Madness: A Very Short Introduction - Andrew Scull 2011

Madness and meaning

The German psychiatry that played such a prominent role in murdering its patients had established itself as the most prestigious branch of the emerging profession in the second half of the 19th century, a period when German medicine in general was forging close links with science and the laboratory and was widely acknowledged to be the best in the world. In the French-and English-speaking worlds, mad-doctoring remained essentially an administrative speciality, and one shorn of any links to the university, to research, or to formalized training. Would-be psychiatrists learned their trade by apprenticeship, taking on unpaid junior positions in barracks-asylums, and then moving up the bureaucratic ranks little by little before eventually (they hoped) securing a position as asylum superintendent, whence they could rule, in autocratic fashion, over miniature kingdoms of the mad. But whatever degree of authority they purported to exercise in these Potemkin villages, they were locked away in them almost as securely as their charges. They remained conspicuously mired in the status of salaried employees, and were forced to confront and cope with a clientele composed of the least attractive members of the lower orders of society. Like similarly situated groups such as workhouse doctors and public health officers, they could lay claim to at best a tenuous hold on social respectability, and but a paltry measure of the autonomy usually granted to those engaged in professional work. Those who eschewed the public asylums might move to the private sector and take charge of a profit-making madhouse, but that brought its own sort of stigma. For though the trade might prove lucrative, it was a grubby sort of business, too overtly tied to the pursuit of profit from speculating in human misery, too self-evidently at odds with the ideological construct of a disinterested profession.

By contrast, German psychiatrists pioneered a quite different mode of practice. Like their counterparts in internal medicine, they built solid ties to the world of the university and the laboratory. Indeed, the founding father of the German specialty was Wilhelm Griesinger, a man who had established his reputation as an expert on infectious diseases as professor of medicine at the University of Tübingen and subsequently as professor of pathology at Kiel, before becoming director of the Canton hospital and mental asylum at Zürich in 1860. Early in his career, Griesinger had spent a short period as a junior doctor at an asylum at Winnenthal, and in 1845 had audaciously published a textbook of psychiatry. At Zürich, he produced a vastly expanded second edition, and shortly thereafter moved to Berlin, finally occupying a chair in psychiatry.

Borrowing from the now well-established pattern in German medicine, Griesinger established a new model of practice, one that linked research and teaching via the university clinic. Asylums were relegated to being a source of clinical material, and it was the clinics and their associated laboratories and research institutes that became the core of a novel approach to medicalizing madness. Two decades earlier, Griesinger had proclaimed that all mental illness was brain disease. Henceforth, the German psychiatric enterprise that built on the foundations he had laid would embrace this speculative claim as the basis of a new science. With a new journal, the Archiv für Psychiatrie und Nervenkrankheiten (the Archives of Psychiatry and Nervous Diseases), basic research into brain pathology moved to the fore.

Griesinger was not around to see it, for within months of writing a truculent editorial for the first issue of the Archiv, he was dead of a ruptured appendix. Nonetheless, his view that psychiatry must ’emerge from its closed-off status as a guild and become an integral part of general medicine accessible to all medical circles’ continued to inspire his colleagues, as did his insistence that ’patients with so-called “mental illnesses” are really individuals with diseases of the nerves and the brain’.

On one level, the results of this emphasis on brain pathology and on the centrality of the laboratory were impressive. German psychiatrists looked to be engaged in the same sorts of activities as their erstwhile medical colleagues. Focusing on anatomy, men like Flechsig, Alzheimer, Nissl, and Meynert (the latter working in Vienna) dedicated themselves to the study of the architecture of the brain and spinal cord. They developed techniques for fixing and staining brain tissues for microscopic examination, and occasionally, as with Alzheimer’s discovery of the plaques and tangles in the brains of those with the illness that came to be named after him, they were able to uncover links between mental symptoms and underlying pathology of the tissues. But none of this basic science made any contribution whatsoever to clinical care, let alone cure. On the contrary, Alzheimer’s disease was the model for German psychiatry’s heavily pessimistic view of the therapeutic prospects of the mad.

For the overwhelming majority of mental patients, the aetiology of their disorders remained as mysterious as ever. The best efforts of all this laboratory science led nowhere. The claims about the connections between brain disease and mental illness remained an article of faith, not a demonstrable fact (just as they do for the most part today). ’Brain pathology’ was, in truth, brain mythology. Moreover, the emphasis on supposed structural defects in the brains of the mad fed into the generalized despondency of the degenerationist era. German psychiatrists shared the conviction that mental illnesses were essentially untreatable diseases.

Though patients in the clinics of the general hospitals served as teaching material, the much larger numbers of chronic patients in the huge state asylums served only as a source of specimens for the microscope and the dissecting table, once they finally expired. Academic psychiatrists otherwise evinced no interest in them and abandoned them to their fate.

Emil Kraepelin had problems with his eyesight, precluding him from participating in the laboratory activities that preoccupied most of his colleagues. Perhaps consequently, perhaps not, he became increasingly sceptical of the claims of the cerebral pathologists, which he rightly saw as speculative and, ironically, not rooted in empirical findings, for all their asserted scientific rigour. He turned instead to the longitudinal study of the fate of the masses in the asylum, seeking to map the natural history of mental disorder. The upshot was the creation of a new nosology, a classification of types of mental illness that he spread through successive editions of an increasingly influential textbook. Where many had viewed madness or psychosis as a unitary entity, under Kraepelin’s influence, henceforth the emphasis on its division into specific disease entities would mark the field. Most critical was the division between what were asserted to be two different forms of madness: dementia praecox (relabelled as schizophrenia in 1910 by the Swiss psychiatrist Eugen Bleuler, who saw it as not necessarily involving dementia or restricted to the young); and the at first no more than residual category of manic-depressive psychosis, held to be an only somewhat less pernicious, because sometimes remitting, form of mental illness.

If Kraepelin’s views became clinical orthodoxy among institutional psychiatrists, they did not mark any fundamental break from the pessimism and biological assumptions that had come to mark the field - or from its embrace of eugenics, of which Kraepelin was a major proponent. Dementia praecox and its subtypes (hebephrenic, catatonic, paranoid) was by far the most important form of psychosis for Kraepelin and his followers, and it embodied in its very name (’early dementia’) the notion of irreversible clinical and cognitive decline. Kraepelin emphasized the presence of delusions and auditory hallucinations, disorders of thinking, and the flattening of affect. Here were patients exhibiting incoherence, agitation, and an inability to form relationships with others, their grossly disturbed thought processes eventually subsiding into an increasingly denuded mental universe. That their prospects of recovery were essentially nil only added to the gloominess that surrounded the diagnosis.

Talk of degeneration and dementia seemed to locate madness among the socially marginal, the poor, and the despised. In reality, mental disturbance observed no such social limits. Indeed, as madness drew more attention, and presumed experts on mental disturbance proliferated, so too did the range of conditions psychiatrists spoke of as akin to mental illness and within their sphere of competence. The French spoke of demi-fous, the half-mad, the English and the Americans of those dwelling on the borderlands of insanity, inhabitants of the shadowy region the British physician Mortimer Granville called ’Mazeland, Dazeland, and Driftland’. Here were still somewhat functional, often affluent, patients, desperate to avoid falling into the pit of the asylum, and simultaneously the source of perhaps more treatable and certainly more lucrative and socially desirable patients.

It was in this context that the ancient category of hysteria enjoyed new prominence in the last third of the 19th century. All across Europe and North America, women especially (though not exclusively) seemed to fall into fits, to be troubled with paralyses with no obvious physical cause, to exhibit extreme emotional instability, to utter cries and shrieks, and to resort to seemingly impossible physical contortions. The most flamboyant and dramatic enactments of this seeming epidemic of mental disorder were staged at a clinic in Paris, where the most famous neurologist in the world, Jean-Martin Charcot, served as master of ceremonies. Here the half-mad disported themselves on cue before an audience of intellectuals, politicians, and demi-mondaines.

These occasions were, as one critic acerbically noted, a sort of ’vivisection of women’, a hysterical circus with unmistakable erotic overtones, and thus, of course, immensely popular and widely publicized. Tuesday after Tuesday, the grand old man of French neurology acted as master of ceremonies, inducing a kaleidoscope of dramatic symptomatology with a wave of his hand and the force of his gaze. Hysteria was, he insisted, a real neurological disease, and those exhibiting it were indeed a degenerate lot. Yet for all Charcot’s eminence, the whole enterprise had a disreputable air. The bane of fin-de-siècle medicine, the ’disease’ that Philadelphia neurologist Silas Weir Mitchell despairingly called ’mysteria’, was regarded by many contemporaries as a form of fraud or dissimulation; and hypnotism, the intervention on which Charcot relied to entertain and instruct his audience, was in their eyes no more than a relabelled form of mesmerism, long dismissed by respectable medical men as mere quackery. Unsurprisingly, on Charcot’s death in 1893, his circus rapidly ceased operations, but the disease itself lingered on, though the epicentre of the disorder mysteriously drifted some hundreds of miles to the east, to a soon-to-be-famous set of consulting rooms at Berggasse 19 in Vienna.

13. A hysterical spasm of the entire body of Paule G, provoked by stroking her right forearm. Her rigid body spans two stools. An image taken from Leçons cliniques sur I’hystérie et I’hypnotisme (Paris, 1891)

Hysteria had been joined in the 1880s by a new mental malady of the affluent professional classes, neurasthenia - literally, weakness of the nerves - a mental disorder brought on, so its proponents claimed, by overwork and the pace of modern civilization. Overdrawing their stock of nervous energy, running down their batteries, bankrupting their brains - or so the theorists of marginal madness put it, in metaphors sure to flatter those they sought to attract and treat - the rich and the successful also succumbed to mental distress and breakdown. Naturally enough, these captains of industry and finance, these representatives of the best and the brightest, did not look kindly upon suggestions that they were a biologically inferior lot. Nor did they relish confinement in the warehouses of the unwanted that asylums had now become. Much more palatable was an alternative vision of the sources of mental disturbance that some now began to advance, among neurologists and other ’nerve doctors’ on both sides of the Atlantic, one that sought explanations in the realm of human psychology, and treatment by psychodynamic means, preferably on an out-patient basis.

It would be wholly wrong to attribute this challenge to biologically based psychiatry as the product of one person. On the contrary, men like George Beard and Morton Prince in the United States, Paul Dubois in Switzerland, and Pierre Janet in France (to say nothing of religiously based mind-healing cults, like Mary Baker Eddy’s Christian Science) were busy inventing their own explanations and interventions for these protean forms of mental upset. But nowhere were these innovations developed more powerfully and effectively than in Vienna, where Sigmund Freud began to proclaim that madness had meaning - indeed, was produced at the level of meaning, and had to be cured at the level of meaning.

Based on the first few cases he treated with his older colleague Josef Breuer in the 1880s, Freud had largely abandoned what he came to regard as the somatic prejudices of his youth. His hysterical patients, he thought, were suffering from repressed traumatic memories, memories that provoked the symptoms they now manifested. And their symptoms, he initially surmised, could be relieved by recalling what had been driven underground. Utilizing hypnosis, as earlier repressed experiences surfaced, a process of emotional catharsis ensued, and the patient could be pulled back from the brink of insanity.

Freud rapidly lost his faith in hypnosis and the cathartic method, but not his conviction that the sources of the mental disturbances among his patients lay in ’murdered memories’, or rather in thoughts too disturbing to admit to one’s consciousness. In the hothouse atmosphere of fin-de-siècle Vienna, he gradually developed an ever more elaborate model of human psychology, one largely based on clinical encounters with a small number of, mostly female, patients drawn from the ranks of the Jewish haute bourgeoisie. It was a theory he and his followers came to see as equally applicable to the mad and the sane, the hysterical and the ’normal’. It placed sex at the centre of our very being, though it moved from an initial claim that actual seductions and sexual molestations were at the root of psychopathology to a subsequent emphasis on fantasy and the purportedly universal and critical impact of the child’s hitherto overlooked ’erotic’ relations with his or her parents.

Over the course of a decade, between 1895 and 1905, Freud developed the notion that the libido, the unconscious sexual drive, was the central psychological underpinning for all human beings.

All sorts of psychological discomforts and disturbances flowed from that fundamental reality, and from civilization’s demands that these forces be channelled in ’acceptable’ directions - a fraught process, and one that often remained incomplete and unsatisfactory. The nuclear family was the scene of often frightful and dangerous psychodramas that populated the unconscious, fomented its repressions, and created its psychopathologies. As the infant struggled to grow up, and the child to mature, the perils of Oedipal conflicts awaited - the unacknowledged and unacknowledgeable desire for an erotic relationship with the parent of the opposite sex - and too often wreaked havoc on the adult personality. Forced to repress unacceptable desires, to deny their fantasies, or to drive them underground, children were riven with psychic conflict. Cravings and suppressions, a search for substitute satisfactions, false forgetting, the constraints of ’civilized’ morality - in all these respects and more, the conflict between Eros and Psyche created a minefield from which few emerged unscathed and unscarred. Madness was not just a problem of the Other, therefore, not a condition unique to the degraded and degenerate, but on the contrary, lurked to some degree within all of us. Sublimated in other directions and with greater success, the same forces that led one to mental invalidism allowed another to produce accomplishments of surpassing cultural importance. Civilization and its discontents were locked in an indissoluble embrace.

To say the least, these were controversial claims, and they were far from obtaining universal consent, either among Freud’s fellow psychiatrists, or among the public at large. If they were taken seriously, however, they provided a very different perspective on the disturbed thoughts and behaviours of the mentally ill. Instead of being meaningless noise, the epiphenomenal manifestations of a physically damaged brain, psychoanalysis (as Freud’s system came to be called) insisted that disturbed affect, cognition, and actions were of the utmost significance, and held the key to unlocking the wellsprings of madness. They provided clues that might be pieced together to allow the patient to grasp the underlying dynamics of his or her disordered personality. Making manifest what the psyche invested so much energy in burying, so the psychoanalysts proclaimed, was a profoundly difficult task, one that took courage and determination on the part of both patient and therapist, and that inevitably required months, if not years, of probing deeply rooted defences to force the unconscious into consciousness. In place of the public theatre of Charcot’s demonstrations, an intimate drama à deux materialized, one hidden behind the doors of the consulting room and the studied silence of the psychoanalyst.

Psychodynamic accounts of the origins of madness thus went hand in hand with a new emphasis on listening to the mad, and teasing out from their utterances the symbolic meanings of their symptoms, the psychological roots of their disturbance, and the means of reconstructing their damaged psyches. Though initially developed to diagnose and treat still ambulatory, if disturbed and distressed, neurotics, in succeeding generations, and most especially in North America, Freud’s notion that madness and its cure were rooted in systems of meaning eventually was broadened to encompass even the most seriously psychotic. That was not an extension of which he personally approved, but after his death, it happened anyway.

Such was the cultural resonance of the psychoanalytic project, as it provided novel insight into human personality and human action, that soon its interpretations of the clash between Eros and Civilization leaked out of the realm of the pathological into discussions of the psychopathology of everyday life; and then into the arts. Freud himself had led the way in suggesting that psychoanalytic theory could be used to advance the interpretation of art, in speculative essays about Leonardo and Michelangelo, and his work was rife with literary allusions, beginning, of course, with the central concept of the Oedipus complex. Other psychoanalysts purported to trace the origins of scientific and artistic creativity in the psychodynamics of the personality, and interpretations of the hidden symbolism to be found in painting and in fiction began to proliferate.

Reciprocally, artists and writers began to self-consciously play with Freudian themes. Painting, drama, advertising, and that quintessential 20th-century innovation, the movie, soon were saturated by Freudian symbolism and ideas. The Surrealists, in particular, overtly made use of Freudian ideas, and literary criticism, if not much of mainstream literature itself, seemed to import psychoanalytic ideas wholesale. Manuals of child-rearing warned sternly of the perils associated with toilet-training and psychosexual development. And the evils of Hitler and Stalin were the subject of psychoanalytic speculation, some of it even commissioned by the Office of Strategic Services, the direct ancestor of the modern CIA. In many quarters, madness had recovered its meanings with a vengeance.

Yet for many medics in the first half of the 20th century, the idea that mental disorders could be cured by talk, and that they were rooted in childhood sexuality, was not just unsettling, but positively absurd. The French largely responded by ignoring Freud and his followers as a species of Teutonic nonsense. Psychoanalysis would make no serious inroads in France until as late as the 1960s, and then only in the distorted and convoluted form pioneered by the would-be guru Jacques Lacan. Through the 1920s, the centre of psychoanalysis remained in the German-speaking world - in Vienna, Zürich, and Berlin. But whatever support Freud managed to secure there (and his system was viewed with little favour outside a restricted circle) was irretrievably lost with the rise of the Nazis, for whom his ideas were the very embodiment of degenerate Jewish ’science’.

Most British psychiatrists, led by men like Thomas Clouston and Sir Charles Mercier, were equally hostile and dismissive. For the most part, it was not sex as such, or any sense of prudery, that motivated their opposition. They were willing to acknowledge that sex played a limited role in the genesis of some sorts of psychic disturbance. (Many had long postulated, for example, a causal link between masturbation and madness.) But that the libido was a universal cause of people’s mental instabilities struck them as risible, and Freud’s focus on what were widely regarded as perverted forms of sexuality (to say nothing of his perspective on family dynamics) was for these Edwardian gentlemen quite beyond the pale. To wallow in such filth in the analytic hour struck them as precisely the reverse of what was needed, for it encouraged the very sorts of morbid introspection that were a feature of madness. Psychoanalysis, as Sir Clifford Allbutt put it, was an ’odious’ development. Freud, not to put too fine a point on it, was a fraud.

And what of America? Freud had famously visited the United States in 1909, but had dismissed both psychoanalysis’s prospects in so crude a culture, and the country itself: ’America is gigantic, but a gigantic mistake.’ It is a major historical irony, therefore, that it was here that psychoanalysis would establish, first a secure bridgehead, and then for some decades a dominant position, not just among professional psychiatrists, but in the culture more generally. At first, most Americans’ exposure to psychoanalytic ideas came indirectly, through the efforts of the nascent advertising industry to sell using Freudian symbolism and appeals to the unconscious (to say nothing of a fixation on sex), and rather later through the penetration of Freudian ideas into Hollywood films. But once Benjamin Spock’s Baby and Child Care became the Bible of how to navigate the perils of childhood, they were introduced to them much more directly, albeit in simplified and bowdlerized form.

Yet in the United States too, through the first four decades of the 20th century, the experts in the diagnosis and treatment of madness, and most certainly those amongst them who treated the inhabitants of America’s mental hospitals, initially shared the scorn for psychoanalysis exhibited by their European counterparts. And the disdain of institutional psychiatrists everywhere expressed itself, not just in verbal hostilities, but in a renewed commitment to a somatic interpretation of madness, made manifest in a veritable orgy of therapeutic experimentation on the vulnerable bodies of those who had been certified as mad. Drugs, electricity, malarial mosquitoes, and the surgeon’s scalpel all now made an appearance as means of attacking madness at its alleged roots, if not the mad themselves.

A New Jersey psychiatrist, Henry Cotton, claimed to have discovered the sources of all forms of madness in chronic latent infections, hidden in the corners and crevices of the body, and pumping out toxins that poisoned the brain and disturbed both the emotions and the thought processes. In a pre-antibiotic era, that meant a resort to ’surgical bacteriology’ — put more bluntly, surgical evisceration, as teeth, tonsils, stomachs, spleens, colons, and uteri were cast aside in the pursuit of focal sepsis. It was a deadly pursuit which nonetheless attracted not inconsiderable support for a time on both sides of the Atlantic. Cotton’s notions even made a brief appearance in Scott Fitzgerald’s Tender is the Night, and Fitzgerald had ample experience with the psychiatric universe at one remove, through the travails of his wife Zelda, who for a time was treated by Cotton’s mentor and protector, the eminent Swiss-American Adolf Meyer.

The mistaken notion that seizures and schizophrenia could not co-exist prompted a search for suitable means to provoke artificial grand mal convulsions - using camphor, then metrazol (known in Europe as cardiazol), and finally electricity. Experiments with sleep therapy, designed to give the damaged brain time to recover, segued into experiments with using one of the true miracles of 20th-century medicine, insulin, to induce lengthy comas, from which, it was alleged for a time (till eventually controlled trials demonstrated it was a myth), as many as 80% of the schizophrenic could be reclaimed into the ranks of the sane. As one enthusiast of the time boasted,

we act with both [insulin and metrazol] as with dynamite,

endeavoring to blow asunder the pathological sequences and

restore the diseased organism to normal functioning…we are

undertaking a violent onslaught with either method we choose,

because nothing less than such a shock to the organism is powerful

enough to break the chain of noxious processes that leads to

schizophrenia.

Obsessed with the idea that fever might somehow clear the brains of the deluded and distracted, a Viennese psychiatrist, Julius Wagner von Jauregg, experimented with a variety of febrile agents, include typhoid vaccine and the organisms responsible for erysipelas and rat bite fever in order to validate his hypothesis, before settling, late in the First World War, on the use of malaria to provoke remitting fevers that could be cut short (if not always) by the administration of quinine. Not long before, the origins of general paralysis of the insane in infection with the syphilitic parasite had been definitively demonstrated in the laboratory, and it was to those afflicted with this dreadful disorder - which produced a fearful combination of psychiatric and neurological symptomatology, a steep physical decline, and a particularly nasty end, demented, paralysed, choking on one’s own vomit - that Jauregg directed his ministrations. Perhaps it worked. Certainly, clinicians of the era believed that it did (though the treatment would be superseded by treatment with penicillin before ever it was put to the decisive test of a controlled trial). And the Nobel Committee rewarded Jauregg with one of its prizes, in 1927. But Jauregg’s conviction that other forms of insanity would yield before the onslaught of fever therapy proved misplaced, and even though many other psychiatrists experimented with diathermy machines, instruments designed to break down the body’s ability to maintain a constant temperature, no other forms of psychosis responded.

Perhaps the most dramatic of these somatic interventions, however, emerged in the mid-1930s, first at the inspiration of a neurologist practising in the backwater of Lisbon, Portugal. Egas Moniz proposed a direct assault on what most of his psychiatric colleagues had long considered the seat of madness, the brain itself. And he did so via an operation designed to destroy brain tissue, particularly portions of the frontal lobes of the brain, an operation he called a prefrontal lobotomy. Picked up by an ambitious American duo, the neurologist Walter Freeman and the neurosurgeon James Watts, faculty members at George Washington University Medical School, the new operation survived a rocky initial reception among American psychiatrists and was embraced in North America and across much of Europe and its dependencies. Freeman, in particular, worked tirelessly to proselytize for the miraculous operation that relieved one of care and took away the sting of psychosis. He operated on children as young as four years of age, and when the relative complexities of boring holes in the skull and using a neurosurgeon to slice through the white matter of the brain with something resembling a butter knife threatened to preclude the extension of its benefits to the thousands of patients languishing on the back wards of mental hospitals, he popularized a different technique. Using an ice pick and a mallet, having reduced the patient to unconsciousness with a rapid series of electrical shocks to the brain, he attacked the brain via the eye-socket, puncturing the orbit and with sweeping motions severing the fibres he was convinced lay at the root of mental suffering.

Moniz would win the second Nobel Prize for Medicine awarded for a psychiatric intervention in 1949 for an operation that would subside into near-oblivion over the next decade or so. Its very name would come to symbolize psychiatry run amok. Walter Freeman, once dubbed by Time magazine as the man with the golden ice-pick and lauded in the pages of the New York Times by its science correspondent, would end his days retired to California, isolated and increasingly reviled as a moral monster.

The human brain is a remarkably resilient organ. Even under these assaults, some semblance of humanity sometimes survived amongst those who underwent the operation. A number of those tortured by obsessions and compulsions that had dominated their lives found some surcease. The schizophrenic, as Freeman frankly admitted, still heard voices and hallucinated, but for some patients, the force of these disturbances was lessened. Some psychiatrists, patients’ families, and even patients themselves, interpreted such outcomes as improvements over the prior madness. Not everyone, in other words, was reduced to the status of a zombie or human vegetable, as later generations would come to believe (though many indeed were, and languished as burnt-out cases on the ’continuous treatment’ wards of the local mental hospital). But all were permanently brain damaged, and badly so, their capacity for empathy, for forethought, for self-restraint, in many ways, their most centrally human qualities, irretrievably lost.

14. Walter Freeman performing a transorbital lobotomy at the Western State Hospital, Fort Steilacoom, Washington, 8 July 1949. The patient has been rendered unconscious by two electroshocks to her brain, administered in rapid succession, and Freeman is using a mallet to drive an ice-pick-like device through the eye socket into the frontal lobe of the brain

It has become fashionable in some scholarly circles to suggest that perhaps lobotomy was not so bad after all; that its proponents ought to be cut some slack, given the grim clinical realities that they confronted in the 1930s and 1940s; that after all, many of them acted with the best of intentions and within the limitations of the science of the times. For others, the lobotomy era is symbolic of how society’s efforts to grapple with the nightmare that is severe mental illness seems at times to license remedies that are worse than the disease, interventions that themselves almost appear to constitute a form of madness. As is doubtless apparent, my sympathies, at least, belong with the latter camp, those who seek to obey the ancient Hippocratic command: ’First do no harm.’ And whatever one’s ultimate judgement about the merits of Freud’s system, it bears mentioning that much of the professional opposition that persisted even in lobotomy’s heyday came from the ranks of the psychoanalysts. For those who saw madness as rooted in meaning, taking an ice-pick to the frontal lobes was a category mistake, as well as an act of barbarism.