurosis known to medical science: hysteria.

The swooning woman at the center of the painting has a name: Blanche Wittman, also known as the Queen of the Hysterics. The man presiding over the scene is Jean-Martin Charcot, known as the father of clinical neurology, more reservedly as the father of French neurology (as if neurology were as regional as cuisine), and sometimes derisively as the Napoléon of the Salpêtrière. Everyone in the painting can be identified by name and by profession, and a legend posted on the wall does just that. The group includes not just medical men but literary figures, artists, and statesmen, and they are there to lend gravitas to what was an elaborately crafted ritual and a highly controversial practice that might otherwise have appeared somewhat shady, if not scandalous.

Une Leçon Clinique is a bright and crisp painting, both real and unreal: real in its vivid attempt to capture the likenesses of living men and women, unreal in its frozen formality. The more you look at it, the more impossible the scene appears. It was not commissioned, a rarity in a historical painting. Brouillet took a chance that the public and the press would want to see the most-talked-about phenomenon in Paris, especially if it featured the city’s most famous physician and his most celebrated patient. He was right. Hailed by the critics of the time as “one of the most important artworks of the Salon,” and possibly “the most sensational painting” out of the more than five thousand other works on display, it drew large crowds from the opening day. The Salon itself, an annual event put on by the French Academy of Beaux-Arts, drew up to a half million people to the Palais de l’Industrie during its two months’ duration. Most of them would have made a beeline for Brouillet’s large canvas because of its subject, its overt sexuality, its composition, and its sheer size. According to contemporary accounts, the crowds also came for the same reason Beatles fans were drawn to the cover of the Sgt. Pepper album. They wanted to see how many faces they could identify. Perhaps this explains the critic Louis de Meurville’s dismissive remark, in the Gazette de France, that “it takes only a minute to admire the truthfulness of the characters and the light. Beyond that, there is nothing more to discover.”

Meurville can be forgiven for focusing only on the surface quality of the work. He was not in a position to understand how Brouillet, in this one canvas, had inadvertently captured a seminal moment in the history of medicine. The scene he so carefully composed would foretell not only the birth of psychoanalysis but also a regrettable split between neurology and psychiatry, and the failure of medical science to take ownership of the study and treatment of mental illness. In short, Brouillet attempted to portray the culmination of a century’s worth of bad science on the threshold of giving way to good science. In the end, he showed the very opposite.

Jean-Martin Charcot deserved better. In the 1860s, at the outset of his career, he laid the groundwork for the medical specialty of neurology through a remarkable sequence of discoveries. He differentiated multiple sclerosis and Parkinson’s disease from a multitude of similarlooking ailments, naming the latter for the English physician who first described it. He identified the symptoms of poliomyelitis and of tabes dorsalis, or syphilis of the spinal cord. He detected the role of uric acid buildup in cases of gout. More famously, he differentiated the pathology of amyotrophic lateral sclerosis, or Lou Gehrig’s disease (known in France as Charcot’s disease), from other forms of paralysis. In short, Charcot deciphered the workings of the human nervous system through a careful and perceptive examination of the many ways in which it can go wrong. He correlated fanatically precise observations during his patients’ lives with careful examination of their brains after their deaths. In doing so, he left behind centuries-old preconceptions and prejudices in favor of an objective empiricism. He then built a research enterprise that served as the model for the modern teaching hospital and for the entire enterprise of medical investigation. According to a contemporary, the writer Léon Daudet, “No one anywhere in the civilized world would publish a book on diseases of the nervous system without seeking his approval, his imprimatur, in advance.”

But just when everything seemed to be going his way, Charcot stunned his colleagues by redirecting his efforts toward a paradoxical phenomenon regarded by mainstream physicians more as a nuisance than as a real disease. Charcot plucked hysteria, long thought to be an affliction unique to women, from its marginalized place in medicine, and set it alongside epilepsy, ALS, MS, and Parkinson’s as a very real disease of the body. But that wasn’t all. He ventured into even more treacherous territory when he introduced hypnotism into his arsenal of diagnostic tools, and he achieved an initial breakthrough with a group of patients consisting mostly of attractive young women. Charcot’s reputation alone brought this unlikely enterprise some legitimacy within the French Academy of Sciences, but outside of the academy not everyone was on board.

Hysteria is an umbrella term denoting afflictions of body and behavior displayed vividly by a patient while remaining awkwardly unverifiable even with an autopsy. Today we resort to less controversial terms, including conversion disorder, functional illness, somatization disorder, dissociative states, pseudoepileptic seizure, and psychogenic pain disorder to describe the same phenomenon. It is hard to say what distinguishes hysteria from a genuine illness, or a pseudoseizure from a real one, but one hint is the sheer outrageousness of its manifestations. Charcot left behind a trove of photographs showing a woman suspended between two chairs, supported only at the neck and ankles, stiff as a board; a patient with arms outstretched, as if crucified; a scantily dressed woman with her right arm rigidly extended and her right leg provocatively stretched out of her gown. None of these images accords with the way the human brain is wired. They look more like stunts than symptoms.

By any name, hysteria was and still is the bane of every neurologist’s existence. It produces a constant white noise of symptoms and signs, some real and some feigned. Hysterical patients—meaning those whose condition is ultimately classified as “functional,” or structurally normal—parade through every major hospital on a daily basis. The manifestations are only a bit less flagrant than in Charcot’s time, but they are no less peculiar. There is no objective way to verify what the patient is feeling or of telling whether his or her actions, no matter how extreme, are beyond conscious control. You have to take the person’s word for it. Estimates place the proportion of such cases in neurology departments at up to 30 percent. It is a serious and nagging problem for the profession, not to mention for the patients themselves.

The word is unfortunate. Hysteria, from the Greek for uterus, shows up as early as the Hippocratic texts of the fifth century bc, reflecting an ancient belief in a wandering womb as the source of many women’s health issues. According to the Greeks, the uterus traveled around the body, creating sensations of pressure and unease, especially in the throat, including a feeling of choking and the loss of the ability to speak. Such was the theory, and it established hysteria exclusively as a disease of women. It was a neat explanation, it fit the known facts of the time, it let men off the hook, and it exonerated the brain completely. Its fabulistic limitation and its eventual downfall is its anatomical impossibility.

In her book Hystories, the feminist literary critic Elaine Showalter calls hysteria “a mimetic disorder.” It mimics what she calls “culturally permissible expressions of distress.” These expressions change over time and between cultures. In Charcot’s Paris, permissible expressions included convulsions, fainting, numbness, paralysis, and blindness. According to Showalter, most of these have gone out of fashion, and in their place have arisen chronic fatigue, repetitive stress, and eating disorders. This is not entirely correct. If Showalter had spent any time in my neurology clinic, she would have seen what Charcot saw. There are always new twists, but old-fashioned hysteria has not disappeared.

The pleasant walk from the medical school housing Brouillet’s painting to the Salpêtrière Hospital where Charcot worked takes about twenty minutes. Charcot would still recognize the route today. At the halfway point, the buildings turn modern, but once at the hospital gate, he would be reassured: the place looks much the same as he left it. It does, however, look very different than when he first arrived, and the changes had everything to do with Charcot himself.

The Pitié-Salpêtrière Hospital constitutes a walled city within a city. It lies between the Place d’Italie and the Gare d’Austerlitz in Paris’s 13th arrondissement. The hospital within this vast complex is the house that Charcot built. When he first came on the scene, it was little more than a hospice on the lowest rung of Paris’s social welfare system, a dumping ground built on the outskirts of the city as a place to dispose of unwanted women. In their collective misery, Charcot saw vast potential. Within the span of a decade, drawing upon the reservoir of neurological disease at his disposal, he made his landmark discoveries, laying the groundwork for modern neurology. He lectured in pathological anatomy, trained a generation of pioneering physicians, and made his lectures and demonstrations an obligatory stop for any aspiring researcher, including a young Sigmund Freud. He built laboratories, invented new physiological measuring devices, introduced the use of photography, and was instrumental in excising religion from the institutional practice of medicine. But in one sense the sprawling abundance of the Salpêtrière posed a great danger. The self-sufficient isolation of the place set Charcot up for the biggest mistake of his career.

The building got its name from a gunpowder factory and storage annex (a saltpetery) erected on the site in the early 1600s. Within a few decades, King Louis XIV repurposed the buildings. The saltpetery gave way to a hospice for the indigent, but the original name stuck. At the time, Paris was increasingly overrun by society’s castoffs, and the Salpêtrière became a destination for women and wayward girls deemed unsuitable for the streets of Paris—thieves, vagrants, prostitutes, alcoholics, blasphemers, epileptics, syphilitics, foundlings, the elderly, and the criminally insane. Rounded up on nightly patrols, many were housed in a prison on the site prior to being deported to America, as happened to Manon Lescaut in the famous novel of that name by Abbé Prévost. Those left behind added to a burgeoning population. In due course, a hospital was added.

The Salpêtrière gave Charcot access to what he called a “grand asylum of human misery” and a “museum of living pathology.” He put it to good use. In the 1870s he raised funds, ordered the construction of specialized laboratories, staffed them with bright young interns, developed a curriculum and a research agenda based on detailed observation, and attracted students from around the world. Breakthrough discoveries followed in quick succession and revolutionized the study and understanding of the nervous system. It is easy to see why. He opened the hospital to the surrounding community by establishing a free outpatient clinic. He built a dormitory for men in order to diversify his patient pool. He outfitted a four-hundred-seat amphitheater in order to give demonstrations to the public, and these began to attract large audiences. Not just aspiring researchers, but the literati, the entertainment world, politicians, and a host of hangers-on descended upon the hospital each week to witness Charcot’s lectures. A lot of this had to do with his star patient.

Blanche Wittman’s life story reads like a horrific fairy tale. A young girl living in squalor finds a golden ticket to a magical place presided over by a real-life Willy Wonka. Once there, she is installed as the queen. During her reign she receives visitors from the cream of society, from the stars of the theater and the literary world. She becomes the toast of Paris. When she finally steps down from her throne, she is slowly poisoned, chopped into pieces, and dies. As fantastical as this might sound, it is a fairly accurate account of Blanche’s life and fate.

Marie Wittman, her real name, was born in Paris in 1859 to an abusive out-of-work carpenter father and a laundress mother who toiled sixteen-hour days. Before she was in her teens, Marie saw her father sent off to an insane asylum, where he died; she saw five of her eight siblings die in childhood; and then she had the misfortune of being apprenticed to a furrier who made constant sexual advances to the point where she often collapsed in convulsions. She ran away at age fourteen to rejoin her family, but her mother died a year later. With her remaining siblings packed off to foster homes and orphanages, and being too old to be placed herself, Marie had no choice but to return to the furrier, at whose hands she endured sexual abuse for eight months before fleeing again, this time to a friend’s house. She managed to secure a job at the second-lowest rung of the career ladder available to young women by becoming a ward girl at a local hospital. Hours were long, the work filthy and backbreaking, and she contended with dizziness, convulsions, and fainting spells. Frequently belligerent and combative, she did not last long in school, could not read or write very well, had a string of brief romances, and continued to suffer from the trauma of her abuse. Eventually the convulsive attacks landed her at the Salpêtrière, where she was admitted to the epilepsy ward. For whatever deep-seated reason, once there she continually barked out the name Blanche. It might have been the name of one of her dead siblings, or simply a reaction to having to wash sheets, but the name stuck, and she thenceforth became Blanche Wittman. She was just eighteen years old, and she would remain at the Salpêtrière for the rest of her life.

Why Charcot took an interest in her is not clear. She was one of dozens of women who, although not epileptic themselves, mimicked the convulsive attacks of the patients whose quarters they shared. Pseudoseizures were contagious; scores of women at the Salpêtrière came down with them. But contagion is not synonymous with disease. Charcot called it “hystero-epilepsy” at first, in order to distinguish it from the real thing. He then decided to delve deeper. As he knew very well, some patients feigned seizures to get attention, and his staff became adept at distinguishing simulated from real convulsions. But Blanche Wittman and a few others defied categorization—they were neither epileptic nor simply acting. Their fits and altered minds seemed more neurological than psychiatric. Skeptics—and there were many—assumed the entire phenomenon had been manufactured by Charcot himself, that it was nothing more than a carefully choreographed act.

Hysterical, madame, here is the great word of the day.” Guy de Maupassant had had enough of hysteria. In 1882, the emerging literary star and cultural commentator penned an editorial for the Parisian literary journal Gil Blas, in which he let loose:

Are you amorous? You are a hysteric . . . You are a gourmande? Hysteric! You are nervous? Hysteric! You are this, you are that, you are just like any woman since the beginning of time? Hysteric! Hysteric! I tell you. We are all hysterics, since Charcot, that grand priest of hysterics, that breeder of chamber hysterics, maintains at great cost in his model establishment a number of nervous women among whom he inoculates with madness and of whom he makes demoniacs in no time.

In his wanderings through various Parisian social circles and haunts, both high and low, Maupassant had visited the Salpêtrière. He may even have sat alongside a young Sigmund Freud while witnessing a phenomenon seen almost exclusively within its walls. He was not impressed. “[Charcot] produces on me the effect of those storytellers of the school of Edgar Allan Poe who go mad through constantly reflecting on queer cases of insanity,” one of his fictional characters says. “He has set forth some nervous phenomena that are unexplained and inexplicable; he makes his way into that unknown region that men explore every day and, not being able to comprehend what he sees, he remembers perhaps too well the explanations of certain mysteries given by priests.”

Maupassant had a difficult relationship with doctors in general. Outwardly, he was the picture of robustness. An avid outdoorsman, he spent hours rowing his boat down the Seine or sailing off the coast of Étretat. He was also a notorious ladies’ man. In his early years in Paris, just after getting out of the navy, he lived on the ground floor of an apartment house populated by prostitutes. They got along very well. Maupassant even used his neighbors’ experiences in some of his early short stories. It should have come as no surprise to him when, at the age of twenty-seven, he made an astounding discovery. “I’ve the pox!” he wrote to a friend. “At last! It’s true! . . . and I’m proud, by God, and despise above all the bourgeoisie. Hallelujah! I have the pox, and so have no need to fear catching it.” By the pox, he meant syphilis.

It seemed to worry him hardly at all. He blamed it on a fisherwoman he had encountered by the banks of the Seine, although the pool of suspects was vast. Maupassant was almost pathologically drawn to women. From the river to the streets to the cafés to the salons, he had scores of casual encounters. In a letter to his mother (of all people), he wrote: “I am obsessed by women. I cannot pass up their caresses. And when a woman stops me in the street, by chance, despite her fetid breath and her repugnant filth, I cannot resist for long that silent and powerful call of the flesh that wells up like the waves from below, from the depths of my entrails, and places a blindfold on my eyes, a gag on my conscience, and reduces you in an instant to the mercy of these bitches.”

Maupassant claimed not to have noticed the first stage of his disease, although in looking back, he remarked, “Many symptoms to which I attached no importance served to make that discovery extraordinary.” Two years later, in 1877, his hair began to fall out, but not in a typical balding pattern. A physician immediately recognized it as syphilis, but his symptoms receded quickly enough to allow the writer to ignore this diagnosis, and he easily found other doctors who assured him his condition was merely degenerative and hereditary, not syphilitic. Meanwhile, he enjoyed a streak of success as a popular novelist and editorial journalist. Under the mentorship of Gustave Flaubert, another syphilitic, his reputation soared. But behind the scenes, the harsh reality of Maupassant’s declining physical state became increasingly difficult to ignore. While his womanizing continued almost unabated, Maupassant took the precaution of using condoms when sleeping with his mistresses. Prostitutes did not receive the same consideration. Though publicly arrogant and boastful, he understood the impossibility of marriage. His eye problems, well documented in his letters, were the most telling sign of his worsening condition. To Flaubert he wrote, “I can hardly see out of my right eye. My doctor is a bit worried and thinks there’s a congestion of some part of the organ.” The doctor, Jean Marie Charles Abadie, told him, “Syphilis is often the cause of such paralyses.” Grudgingly, Maupassant sought out Charcot. He was desperate.

The consultation occurred in 1886, the same year André Brouillet was immortalizing Charcot in oils. Maupassant explained his symptoms in detail. For years he had struggled with migraine, hair loss, toothache, intestinal bleeding, nervousness, insomnia, and vision problems. “I live with an abominable hypochondria,” he admitted, “and suffer still from a neuralgia of the neck from the nape extending up to the interior of the skull to the base of my eyes and ears. . . . I’m half-broken with fatigue, with headache and nervous illness. Everything pains me and I’ve no relief except for those hours when I write. . . . I only have a sense of well-being when near the sea or in the mountains.”