The Inflamed Mind Page 8

  Fliess was younger, less respectable and less scientifically distinguished than Breuer, but perhaps more liberating creatively for Freud. He was a “brilliant but unbalanced” surgeon in Berlin, who used cocaine enthusiastically as an anaesthetic for operations on the nose, and had an almost mystical interest in the significance of biorhythms, like the menstrual cycle, that oscillated over periods of 23 or 28 days. For about 15 years after they first met in 1887, Fliess and Freud corresponded extensively and conspired to develop a naso-genital theory according to which neurotic or hysterical symptoms originating in the female genitals could be treated by applying cocaine to the nose, or even by a surgical operation on the nose.28

  It was on the train back to Vienna, after visiting Fliess for several days in Berlin in September 1895, perhaps just as his carriage was jolted as it passed over some points in the track, that Freud began to write an essay that crystallised his intellectual switching of tracks from the brain to the mind. He dashed off 40,000 words in a few weeks and urgently sent them to Fliess; how Fliess responded we don’t know because Freud later destroyed all the letters he’d received from him. We do know that years later, when Freud’s passion had cooled to the point that the name Fliess wasn’t mentioned in his autobiography, Freud tried to destroy the only extant copy of the manuscript. It was smuggled out of Nazi Germany by a circuitous route and eventually published in 1950, entitled Project for a Scientific Psychology.29 It is the raw manifesto of psychoanalysis. All the pale-blue volumes in the Institute of Psychiatry library originated from this unfinished and very nearly unpublished blueprint.

  Freud conceived of an elusive psychic energy, which obeyed the physical laws of motion yet was not measurable, as it flowed through chains and circuits of nerve cells, its direction of travel determining the content of consciousness. He illustrated his idea in one of the very few diagrams or graphics he ever incorporated in his prolific output of words (Fig. 5). It was a most audacious effort to reach across the Cartesian divide from his neuroscientific base on the body side to the terra incognita on the mind side. Freud never tested or supported his idea by any laboratory experiments and, given the technological state of neuroscience at the time, he wouldn’t have succeeded even if he’d tried. Freud’s Project aspired to create a new science of the mind based on the emerging science of the brain - and he coined the new word psychoanalysis to summarise this revolutionary agenda - but it did not play out like that. Psychoanalysis might have been first imagined by Freud as a point of connection between the domains of the mind and the body but it subsequently departed ever more completely to the mental side.

  Patients talked and Freud listened. Patients didn’t talk and Freud listened to that too. As he listened to what his patient was or was not saying, he also listened to himself. It was all in the minds of the two of them, in the dialectic of transference and counter-transference. The psychoanalytic relationship became Freud’s new lab. It was in those hours and hours of consultation that he heard or inferred the raw material that he assembled into the books that made him world-famous. Unchained from its original coupling to the brain, psychic energy in the form of libido freely suffused his theories. Libido had a life story that dated back to birth and the infant’s first relationships with its mother and father. Libidinal development could be interrupted or perturbed by the quality of the child’s relationship with its parents, or by the child’s real or fantasised exposure to sexual abuse. Libido could animate consciousness and it could also abide unconsciously, lurking beneath the surface of the mind as a charge of psychic energy attached to traumatic but forgotten memories, furtively driving the formation of symptoms as a twisted alternative to the pain of reliving in adult life the unbounded humiliations and deprivations of childhood. It was the work of psychoanalysis to seek out these libidinal depth charges, buried deep in the mind, and to discharge them cathartically, to release libidinal energy from its infantile attachments and so to relieve the unconscious pressure to make symptoms.

  Figure 5: Freud’s first draft of the ego. Psychic energy, or libido, signified by a cryptic glyph that looks a bit like a Q for quantity, enters this schematic brain and flows from one nerve cell to another. The direction of flow is dictated by the resistance of the gaps between nerve cells and by the extent to which cells are already charged with energy. Freud imagines that the first nerve cell, a, represents a hostile memory. As that cell is activated by psychic energy an unpleasant memory will come to mind. The libidinal energy could then automatically flow through the first cell to activate a second cell, b, a nerve cell for unpleasure or sadness. Alternatively, the group of nerve cells labelled α, β, γ, δ - which Freud called the ego - may already be sufficiently charged with energy to divert the incoming quantum of psychic energy in their direction, away from the unpleasure cell, thus inhibiting the sad feelings that would otherwise be triggered by a hostile memory. It is his original map of a psychological defence mechanism, the ego suppressing subconsciously revoked emotional pain, projected onto the cutting edge neuroscience of his day. Freud’s visionary sketch admits no doubt even about the existence of synaptic gaps between cells, although at the time no one, not even the great Ramón y Cajal, could actually see them (Fig. 8).

  Freud liked to think that he navigated his intellectual journey from the lab bench to the couch in “splendid isolation”. Psychoanalysis was uniquely and entirely his discovery, by an act of heroic self-analysis, and anyone else wishing to become a psychoanalyst must first be analysed by Freud himself, or by someone who had been analysed by Freud. The profession of psychoanalysis was originally constituted like a family, with each analyst dynastically related through their own analysis to the patriarchal authority of Freud. But as the family grew larger it became more fractious and schismatic. Psychoanalytic theory diversified into different species and subspecies, each with their own distinctive jargon and preoccupations, each motivating a different type of what became known generically as psychotherapy.

  These days, a patient seeking treatment for depression in the NHS is unlikely to be inducted into the Freudian lineage by old school psychoanalysis. It takes too long, it’s too expensive and there’s never been much evidence that it works for the theoretical reasons it’s supposed to work, or that it works much better than any other flavour of psychotherapy.30 Most studies have shown that psychological treatment (of some sort) for depression is better than nothing, on average, and that for some people it can be very effective. But it doesn’t seem to matter too much whether it’s Freud’s psychoanalysis, Jung’s analytical psychology, Beck’s cognitive therapy, or another charismatically advocated brand. The best predictor of therapeutic response is not the therapist’s training background, or what’s written in the standard treatment manuals, but the quality of their personal relationship with the patient, the strength of the therapeutic alliance between them. Simply finding someone to talk to, someone who knows, or at least thinks they know, what to say and what not to say, someone thereby empowered to break the circle of silence, may be the most important ingredient of successful psychotherapy for many patients.

  Stigmatisation and psychotherapy are both strongly motivated by the Cartesian divide, by the isolation of depression as a disorder purely of the mind. They are both everyday experiences of living with depression that are conditioned by or compliant with the medically orthodox ideology - we could call it the MOI position - that mind is distinct from body. We might think of stigmatisation as bad and psychotherapy as good but they are equally to be expected in a dualistic world. Much less predictably ordained by the Cartesian settlement, but nonetheless now a matter of routine clinical practice, is the widespread use of anti-depressant drugs.

  In an ideal world, purely illuminated by the light of Cartesian reason, Prozac should never have happened.

  Dancing in the sanatorium

  Drugs are molecules, collections of atoms, tiny pieces of the physical world, that work by targeting and perturbing the biochemical machinery of the body. The existence of
drugs that could have beneficial effects on depression, or any other undesirable mental state, is inconceivable to the extent that you are a hard Cartesian. If you are a radically divisive dualist, who thinks that one’s thought can have nothing to do with anything at all in the physical world, who believes, like Descartes, that the soul can survive the death of the body, then psychoactive drugs are logically impossible. How could targeting a brain or body mechanism for drug treatment make sense if the symptoms are caused by the turbulence of “animal spirits”? It would be like trying to tune a musical instrument by looking at it, rather than listening to it.

  But, in fact, as we all know, many psycho-active drugs exist and have been widely used for various purposes by Homo sapiens for ever. Alcohol, opiates, psilocybin, cannabinoids and atropine are among the mind-altering drugs that early humans discovered in plants and used for prehistoric sacred or healing rituals for about 100,000 years before Hippocrates. The written Hippocratic corpus then prescribed abundant and creative use of medicinal herbs to rebalance temperamental humours throughout the ancient and middle ages. In 17th-century cities like London, the guilds or societies of apothecaries, who specialised in horticulture and the formulation of herbal remedies, were commercially prosperous and professionally ambitious organisations. Sir Hans Sloane, having made a fortune from London property investments and Jamaican sugar plantations, built a beautiful garden for the Apothecaries’ Company in 1673. It was situated close to the river Thames in Chelsea, where he was lord of the manor, so that it was easy for new plants to be shipped in from all over the world. The garden was used to describe, catalogue and investigate freshly imported plants, many of them never before seen by science, from Asia Minor, the Caribbean, America, China and South Africa. Plants were carefully evaluated for their beneficial or useful properties as foods, as sources of fibre for clothing material, and as medicines. It might have seemed to Sloane, the shrewd investor that he was, that nothing could possibly go wrong with this buccaneering business model. Opportunities for research- and-development-led innovation and global sales growth must have beckoned from all angles to a forward-thinking 17th-century apothecary in London. And Sloane was right. Herbal remedies for Hippocratic distempers was a good business, for about 200 years; until about 1850, when Hippocratic theory collapsed under the growing mass of discoveries about the body machine, and herbal remedies began to be seriously challenged and overtaken by the innovation in chemical drugs.

  The success of the Sloane business model, while it lasted, was sustained in the face of torrential sarcasm and incredulity from its ultimate customers, the patients. People who had to consult 17th- and 18th-century physicians, even in sophisticated European cities like Paris, had little hope of coming away any the wiser about the cause of their disease. Physicians were notorious for their impenetrable professional babble, a mumbo-jumbo of non sequiturs and circularity, obscured by as many Greek and Latin words as possible. Satirists like Voltaire and Molière filled theatres with their dark comedies about medical buffoonery, venality and lethality.

  Molière must have consulted many physicians, sometimes desperately and against his better judgment, because at the peak of his career he was in the process of dying from consumption, as tuberculosis (TB) was then called. He would have heard physicians pontificate to him and contend with each other; he knew their combination of pomposity and incompetence very well. At the start of Le malade imaginaire,31 a comedy-ballet he composed as a divertissement for King Louis XIV, the curtain rises on a shepherdess, singing sweetly:

  Doctors, your learning is purely illusion

  Your remedies rubbish, your order confusion

  Your big Latin words are unable to cure

  This sickening sadness I have to endure

  So from my sorrow, one thing is sure;

  Doctors, your learning is simply absurd.

  Before it was scientifically diagnosed as TB and antibiotics were available to treat it, many men and women would die of consumption, like Molière. But he was perhaps the only man in history to do so on stage. For the Parisian début of this new and final play of his, Molière himself played the central part of the hypochondriac. On the fourth night of the opening production, he started coughing up gouts of blood, for real, the spreading red stains on his green satin costume clearly visible even from the cheapest seats. He collapsed in front of his audience and died a few hours later. It was, for one night only, the ultimate coup de théâtre in his life-long campaign against Hippocratic medicine.

  You might ask yourself, if things were really as bad as Molière was saying, why were any of the fashionable Parisian theatre-goers who thronged to his plays still consulting these ludicrous physicians? Once he’d told them the truth about their doctors they could have walked away; but instead they laughed. They couldn’t walk away. Even the most discerning customers couldn’t kill the business model, because they had nowhere else to go, and, sure as hell, they were going to get sick at some point. The Hippocratic business was robust to any amount of reputational risk while it was the only game in town. But it imploded completely in the face of competition, once chemical as well as herbal medicines began to be available to patients.

  Being a supremely well-connected physician and scientist, Sir Hans Sloane would probably have heard of the first prophet of doom for his business model, even as he was investing in the Chelsea Physic Garden in the 1670s. The prophet’s real name was Philippus Aureolus Theophrastus Bombastus von Hohenheim but when he was about 30, in the 1520s, he started calling himself Paracelsus. His father was a Swiss physician and he was apprenticed in medicine and alchemy from an early age. He was self-confident, talented, perfectly poised for a conventional medical career. But he would not allow himself to be trained, or licensed, in the Hippocratic tradition. He publicly burnt copies of the ancient corpus, criticised apothecaries for selling hocus-pocus potions, and despised academic physicians. He deliberately outraged the medical authorities in every city he visited; and so he was driven from Basel to Zurich, from Zurich to Heidelberg, from city to city, all his life. He thought of himself as a radical reformer of medicine on the same scale as Martin Luther was a reformer of the Church. Instead of four Hippocratic humours, he modestly proposed three Paracelsian elements (sulphur, mercury and salt) and he used these as the principal ingredients in his chemical remedies.

  When he wandered into Nuremberg in 1529, the local physicians were goaded by his taunts and sneers to challenge him to cure the incurable: 15 patients with the French disease, as the ongoing plague of syphilis was then known by German-speaking people. Paracelsus visited the patients in the leper colony, where they were held outside the town walls, and it was almost miraculous what he did - the skin ulcers and sores of the syphilitic patients vanished (or at least some of them did) - thanks to his innovative and secretive use of a mercury ointment. It wasn’t quite the cure he said it was. Mercury killed the syphilitic germs that it contacted on the skin - which helped the visible ulcers heal - but there were many untreated and invisible germs in the body that his ointment couldn’t reach. Still, it was good enough to get him safely out of Nuremberg and back on the open road, where 12 years later he was killed in a drunken brawl outside Salzburg (Fig. 6).

  Paracelsus died penniless and without honour in his own time, but he did foresee the future correctly in some ways. Three hundred years after his death, in the second half of the 19th century, the Hippocratic establishment he’d raged against all his life was finally collapsing in the face of Cartesian medicine. And the first pharmaceutical companies, like Merck and Roche, had begun using chemistry rather than alchemy to discover, purify, measure and manufacture drugs. A new industry began to grow from chemical and dye companies, many of them founded in cities like Basel, that had been much frequented by Paracelsus. The pharmaceutical industry was getting organised to do what he had tried to do in his alchemical workshop, but big time, and with the benefit of better science.

  Figure 6: First prophet of pharmaceuticals. Paracelsus was
neither pretty nor manly looking. He never married and he couldn’t grow a beard. It is said that he might have suffered a nasty case of mumps before puberty, which infected and destroyed his testes. But his personal motto, inscribed in the border in this image, was defiantly self-assertive: “Let no man belong to another who can belong to himself.” He is surrounded by occult symbols of his hermetic knowledge, like the Rosicrucian motif of a child’s head emerging from the landscape visible through the window behind him. And he is clutching with both hands his immense sword of mysterious provenance, called Azoth, a magic word for the force of nature. You’d never guess from this composed and esoteric portrait but Paracelsus was notoriously argumentative when drunk, and quick to start slashing the air with Azoth to make his points even clearer to the idiots with whom he was debating. Experts believe this may have had something to do with his violent death in a tavern at the age of 48. Those of us living after Freud might also think of the mighty Azoth as a phallic symbol compensating for his lived experience of castration.

  The first breakthrough pharmaceuticals were the new wonder drugs for infectious diseases that started appearing on the market in the first half of the 20th century. Paracelsus’s mercury cure for syphilis, which was often as dangerous to the patient as the disease, was supplanted by more effective and less toxic chemical drugs from about 1910. Penicillin - the first antibiotic pharmaceutical - proved to be extremely effective and safe as a treatment for syphilis and other infections from the 1940s. Other new antibiotic drugs were produced for the treatment of TB in the 1940s and 1950s, including one that eventually and unexpectedly opened up a huge pharmaceutical business for the treatment of depression. The age of Prozac originated accidentally from this great wave of innovation in antibiotics.