The Makings of Modern Madness

T he paradigm of mind–brain dualism, like the story of syphilis, is by no means virgin territory. However, Allan Ropper and Brian Burrell’s How The Brain Lost Its Mind: Sex, Hysteria, and the Riddle of Mental Illness puts both the legacy of dualism and the story of syphilis under the microscope, and offers a novel “redress [to the] derailing of a coordinated neurological and psychiatric approach to mental illness.” With the experience of a leading academic neurologist (Ropper) and an authority on brain collections (Burrell), the pair team up for their second book. They present a highly readable switched-at-birth story in which the discipline of neurology pursued an inscrutable malady termed “hysteria” and the emerging field of psychiatry gained purchase through claiming as its own the first known organically based cause of mental illness, neurosyphilis.

Neurosyphilis is a sexually transmitted disease that manifests years after infection with prominent psychosis and mania. Hysteria, which has gone by many names, from neurasthenia to functional neurological disorder, remains a common but elusive phenomenon in which neurological symptoms have no obvious neurological basis and, thus, are attributed to a psychiatric origin. But there’s the rub: We cannot help but describe mental illness without reinforcing these neurological–psychiatric and brain–mind antitheses. This book excels in explaining the source and maintenance of these divisions in the early makings of modern madness.

The book is framed at the outset by inviting the reader into a doctor’s perspective, through an artistic lens. It begins with an illustration of André Brouillet’s classic painting A Clinical Lesson at the Salpêtrière Hospital, sitting the reader down in the midst of the first clinical neurologist’s teaching hospital. It was there that the neurologist Jean-Martin Charcot — who described ALS and multiple sclerosis in the mid 19th century — became obsessed with the causes of convulsions. He observed in autopsies that the brains of epileptics had lesions, indicating a structural basis for their seizures. But the brains of those with grand hysterie appeared normal; he concluded that convulsions in their case were caused by unseen, so-called dynamic lesions. The painting depicts Charcot’s most famous patient, a swooning hysteric in a sexually charged pose, embodying the inseparable nature of sex and madness in the modern mind. His protégées (including Gilles de la Tourette and Sigmund Freud), who developed the foundations of neurology and psychiatry, would respond to or refute his theories as they explored for themselves the secrets of mental illness.

Major inflection points in the unfolding understanding of these diseases are described in a series of easy narratives introducing key medical figures such as Charcot, Freud, Phillipe Pinel, Alexander Fleming, and Thomas Parran Jr., and the history is grounded subtly in the methodical medical approach as we follow these diseases through observation, hypothesis, laboratory discovery, treatment, and their societal implications. The relationship between sex and madness fostered in this 19th-century medical milieu is shown to have infected the arts and letters as well. Literary characters as diverse as Stoker’s Dracula and Conrad’s Colonel Kurtz become diagnosed as cultural carriers of society’s widespread angst regarding syphilis—the public caught between an attraction for and repulsion at the madness syphilis could inflict upon genius.

The arts and sciences can make strange bedfellows, but one of the real successes of this book is the way it draws new connections between well-visited subjects that are usually siloed in their own fields and shows their contribution to the current understanding of mental health and disease. Shifting attitudes towards sexual health and mental health often went hand in hand, and this is finely contextualized in explorations of public-health successes — and scandals, such as the Tuskegee Syphilis Study, in which marginalized groups disproportionately susceptible to certain diseases were mistreated.

In the last third of the book the story pivots away from hysteria and neurosyphilis entirely, to new conundrums about the organic vs. inorganic causes of maladies. Tourette, before he likely succumbed to neurosyphilis, was a talented physician who described a constellation of obsessive compulsive traits and tics we now call Tourette Syndrome. The inexplicable remained a moral eccentricity or a psychiatric condition until modern-day antipsychotic medications were shown to alleviate symptoms. A pharmacologic response grounded Tourette’s in a yet-to-be-elucidated biological basis, but biological nonetheless, and in doing so further troubled the borders between neurology and psychiatry.

The authors then turn to the age of psychotropic medications and what their effectiveness means for this or that psychiatric illness, a topic that is within the bounds of their thesis, but nevertheless feels tangential to the incredible narrative power of their historical investigation of the twin subjects, syphilis and hysteria. A final peroration revisits a theme of over-medicalizing the norm, the phenomenon of ascribing pathology to normal variation in human behavior. The discussion may feel disparaging of patients’ complaints to those who do not have direct experience with this very real concern creeping into consultation rooms, but the authors’ point is to emphasize that a disjointed psychiatric vs. neurologic approach to mental illness leaves the medical field susceptible to the threats of fads, misinformation, and inefficacies when attempting to formulate a coherent approach to brain diseases with cognitive, behavioral, and affective features, from obsessive compulsive disorder to schizophrenia to depression.

This soberly researched and engagingly told history is a must-read for anyone curious to better understand how genius, madness, and sex got mixed up over the course of neurology and psychiatry’s quest to understand and treat two canonical diseases.