How the Brain Lost its Mind
Authors: Allan Ropper and B.D. Burrell
The overarching philosophical theme of this book is the ageless ‘mind versus brain‘ debate, a discourse that has raged for eons and engendered a rift between neurology and psychiatry. And the subject matter at the heart of the book is neurosyphilis – the similarly enduring disease that has straddled the boundary between the two specialisms. The authors tackle what they see as the false dichotomy between the contrasting ways in which neurologists and psychiatrists approach ‘the central question of the nature of mental illness’, each conceiving it ‘from their own vantage point‘, with both engaged in ‘a kind of algorithmic minuet, dispensing diagnoses and drugs‘. In seeking to bridge this ‘regrettable split‘ which they blamed on the ‘bad science‘ of hysteria championed by the great neurologist Jean-Martin Charcot, the authors propose that the history of neurosyphilis offers ‘some common ground‘ on which ‘to begin the conversation anew’. With wide-ranging arguments that traverses history, science, and the arts, the book sets out ‘a coordinated neurological and psychiatric approach to mental illness’ which is anchored on ‘sharing our perspectives‘ (pages xi, 9, 11-15, 86 and 197).
In its comprehensive historical portrayal of syphilis, the book harnessed the powers of metaphor and allegory to illustrate the diverse dimensions of the iconic disease. For example, in referring to it as The Great Imitator, the nickname given to it by the venereologist Jonathan Hutchinson, the authors convey the nature of syphilis which, by its protean clinical features, may pass for such diseases as smallpox, leprosy, and epilepsy. Cupid’s disease, another epithet the authors used, reflects the disease’s proficient sexual transmission – the mechanism by which it ‘cast a pall over the sexual lives of people from all walks of life for the better part of a century’. Another monicker which syphilis acquired is The Great Pox, a reminder of its disfiguring dermatological manifestations. The authors also crafted their own symbolic representations of syphilis such as when they alluded to its interminably long latent period and caricatured it as ‘a kind of insidious Trojan horse‘ which, after lurking for decades, can ‘bring down its victim in just a few years’. Similarly, in referring to its tenacious perseverance, the book represented syphilis as ‘the cockroach of the bacterial world, destined to survive the antibiotic holocaust‘. Further stressing this enduring attribute of syphilis, the authors pointed out that the disease is already staging a ‘steady comeback‘, and they ominously warned that any hopes of completely eradicating it is ‘just wishful thinking‘ (page xi, 68-69, 85 and 202-203).
In chronicling the evolution of the scientific understanding of syphilis, the book focused on the contributions of the early scientists who researched its clinical and pathological features. The authors traced the earliest recognition of syphilis as a distinctive disease to Philippe Ricord who distinguished it from gonorrhoea, and who documented its progression from chancre to gumma. The book however attributed the turning point in the understanding of neurosyphilis to the autopsy studies of Antoine Bayle which had demonstrated meningeal inflammation in the brains of young people who had suffered with insanity. True to scientific form, the authors noted that Bayle’s contemporaries, unwilling to countenance any connection between madness and brain disease, disparaged his findings until Florentin Calmeil confirmed the pathological findings, and went on to name the disease general paralysis of the insane. The authors argued that the focus Calmeil and later psychiatrists such as Wilhem Griesinger placed on the mental manifestations of neurosyphilis made it ‘the first genuine psychiatric disease’, and this enabled psychiatry to become established as a ‘branch of medicine‘. Other scientists the book commended for further defining neurosyphilis included Douglas Argyll Robertson who described ‘prostitutes pupil‘, and Moritz Heinrich Romberg who recognised the inability of people with tabes dorsalis to stand steadily with their eyes shut (pages xi, 58-60, 69-70 and 79-84).
The later history of neurosyphilis was as compelling as its earlier stages, and the book chronicled this with an emphasis on the major breakthroughs that established the investigations and treatments of the disease. One such advance was the discovery, based on the original aniline dye experiments of William Henry Perkin, that Treponema pallidum, the spirochete that causes syphilis, can be stained with methylene blue. Other significant landmarks in the testing for syphilis which the book reviewed included the introduction of a complement blood test by August von Wasserman, and the demonstration of syphilis in the brain by Hideyo Noguchi. On the therapeutic front, the authors noted the impactful discoveries of salvarsan by Paul Ehrlich, and of pyrotherapy by Julius Wagner-Jauregg. They also celebrated the research of Alexander Fleming, Howard Florey, Ernst Chain, and John Mahoney on penicillin. Conversely, the book also explored the dark history of syphilis research; this was symbolised by the infamous Tuskagee Syphilis Study which sought to document the disease’s natural history by deceptively withholding treatment from 399 black men, and by the Guatemala syphilis experiments which set out to work out the effective dose of penicillin by deliberately infecting people with the disease (pages 113-124 and 132-146).
The lives of the historical victims of neurosyphilis, many of them colourful and unconventional personalities, formed a major theme of the book. One figure who stood out in this regard was Guy de Maupassant, the writer who the book depicted as ‘almost pathologically drawn to women’. The authors described his dramatic mental decline which started with delusions, and culminated in confinement in a mental asylum. It will be unsettling for Charcot enthusiasts when the authors asserted that he misdiagnosed Maupassant as suffering with neurasthenia, the male equivalent of hysteria, an error the authors contend was the ‘biggest mistake of his career’. Another prominent, and perhaps surprising, inclusion in the book’s pantheon of neurosyphilis casualties was Gilles de la Tourette, a Charcot-protégé who the authors claimed contracted syphilis as a medical student; they went on to narrate how the disease ‘deranged his mind‘, and how he ‘descended into madness‘ with grandiose delusions. Other notable personalities the book cited as preys of neurosyphilis included the playwright Alphonse Daudet, the philosopher Friedrich Nietzsche, the painters Edouard Monet and Vincent van Gogh, and Lord Randolph – Winston Churchill‘s grandfather (pages 15-24, 59-64 and 91-92).
The key lesson the authors extracted from their comprehensive overview of the history of neurosyphilis is that disorders of the mind are as much ‘diseases of brain structure and function‘ as other neurological diseases. In tracing its journey from psychiatry to neurology, the book not only depicts neurosyphilis as the metaphoric disease by which all mental disorders should be conceived, it also portrays it as ‘the ideal lens through which to view all forms of mental alienation‘. The book maintains that even though mental illnesses such as schizophrenia and bipolar illness have ‘no scientific explanation‘ yet, they are nevertheless ‘true’ brain diseases because the brain is the ‘platform for the mind‘. In extending their thesis to the therapeutic plane, the authors advocated for a ‘convergence‘ of treatments for neurological and psychiatric disorders, arguing that both are manifestations of disordered brain mechanisms. And to justify this line of thinking, they referred to how the antipsychotic drug chlorpromazine, and the anti-parkinsonian drug levodopa, both exert their effects on the brain’s dopamine pathway (pages 2-6, 154-186 and 209-212).
This is a rip-roaring account of one of the most fascinating and devastating medical diseases. With intriguing stories from the history of medicine and the arts, the book forensically documents the nature of a disease which has defined medicine as much as it has influenced society and culture. Although the authors contend that neurosyphilis lies at the heart of the schism between neurology and psychiatry, they nevertheless also see in it the key to the reconciliation of the two specialties. The book however did not set out clear recommendations for aligning neurological and psychiatric practice, nor did it harmonise its assertion of a common origin of psychiatric and neurological diseases with its admission that pathological evidence of mental diseases may never be established. The principle behind the authors arguments is however sound, and they supported their contentions with sufficient historical material.
This book is not only a study in the clinical manifestation of a great historical disease, it is a call to consider a unified view of all mental diseases as disorders of the brain. The book justifies this convergence on the remarkable history of the transformation of the scientific understanding of neurosyphilis, and on its attribution of the split between neurology and psychiatry to historical errors. The book teaches the need to keep an open mind on the way we conceptualise all diseases, and the requirement for flexibility in their classification. These lessons are relevant to all of medicine, and I recommend the book to all doctors.
Publisher, Place, Year: Atlantic Books, London, 2019
Number of chapters: 17
Number of pages: 243
Star rating: 5