How the Brain Lost Its Mind

Description

A noted neurologist challenges widespread misunderstandings about brain disease and mental illness.

Why do we think of mental illness as a brain disease? Is there a difference between a sick mind and a sick brain? How the Brain Lost Its Mind, written by a prominent neurologist and a student of medical history, traces the origins of our ideas about insanity and the collision course that simply reduces the mind to the connections between nerve cells. Starting with syphilis of the brain, the disease that made insanity a medical problem and started the field of psychiatry, the authors study a host of famous and infamous characters–among them van Gogh, the Marquis de Sade, Nietzsche, Guy de Maupassant, and Al Capone.

How the Brain Lost Its Mind explains how we have twisted ourselves into the medicalization of every minor mood and thought, each with a pill to cure the psychopathology of ordinary daily life. How are we to understand serious disorders such as schizophrenia and Tourette’s syndrome, in which the brain under the microscope is entirely normal? By delving into an overlooked history, this book shows how neuroscience and brain scans alone cannot account for a robust mental life, or a deeply disturbed one.“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 at Columbia University Vagelos College of Physicians and Surgeons; Past President of the American Psychiatric Association; 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 makes 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 at 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 co-author, 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 at Harvard Medical School; author of The Frontal Brain and Language

“A thrilling journey from the dramatic common origins of neurology and psychiatry, through their historical divergence, to their current realignment.  The medical, scientific and social histories of two fascinating conditions are brilliantly interwoven and contrasted. Fascinating stories, masterfully told, bring to life the notable patients who suffered with these strange maladies, and the extraordinary doctors who treated them as they sought cures. This is essential and engaging reading for anyone who wants to understand these most interesting medical and philosophical issues, and how they have played out across continents and centuries.”—David Silbersweig, MD, chairman, Department of Psychiatry, co-director, Center for the Neurosciences, Brigham and Women’s Hospital; Stanley Cobb Professor of Psychiatry, Harvard Medical School

“A page-turner vividly depicting the struggles of medicine’s perennial sibling rivals: neurology and psychiatry. The dramatic interactions between clinical investigators and patients—occasionally one and the same—demonstrate how ideas relating mind to brain pervasively influence our sense of ourselves.”—Paul McHugh, MD, Chairman Emeritus of Psychiatry, Johns Hopkins University School of Medicine

“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, PhD, author of The Biological Mind; Professor of Biological Engineering, Brain & Cognitive Sciences, Nuclear Science & Engineering

“Know someone who has bizarre thoughts or strange behaviors? Ever wonder whether it means mental illness or a brain disease or both? Ropper and Burrell have written an insightful, fantastically readable analysis of what was once called ‘hysteria.’ Also, by studying how things can go wrong, we learn a great deal about the working of the human mind when things go right.”—Elizabeth Loftus, PhD, Distinguished Professor of Psychological Science, University of California, Irvine; author of Eyewitness Testimony

“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 well written 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

“A compelling read.”—Library JournalAllan H. Ropper, M.D., is professor of neurology at Harvard Medical School and Raymond D. Adams Master Clinician of the Department of Neurology at Brigham and Women’s Hospital. He is also a deputy editor of The New England Journal of Medicine and a fellow of the American Academy of Neurology, the Royal College of Physicians, and the American College of Physicians. Dr. Ropper is an author of the most widely consulted textbook of neurology, Principles of Neurology, currently in its eleventh edition, and coauthor with Brian David Burrell of Reaching Down the Rabbit Hole.

Brian David Burrell is a member of the mathematics faculty at the University of Massachusetts Amherst. A teacher and writer, he is the author of several books, including Postcards from the Brain Museum, The Words We Live By, and, jointly with Dr. Allan H. Ropper, Reaching Down the Rabbit Hole. He is an authority on brain collections worldwide, and has discussed his work on NBC’s Today, C-SPAN’s Booknotes, and NPR’s Morning Edition.

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’ecole-de-Medecine, 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 Andre Brouillet, a journeyman artist who studied with the great Jean-Leon Gerome, had a moment of passing fame, and then slid back into obscurity. He titled the work Une Leon Clinique a la Salpetriere (A Clinical Lesson at the Salpetriere 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 Gerome 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 piece de resistance, 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 Napoleon of the Salpetriere. 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 Leon 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 similar-looking 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 Leon 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 Salpetriere 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 Pitie-Salpetriere 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 Salpetriere posed a great danger. The self-sufficient isolation of the place set Charcot up for the biggest mistake of his career.

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