Footnotes to the History of Psychiatry

Pierre Janet and Félida Artificielle: Multiple Personality in a Nineteenth Century Guise

2009-01-02T05:11:00.000-08:00

In 1970 Henri Ellenberger noted that the work of Pierre Janet (1859-1947) “can be compared to a vast city buried beneath ashes, like Pompeii. The fate of any buried city is uncertain. It may remain buried forever. It may remain concealed while being plundered by maurauders. But it may also perhaps be unearthed some day and brought back to life” (Ellenberger, p. 409). In recent years, this excavation has begun. Some have only been interested in finding anticipations of their own work in Janet (van der Kolk and van der Hart, 1989; Pitman, 1984). Others, however, have taken into account the historical context in which his work was produced (Carroy and Plas, 2000a; Carroy and Plas, 2000b; Plas, 2000; Crabtree, 2003), suggesting a long overdue beginning of detailed Janet scholarship.

Ian Hacking’s recent discussion of Janet, in his historical and philosophical consideration of multiple personality phenomena, suggests a further opportunity for taking a closer look at Janet. Hacking argued that the clinical form as well as the frequency of “multiples” in late twentieth century were dependent on historically specific concerns. He supported this argument by describing a complex set of factors that converged in the 1880s to open the door for a smaller wave of multiple personality phenomena that occurred at that time (Hacking, 1995, pp. 159-170).

One can demonstrate this convergence by considering the Janet’s earliest work. Done between 1883 and 1889, before he received his medical training, this work formed the basis of Janet’s doctoral thesis in philosophy, published as L’Automatisme psychologique (Janet, 1889). Janet’s detailed descriptions of his early work allow us to appreciate the different guises which multiple personality phenomena have taken in the nineteenth century and twentieth centuries. These descriptions also allow us to unearth a picture of Janet discovering what he took to be a new phenomenon and then coming to critically appreciate the paradox inherent in his discovery.

In both the nineteenth and twentieth centuries “multiples” have been characterized by asymetric memory defects. While the normal, first or waking personality cannot recall what has happened to subsequent personalities, subsequent personalities typically can recall the experience of earlier ones. In the twentieth century subsequent personalities or alters play a variety of roles in relation to the patient, who is apparently a victim of child abuse. Janet, by contrast, worked with patients suffering from hysteria, who experienced a variety of puzzling symptoms. Among his most remarkable early findings was that he could replace an hysterical patient’s waking personality, with all of its symptoms, with another personality that was perfectly normal. He called this phenomenon “complete somnambulism” (Pierre Janet, 1887, 469). This was a “multiple” as remote as imaginable from what has appeared in the United States in recent years.

Influences on Pierre Janet during the 1880s

To fully understand Janet’s discovery of complete somnambulism it is necessary to take into account at least four factors that influenced him during the 1880s (Carroy and Plas, 2000b). Janet graduated from from the prestigious Ecole Normale Supérieure in 1882 and the following year, while teaching philosophy at a Lycée in Le Havre, began looking for a subject for his doctoral thesis. The first influence on Janet was the philosophy he was expected to teach. As a philosophy teacher in a lyceum, Janet’s job was to teach a curriculum overseen by his uncle Paul Janet (1823-1899), a leader of the French school of philosophy known as Spiritualism, not to be confused with “spiritisme”, or communicating with the spirits of the dead. (Ellenberger, 1970, p. 334; Goldstein, 1994; LeBlanc, 2001, pp. 57-69).

Spiritualism was established in the 1820s by Victor Cousin (1792-1867) as a means of combating “empiricism’ or “materialism” which, in his opinion, had had disastrous social and political consequences during the Revolution. While remaining a secular philosophy, with no links to the Catholic church, Spiritualism claimed to provide proof for those principles which were considered necessary to an orderly, stable society: the existence of God, free will, and objective standards of good and evil. Of central importance to Spiritualists was the belief each individual possessed an immaterial and indivisible self. Spiritualism portrayed itself as a science, a psychology, which studied the self through introspection (Goldstein, 1968, p. 260; Brooks, 1998, pp.29-67; Barberis, 2002). Pierre Janet’s decision to study pathological states of consciousness was, consequently, encouraged by his uncle Paul, who saw him as “reconquering this domain” for philosophy (Paul Janet, 1897, p. 556; Carroy and Plas, 2000a).

During the 1880s Spiritualism’s claims, both methodological and empirical, were being vigorously challenged by the philosophical school known as positivism (Barberis, 2000). As a young philosopher Pierre Janet was also influenced by this school. The leading positivist of the day Theodule Ribot taught that philosophical problems could be solved through psychological experiments and that hypnosis was a promising method of experimentation (Pierre Janet, 1915-17; Brooks, 1998, pp. 175-185). He had written two highly influential books introducing French audiences to scientific psychology as practiced in England and Germany. Ribot thought psychology should be pursued according to the “method of the natural sciences.” He adopted the views of Claude Bernard that disease provided an experiment in nature. During the 1880s he published a series of monographs on diseases of Memory, the Will, and Personality, which exemplified this approach (Nicolas and Murray, 1999; Nicolas and Charvillat, 2001). Janet read Ribot while still at the Ecole Normale and followed his monographs as they came out during the 1880s (Brooks, 1998, p. 175).

While Janet took his scientific orientation from Ribot, he was also heavily influenced by the observations and theories of the esteemed neurologist Jean Martin Charcot (1825-1893) and his students at the Salpêtrière in Paris. In 1882, Charcot presented a paper entitled “On the Various Nervous States Determined by Hypnotization in Hysterics” to the French Académie des Sciences. By giving this paper to this audience, Charcot legitimized serious research on a subject that had long suffered from academic scorn and neglect. While Janet was initially interested in studying hallucinations, the ease of finding hysterical patients to serve as hypnotic subjects changed the direction of his research (Ellenberger, 1970, pp. 334-6). At the outset of his research, Janet sought and received guidance directly from Charcot, who was generally regarded as the preeminent expert on hysteria (Pierre Janet, 1892, p. 324). Charcot’s advocacy of the idea that anesthesia was not merely a symptom of hysteria, but the cause of other hysterical symptoms was of particular
importance in Janet’s research. (Pierre Janet, 1925, p. 237).

Popular ideas about hypnosis, sleep and somnambulism were the fourth important influence on Janet. Although initially ignorant of the work done by early nineteenth century magnetizers or mesmerists, Janet, like others who flocked to the study of hypnosis in the 1880s, adopted several of the central tenets of those early workers: Waking and sleep are radically opposed states. When phenomena from one state intruded into the other, the results are pathological. Hypnosis is a form of sleep. Somnambulism is a waking sleep; and post hypnotic phenomena involve the intrusion of sleep states into waking life (James, 1995). Like most educated people in the late nineteenth century, Janet too regarded hypnosis as a form of sleep, and somnambulism as a pathological intrusion of waking phenomena into sleep (James,1995). These unexamined presuppositions colored his interpretation of what he found in his research.

Félida and the question of an unconscious second self

Janet discovered his apparent ability to cure hysteria by creating a healthy second personality while attempting to address an important philosophical problem, namely the possible existence of an unconscious second self (LeBlanc, 2001). This problem emerged in 1876 when Etienne Eugène Azam (1822-1899) published the case of a woman by the name of Félida, who appeared to have what he called “doublement de la vie.” Born in 1843, her father died while she was a baby and as a child she had to earn her living as a seamstress. Although she was a hard worker, she was sullen and taciturn and by
age thirteen she was complaining constantly of headaches, neuralgias and other symptoms. By age fourteen she began having almost daily episodes of sharp pain in her temples followed by a period of lethargy lasting for a few minutes. When she awoke she was happy, vivacious and free of symptoms. After a few hours she would return to the lethargic state and then to her ordinary personality, with no memory of the previous few hours. As time passed Félida spent more and more time in her symptom free second state (Azam, 1876).

Because of the dramatic difference between Félida’s two states of consciousness and her inability to remember the second state, the latter was generally accepted as a second self or personality. This spontaneously occurring second personality posed a profound threat to the concept of the unity of the self, which was at the heart of the philosophy of Spiritualism, as advocated by Paul Janet. As Pierre Janet later wrote: “Her history was the great argument of which the positivist psychologists made use at the time of the heroic struggles against the spiritualistic dogmatism of Cousin’s school” (Pierre Janet, 1907, p.78).
If Félida had two selves, one of whom could not remember the other, then Spiritualism was built on very shaky ground. A unitary self, responsible for an individual’s actions, was central to Spiritualism’s ideas about morality. In addition, the introspectionist method and its findings made no sense without a unitary self to observe and be observed. As Paul Janet wrote: “if the self can feel double, what does its unity, that spiritualist psychologists consider as the basis of their doctrine, consist of” (Paul Janet, 1876). Félida’s second state also raised serious questions about the idea of somnambulism as a form of sleep. Somnambulism was first observed in 1784 by Amand-Marie-Jacques de Chastenet, Marquis de Puységur (1751-1825). Using techniques he had learned from Franz Anton Mesmer (1734-1815), Puységur found a 23 year old peasant named Victor Race who fell into what seemed like a paradoxical sleep, in which he seemed more awake than in his normal state (Ellenberger, 1970, p. 70). Over the next century, until Félida made her appearance, medical scientists did not seriously attempt to understand this paradox. Although Félida was also brighter and healthier in her second state, Azam, for example, continued to hold the conventional view that this state was a pathological form of sleep (James, 1995, pp.241-2; Carroy, 1991, p.106). When Pierre Janet later independently discovered the same second state, calling it “complete somnambulism,” he was forced to challenge this conventional view.

Lucie and Adrienne

Pierre Janet became personally involved in the controversy over the production of an unconscious second self in 1886. The professor of medicine Hippolyte Bernheim (1840-1919) and the physiologist Charles Richet (1850-1935) had found that some subjects, in experiments involving post-hypnotic suggestion, not only carried out suggestions in an automatic manner, but also acted in ways that seemed to involve independent thought. Subjects could, for example, perform an act, not on waking, but at the end of a specified number of days. This was a feat involving more than suggestion because of the need to keep track of the number of days elapsed. Spiritualist philosophers like Paul Janet worried that “to understand these facts, we must infer an unconscious faculty for measuring time” (Janet, 1886, p.582; LeBlanc, 2001, p. 59).
Pierre Janet attempted to reproduce these experiments with a nineteen year old patient he called Lucie, who suffered from daily attacks of convulsions and “délire,” that Janet regarded as due to hysteria. Janet had no difficulty
eliminating these hysterical symptoms by producing, “the most complete hypnotic sleep” (Pierre Janet, 1886, p. 577). Once she was “asleep” Janet suggested to her that, on awakening, she would carry out a particular act after hearing him clap his hands six times. When he woke her, she did not remember what had occurred during sleep. While she was distracted by other people talking to her, Janet clapped his hands. On the specified clap she did what he had suggested without being able to explain why she had done it. Such experiments demonstrated that Lucie too could pay attention, count, and use judgment without remembering having done so (Pierre Janet, 1886; Crabtree, 2003).
Janet wondered how she could do this. Although there would have been general agreement at the time that Lucie had performed the calculations unconsciously, many researchers, like the English physiologist William Benjamin Carpenter, for example, were inclined to describe such unconscious phenomena in physiological terms, as unconscious cerebration, that is to say in terms of the operations of various centers in the brain (Brown, 1983; Crabtree, 2003). This readily available explanatory option, however, conflicted with Janet’s training within the tradition of Spiritualist philosophy. Influenced by the philosopher Maine de Biran, as well as his uncle, Paul Janet, Pierre he was reluctant to reduce consciousness to brain function, and thereby give up the concept of self. Consequently when Pierre Janet was confronted with evidence of post-hypnotic mental operations, he was inclined to interpret them as due to a rudimentary second consciousness or self. For him, even though Lucie was unaware of why she carried out these post-hypnotic suggestions, they were
“conscious” in that they were mental and not physiological phenomena. Nonetheless Lucie’s second consciousness, like Félida’s, posed serious problems for the Spiritualist concept of the self as espoused by Paul Janet (Goldstein, 1994;
LeBlanc, 2001, p.64). In 1889 Pierre addressed this problem. Although he abandoned the immediate intuition of the self, that was so important in Spiritualist doctrine, he saved the unity of the self under the heading of “mental synthesis” (Carroy and Plas, 2000a, pp. 237). This compromise was sufficient for Paul Janet, who was able to remark that, “We believe we can conclude that the fact of successive existences strikes no blow at the notion of the self ” (Goldstein, 1994, p. 204).

Not everyone was interested in denying the radical implications of Pierre Janet’s findings. In 1889 the philosopher André Lalande praised Janet for having “proven the fact, long rejected for metaphysical reasons, that there are, in spite of the apparent antinomy of the words, states of unconscious consciousness” (Faure, 1989, p. 937). In 1890 William James proclaimed to the Anglo-Saxon world that Janet had demonstrated that “the total possible consciousness may be split into parts which coexist but mutually ignore each other” (James, 1950, p. 206).
Having decided that these post-hypnotic mental operations, represented a rudimentary second self, Janet attempted to communicate with this self while Lucie was awake. Since Lucie’s spoken words indicated no awareness of these mental operations, he devised a creative application of the controversial technique known as “automatic writing,” which “spiritistes” used to receive communications from the dead (Hess, 1991, pp. 59-79; Myers, 1887, pp. 237- 240). While Lucie was talking with someone else, Janet, stood behind her and whispered questions to her. She answered in writing. When asked to look at what she had written, Lucie expressed surprise or denied that she had written what was on the page. Able to communicate with Lucie’s calculating hypnotic state through automatic writing, Janet “baptized” what he regarded as a spontaneously occurring second self with the name Adrienne (Pierre Janet,
1886).
Among the differences that Janet noticed between Lucie and Adrienne was the fact that Lucie never looked at a page while Adrienne was writing on it, but always looked at the page when she, “herself,” was writing. For Janet this was clearly the result of Lucie’s hysterical inability to feel what her hand was doing. It also suggested that while Lucie did not have tactile and muscular sensations in her hand, Adrienne did. Janet speculated that perhaps Adrienne suffered from none of Lucie’s hysterical deficits. From this he wondered whether all patients with hysterical anesthesias , like Lucie, might not have an unconscious second self, which, like Adrienne, did not suffer from the hysterical symptoms that plagued the waking patient (Janet, 1887).
As remarkable as this speculative leap may seem, it was supported by the idea that altered sensitivity of the skin and muscles was the fundamental feature of hysteria. Since the 1850s Victor Jean-Marie Burq (1822-1884) had been using metal plates to treat hysteria in women by removing anesthesias from the afflicted parts of their bodies. Burq believed that, because anesthesia was the essential phenomenon of hysteria, removing the anesthesia, by any means, would eliminate all hysterical symptoms. Because Burq’s metal plates could also interrupt hypnotic trances, it seemed that anesthesia was the basis for both these trances as well as hysteria. In the late 1870s Charcot invited Burq to demonstrate his treatment, known as aesthiogenesis, and affirmed its value (Harrington, 1988).
As an admirer of Charcot, it is not surprising that Janet was influenced by Burq’s ideas as he worked with Lucie and other patients in the 1880s (Pierre Janet, 1925a, p. 237). While the fact that Lucie did not remember what
occurred to Adrienne was crucial to Janet’s view of these states as distinct personalities, he saw this amnesia as secondary to her anesthesia. Indeed Janet saw this dependence of memory on sensation as quite general. In 1889 he went so far as to state this as a law: “When a certain kind of sensation has been abolished, the images and by consequence the memories of phenomena which have been furnished by that kind of sensation are abolished as well ” (Janet, 1889, 136-7).
In Janet’s view this anesthesia was not a true anesthesia due to the destruction of a neural capacity, but rather a form of negative hallucination that could be induced in a subject through suggestion or hypnosis (Janet, 1887). Nonetheless he saw all the phenomena surrounding his experiments with Lucie --her hysterical symptoms, her amnesia after being woken from a period of somnambulism and her capacity for automatic writing--as deriving from this anesthesia. His discovery of complete somnambulism depended upon his belief in Burq’s aesthiogenesis. Indeed these experiments with the phenomenon of aesthiogenesis made such a deep impression on Janet, that long after Burq’s ideas had been discredited, he wrote, “Something of our first loves always remains with us. We have much difficulty rejecting, as illusions, studies that interested us in our youth” (Pierre Janet, 1919, vol. 3, p. 75).

To test these ideas Janet conducted further experiments where he found that whatever one personality could do the other could not. By suggesting a deficit to Lucie, he could create a capacity in Adrienne, and by suggesting a capacity to Adrienne he could create a deficit in Lucie. When he tried to push this observation to its logical conclusion, that is, to see if Adrienne could speak, he had difficulty. As he attempted to deepen Lucie’s hypnotic state by making “passes” in front of her face, she became totally unresponsive. Lucie would not speak and Adrienne would not write. After a half an hour, however, the young woman “sat up straight, her eyes at first closed then open.” At his request she began to speak. “But the person who now spoke,” Janet remarks, called herself Adrienne, not L[ucie].” Moreover Lucie “had absolutely disappeared, it was impossible to obtain any manifestation of her” (Janet, 1887, pp.467-8).

He had replaced Lucie with Adrienne. Moreover, as his speculations predicted, Adrienne had none of Lucie’s hysterical symptoms. She also had a complete memory of Lucie’s life and was unresponsive to suggestions. Like Félida’s second self, Adrienne was healthy. Had Janet discovered a spontaneously occurring second self, like Félida’s, or had he created this state of “complete somnambulism”? Regardless, Adrienne could only talk with him for a short time. After about twenty minutes, Lucie, with all her symptoms, returned (Pierre Janet, 1887, p.468).

Janet next began to suggest anesthesias to Adrienne. As he did Lucie recovered her ability to feel. With this her other hysterical symptoms disappeared as did her suggestibility. Soon Janet could no longer communicate with Adrienne. He wondered if he “had killed Adrienne by suppressing the tactile sensibility that perhaps had played an important role in this abnormal synthesis of conscious phenomena” (Pierre Janet, 1887, p. 471). While he accepted his obligation to treat Lucie for her hysteria, Janet regretted having “killed” Adrienne. What intruiged him was the fact that a somnambulistic state which ordinarily existed sub-consciously could be made to exist as an alternate consciousness.

Léonie, Léontine and Lénore

At this time Janet’s only other experience with alternating consciousness was with a 45 year old peasant woman he called Léonie, who had been his first subject (Plas, 2000, pp. 93-8). Léonie readily entered a somnambulistic state, and Janet used automatic writing to communicate with her second self. This second self informed Janet, in writing, that her name was Léontine. Unlike Adrienne, who was a rather rudimentary personage, Léontine had existed for a long time and truly had a mind of her own. On one occasion, for example, after Léonie had returned to her home, Léontine wrote to Janet expressing concern for Léonie’s health (Pierre Janet, 1888, pp. 252-3). When Janet noticed that Léontine, that is Léonie “asleep,” appeared to suffer from hallucinations, he was led to discover a third personality, who called herself Lénore (Pierre Janet, 1888, pp. 267-272).

Strikingly Lénore did not have the hysterical anesthesias that were present in Léonie and Léontine, was not at all suggestible and could remember the whole of Léonie’s life. Like Adrienne, Lénore was healthy. Janet had discovered another instance of complete somnambulism. Lénore, however, disabused naive young Janet of the idea that she represented a spontaneously occurring case of complete somnambulism, as Félida presumably did. Lénore revealed that she had been created twenty years earlier by an animal magnetizer known as Dr. Perrier (Pierre Janet, 1888, p. 272). In contrast to Adrienne’s transient existence, Lénore had persisted and alternated with Léonie over the years. Perhaps Dr. Perrier had deliberately created her to cure Léonie of hysteria.

Jules Janet and Marceline

While Janet’s concerns at this time were primarily philosophical and experimental, the question of whether he could use complete somnambulism therapeutically was hard to avoid. Indeed it wasn’t long after his discoveries
with Lucie and Léonie that he encountered an opportunity to do just that. In 1887 his younger brother Jules, at the time a medical student at La Pitié Hospital in Paris, told him about the case of a twenty year old patient, called Marceline, “who had been reduced to an extreme degree of emaciation and weakness” (Pierre Janet, 1925b, p.803). She would not eat or urinate. She vomited what she was fed by nasogastric tube and had to be catheterized several times a day. She also appeared to have lost all cutaneous sensation and had large gaps in her memory of her life. Because other treatments had failed, Jules Janet was able to get permission to treat her using some of the hypnotic techniques he had learned from his older brother (Pierre Janet, 1910).

Applying the idea that hysteria could be cured by removing anesthesias, Jules attempted cure Marceline’s presumably hysterical illness by using all available means to restore conscious sensation (Pierre Janet, 1925, p.237). To do this Jules first determined what sensations were connected with an altered function and then forced her to recover consciousness of these sensations. If an arm was paralyzed, for example, this involved pinching, pricking, and
electrically shocking as well as mobilizing and massaging it. After each excitation, Jules asked Marceline what she felt and forced her to pay close attention so that she could distinguish one sensation from another, even growling when she made a mistake. To get her to eat he followed the same procedure with her mouth, lips, and pharynx. Marceline complained that this work was hard and painful. At times she grimaced, cried, and twisted her limbs (Pierre Janet, 1910, pp. 521-2).

After ten days, however, Jules succeeded in producing a state quite similar to the complete somnambulism that Pierre had discovered in Léonie and Lucie (Pierre Janet, 1910, p.334). Marceline was transformed. She was able to
eat without vomiting and urinate without difficulty. Marceline was more than
merely symptom free, however. She was a new person. She no longer had large gaps in her memory of her life. She also expressed herself with more vivacity, “… stood straighter,… walked more rapidly. … look[ed] at people when she spoke to them and appeared to have come down from the clouds.” Marceline was, moreover, quite aware of this dramatic change. “It appears to me,” she exclaimed, “that I am really living, that this is a new existence and that I am not afraid to confront it” (Pierre Janet, 1910, p. 485).

In terms of nineteenth century ideas of hypnosis as sleep, however, Marceline’s new existence was a total eclipse of her waking state and self-evidently pathological. Jules and Pierre Janet were concerned about the risks involved in leaving someone “asleep” for a prolonged period. As a result, following each period of complete somnambulism, during which Marceline ate and urinated, Jules woke her. She immediately fell back into her previous state. Her anesthesia, anorexia and annuria returned. In addition she completely forgot what had happened during her period of health. For a time Jules continued putting Marceline into the state of somnambulistic health before every meal and waking her shortly thereafter. When this became too burdensome, Jules and Pierre, with some trepidation, decided to leave her in the somnambulistic state for longer periods. To their surprise she did well. In reporting this at the time Jules was particularly enthusiastic. He wrote that, “ it would be a means of curing hysteria to have her live indefinitely in this state where in effect she would be absolutely complete and would no longer be subject to any disorder” (Pierre Janet, 1925a, p. 239).

After a while her family took her home in that state. A few weeks after returning home, however, “her mother brought Marceline to the hospital in a pathetic state. On the occasion of her menstrual period,... (she) had awoken completely ” (Pierre Janet, 1910, p. 336). She had no memory of her period of health and was very bewildered at finding herself in her own house without understanding how she had left the hospital. Jules was able to reinduce complete somnambulism, and she was then able to remember her previous period of health (Pierre Janet, 1910, p.336).
This cycle of recovery and relapse persisted over the next seventeen years until her death from pulmonary tuberculosis. During her periods in the state of somnambulistic health she was able to live independently and achieve some measure of success in her career. She was a virtual “Félida Artificielle,” as Pierre Janet later called her. During each relapse she sought out Pierre Janet, who had taken over from Jules, and requested that he return her to the state of complete somnambulism. The frequency with which Marceline relapsed and the amount of work required to return her to the state of complete somnambulism made this a less than satisfactory treatment. Janet quickly recognized this therapeutic limitation (Pierre Janet, 1910).

Nonetheless Janet’s experience with Marceline transformed his ideas about the nature of somnambulism, multiple personalities and the dichotomy between waking and sleep. How could one consider Marceline’s “waking” state,
which was inconsistent with life, her normal one? Janet recognized that this was the position taken by “Azam, as well as all…(other) authors” (Pierre Janet, 1907, p.89). Janet, however, argued that a state in which she could not eat or urinate must not be regarded her normal one. Moreover she had lived for years as a normal child before the onset of her symptoms. Looked at in this light, inducing somnambulism did not involve creating a new state or a new personality, but
returning Marceline to the normal state she had enjoyed as a child (Pierre Janet, 1907, pp.89-92).

If inducing a state of complete somnambulism involved returning Marceline to the healthy state she had enjoyed as a child, then her “awakening,” during which she forgot the state of health, was nothing but a relapse. As Janet began to think of Marceline in terms of recovery and relapse, the notion that her different states were distinct personalities and the idea that somnambulism was a form of sleep began to make less sense to him. How could one call a state in which a patient felt better, remembered more of her life and was more successful a form of sleep, especially if she lived in this state for years? As Janet began to develop his mature theories he came to think of recovery in terms of “excitation” rather than sleep. He began to use the terms “instant clair” and “état alerte” to refer to the phenomenon he had observed in Marceline (Pierre Janet, 1925a, p.50; Pierre Janet, 1910, p. 342). Her illness, he came to think, was due to a
profound reduction in psychological tension. Her instants clairs were, in turn, due to a dramatic increase in tension.

Although Janet’s reflections on Marceline’s cure undercut his convictions about somnambulism and multiple personality phenomena, the drama of sudden recovery and subsequent relapse stayed with him. Janet continued to
look for dramatic cures like Marceline’s, but they were rare. By 1889 he was able to report related findings with his patients Marie and Rose (Pierre Janet, 1889, pp. 108-9). His brother Jules demonstrated the phenomenon on Charcot’s “celebrated subject” known as Witt (Pierre Janet, 1889, p. 179). Over the years, however, among “several thousand” patients, Pierre Janet was able to obtain nothing more than an “imperfect form of complete somnambulism” in fifteen
cases (Pierre Janet, 1925b, pp. 453-4). Only two patients, Marcelle and Irène, showed the phenomenon clearly enough to warrant extended discussion (Pierre Janet, 1925a, pp. 1-69; Pierre Janet, 1925b, pp. 812-17; Leys, 2000, pp. 112-16).

Janet’s early experiments with hypnosis were based on nineteenth century assumptions about sleep and waking, the nature of the self and hysteria. Based on these assumptions he was able to replace Marceline’s hysterical personality with a healthy second one. His appreciation the paradox of a second personality, which was healthy but asleep, undermined the assumptions on which this work had been based, clearing the way for his ideas about psychological tension. Janet’s work demonstrates how an outbreak of multiple personality phenomena depends on the plausibility prevailing assumptions. Recalling Janet’s encounter with his “Félida Artificielle” should encourage us to 19
look closely at the historical and cultural context in which our recent epidemic of “multiples” has occurred.

References

Azam M. (1876). Amnésie périodique, ou doublement de la vie. La Revue Scientifique, 5. 481-489.
Barberis, D. (2002). Moral Education for the Elite of Democracy: The classe de philosophie between sociology and philosophy. Journal of the History of the Behavioral Sciences, 38..
Brooks, J. (1998). The Eclectic Legacy: Academic Philosophy and the Human Sciences in Nineteenth-Century France. Newark: University of Delaware Press.
Brown, E. (1983). Neurology and Spiritualism in the 1870s. Bulletin of the History of Medicine, 57. 563-78.
Carroy, J. (1991). Hypnose, suggestion et psychologie: L’invention de sujets. Paris: Presses Universitaires de France.
Carroy, J. and Plas, R. (2000a). How Pierre Janet Used Pathological Psychology to Save the Philosophical Self. Journal of the History of the Behavioral Sciences, 36. 231-40.
Carroy, J. and Plas, R. (2000b). La genèse de la notion de dissociation chez Pierre Janet et ses enjeux. Évolution Psychiatrique, 65. 9-18.
Crabtree, A. (2003). “Automatism” and the Emergence of Dynamic Psychiatry. Journal of the History of the Behavioral Sciences, 39..
Ellenberger, H. (1970). The Discovery of the Unconscious. New York: Basic Books.
Faure, H. (1989). Pierre Janet, à l'occasion du centiéme Anniversaire de l'automatisme psychologique. Annales Medico-Psychologique, 147. 937.
Goldstein, D. (1968). Official Philosophies: in Modern France: the example of Victor Cousin. Journal of Social History, 1. 259-279.
Goldstein, J. (1994). The Advent of Psychological Modernism in France: An Alternate Narrative. In D. Ross (Ed). Modernist Impulses in the Human Sciences 1870-1930 (pp. 190-209, 342-346). Baltimore: Johns Hopkins University Press.
Hacking, I. (1995). Rewriting the Soul. Princeton: Princeton University Press.
Harrington, A. (1988). Neo-Mesmerism in French psychiatry. In W.F. Bynum, R. Porter, M. Shepherd (Eds.). The Anatomy of Madness (pp. 226-246). London: Routledge.
Hess, David. (1991). Spirits and Scientists: Ideology, Spiritism, and Brazilian Culture. University Park (Pa.): Pennsylvania State University Press.
James, T. (1995). Dream, Creativity, and Madness in Nineteenth-Century France. Oxford: Clarendon Press.
James, W. (1950). The Principles of Psychology. Dover Publications.
Janet, Paul. (1876). La notion de la personnalité. Revue Scientifique, 10. 574-5.
Janet, Paul. (1897). Principes de Métaphysique et de Psychologie. Paris: Libraire Ch. Delagrave.
Janet, Pierre. (1886). Les actes inconscientes et le dédoublement de la personnalité pendent le somnambulisme provoqué. Revue Philosophique, 22. 577-592.
Janet, Pierre. (1887). L’anesthésie systématisée et la dissociation des phénomènes psychologiques. Revue Philosophique, 23. 449-472.
Janet, Pierre. (1888). Les actes inconscients et la mémoire pendent le somnambulisme. Revue Philosophique, 25. 238-279.
Janet, Pierre. (1889). L’Automatisme psychologique. Paris: Alcan.
Janet, Pierre. (1892). L’anesthésie hystérique. Archives de Neurologie 24. 323-352.
Janet, Pierre. (1907). The Major Symptoms of Hysteria. London: Macmillan & Co.
Janet, Pierre. (1910). Une Félida artificielle. Revue Philosophique, 69. 329-357, 483-529.
Janet, Pierre. (1915-17). Théodule Ribot. Journal de Psychologie. 12, 263-282.
Janet, Pierre. (1919). Les Médications Psychologiques. Paris: Librairie Félix Alcan. vol. 3 75.
Janet, Pierre. (1925 a). Névroses et Idées fixes. Paris: Alcan.
Janet, Pierre. (1925 b). Psychological Healing. London: George Allen & Unwin.
LeBlanc, A. (2001). The Origins of the Concept of Dissociation: Paul Janet, His Nephew Pierre, and the Problem of Post-Hypnotic Suggestion. History of Science, 39. 57-69.
Leys, R. (2000). Trauma. Chicago: University of Chicago Press.
Myers, F.W. H. (1885-7). Automatic writing --III. Proceedings of the Society for Psychical Research, 4. 209-261.
Nicolas, S. and Murray, D. (1999). Théodule Ribot (1839-1916), Founder of French Psychology. History of Psychology, Vol. 2, No. 4.
Nicolas, S. and Charvillat, A. (2001). Introducing Psychology as an Academci Discipline in France: Théodule Ribot and the Collège de France(1888-1901). Journal of the History of the Behavioral Sciences, 37, 143-164.
Pitman, R.K. (1984). Janet's Obsessions and Psychasthenia: a synopsis. Psychiatric Quarterly, 56. 291-314.
Plas, R. (2000). Naissance D’Une Science Humaine: Psychologie. Rennes: Presses Universitaires de Rennes.
van der Kolk, Bessel and van der Hart , Onno. (1989). Pierre Janet and the breakdown of adaptation in psychological trauma. American Journal Psychiatry, 146. 1530-40.

Edward M. Brown, Journal of the History of the Behavioral Sciences, 39 (2003) 279-288.

Joseph Delboeuf and the History of Psychological Healing

2009-01-01T23:14:00.000-08:00

During the late twentieth century a number of controversies erupted in the United States over such questions as the genuineness of multiple personality phenomena and the recovery of lost memories of sexual abuse. On one side psychotherapists insisted that the phenomena in question were genuine and that they had been overlooked because of bias and ignorance. On the other side critics argued that overly zealous therapists were unwittingly suggesting the phenomena to their patients and thereby creating unnecessary morbidity. What characterizes these episodes is the polarization that develops between those who have seen the phenomenon and those who have not. It is an embarrassing polarization, seemingly more appropriate to religious disputes of earlier centuries than to twentieth century medical science. While these controversies died down, it is apparently only because the adversaries have withdrawn from combat. As periodic eruptions show, however, both sides still cling to their polarized views of the essential truths in these important clinical issues.

For the historian, what is striking is how frequently such controversies seem to recur. From the royal commission investigating Mesmer's claims, to the debates over somnambulism and spiritualism, through the debate between Charcot and Bernheim over hypnosis, and to the various schools of psychoanalysis the same question has reemerged. Insight into the social-psychology of these controversies has not been lacking, though it seems as if it must be rediscovered with each new eruption of controversy.
In 1886 the Belgian philosopher Joseph Delboeuf boldly proposed a social-psychological and historical explanation of the polarizing controversy he was witnessing, that has resonance through the twentieth century to the controversies we have recently been experiencing. "Doubtless there is an action of the hypnotist on the hypnotized--like master, like disciple" he argued in a manner that many would agree with, then and now. Delboeuf, however, went further insisting that, "... the subjects themselves, primarily the first , shape… the person who molds them and, without his knowledge, dictate his method and tactics to him. In this way, turning the proverb upside down, we can say : like subject, like master' [Delboeuf, August 1886, 149].
Delboeuf's formulation not only turns the proverb upside down but provides a way of understanding how polarizing controversies and schools of psychotherapy develop in psychiatry. Delboeuf has, however, received little attention in the anglophone world. He has a small place as a footnote to the history of psychoanalysis. Freud quoted one of Delboeuf's dreams at length to demonstrate how forgotten memories influence the creation of dreams and introduced the interpretation of his own dreams by quoting Delboeuf's modest statement that, “Every psychologist is obliged to admit even his weaknesses if he believes that doing so will throw light on some obscure problem" [Freud, 1900/1961,105]. In France Jacqueline Carroy and Francois Duyckaerts have appreciated Delboeuf's broader significance [Carroy, 1991; Duyckaerts, 1992]. Following up on their work, this paper uses detailed published accounts of Delboeuf’s investigations of patients at the Salpêtrière in Paris, his observations on the subjects of the stage hypnotist Donato and his own experiments in Liege Belgium to describe the observations that led him to his memorable insight into the social-psychology of polarizing controversies in psychiatry.
Delboeuf achieved his insight during the polarizing confrontation over hypnosis that occurred in France during the 1880s between the illustrious Parisian neurologist, Jean Martin Charcot and Nancéén professor of medicine, Hippolyte Bernheim. Charcot argued that hypnosis was pathological and could be most readily, if not exclusively found, among hysterics. He had made his reputation as a neurologist by studying dramatic symptom complexes as prototypes of disease entities. Following this procedure in his study of hypnosis, he claimed that he had discovered a distinct three stage process consisting of lethargy, catalepsy and somnambulism, which could be elicited in hysterics. Bernheim , by contrast, saw nothing pathological about hypnosis, and no connection with hysteria. Bernheim came to hypnosis by observing the clinical practice of a country doctor A. A. Liébeault. Liébeault's aim was to heal his peasant patients of a wide variety of ailments, using hypnosis as a vehicle to suggest to them that they return to health. From his observations of Leibault Bernheim persuaded himself that hypnosis did not involve characteristic phenomenon, such as Charcot had found, but merely the imposition of the will of a hypnotist on a simple and passive subject [Ellenberger, 1970; Gauld, 1992].

Born in 1831 and Delboeuf received his doctorate in philosophy and letters in 1855. Before turning his attention to hypnosis, Delboeuf had an active and successful career in philosophy and psychology. He was a skeptic, a rationalist, and an experimental psychologist, with a profound commitment to the concept of freedom. Though skeptical about much of what he heard reported about hypnosis, he was not willing to dismiss the phenomena as mere imposture. As a rationalist he was determined to avoid being seduced by the 'mysteries' of hypnosis and to connect the explanation somnambulistic phenomena to the realm of psychological phenomena already analyzed by scientists [Delboeuf, 1887, 113]. In 1869, for example, he anonymously wrote articles offering naturalistic explanations for the regularly occurring stigmata of the would-be saint Louise Lateau. He even proposed an experiment to test the regularity of their occurrence. His commitment to freedom was such that in 1882, in the midst of the rising tide of positivism, he published an extended argument for the role of freedom, not only in human affairs, but also in the whole material world [Duyckaerts, 1992, 11-13].

When he finally turned his attention to hypnosis, during the last ten years of his life, these philosophic commitments colored his approach and influenced his conclusions. His approach was not that of a neuroscientist, seeking to establish new disease prototypes, or that of a medical doctor attempting to treat patients. As a philosopher with a deep commitment to freedom, he was reluctant to see hypnotic phenomena as either the result of disease, like Charcot, or as the result of mental passivity, as did Bernheim. As a rationalist he was determined to find simple explanations for his observations, As an experimental psychologist he was prepared to test these explanations by constructing experiments designed to prove them false. What is particularly intruiging for the historian of psychiatry is that Delboeuf's skeptical, rationalist, libertarian, and experimental outlook led him not only to a reconsideration of the phenomenon of hypnosis but to a reconsideration of the history of hypnosis itself.
His first introduction to animal magnetism, as it was still known, was in college. Reading about a miraculous cure he turned to the library to see what he could read on the subject. By luck he came upon Alexandre Bertrand's Treatise on Somnambulism, written in the 1820s [Delboeuf, 1886a, 441]. Bertrand is well known as a skeptic about the 'fluidist' explanations, who , rather than dismissing the observed phenomena out of hand, sought other explanations. Delboeuf was to adopt a very similar orientation towards the hypnotic phenomena he later observed. Bertrand is less well known for his insightful social-psychological analysis of the controversies swirling around in the 1820s. Bertrand regarded those who saw themselves as possessed by demons and those who felt infused with magnetic fluid as equally unreliable witnesses of what was actually influencing them. He saw the phenomena displayed by these very different subjects as originating in the imagination of a subject. Her magnetizer or exorcist was so impressed by this that he later unconsciously molded other subjects to resemble her [Bertrand, 1823]. Without directly citing Bertrand, Delboeuf was later to offer a very similar analysis of the controversies of the 1880s. Bertrand's influence, however, undoubtedly guided Delboeuf's own experiments and helped him reach his conclusions as rapidly as he did.
Delboeuf's direct involvement in hypnosis began in December 1885, when he visited Charcot's clinic in Paris. He had dabbled with hypnosis previously, but lore about its dangers and the stigma attached to its practitioners had always limited how far he went. In Paris he had strong philosophical reasons to challenge one of Charcot's fundamental findings. Delboeuf was concerned by the observation that, on waking, somnambulists could not remember what had occurred during 'sleep'. This troubled him because he had a metaphysical commitment to the idea that nothing, not even a memory, is permanently lost from the universe. Because he regarded personal memory as defining the self, which was the basis of personal identity, the failure to remember what occurred during hypnotic sleep also created the paradox of a person with two identities.
At the start of his investigations Delboeuf accepted the commonly held nineteenth century assumptions that hypnosis was a form of sleep and that somnambulism was a form of dreaming. Based on these assumptions was sure that there must be conditions which would allow for remembering what occurred during somnambulism just as there were conditions that allowed for remembering dreams. After Charcot's students demonstrated that subjects did forget what they had done after being awoken from a somnambulistic state, Delboeuf created an experiment in which subjects were woken in the midst of putting out an imaginary fire. As he predicted, they remembered the fire as if it were a dream.
As a newcomer to hypnosis Delboeuf viewed Charcot's demonstrations with respect. Nonetheless a number of observations aroused his skepticism. He thought that pictures of ecstatic saints lining the waiting room offered suggestions to patients on how to behave when hypnotized. Charcot's first patient greeted him with such familiarity that Delboeuf thought that she resembled an experimental subject more than a sick person [Delboeuf, 1886, 123]. As he watched Charcot's demonstration of catalepsy, one of the three characteristic stages of hypnosis, Delboeuf recalled that stage hypnotists had demonstrated the same phenomena at least forty years earlier [Delboeuf, Oct 1886, 125].
It was important to Delboeuf's perspective on hypnosis that he never made a distinction between hypnotic phenomena created by stage hypnotists and those observed by doctors. Indeed he seems to have identified more with the stage hypnotists than with the doctors. Even before going to Paris to observe Charcot, Delboeuf had published an anonymous defense of the stage hypnotist Donato, who had been dismissed as a charlatan by “les Parisiens” . Delboeuf saw the medical critique of stage hypnotists as largely turf protection and efforts to legally curtail the activities of men like Donato as an unwarranted and even dangerous restriction of human freedom. His familiarity with the work of these 'charlatans' was an important source of his understanding of the social-psychology of healing movements.
After observing Charcot's demonstrations, Delboeuf was inclined to agree with Bernheim that such phenomena were the result of unconsciously suggestive maneuvers [Delboeuf,Oct 1886, 125]. His conclusions were not, however altogether in accord with Bernheim's, revealing the influence of Delboeuf's convictions about human freedom. Delboeuf concluded that what he had observed was due, not just to unconsciously suggestive maneuvers on the part of the hypnotist, but to an excessive willingness to accommodate [un excèss de complaisance] on the part of their subjects. "They could speak,' he insisted, for example, 'but they felt a duty to be quiet' [Delboeuf, Oct 1886, 147].
After leaving Paris, Delboeuf did not go directly to Nancy to observe Bernheim but returned home to Liege to try to reproduce Charcot's results for himself. He initially accepted Charcot's view that hypnosis was easier to induce in hysterical patients, but achieved only mixed results with such patients. Remembering Bernheim's claim that hypnosis were easier to produce in healthy, but simple subjects, Delboeuf began a series of experiments using two sisters who were his servants, without apparent concern about the influence of his role as master on his servants as subjects. Perhaps this worked because Delboeuf conducted his hypnotic sessions like a philosophy professor teaching a new student, at times speaking of giving his subjects 'a little lesson in psychology' [Delboeuf, May, 1886,455]. If his authority facilitated their learning, so much the better.
When his experiments with the younger sister, M, were disappointing, Delboeuf decided to try to hypnotize the older sister, J., although he thought she would give him more trouble as a subject, because she was more intelligent than her sister. Contrary to these expectations, she rapidly entered a state of somnambulism and he was able get her to demonstrate a wide range of the phenomena he had observed in Paris. Delboeuf’s interpretation of J…’s rapid progress is remarkable for its contrast with with the the interpretations that both the Salpêtrière and the Nancy schools would have given to such performances. To Charcot and his followers J… would have to have been a hysteric. To Bernheim and his followers she would have been considered merely suggestible. In either case the power would lie in the hands of the hypnotist, while the subject would be either sick or extremely passive.
For Delboeuf their roles were reversed. First, he marveled at her “intelligence,” self-consciously emphasizing it was her intelligence that allowed her to learn just what he wanted her to do so quickly and completely that a spectator could not discern just how he communicated his wishes to her. Second, he modestly noted that if his psychological studies had not put him on guard, he could have been fooled into believing that he had influenced her by his thought or will.
His realization that his servant was smart enough to fool him, and that he was potentially gullible enough to be fooled into believing that he had power over her, opened the door to his realization that this dynamic could well have been working between largely female subjects and largely male hypnotists throughout the nineteenth century. This must have been, he added, how many magnetizers, honestly, came to believe in the power of their will [Delboeuf, 1886b, 153-4].
While Delboeuf was conducting his experiments with J..., he was invited to observe the work of an amateur magnetizer with a group of teen age boys, all of whom behaved in the same manner when hypnotized. Because of his familiarity with the stage hypnotist Donato, Delboeuf immediately realized that these subjects must have ‘passed through Donato's hands'. As Delboeuf knew, when Donato arrived in a new city, he recruited a cadre of subjects, usually of adolescent boys, who he trained in his method, or as Delboeuf put it, 'poured into his mold'. During public performances Donato called upon these subjects to do things that provoked astonishment and laughter in the audience. It was a group of these boys that the magnetizer had unwittingly discovered, and had made no effort to reshape.
Because Delboeuf did not make the standard distinction between hypnosis as used in science and in entertainment, it appeared obvious that the type of subject that Donato created for his commercial purposes was a third type of hypnotic subject along with those “discovered” at the Salpêtrière and at Nancy. Donato’s boys had volunteered to be hypnotic subjects and might be seen as motivated to produce the best possible performance. Indeed, he added, he could put his subject J… into a forth category.
Expanding the number of categories of hypnotic subjects by accepting the legitimacy of his own subject J… as well as Donato’s subjects on the same footing as those of both Charcot and Bernheim had important implications for his thinking. His conclusion from this insight is worth quoting:
…if the subjects from Salpêtrière and those from Nancy present such remarkable differences, they have probably come from a certain type of training in part intentional, in part unconscious, in part accidental. The hypnotists would have been …inspired by the first results that they obtained and would have endeavored to obtain them subsequently, believing that they were essential and characteristic; the subjects, so influenced and almost guided, would have in their turn be used as models by newcomers who saw them or who heard them talked about; there would be, in this way, instituted a latent teaching supported by different traditions according to the milieux, and so would have given rise to types of schools in conflict today.
Delboeuf's conclusion relates not only to the schools in conflict in his day but also to the schools in conflict in our day. More is at stake, however, than an original subject persuading her therapist, hypnotist, magnetizer or exorcist of the genuineness of her performance and he then training future subjects and students in his school. The first subject, her handler as well as future subjects and handlers must be prepared to accept a particular interpretation of the observed phenomena. In one period, demons have explained things for some. In other periods magnetic fluids, messages from the dead and more recently alters. Polarization occurs between those who are prepared and trained to see and believe and those who are not. The process that Delboeuf, and Bertrand before him, described helps explain how such polarizing conflicts develop and perhaps assures that they will continue to recur.
Not satisfied with having established this typology of hypnotic subjects, Delboeuf, the experimentalist, also attempted to show that he could transform one type into another. Using imitation, he decided to produce hypnotic subjects in the same mold. First, he had M., who did nothing more than 'sleep', when he hypnotized her, watch J… demonstrate lethargy and catalepsy. As predicted M… was now able to enter these states, something she previously could not do. In a second experiment he had two of Donato’s subjects, who had their own type of hypnotic performance, watch J. and M. In a short time Delboeuf was able to get Donato's subjects to imitate J. and M. point for point. Not only was Delboeuf able to get these subjects to change type, but once they did so they continued to display the new set of hypnotic behaviors. The stability of this learned behavior as well as the failure to observe the learning, Delboeuf argued, created the illusion that scientists like Charcot were discovering naturally occurring phenomena.
Having recognized how types of subjects are created and modified, as well as how hypnotists deceive themselves into overestimating their power, Delboeuf was in a position to critique the very assumptions with which he had begun his investigations, namely that hypnosis was a form of sleep. Delboeuf's attitude toward his subjects and his relationships with his subjects were already quite different from either those of Charcot or Bernheim. This led to different perceptions of what was going on during hypnosis. On the question of what, if anything was on subjects’ minds while they were in a state of hypnotic sleep it was easy to assume that nothing was on their minds. Indeed when asked they usually said that they were thinking of nothing. Delboeuf, however, noticed that J… was hardly indifferent to sounds around her. When asked, for example, to wake when the clock struck a particular time, she never failed to do so. For Delboeuf this was clear evidence of mental activity [Delboeuf, 1886b, 155]. With another subject S., who was unusual for the time in that she volunteered to be a subject, Delboeuf, who no longer believed subjects had to forget their somnambulistic state, could simply ask what was on her mind. In a series of experiments where he forbid her from doing things such as writing the number “7”, she complied but became sad. When he asked her why she was so sad she replied, " I cannot do what I want. M. Delboeuf had forbidden me to write ‘7’. It is in spite of myself. I am sad because of the uselessness of the efforts that I make.” Delboeuf found S.’s belief that she was not free and her revolt against the constraints he had imposed on her confirmed his view that subjects are not simply clay in the hands of their hypnotizers. [ Magnétisme Animal 18-19]
Delboeuf began his investigations persuaded that hypnosis was a form of sleep and somnambulism was a form of dreaming. These comparisons were essential to his efforts to refute the philosophically provocative assertion that subjects cannot remember their somnambulistic state on waking. Initially, while visiting Charcot in Paris, he attempted to create conditions that allow for remembering. Later he concluded that the whole question of remembering or forgetting was a matter of the type of somnambulist one created. He began to see the idea of hypnosis as a form of sleep as useful metaphor for creating certain phenomena. Making use of this metaphor depended, in turn, on the subject's willingness to accept the hypnotist's suggestion that she was 'asleep.' With this insight Delboeuf went on to claim, somewhat tongue in cheek, that there was no such thing as hypnosis [Delboeuf, 1891-2]. In the last paper that he wrote before his death in 1896, at the age of 65, he more seriously suggested that the term hypnosis no longer be used because it created the misimpression that sleep was involved in the process. Instead he suggested that the term hypnosis be replaced by the term 'psychotherapy', or better yet 'psychodynamics' [Delboeuf, 1892-3]. With this suggestion Delboeuf completed his liberation from the mold of nineteenth century ideas about hypnosis and opened the way to twentieth century ideas about the collaboration of patient and therapist. Perhaps it is not surprising that Freud found so much to learn from the modest Belgian philosopher, who believed in freedom.

Edward M. Brown

As presented to the European Association for the History of Psychiatry, Madrid, Spain, September 2002.

References
Bertrand, Alexandre. Traité du somnambuisme et des différentes modifications qu'il présente, [Dentu, Paris, 1823].
Carroy, Jacqueline. Hypnose, sugestion et psychologie: Linvention de sujets, [Paris, Presses universitaires de France, 1991].
Delboeuf, Joseph. 'La mémoire chez les hypnotisés,' Revue Philosophique, 21 [May, 1886a] 441-472.
Delboeuf, Joseph. 'De l'influence de l'éducation et de l'imitation,' Revue Philosophique, [August, 1886b]146-171
Delboeuf, Joseph. 'Une Visite à la Salpêtrière,' Revue de Belgique [15 Oct. 1886c] 121-147.
Delboeuf, Joseph. 'De la prétendue veille somnambulique,' Revue Philosophique 23 [Feb. 1887] 113-142.
Delboeuf, Joseph. Magnétisme: À propos d'une Visite À L'Écold de Nancy, [Félix Alcan, Paris, 1889].
Delboeuf, Joseph. 'comme Quoi il n'y a pas d'hypnoitisme', Revue de l'hypnotisme, 6 [1891-2]129-135.
Delboeuf, Joseph. 'Quelques Considérations sur la Psychologie de l'Hypnotisme', Revue de l'hypnotisme, 7[1892-3] 200-210.
Duyckaerts, François , Joseph Delboeuf, philosoph et hypnotiseur (Paris: Les Empêcheurs de Penser en Rond, 1992).
Ellenberger, Henri. The Discovery of the Unconscious, [Basic Books, New York, 1970]
Freud, Sigmund. The Interpretation of Dreams, Trans. James Strachey, [John Wiley & Sons, New York, 1961].
Gauld, Alan. A History of Hypnotism, [Cambridge UK, Cambridge U.P., 1992].

French Psychiatry's Initial Reception of Bayle's Discovery of General Paresis of the Insane

2009-01-01T08:30:00.000-08:00

During the nineteenth century general paresis of the insane emerged as a new psychiatric disorder which was extremely common and completely devastating. While retrospective studies have found earlier instances of what may have been the same disorder, the first clearly identified examples of paresis among the insane were described in Paris after the Napoleonic Wars.1 General paresis most often struck people (men far more frequently than women) between twenty and forty years of age. Within a matter of months to a few years after the appearance of the first symptoms, it reduced its victims to a state of dementia and profound weakness. No treatment was known, and patients uniformly died. During the nineteenth century its prevalence came to be widely recognized. By 1877, for example, the superintendent of an asylum for men in New York reported that in his institution this disorder accounted for more than twelve percent of the admissions and more than two percent of the deaths.2 In the twentieth century, with the development of accurate diagnostic methods, general paresis was definitively linked to syphilis and with the development of effective treatment methods for syphilis it has become rare.

While historians have recently effectively applied social, political and economic analyses to psychiatry's past, they have largely ignored the history of general paresis. When they have discussed this disorder, they have treated it as an example of psychiatry's success in defining and explaining disease.3 The history of general paresis of the insane is, however, richer in historical ironies and more revealing of social and intellectual conflicts than such accounts suggest. Ackerknecht, for example, noted that while Antoine-Laurent-Jesse Bayle's "discovery of progressive paralysis as a separate disease picture (in 1822)... was of immense importance," Bayle was nonetheless "caused to leave psychiatry altogether."4
Why was there such a contrast between Bayle's fate and the ultimate glorification of his discovery, one might ask. For some like Jacques Postel and Rene Semelaigne this question does not arise because they deny that Bayle was "caused to leave psychiatry." Instead they argue that Bayle was never seriously interested in psychiatry and that he left the field at the first opportunity. This view is, however, implausible. While Bayle may never have had an interest in treating the mentally ill, he was a dedicated researcher. As such it is hard to imagine him abruptly and voluntarily abandoning a field in which he had just made what he regarded as an epochal discovery. Further, as Semelaigne noted, Bayle always followed debates over general paresis and was always ready to defend his priority in the discovery of that disorder.5
Jan Goldstein has proposed a purely sociological explanation for Bayle's departure from psychiatry. Noting that Bayle, was a student of Antoine-Athanase Royer-Collard, a rival of Jean-Etienne-Dominique Esquirol, who was the leader of that circle of psychiatrists which established psychiatry as a profession in France, Goldstein argues that "when Royer-Collard died in 1825, Bayle was without a protector, and Esquirol showed no inclination to take the talented young man, under his wing."6 Goldstein, however, fails to ask why Esquirol would not have wanted to adopt such a talented young man and does not explain why the leading members of Esquirol's circle responded to Bayle's announcement of his discoveries, not only by rejecting his conclusions, but also by ridiculing his logic, his claims to originality and even his writing style. This reaction suggests that Bayle's ideas may have been troubling or even threatening to Esquirol and his followers. After all Bayle was only twenty-seven and had only recently finished his training when Royer-Collard died. Certainly such a youthful protege of a rival could have been dismissed more quietly.
Paul Bercherie explains the intensity of the rejection of Bayle's ideas by suggesting that Bayle's contemporaries were misled by his enthusiastic exaggerations and wrongly believed that he was proposing pathoanatomical explanations for syndromes they were familiar with. As a consequence, he argues, they failed to recognize that Bayle's conception of general paresis as a disease was radically innovative.7 While Bayle's enthusiastic and even arrogant style no doubt provoked his critics, as Becherie suggests, the clarity of Bayle's arguments as well as the arguments of his critics leave little doubt that it was precisely because they did understand the radically innovative nature of his ideas that they reacted so violently.
In 1960 Leibrand and Wettley noted that the opposition to Bayle's ideas was so strong because these ideas breached the nosology of Pinel and Esquirol.8 What they fail to note is that Bayle went beyond describing a disease which cast doubt on the existing nosology. He also advocated an alternative methodology and criterion for making disease attributions in psychiatry. In doing so Bayle challenged the credibility of the framework which gave legitimacy to the therapeutic and research activities of the dominant school of psychiatry. While later in the nineteenth century Bayle's ideas acquired considerable support, in the 1820s Bayle was an isolated figure who was ostracized because of the threat posed by his ideas.

Pinel's Research Principles
The construction of the framework on which psychiatry's therapeutic and research activities were based was begun by Philippe Pinel, the founding father of French psychiatry. Pinel, who was also an important theorist in the post revolutionary reform of general medicine, was particularly concerned to establish both medicine and psychiatry on firm empirical footings and to avoid the speculative excesses of eighteenth century medical theorists. Pinel believed that these excesses could be overcome only by carefully observing symptoms, and classifying diseases according to their external manifestations, in the manner in which naturalists classified living creatures.9 A frequently cited passage from the introduction to the first edition of Pinel's Treatise on Mania, published in 1800 can be taken as a succinct statement of what I will call his research principles:

One who takes mental illness as a particular object of his researches, will make a bad choice by indulging in vague discussions about the seat of the understanding and the nature of diverse lesions; because nothing is more obscure and more impenetrable. But if one restricts oneself within broad limits, only to the study of its distinctive characteristics, as manifested by external signs, and adopts as the principle of treatment only the results of an enlightened experience, one returns to the course which must be followed in general by all parts of natural history, and by proceeding with reserve in doubtful cases, one will no longer have to fear going astray.10

In medicine Pinel's ideas had a short life, being superseded by anatomie pathologique, which sought to correlate symptoms with specific autopsy findings, and gave the latter primacy in defining the nature of disease.11 In psychiatry his views had greater longevity, albeit in modified form. What gave Pinel's ideas this longevity in psychiatry was the conviction that psychiatrists could cure a mental disease, that is eliminate its symptoms, without reference to visible anatomical lesions. The results of psychiatric treatment, not anatomical localization, formed the ultimate basis for psychiatry's diagnostic credibility. Pinel's most influential student J.E.D. Esquirol expressed this position clearly in 1816. After a discussion of the inconclusive results of patho-anatomical studies of the insane, he argued that,"happily" these results were "not indispensable" because "for the cure of madness, it is no more necessary to be familiar with its nature than it is necessary to be familiar with the nature of pain to successfully employ pain relievers and sedatives."12
The treatment on which the profession of psychiatry was built in the early nineteenth century was known as moral treatment. During the 1790s, after taking charge of the Bicetre, an asylum for insane men, Pinel observed the way in which the lay managers of that asylum influenced patients. Based on these observations he developed the idea that the insane could be influenced by moral, that is, essentially psychological, means.13 According to Pinel passions such as joy, anger, fear and sadness affected circulatory, respiratory and gastro-intestinal functions which in turn, by a process of sympathetic influence, affected the functioning of the brain. 14 While not denying that the body was implicated in madness, the psychosomatic logic of moral treatment required that insanity be understood functionally, as a nervous disorder, and not as a result of a visible lesion.15

Georget's Revision of Pinel's Ideas

For Pinel the method of classifying psychiatric diseases by describing symptoms and the method of curing these diseases by removing symptoms through moral treatment were interdependent. Together they formed a framework for research and treatment.16 To the extent that anatomie pathologique was successful in establishing symptom-lesion correlations as the basis of legitimate disease attributions it threatened the psychophysiologic rationale of moral treatment and thereby the credibility of this framework. By the third decade of the nineteenth century some psychiatrists, particularly Etienne Jean Georget, were aware of the limitations of Pinel's ideas and were at pains to revise them. To adequately understand psychiatry's reception of Bayle's discovery of general paresis one must therefore view this reception against the backdrop of Georget's work. This is especially true since Georget, before his death in 1828, was Bayle's most outspoken and articulate critic.
In 1820, two years before Bayle's first work on general paresis, Georget published On Madness.17 The aim of this work, it can be argued, was to protect the rationale of moral treatment in terms consistent with anatomie pathologique. While Georget supported Pinel's rejection of eighteenth century speculative systems of pathology, approvingly quoting Pinel's statement of research principles, he took issue with both Pinel and Esquirol because they had described the phenomena of madness, "without demonstrating their source;...(and) described the facts scrupulously without connecting them to a cause."18 Rejecting religious views of the mind, Georget insisted that symptoms represented bodily changes. Moreover, influenced by the phrenologic teachings of Franz Joseph Gall, Georget sought to establish the materialist contention that the brain was the seat of the mind.19
For Georget a credible theory of the cause and cure of madness had to be consistent with anatomie pathologique. Indeed autopsy findings on insane patients formed an important section in De la Folie.20 Georget accepted the view that disease attributions had to be based on specific organ function and not on older humoral theories. As a result he sought "to fix the seat (of madness), to demonstrate the source of the disorders produced, as one does in all other diseases..."21 However,true to his psychophysiological views on madness, Georget also insisted that it was "less on its physical dispositions than on its functions that one must form the divisions of the nervous system; it is thus always that anatomy must follow physiology."22
Georget rejected Pinel's suggestion that the seat of madness might be found in disorders of the intestines.23 Instead he argued that madness was a primary or idiopathic disease of the brain. As a result moral influences could be seen as causing madness by directly influencing the brain and moral treatment as curing madness in the same direct manner. Psychiatrists were, like other doctors, responsible for diseases of a specific organ and, moreover, they had an effective treatment for disorders of that organ.For Georget this was the basis of psychiatry's legitimacy as a medical specialty. If insanity were merely secondary,or sympathetic, to a disorder in another part of the body, he argued, this legitimacy would be challenged. He expressed this opinion as follows:

If (insanity) is idiopathic, the organ from which all the disorders emanate, merits the attention of the doctor: to re-establish its functions,... but if it is sympathetic, it is necessary most particularly to address oneself to its cause, to the distant affection which produces and maintains it; otherwise one can only palliate, ... The treatment of madness must thus especially be founded on the state of the brain...24

Aware that some patients seen in asylums were not curable by moral treatment and that some had lesions of the brain and other parts of the body, Georget protected the psychophysiological rationale of moral treatment by adopting what has been called a dualist position.25 He drew a sharp distinction between acute delirium (le delire aigu) and madness proper. The former he regarded as secondary to intoxications, head trauma and disorders in other organs. It was likely to be both incurable and associated with lesions of the brain or other organs. Madness proper was defined in this scheme as an idiopathic disorder that was not associated with visible lesions but was due to physiologic changes in the brain. It was caused exclusively by the interaction of predisposing factors, such as heredity, and precipitating moral or emotional factors such as grief and fear. It was curable by moral treatment.
This distinction between le delire aigu and madness proper was supported by Georget's review of autopsy findings among the insane. On the basis of this review. Georget argued for the value of negative as well as positive autopsy findings. He supported his view that madness was an idiopathic or physiological disorder of the brain by pointing to the fact that autopsies done on patients with madness proper revealed no consistent lesions in the brain.26 Because such lesions could not be found, the success of the direct treatment of madness by moral means, rather than anatomie pathologique, could remain the basis of psychiatry's scientific and professional credibility.

Bayle and the Discovery of General Paresis

Before entering psychiatry, Antoine Bayle had already studied with Rene-Theophile-Hyacinthe Laennec, who was one of the leading advocates of anatomie pathologique, as well as a friend and associate of Antoine's uncle Gaspard-Laurent Bayle.27 Antoine Bayle greatly admired these men and sought to emulate them. He also believed that their ideas were in direct conflict with Pinel's. The younger Bayle saw the teaching of medicine at the beginning of the nineteenth century as divided between two schools, that of Pinel and that of Corvisart, with whom Laennec and his uncle had studied. Of Pinel's teachings in medicine he wrote that, "one could not at all hide the fact that they could lead one astray by making one neglect the organic causes of diseases, by focusing too exclusively on derangements of function."28 According to Bayle, Laennec appreciated this difficulty and felt that the best foundation for medicine was the disciplined search for lesions.29 It is clear that in the conflict which he saw between the medical teachings of Pinel and those of Corvisart, Laennec and the elder Bayle, Antoine Bayle identified with the latter.
We do not know just why Bayle entered into psychiatry. Postel and Semelaigne suggest that when Bayle was offered a position in psychiatry by one of his uncle's friends, it was only his poverty which led him to accept. However, we also know that the elder Bayle had written that anatomie pathologique:

had not made enough progress toward sufficiently clarifying the diverse genres of organic diseases: many degenerations which present different structures are still confounded and linked under the same designation. It will be difficult for a long time to remedy these difficulties, because few doctors are placed in a position favorable to making autopsies... to remedy these difficulties... nothing would be more advantageous than an exact monograph on each of the orders or genres which compose the class of (organic diseases).30

While the promise of economic security may have motivated Antoine Bayle to enter psychiatry in 1818, it also seems likely that he saw a position at a psychiatric institution as an opportunity to act on his uncle's suggestion. Certainly psychiatric hospitals at that time presented a rich field for autopsy studies.
The younger Bayle began his brief career in psychiatry as an interne at the Royal Asylum for the Insane at Charenton, where he studied under A-A Royer-Collard. Evidence suggests that Bayle and Royer-Collard's relationship was a close one. Both were Royalists; and Bayle's praise for Royer-Collard as a mentor was lavish.31 While at Charenton, Bayle focused his efforts on clinico-pathological research. He performed a great number of autopsies, and when writing about treatment, he cited Royer-Collard's experience rather than his own.32
The substantial prevalence of paralytic symptoms among the insane, as well as the fatal prognostic implications of a diagnosis of paralysis were well known when Bayle entered Charenton. In 1816 Esquirol had noted that a majority of a series of two hundred and thirty patients suffering from dementia were also afflicted with paralysis.33 At about the same time he gave a detailed description of the physical symptoms of this paralysis and noted that death could soon be expected following its diagnosis.34 Paralysis had also been observed at Charenton. Trouseau noted that this diagnosis could be found frequently in the case books of that asylum before Bayle arrived.35
At the time of Bayle's research, the prevailing interpretation of the occurrence of paralytic symptoms among the insane was that these symptoms represented a complication of the insanity. This had been Esquirol's view for some time. In his discussion of madness in the authoritative Dictionnaire des Sciences Medicales, Esquirol, without any particular justification, simply listed la paralysie as a complication along with la phthisie and le scorbut.36 It appears that he regarded it as a complication because the physical symptoms of paralysis occurred after the mental symptoms of insanity and because he could not correlate these symptoms with any particular form of insanity. It is also probable that Esquirol's conception of insanity as a cluster of mental symptoms precluded his seeing a physical symptom like paralysis as other than a complication. It was with this conception of insanity as a cluster of symptoms as well as Esquirol's interpretation of paralysis as a complication that Bayle took issue.
Bayle first announced his views about paralysis in his medical thesis in 1822, when he was only twenty four years old. This work presented the results of Bayle's patho-anatomical researches at Charenton. It was divided into three chapters each devoted to describing cases of insanity which were secondary to disorders located outside of the brain. While the chapters on insanity secondary to gastro-enteritis and gout have been forgotten, the fact that they were presented alongside of the chapter on general paresis suggests that Bayle's overall purpose was to establish the clinico-pathological foundation of the idea of symptomatic insanity. Bayle's choice of the autopsy finding "Chronic Arachnitis," rather than either the physical or mental symptoms, for the title of his chapter on general paresis also suggests his angle of vision.
This chapter contained the main features of Bayle's ideas on the relationship between the mental symptoms of insanity, paralysis and the results of autopsy .37 It ambitiously rejected Esquirol's view that paralysis was a complication of insanity. Instead Bayle argued that paralysis was only one facet of a complex disorder which included both mental and physical symptoms and which arose secondary to a chronic inflammation of the arachnoid lining of the brain. He described this disorder as occurring in three stages. The first was characterized by a mild paralysis, particularly affecting speech, and a monomania, particularly a monomania involving grandiose ideas. The second stage was characterized by a generalized mania and a worsening of the paralysis and the third by dementia and severe paralysis. In each of six cases, he detailed the clinical course and noted the constant presence at autopsy of an inflammation of the arachnoid membrane. Following the logic of Laennec's anatomie pathologique, he reasoned that all of those symptoms associated with constant pathological findings ought to be regarded as part of a single disorder, and that those pathological finding ought to be regarded as the immediate cause of the symptoms.
The first of these cases, Claude-Francois L., was admitted to Charenton in October 1818, shortly after Bayle began his work there. This case provides an example of Bayle's approach to explaining psychiatric diseases. On admission this patient was "in a demented state, with ideas that are predominantly ambitious, and with his partial paralysis ...advanced," By the time of his death, this patient provided Bayle with a fully developed picture of the clinical course of the disease. Finding an inflammation of the arachnoid lining of the brain on autopsy, Bayle concluded that the full course of this patient's illness could be explained by this lesion. After presenting the autopsy findings he asked rhetorically, "Does not this observation prove that the disorder of the intellectual faculties was the symptom of a chronic arachnitis and not an essential delire." 38
Pursuing the conclusion that the lesions he has found are "the anatomic characteristics of chronic mental disturbance," Bayle attempted to explain in detail how these lesions resulted in the particular symptoms observed. Claude-Francois L.'s symptoms began with a loss of consciousness which Bayle argued was due to sudden congestion of the blood vessels of the pia mater and the cerebrum. Bayle explained the difficulty with speech, staggering gait, agitation and monomania which occurred during the second period of the disease as due to the increasing inflammation of the arachnoid lining and an outpouring of serous fluid which pressed on the brain. In the third period the trembling, loss of sphincter control and complete dementia were explained in the same manner as due to chronic inflammation of the arachnoid and increasing pressure on the brain from serous exudate.39

Georget and Bayle

Bayle was aware of Georget's book when he wrote his medical thesis. He noted that Georget's views differed from Pinel's in that Georget regarded madness as "always an idiopathic cerebral disorder." He considered opinions such as Georget's, however, as "too exclusive." It seemed to Bayle that "any physician who is not dominated by any preconceived ideas... will not be able to deny that mental disease is most often idiopathic but sometimes he will find it symptomatic."40 This, he added was the opinion of Royer-Collard. While Bayle's thesis did receive public notice, it did not provoke great controversy.41 In part this was due to Bayle's limiting himself to announcing an exception to the principle of madness as an idiopathic brain disease.
The year 1822 was, however, also a year of considerable political turmoil in French medicine. In October of that year the Restoration government dismissed the largely republican faculty of the Paris medical school and replaced them with royalist sympathizers. While this political interference may have hurt the teaching of medicine, it also resulted in the elevation of Laennec, who like Bayle was a royalist, to a position of power.42 This changing political climate must have emboldened Bayle. In 1824 Bayle participated in founding the Revue Medicale, a journal which served as a vehicle for his ideas for a number of years.43 In 1825 he published a theoretical statement of his views in this new journal. This virtual manifesto was provocatively titled "A New Doctrine of Mental Disease." 44 This was strictly a theoretical statement published without data, which Bayle promised to present in a later treatise.45
The most obvious feature of this "new doctrine" was Bayle's ambitious reversal of his earlier position that most mental illness is idiopathic. He now insisted that "sometimes, but very rarely" madness is due to strictly psychological factors affecting the mind.46 In the greatest number of cases, he insisted, madness is due to a physical lesion, most often a chronic inflammation of the meninges, but sometimes a specific or sympathetic irritation of the brain.
Another feature of Bayle's "new doctrine" was methodologic. Bayle explicitly rejected Pinel's statement of research principles.47 He also rejected and reversed the approach to symptom-lesion correlations used by those "modern authors" who concluded that one cannot account for the symptoms of madness through organic lesions. According to Bayle they reached this false conclusion because they tallied the frequencies of various symptoms and only then attempted to correlate these frequencies with the frequencies of various lesions found upon autopsy. By beginning with symptom clusters and looking for lesions they failed "to see in the history of a particular patient the organic lesions in opposition to the symptoms which correspond to them..." Consequently they lost the opportunity to explain the symptom through the lesion. Bayle, by contrast, concluded that a disease was present in a particular case when he found a lesion. He then collected a great number of individual histories of madness and linked those with the greatest similarity in a manner which allowed him to arrive at a general doctrine.48
Unlike his thesis, Bayle's "new doctrine" did provoke criticism. Among those provoked was Georget, who, it is likely, spoke for Esquirol and his circle.49 Georget noted that Bayle had dramatically changed his opinions. In 1822, he pointed out, Bayle had agreed with the view that madness is most often idiopathic and only sometimes symptomatic, while in 1825 he reversed himself. "From 1822 to 1825," Georget exclaimed, "what a change!!" Noting that Bayle had been a student at Charenton in 1822 and had not worked there since 1822, Georget went on to suggest that Bayle's earlier views were perhaps only flattery addressed at the men in power at that time.50 He acknowledged that his critique of Bayle was "severe," but justified this severity by what he called Bayle's " exaggerated pretension."51 Had Bayle not announced a "New Doctrine," but rather stuck to his earlier claim to have found only an instance of insanity caused by an inflammation of the meninges, Georget noted that he would not have taken up his pen.52
Georget treated Bayle's "new doctrine" as nothing more than a series of speculative assertions or what he sarcastically called "novelties." Consequently he contented himself with demonstrating that in presenting each of these novelties Bayle was either inconsistent, vague or unoriginal. Of Bayle's claim, for example, that "in one case in five among men and one case in thirty or thirty-five among women... madness is the result of a chronic inflammation of the meninges," Georget rightly noted that the observation of such an inflammation was not new.53 He added that Pinel and Esquirol considered such an inflammation, not as the cause, but as a complication of madness. "It is a question," he asked rhetorically, "of knowing who is right between these doctors and M.Bayle."54
What galled Georget most about Bayle's "new doctrine," however, was Bayle's assertion that "all the doctors who have written before him, all of whom he calls excellent observers," had failed to use the proper method of reaching conclusions about the relationship between symptoms and lesions.55 No doubt regarding himself as one of these excellent observers, Georget did not discuss the substance of Bayle's methodologic position. Instead he concluded this review by dismissively expressing doubt that Bayle could back up his theory with proof.56
The next year Bayle accepted Georget's challenge and published a six hundred page treatise on chronic meningitis, which included a detailed description of ninety cases. He repeated his claim that, "the majority of mental illnesses are the symptom of a primary chronic inflammation of the membranes of the brain."57 As in his thesis he attempted to explain both mental and physical symptoms through the effects of chronic meningitis. He accepted the objection that in "the actual state of science" the question of how an inflammation of the linings of the brain could result in dominant ideas of ambition was "almost insoluble."58 Nonetheless he was willing to conjecture. Rejecting phrenological explanations, he argued that meningitis might be seen as predisposing a patient to certain ideas in the same way as gastritis predisposed patients to hypochondria and pulmonary tuberculosis to unfounded optimism.59 If individuals struck with chronic meningitis were imperious, vain, prideful and ambitious before becoming ill, then "everything unites to give their delusions an analogous character."60
Georget also reviewed this book. He was as sarcastic as before accusing Bayle of writing a book which was "six times too long, the reading of which was as fatiguing as possible."61 He did, however, summarize Bayle's theory and his data lucidly and accurately. Georget was not, as Becherie has suggested, misled into believing that Bayle was merely proposing a pathological anatomy for generally familiar syndromes.62 Rather, he was opposed to what he regarded as the faulty logic of Bayle's accepting autopsy findings as signifying the presence of disease and reasoning from these findings to explain symptoms.
Georget based his argument on the first two cases presented in Bayle's book. The first, Claude-Francois L., was a reprint of the same case Bayle had presented in his thesis. This patient demonstrated all three stages of the illness. The second patient choked to death early in the course of the illness. Finding the arachnoid slightly inflamed in the second case Bayle counted it as an example of general paresis, even though the patient presented with monomania but not with paresis. For Bayle these two cases presented autopsy findings at different stages of the same disorder. For Georget treating these two cases as due to the same disease was a failure of logic. According to Georget, Bayle:

didn't have a method of proceeding to arrive at the demonstration of such an opinion; it was necessary to present simple cases, where the phenomena have been observed separately; there are among the insane, ambitious monomanias without paralysis, and paralyses without ambitious monomanias, whatever M. Bayle says to the contrary; it is in comparing the autopsy results from one or another illness that one can perhaps succeed in distinguishing them."63

For Georget the presence of an illness was determined by the careful observation of symptoms. Only when such an illness had been defined did looking for causes make sense. To emphasize this Georget concluded this review by suggesting that bias had prevented Bayle from abiding by Pinel's research principles. "It is necessary," Georget argued, "to assemble a certain number of facts, observed and researched with exactitude, it is necessary to compare them, and to derive all natural inductions; it is necessary to study disorders of movement among the insane, ambitious monomania and dementia, and not chronic meningitis, except to conclude in the end that the affection is the cause of the enumerated symptoms."64

Calmeil

In the same year that Bayle published his treatise Louis Calmeil, like Bayle, a physician at Charenton, but like Georget a student of Esquirol, also published a treatise entitled On Paralysis, Considered among the Insane. Calmeil's several references to Bayle throughout this book, make it clear that he was not merely announcing his own findings, but also responding to Bayle's claims.65 On the opening page of his book Calmeil makes it clear that his opposition to Bayle was stimulated by Bayle's "wanting to establish the extraordinary principle that the majority of the time mental illness has for its immediate cause a physical lesion of the meninges."66 Calmeil reported sixty cases of paresis with autopsy findings on thirty nine. His method of tracing the connections between clinical and post mortem findings differed from Bayle's. He took symptoms, "one by one," observed their development in the manner approved by Pinel and Georget and then predicted what he would find on opening the body.67 In contrast to Bayle's observation of constant pathological findings associated with paralysis, Calmeil found a great variety of lesions at autopsy. Because he found such a variety of lesions, he argued that these lesions could not "sufficiently explain the symptoms observed during life."68 After reviewing the various mental symptoms associated with paralysis, he insisted that one deceives oneself if one concludes that the progression of these symptoms follows the neat three stage model proposed by Bayle.69
Georget reviewed Calmeil's book, predictably praising him for his wisdom and restraint.70 Bayle, on the other hand, responded to Calmeil as sarcastically as Georget had responded to him. Calmeil had concluded that, "it is a chronic inflammation which gives rise to general paralysis, by inducing in the brain a modification which we have not been able to appreciate." Bayle responded by asking rhetorically, "what is this chronic inflammation which has none of the characteristics of inflammations...," that is, does not present with visible lesions.71 The differences between Bayle's and Calmeil's autopsy findings were not a matter of simple empiricism. Laennec had emphasized the importance of inflammatory lesions on the linings of various organs as one of the principle findings of pathological anatomy.72 In defending himself against Calmeil's argument that only an inflammation of the brain, not one of its linings could result in madness, Bayle later suggested that his view of the pathogenic significance of chronic meningitis was supported by its striking analogy with the pathogenic significance accorded to inflammations of other body linings, as for example pleurisy.73 In opening the bodies of the insane Bayle saw what he saw through lenses provided by Laennec. Calmeil, in turn, also saw what he saw through lenses provided him by Pinel.

Monomania

Georget and Calmeil were at such pains to refute Bayle, not only because the logic of his method of linking symptoms and lesions turned theirs on its head or because his claims for the explanatory power of his findings were so broad, but also because the diagnosis of general paresis threatened the disease status of monomania and consequently its ideological value for psychiatry. Originally described by Esquirol, the diagnosis of monomania referred to a symptom complex including exalted mood, increased energy and a preoccupation with a particular idea.74 According to Esquirol, monomania was not merely a disease but it was "of all diseases, the one whose study offers the broadest and most profound subject for meditation:the study of it embraces... that of civilization."75 Moreover, according to Goldstein, Esquirol believed that the fluid society that was the legacy of the Revolution produced its own peculiar monomania, that of overweening ambition. The ideological significance of the idea that changes in the form of monomania reflected changes in the passions of civilization can be seen in Esquirol's suggestion, made in 1822, that a physician's "familiarity with the causes and character of the regnant madnesses" might allow him to furnish the government with the most certain elements of a moral statistics of population.76
There is no evidence to suggest that Bayle's aim was to undermine the diagnosis of monomania, even though his conservative religious views probably made him uncomfortable with the implications of this diagnosis.77 Nonetheless by treating monomania, particularly ambitious monomania, as merely a symptom of an inflammation of the meninges, Bayle not only relegated monomania to the status of a symptom, he also undermined the social psychological significance of that disease category. In this light Georget's argument against the constant association of monomania and paralysis can also be seen as an effort to preserve the independent status of monomania as a disease.

Conclusion

In the early nineteenth century Pinel's research principles, which had so effectively separated modern psychiatry from the speculative excesses of earlier centuries, were confronted with the challenge of a new way of thinking about disease. Both Antoine-Laurent-Jesse Bayle and Etienne Georget were aware of the inadequacies of Pinel's position. Both attempted to use autopsy findings to establish psychiatric research on firmer footing. Georget attempted to preserve the Pinel's descriptive approach to symptoms and with it the role of moral treatment in legitimizing psychiatric disease attributions. Bayle, in contrast, rejected Pinel's position outright. Instead he sought to demonstrate, through the discovery of general paresis, the primacy of anatomie pathologique as a methodology and a set of assumptions about disease. Bayle's far reaching claims for the significance of his discovery can be understood in terms of his ambitious advocacy for the approach to disease which his uncle and his mentor stood for. For Georget, however, Bayle's insistence that "the majority of mental illnesses are the symptom of a primary chronic inflammation of the membranes of the brain" threatened the primary role he hoped to establish for brain function as the cause of madness.
The united opposition of members of Esquirol's circle to Bayle and his ideas sealed his fate. After Laennec died in 1826, Bayle retired not only from psychiatry but also from clinical medicine, becoming a librarian and bibliographer. Perhaps Bayle, in extending his uncle's legacy to psychiatry, had done all he had intended to do. Georget and Calmeil's reactions to Bayle set the tone for subsequent discussions of Bayle by other authors. As late as 1838 Esquirol in his Maladie Mentale echoed Georget's contention that monomania and paralysis were not constantly associated.78 Even as Bayle's discovery that general paresis of the insane was a distinct disease, involving both mental and physical symptoms and associated with demonstrable pathological findings, came to be accepted, almost ritual references to Bayle's pretensions and exaggerations were regularly expressed. As late as 1855 his claims to priority in the discovery of general paresis were still being challenged.79 It is certainly true that Bayle was provocative and even pretentious in his style. It is also true that Bayle was an outsider whose views would understandably be viewed with suspicion by members of Esquirol's circle. It was, however, the fact that Bayle's ideas threatened the credibility of the framework which which gave legitimacy to the research and therapeutic activities of Esquirol's school, that led to his fate.

1 . E.H. Hare, "The origin and spread of dementia paralytica," J.Ment. Sci,1959, 105: 594-624.
2 . A.E. McDonald, "General Paresis," Amer.J. Insan.,1877, 33: 469.
3 . George W. Henry, "Organic mental disease," in Gregory Zilboorg and George W. Henry, A History of Medical Psychology, (New York, W.W. Norton, 1941), pp. 526-551. George Rosen, Madness in Society, (New York, Harper, 1968), pp.249-258. Henri Colin and Rene Charpentier, La Paralysie Generale (Maladie de Bayle):Centenaire de la These de Bayle (1822-1922),(Paris,, Masson et C ,Editeurs,1922).
4 . Erwin Ackerknecht, A Short History of Psychiatry, (New York, Hafner Publishing Co.,1968, p.51. Progressive paralysis was a commonly used alternative designation for general paresis.
5 .Jacques Postel, "Georget et Bayle: deux destins contraires," Psychanalyse a l'Universite,1978,3:445-463.
Rene Semelaigne, "Bayle et les Travaux de Charenton," in Colin and Charpentier, La Paralysie Generale, p.59.
6 .Jan Goldstein, Console and Classify: The French Psychiatric Profession in the Nineteenth Century, (Cambridge University Press, Cambridge, 1987) p.147-8.
7 .Paul Becherie, Les Fondements de la Clinique, (Navarin, 1985) p.75.
8 .Werner Leibrand and Annemarie Wettley, Der Wahnsinn: Geschichte Der Abendlandishen Psychopathologie,(Verlag Karl Alber, Freiburg,1961) p.448.
9 .Philippe Pinel,Nosographie Philosophique ou la Methode de l'Analyse Appliquee a la Medicine, 6th. ed. (Paris, J.A. Brosson, 1818).
10 .Philippe Pinel,"Introduction a la Premiere Edition," Traite Medico-Philosophique sur Alienation Mentale, seconde edition (Paris, J.A. Brosson 1809) p.ix.
11 .Erwin H. Ackerknecht, Medicine at the Paris Hospital: 1794-1848,(The Johns Hopkins Press, Baltimore,1967).
12 .Jean Etienne Dominique Esquirol, Des Maladies Mentales Considerees sous les Rapports Medical, Hygienique et medico-legal, (Paris, J.-B Bailliere, 1838) vol.1, p.114.
13 .Dora B. Weiner, "The Apprenticeship of Philippe: A new document, 'Observations of Citizen Pussin on the Insane,'" Am. J. Psychiat., 1979,136:1128-1134.
14 . Becherie, Les Fondements de la Clinique, p.33.
15 . Goldstein, Console and Classify, pp. 72-90.
16. Ibid.
17 .Etienne-Jean Georget, De la Folie: Consideration sur Cette Maladie, (Paris, Chez Crevot, 1820).
18 .Ibid., pp.69-70.
19 .Jan Goldstein, Console and Classify (n.6), p.256.
20 .The importance of such findings to Esquirol as well is suggested by the fact that Georget's autopsy research was awarded the prix d'un concours, established by Esquirol. Bayle and Thillaye,Biographie Medicale par Ordre Chronologique, v. 2 (B.M. Israel, Amsterdam, 1967)p.932.
21 .Georget, De la Folie (n.17), p.viii.
22. Ibid., p. 13.
24. Ibid., p. 71.
25. Ibid., p.81.
26 .Postel ,"Georget et Bayle" (n.5). Becherie, Fondements de la Clinique (n.7), p.50.
26 . Georget, De la Folie (n.17), pp.373-504.
27 .Stefan Muller, Antoine-Laurent Bayle: Sein grundlegender Beitrag zur Erforschund der progressiven Paralyse,(Zurich:Juris-Verlag,1965)p.14.
28 .Antoine-Laurent-Jesse Bayle, "Notice Historique:Sur M. Laennec," Rev. Med.,1826,3:85-87.
29 .Ibid. Jacalyn Duffin has demonstrated that, at least after 1822, Laennec's views were more complex than Bayle seems to have taken them to be. Jacalyn Duffin, "Vitalism and organicism in the philosophy of R.-T.-H. Laennec," Bull. Hist. Med.,1988, 62,:525-545; Jacalyn M. Duffin, "The medical philosophy of R.-T.-H Laennec (1781-1826)," Hist. Phil. Life Sci., 1986,8:195-212.
30 .Gaspard-Laurent Bayle, "Anatomie Pathologique," in Adelon et al,Dictionaire des Sciences Medicale, (Paris:C.L.F. Panchouch) 1812,1:71-72.
31 .Antoine-Laurent-Jesse Bayle, Traite des Maladies du Cerveau et de ses Membranes,(Paris:Chez Gabon et Compagnie Libraires, 1826) p.X.
32 . Ibid. p.574. Bayle did publish one example of his own successful use of moral treatment. Antoine-Laurent-Jesse Bayle, "Sur les hallucinations des sens," Rev. Med.,1825, 1: 31-53.
33 . Jean-Etienne-Dominique Esquirol, "Demence," in Adelon et al, Dictionaire (n.30), p.288.
34 .Jean-Etienne-Dominique Esquirol, "Folie," in Adelon et al, Dictionaire (n.30), p.211.
35 .A.Trouseau, "Quelques mots sur l'historique d'une maladie cerebrale caracterisee le plus souvent par une paralysie generale et incomplete, compliquee de delire apyretique," Arch. Gen. Med., 1827,15: 565.
36 .Esquirol, "Folie," (n.34) p.210-211.
37 .Colin and Charpentier, La Paralysie Generale (n.3), pp.11-48; Merrill Moore and Harry C. Solomon, "Contributions of Haslam,Bayle and Esmarch and Jessen to the history of neurosyphilis," Arch. Neurol. Psychiat,,1934, 32:807-829.
38 . Moore and Solomon,"Contributions," (n.37) p.812.
39. Ibid., pp. 812-3.
40. Ibid., p.810.
41 .Antione-Laurent-Jesse Bayle, "Des Cause Morales et Physique des Maladies Mentale,par Felix Voisin," Rev.Med., 1827,3,287.Bayle cites favorable references to his thesis in Bulletin de la Societe Medicale d'Emulation,1823, p.247 and Cercle Medicale, 1823, p.255. Bayle's thesis appeared in November 1822 and was not included in Georget's review of medical theses having to do with the nervous system. Etienne-Jean Georget, "Sur les theses de la collection des Facultes de Medecine de Paris, Montpellier et Strasbourg, ayant specialement pour objet la physiologie ou la pahtologie du system nerveus," Rev.Med.,1822,7,5.
42 .Russell C. Maulitz, Morbid Appearances:The Anatomy of Pathology in the Early Nineteenth Century, (Cambridge University Press, 1987), pp.101-103.
43 .Muller, Antoine-Laurent Bayle (n.27), p. 17.
44 .Antoine-Laurent Jesse Bayle, "Nouvelle Doctrine des Maladies Mentale," Rev.Med., 1,Fev.1825, p.169-215.
45 .Bayle suggests that there was some pressure to publish quickly but doesn't indicate the source of this pressure. Antoine Laurent Jesse Bayle, Traite des Maladies du Cerveau et de ses Membranes,(Paris,Chez Gabon, 1826) p.xxiv.
46 . Bayle, "Nouvelle Doctrine," (n.44) p.177.
47 . Ibid, p173. He repeats this rejection in Bayle, Traite (n.31), p.xix.
48 . Bayle, "Nouvelle Doctrine," (n.44) p.176.
49 .Georget apparently lived in Esquirol's home from the time he fininshed medical school until his death.John MacGregor,The Discovery of the Art of the Insane,Princeton University Press, Princeton,1989)38-44. Margaret Miller, "Gericault's Paintings of the Insane," Journal of the Warburg and Courtauld Institutes,4(1940-41)151-63.
50 .Etienne-Jean Georget, "Nouvelle Doctrine des Maladies Mentale;par A.-L.-J. Bayle," Arch.Gen. Med.,1825, 7:615.
51. Ibid., p.619.
52 .Ibid.
53 .Ibid. p.615
54 .Ibid. p.616.
55 . Ibid. p.618.

56 . Ibid. p.619.
57 .A.-L.-J. Bayle, Traite des Maladies du Cerveau (n.31), p.xxiv.

58. Ibid. p.550.
59 . Ibid. p.553. The emotions associated with pulmonary tuberclosis must have had a special poignancy for Bayle as both Laennec and his uncle G.-L. Bayle were experts on pulmonary tuberculosis and died of it. Jacayln M. Duffin, "Sick Doctors: Bayle and Laennec on their own phthisis," J.Hist. Med. All. Sci., 1988,43:165-182.
60 . Bayle, Traite des Maladies (n31), p.555.
61.Etienne-Jean Georget, "Traite des Maladies du Cerveau et de ses Membranes;par L.J.(sic) Bayle," Arch. Gen.Med., 1826,12:323.
62 .Becherie, Fondements de la Clinique (n.7), p.75
63 .Georget, "Traite des Maladies du Cerveau," (n.61) p.324.
64 .Ibid. p.328
65 .Louis Calmeil, De la Paralysie Consideree Chez les Alienes,(Paris, Bailliere, 1826) pp.7,333,393.
66 .Ibid., p.7.
67 .Ibid., p.192.

68 .Ibid., p.415.
69 .Ibid, p333.
70.Etienne-Jean Georget,"De la Paralysie Consideree Chez les Alienes; par L.F.Calmeil," Arch.Gen.Med.,1827,3:313-315.

71 .A.-L.-J. Bayle,"De la Paralysie Consideree Chez les Alienes; par L.Calmeil," Rev. Med., 1827,3:67.

72.This is not surprising in that pathological anatomy during the early nineteenth century relied only on macroscopic findings and so many of the people whose bodies were examined had died of inflammatory diseases. Maulitz, Morbid Appearances (n.42), pp.19-25.

73 .Antoine-Laurent-Jesse Bayle, "De la cause organique de l'alienation mentale accompagnee de paralysie generale," Ann.Med. Psych., 1855, 1:413.

74 .Jean-Etienne-Dominique Esquirol, "Monomania," in Adelon et al, Dictionaire des Sciences Medicale, par une Societe Des Medicines et de Chirugiens, (Paris, C.L.F. Panckouck) 1819,34:114-126.
75.Goldstein, Console and Classify (n.6), p.158.

76. Ibid., p.158. Jean-Etienne-Dominique Esquirol,"Introduction a l'etude des alienations mentale, Rev.Med., 1822, 8: 36.

77.For a discussion of Bayle's religious views see: Stefan Muller, Antoine-Laurent Bayle (n.27), pp.14-28.

78 .Jean-Etienne-Dominique Esquirol, Mental Maladies, A Treatis on Insanity,Trans E.K.Hunt (Philadelphia: Lea and Blanchard, 1845), p.441.

79.Rene Semelaigne, Les Pioniers de la Psychiatrie Francaise avant et apres Pinel, vol.1, (Paris: J.B. Bailliere, 1930),pp.47-48.

Bulletin of the History of Medicine, 1994, 68:235-253.

Why Wagner-Jauregg Won the Nobel Prize for Discovering Malaria Therapy for General Paresis of the Insane

2009-01-01T08:29:00.000-08:00

In 1927 the Viennese psychiatrist Julius Wagner-Jauregg was awarded one of only two Nobel prizes ever given to a psychiatrist for his discovery of the malaria treatment of general paresis. Compared to his contemporary Sigmund Freud, Wagner-Jauregg's name has almost disappeared from memory.1 Recently, Andrew Scull has suggested that historians have passed over the malarial treatment, along with other somatic treatments, in what he refers to as an 'embarrassed silence.' Indeed in the late twentieth century, the idea, as Scull describes it, of breeding 'colonies of malarial mosquitoes with which to infect tertiary syphilitics and so burn the offending parasites from their brains' seems more appropriate for moral censure than than universal acclamation.2 Our relative silence about malarial treatment may, however, have other sources than embarrassment. Twentieth century psychiatrists have until recently been more interested in psychological treatments than in somatic ones; while historians like Scull have often been more interested in psychiatry's failures than its successes. Moreover diseases like general paresis and pelagrous dementia have been so nearly eradicated that it is hard to remember what a large place they once played in psychiatric practice.

In order to appreciate the significance of the malaria treatment at the time that Wagner-Jauregg announced it in 1921, one must see this innovation in the context of the history of the disease that it cured--general paresis of the insane. In that context Harold Mersky’s views seems closer to the mark than Scull’s facile dismissal. According to Mersky, 'any clinician today (who) could achieve the sort of results with AIDS ... which Wagner-Jauregg obtained with general paralysis, ...would receive the immediate acclaim and the same ultimate rewards as those given for the introduction of malarial treatment.'3 Mersky's comparisons with AIDS is apt in several ways. General paresis was a uniformly fatal disease that most frequently struck people (men far more often than women) between the ages of 20-40. A diagnosis of general paresis was stigmatizing, both before and after it was understood to be caused by syphilis. Before they died paretics became completely demented and unable to care for themselves, dying most often in insane asylums. As with AIDS there was initially great optimism that when paresis was discovered to be caused by an infectious agent--treponema pallidum--that it would yield conventional anti-syphilitic treatment. There was also great disappointment when Salvarsan--the so-called magic bullet for syphilis, failed to interrupt the fatal course of general paresis. Unlike AIDS, however, general paresis had frustrated all attempts to find a cure for over one hundred years before Wagner-Jauregg introduced his treatment.
General paresis of the insane was first identified as a distinct disease by Antoine Laurent Jessé Bayle in the 1820s. He characterized it as having both physical and mental symptoms, a regular natural history and consistent post mortem findings. Although psychiatrists differed over whether or not Bayle had discovered a new disease, they all agreed that finding signs of paresis, even subtle early signs, in an insane patient meant that the patient did not have long to live. Indeed it was just the fact that general paresis had such a uniformly short and fatal course that had allowed Bayle to see it as a single disease. While psychiatrists were proud of their ability to characterize this disease as thoroughly as they could and hopeful that would soon be able to characterize others as thoroughly, they were nonetheless embarrassed by their complete inability to cure patients of this disease.4
This embarrassment was often concealed in callous demonstrations of their prognostic acumen. J.E.D. Esquirol, one of the architects of psychiatry's early nineteenth century therapeutic optimism, as well as one of the first do describe paresis among the insane, for example, boasted that his specialized expertise allowed him to detect signs of paresis that had eluded a provincial colleague. The patient was a 'strong, robust' thirty year old man who had persuaded himself that he possessed immense fortune and had yielded 'to all the excesses of the most fashionable life.' He was brought to Paris by the ‘skillful and estimable' Dr. K., who deferentially presented the patient to Esquirol. 'I commit to your care,' Dr. K. said to Esquirol ‘a very interesting patient, who is but slightly excited, and whom I have withdrawn from scenes calculated to augment his excitement, which you will speedily cure.’ Esquirol conducted a half an hour ‘conversation’ with the patient,during which he observed ‘some hesitation in the pronunciation of certain words’ and an ‘undue readiness’ to remain in a hospital. On the basis of these findings Esquirol disdainfully told his hopeful colleague, 'I think that your patient is incurable; that he will not recover, nor survive a year. Remain in Paris, and you will see, as the malady is making rapid progress.'5 Displays of diagnostic and prognostic abilities such as Esquirol's would be repeated by others during the nineteenth century but such displays could never fully conceal psychiatry's impotence in the face of this completely devastating and extremely common disorder.6
During most of the nineteenth century, before syphilis was taken seriously as the cause of general paresis, writing about the treatment of this disorder tended to emphasize prevention and palliation rather than cure. Initially some like Bayle held out some optimism that an understanding of the pathophysiology of the disorder might lead to a cure. Although Bayle noted that the proportion of deaths to cures was thirty to one, he nonetheless expressed confidence that bleeding 'wisely administered' was the best hope to diminish the ‘terrifying mortality’ of general paresis. 7 This proposal was based on his observation of congestion of the blood vessels of the pia mater of paretics dying in early stages of the disease. In spite of this sophisticated pathophysiological rationale, Bayle's optimistic predictions for blood letting as a treatment for general paresis were, of course, not borne out. In the final stage of the illness, when the patient was weak, bedridden and demented, there was general agreement that treatment should be humanely restricted to palliative measures. Opinions about prevention were more varied, but generally the advice given was, as in other forms of insanity, directed at avoiding emotional turmoil and excesses of alcohol and sex.
Throughout the nineteenth century, in spite of occasional claims of recoveries or remissions, general paresis remained 'a deadly disease, almost invariably fatal.'8 Toward the end of the century, Regis, in France, summarized the general opinion: 'the medical treatment...of general paresis includes an infinite number of agents, none of which, unfortunately, has up to this time, afforded any really favorable results.'9 In England Julius Mickle, author of the first English book devoted to general paresis, looked back nostalgically to ‘earlier writers’ who had 'enjoined the employment of active antiphlogistic' treatments such as ‘low diet, bleeding, leeching, cupping, purgatives, moxas, ...setons,...mercurial innunctions, antimony diuretics, and ...cold to the head.’ Although he wondered if these treatments had ‘suffered from undue neglect of late,’ he did not encourage his readers to attempt curative treatment.10 Indeed he insisted that ‘as soon as he is satisfied of the existence of true general paralysis it is the duty of the physician to say at once that the case is without hope, and curative art without reliable and permanent efficacy.'11

SYPHILIS AND PARASYPHILIS
Although the treatment of general paresis changed dramatically once it was agreed that syphilis was the cause of the disorder, it took many years for this proposition to gain universal acceptance. While Esmarch and Jessen had asserted that syphilis caused general paresis as early as 1857, progress toward the general acceptance of this idea was begun by the eminent nineteenth century 'syphilographer' Alfred Fournier(1832-1914). The favorite student of the early nineteenth century syphilographer Philippe Ricord, Fournier devoted himself to the study of syphilis to the exclusion of almost everything else.12 He dominated French venereology in the last decades of the century and was recognized throughout the western world as an expert on syphilis second to none. 13 Engaged in an ambitious program of research and public health propaganda aimed at showing how widely the effects of syphilis had spread, Fournier's research drew on a card index of 50,000 cases that he had assembled over the years. Throughout the 1880s, he collected data on the relationship between general paresis and syphilis, which he presented in two essays in 1893 and a famous communication read before the Academie de Médicine in on 30 October 1894.14
In that communication Fournier marshaled a variety of evidence for a pathogenic connection between syphilis and general paresis. Most importantly, he noted that between 50 and 92 per cent of paretics could be shown to have had syphilis, while the histories of ordinary insane people did not show nearly this incidence of syphilis. He also noted that while paresis was found rarely in rural areas, among the clergy or among women, it was found frequently among women who lived ‘irregular lives.’ Finally having earlier established to his satisfaction that tabes was due to syphilis he now pointed to the high correlation between that disorder and general paresis. 15 Given the large volume of his data, these were impressive observations. Nonetheless he met skepticism. 'Several times,' Fournier complained, 'I had the experience of having to diagnose syphilitic madness in the presence of very competent and justly famous psychiatrists; and almost invariably my opinion was received as a hypothesis which was possible, rational, perhaps tolerable, but singularly adventurous and tainted with heresy.'16
While issues of professional turf no doubt influenced some of this psychiatric skepticism toward Fournier's diagnostic imperialism, there was one good scientific reason for this skepticism. General paresis did not respond to antisyphilitic treatment. Mercury, for example, had been used to treat syphilis from the early sixteenth century.17 During the nineteenth century, potassium iodide also came to have some vogue in the treatment of syphilis. By the late nineteenth century, doctors had convinced themselves that mercury and potassium iodide were effective treatments for syphilis, even for syphilitic disorders of the nervous system. The failure of general paresis to respond to these treatments led Fournier to propose the peculiar concept of parasyphilis.Parasyphilitic disorders, which in addition to general paresis also included such varied conditions as tabes, neurasthenia and optic atrophy, were, according to Fournier, ‘not, strictly speaking of a syphilitic nature, but are none the less of syphilitic origin.’18 In other words, parasyphilis was a non-syphilitic sequel of syphilis, a degenerative process, provoked, in susceptible individuals, by syphilis. The concept of parasyphilis may have explained to Fournier's satisfaction why general paresis did not respond to mercury and potassium iodide but it didn't do much to persuade the skeptics.19
The riddle of general paresis grew more perplexing with that series of brilliant laboratory findings in the first years of the twentieth century that established conclusively that paresis was caused by syphilis. In 1897 Krafft-Ebing inoculated nine paretics with no history of syphilis with luetic material. When none of them developed symptoms of syphilis, he inferred that they had been previously infected.20 The pathology of paresis was made definite by the work of Nissl and Alzheimer, published in 1904. In 1906 Wasserman introduced a serologic test that not only confirmed the syphilitic nature of active lesions but showed that a latent lesion could be present in an individual. With evidence gained through the use of the Wasserman reaction the relation of paresis to syphilis was rather generally accepted. In 1913 all doubt about the syphilitic nature of paresis was finally eliminated when Noguchi and Moore demonstrated spirochetes in the brains of paretics.
With the conclusive linking of paresis and syphilis, general paresis of the insane finally became a public health concern. As long as general paresis was thought to be due to heredity, nervous shock or excess venery, its epidemiology was not a source of great consternation. With the link between syphilis and general paresis established, the anxiety provoked by syphilis spread to paresis. Rigorous estimates of the percentage of syphilitics who developed general paresis were hard to come by. The first extensive study arrived at a figure of just under five per cent.21 Some studies, however, put the figure as high as ten per cent.22 There was a strong feeling that the frequency of paresis and other syphilitic disorders of the nervous system were increasing and that the same factors that were leading to the increase in syphilis were leading to increases in paresis.23 In 1914 Salmon, adopting a public health stance toward paresis, pointed out that death from paresis made it the eighth leading infectious disease for mortality.24 At the same time Meyer argued for the value and acceptability of putting the assets of patients with positive Wasserman reactions, but no symptoms of paresis, in trust.25

THE MAGIC BULLET
The conclusive demonstration spirochetes in the brains of paretics also catalyzed a wave of enthusiasm for the idea that paresis might be cured with anti-syphilitic treatments. The reason for this enthusiasm was the fact that Noguchi and Moore's discovery occurred very shortly after Erlich and Hata, in 1909, were able to show that arsphenamine, better known as Salvarsan, was an effective anti-syphilitic. Salvarsan, it was hoped, would prove to be as powerful a 'magic bullet' in the treatment of paresis as it initially seemed to be in the treatment of other forms of syphilis.26 There was, however, resistance to treating paretics at all. Critics argued against anti-luetic treatment for paresis on theoretical and empirical grounds. Prior experience showing that paresis was uninfluenced by mercury and iodide had led to a nihilistic attitude toward antisyphilitic treatment. Fournier's ideas about parasyphilis helped create a theoretical basis for pessimism as well. Frederick Mott,the leading early twentieth century British neuropathologist, for example, argued that the paretic process simply could not be modified by anti-luetic treatment and strongly advised against using it. There were even questions as to whether treated cases did more poorly than untreated cases.27 A questionnaire sent to two hundred hospitals, during this period, indicated that only thirty five per cent of those responding were using any antiluetic treatment.28 As Henry Head and E.G.Fearnsides noted:

the treatment of syphilis by modern measures is so
expensive and troublesome that few inmates of our
Asylums and Workhouse Infirmaries receive adequate
injections of neosalvarsan or even effective mercurial
treatment. No one wastes time and money on persons
supposed to be obvious cases of 'general paralysis,' and
we have received letters from medical officers ...
expressing wonder that we should 'take so much trouble
over such a straightforward case of general paralysis.29

Watching patients die from general paresis in the days before fever therapy was a grim business that occurred in a pessimistic and gloomy atmosphere. As one doctor put it, 'nothing is more depressing to me than to see ... cases of paresis in the last stage of the disease, demented and deteriorated, untidy, living a vegetative existence, bedridden with numerous decubitus ulcers, a burden to themselves and others,...'30 Remissions, however, could be even more painful to watch because they did not last. Such patients might be reduced to ‘helpless... bedridden... breathing, heartbeating automata,’ as another doctor wrote, only to recover spontaneously over a period of six weeks to three months. They then appeared to have ‘risen from the dead" and to be "almost well and like themselves.’ Such remissions typically lasted six months --though occasionally five to six years--only to have ‘the symptoms return, often in rapid progression, and usually lead to death after a variable interval of from six months to a few years.’31 Some doctors became hardened by such experiences and objectified and denigrated their paretic patients. Textbook descriptions of patient's grandiose delusions often seem, at least to a late twentieth century reader, to be mocking in tone.32 Braslow has also recently noted from a study of hospital records that paretics in the pre-malarial therapy period were often referred to as 'lazy,' 'silly,' 'childish,' 'obscene,' 'vile,' 'vulgar,' and 'stupid.'33

In the face of both the arguments against treatment and the atmosphere of pessimism, advocates of Salvarsan not only hoped for dramatic results but needed them. There were, however, many difficulties in determining the value of treatment. Possible cures might be discounted. Some patients who improved, it was argued, were actually suffering from ‘cerebral syphilis’ and not paresis, though distinguishing between these two disease states was extremely difficult. It was also suggested that untreated paresis was running a milder course than in former years. Because sample sizes were initially quite small, it was also difficult to allow for the differing effects of treatment on early and late cases.34 Efforts at controlled studies were crude and, as one author admitted of his study, comparison between results with treated and untreated patients was ‘manifestly unfair.’35 Furthermore, because there was so little data on the natural history of the disease, it was difficult to take into account the frequency of spontaneous remissions.
Efforts to evaluate the treatment of general paresis stimulated work on this problem. In an effort to characterize the natural history of untreated, hospitalized paretics, Raynor described the fate of 1004 patients admitted to his hospital between 1911 and 1918. Of these 87% had died, 78% during the first admission.Nine per cent, however, had improved and 3.5% had improved sufficiently to be regarded as remissions.36
Salvarsan was almost immediately tried on syphilitic lesions of the nervous system. The results in cases of general paresis were, however, meager and disappointing. In one series of twenty paretics, six showed ‘improvement.’ Of these six, four were considered ‘remissions’ one of which lasted six months and two of which allowed the patients to return to work. In another series of fifty-one cases, Bernard Sachs noted that the results were not much better than those achieved with mercurials in previous years.37 In 1911 a standard textbook noted that, 'Erlich's Salvarsan ('606') has been used in a great many cases, but so far with rather more harmful than beneficial results.'38 In the same year Albert Neisser noted that 'The more I see, the more I am under the impression that the paralytic process is hastened by '606.'' 39
Because many did believe that Salvarsan should work, efforts were undertaken to deliver the magic bullet more directly to the brain. Salvarsan was initially used intramuscularly without benefit and then, in the first of a series of increasingly invasive maneuvers, it was injected intravenously without great improvement in results.The failure of intramuscular and intravenous Salvarsan to relieve paresis was explained as due to its failure to reach the central nervous system. In response to this obstacle, Swift and Ellis in 1912 proposed the intrathecal injection of arsphenamized serum. This method produced favorable clinical and serological results in meningeal, vascular and tabetic neurosyphilis, but was was without effect in paresis. This led others to inject Salvarsan into the subarachnoid space, the cisterna magna and the lateral ventricles.40 While published reports argued that these techniques were safe, the use of such invasive methods still stirred up much anxiety.41 None of these invasive procedures produced results worthy of the risk. A series of additional drugs including bismuth and neosalvarsan were later introduced but also failed to affect general paresis. The shortcomings of Salvarsan could be seen in the recommendation that it be used only as an adjuvant of mercurial treatment.42

FEVER THERAPY
Long before the wave of enthusiasm for using Salvarsan in general paresis, psychiatrists had occasionally observed mentally ill patients who recovered following an intercurrent illness with a high fever. Remissions and even cures had often been reported following cases of typhoid, which was common in asylums. There were also sporadic reports of doctors trying to treat psychiatric disorders by inducing fevers. Generally these reports did not distinguish between paretics and other patients. In 1876 Alexander S. Rosenblum reported that eleven out of a mixed group of twenty-two psychiatric patients were cured after an attack of recurrent fever. Although he presumably induced this fever, the controversial nature of this procedure led him to omit this fact from his report.43 In 1877 Meyer reported curing eight of fifteen paretics, who he had treated over a period of fifteen years, by rubbing Autenrieth's ointment onto their scalps to induce a deep suppuration. In 1883 Keirnan, in the United States, reported efforts to treat psychiatric patients by vaccinating them for smallpox.44
Wagner-Jauregg became interested in the idea of treating psychoses with fever,shortly after taking up his first position as a psychiatrist in 1883. He observed a female patient who recovered from a psychosis after a bout of erysipelas. In a review of the literature which he published in 1887 he reported on 163 incidents of psychoses remitting after typhoid, and intermittent fevers as well as erysipelas. While Wagner-Jauregg clearly found the idea of treating mental illness by inducing a febrile illness quite attractive, he pursued his research cautiously and with what appears to have been great concern about community disapproval of this approach. In 1888 he began his experiments by injecting several patients with a culture of streptococci taken from a case of erysipelas. Among his reasons for giving up this line of investigation was the fact that 'medical science of that period looked with disfavor at experimentation on human beings.' The depth of his concern about community judgment is suggested by his mention of a colleague who inoculated nine paretics with syphilis and 'almost went to prison for his zealous scientific endeavors.' In the winter of 1890/91 Wagner-Jauregg began injecting the newly introduced tuberculin to induce a febrile reaction 'without resorting to an infectious disease.' He later wrote that he discontinued this treatment 'prematurely because tuberculin was soon considered a dangerous preparation' and ‘it had become practically a crime to use it.'45
In 1895 after Wagner-Jauregg had returned to using tuberculin and other bacterial proteins to induce fever, he first noticed that paretics did better with fever therapy than other psychotics. In 1902 he combined this treatment with mercury and iodide after he became convinced of the syphilitic origin of paresis. In this period others also attempted to induce fevers by injections of sodium nulleinate boiled milk and milk protein. The results of these efforts were poor, perhaps, it has been suggested, because high fevers were not obtained.46 Collateral support for the value of fever in the treatment of neurosyphilis was available. In 1913 one of Wagner-Jauregg's assistants published a significant statistical study 4134 cases of syphilis and observed that those patients who had contracted a febrile disease during the early years of their syphilitic infection almost never developed neurosyphilis. Others also noted that the incidence of neurosyphilis was low in areas where malaria was endemic.47
Although Wagner-Jauregg had suggested the use of artificial tertian malaria to produce fevers as early as 1887, he only began to use this treatment in 1917. The serendipitous presence of a soldier with malaria in his neuro-psychiatric hospital gave Wagner-Jauregg the opportunity that he had been, in a sense, preparing for for thirty years. He also suggests that the brutalities of war may have made him less sensitive both to the glory of discovering a cure for a dread disease and to the possible censure for experimentally infecting sick people with a new disease. As Wagner-Jauregg recalled:

'We were already in the third year of the war, and its emotional implications became more manifest from day to day. Against such a background a therapeutic experiment could stir me little, in particular since its success could not be
foreseen. What meant a few paralytics,would possibly be saved, in comparison to the thousands of able-bodies and capable men who often died on a single day as the result of the prolongation of the war.'48

Wagner-Jauregg took blood from his serendipitously encountered malaria patient and injected into two paretics. Six of his first nine patients showed improvements though four of these eventually suffered relapses.When one patient died because he was inadvertently given malaria tropica rather than the tertian type, Wagner-Jauregg gave up the treatment for a year.He resumed treating paretics only after he was able to obtain a steady supply of the tertian type.49 In 1921 Wagner-Jauregg was able to report that 25% of his first two hundred patients were able to return to work. In 1922 one of Wagner-Jauregg's assistants reported that over 60% of 400 cases observed for over two years had achieved remissions of varying degrees.50
Following the war the use of malaria therapy spread quickly to many countries.’Soon it was definitely established that the progress of the disease could be halted in approximately 70 per cent of cases and that marked improvement could be obtained in 20 to 40 per cent of the cases, the final result depending to a large extent on the amount of damage that had occurred prior to the beginning of the treatment.’51In a review of 2460 cases recorded in the literature by 1926 27.5% were found greatly improved and another 25.6% moderately improved.52 In 1929 there were reports from the Soviet Union of remissions in 64% of treated cases.53
Praise for the treatment appears to have been quite general. Malaria therapy was referred to as a 'therapeutic noble deed,' the 'right way to treat a hopeless disease,' and 'the best treatment available.' The success of the treatment seems to have stifled most open criticism of the method. Even in 1946 Merritt, Adams and Solomon could only speak of 'the transmission of the infection...by inoculation of blood from a syphilitic who has been previously been given malaria (as) a practice which offends the esthetic sense of many individuals.' (emphasis added)54 Wagner-Jaurreg's Nobel Prize was, however, held up because B. Gadelius, a Swedish professor of psychiatry, and a member of the prize committee, could not be persuaded to recommend the award to a ‘physician who injected malaria into a paralytic, because he was in his eyes a criminal.’55 There was also some ambivalence about the results of malarial treatment, even by enthusiastic promoters of the cure. Henry A. Bunker, for example, following a presentation of the benefits of malarial treatment noted that ‘those patients who achieve merely an arrest of their disease...and remain in a stationary stage for four, five and more years are not examples of any great accomplishment from a practical standpoint. In fact my personal opinion is that many of such stationary but permanently institutionalized patients would be better off if they were dead.'56
Malaria treatment continued to be used into the early 1950s. As late as 1946 Merrit, Adams and Solomon still insisted that it was ‘the simplest and most effective method of treatment of paretic neurosyphilis.' 57 There is no question that it was a desperate treatment.Even so there was reason to be proud of it. After a hundred years of hopelessness and despair, it offered hope for people afflicted with a devastating disease. Moreover, as Braslow has recently shown, it even an increased measure of respect for patients had previously been scorned and mocked.58

Notes

1.Magda Whitrow's biography Julius Wagner-Jauregg (1857-1940) (Smith-Gordon, London, 1993) now provides a comprehensive review of his life and work.
2.Andrew Scull, "Somatic treatments and the historiography of psychiatry," History of Psychiatry, 5(1994), 8.
3 .Harold Mersky, "Somatic treatments, ignorance, and the historiography of psychiatry," History of Psychiatry, 5(1994), 387-91.
4 Edward M. Brown, “French Psychiatry's Initial Reception of Bayle's Discovery of General Paresis of the Insane,” Bulletin of the History of Medicine 68 (1994), 235-253.
5 .J.E.D.Esquirol, Mental Maladies, A Treatise on Insanity, Facsimile of the English Edition of 1845, (Hafner, New York and London 1965),436
6.For example Henry Maudsley,Responsibility in Mental Disease (New York, D.Appleton and Company, 1899),80-1
7 .A.L.J. Bayle, Traite des Maladies Du Cerveau et de ses Membranes reprint of the 1826 edition,(New York, Arno Press,1976),574-587
8 .W.Julius Mickle,"General Paralysis," in D.Hack Tuke (ed.) A Dictionary of Psychological Medicine (Philadelphia,P. Blakiston,Son & Co,, 1892), 532
9 .E. Regis, A Practical manual of Mental Medicine (Philadelphia, P.Blakiston, Son & Co.,1895), 462.
10 .W.Julius Mickle. General Paralysis of the Insane (London, H.K.Lewis,1880),171
11. Mickle, General Paralysis of the Insane,.165-75
12. M.A. Waugh, "Alfred Fournier, 1832-1914: His Influence on Venereology," British Journal of Venereal Disease 50(1974),232.
13. John T. Crissey, The Dermatology and Syphilology of the Nineteenth Century (New York ,Praeger), 221
14 .Crissey,The Dermatology and Syphilology of the Nineteenth Century , 223. Alfred Fournier, “Syphilis and General Paresis,” in Selected Essays and Monographs, (London, New Sydenham Soc.(161), 1897),.375-92
15 .Gazette Medicale de Paris, no.44, (Nov.3,1894),522-4.
16 .Claude Quétel, History of Syphilis (Johns Hopkins University Press, Baltimore, 1992),163
17. H Houston Merrit, Raymond Adams, Harry C. Solomon, Neurosyphilis, (Oxford,Oxford University Press, 1946),393
18 .Alfred Fournier, The Treatment of Syphilis, trans. C.F. Marshall, (New York, Rebman Company, 1906),253..M.A. Waugh, "Alfred Fournier, 1832-1914: His Influence on Venereology," British Journal of Venereal Disease 50(1974), 233.
19 .J. Darier, "Alfred Fournier:1832-1914," Annales de Dermatologie et de Syphiligraphie 5(1915), 522-8. One biographer suggested that Fournier was not interested in this concept as a discovery of a law of pathogenesis but only as a conquest in the domain of etiology. Fournier did not attempt to explicate the distinction between "origine" and "nature" which were crucial to the concept of parasyphilis. "It sufficed for him to have charged the dossier of syphilis with some more atrocities." cited in Crissey, The Dermatology and Syphilology of the Nineteenth Century .223
20 . George Rosen, “Patterns of Discovery and Control in Mental Illness," in Madness in Society, (Harper,New York, 1968),247-62.
21 . Thomas W. Salmon, "General Paralysis as a Public Health Problem," American Journal of Insanity 71(1913-4),44 cites a study by Pilcz and Mattauschek of 4,134 officers in the Austrian army who had contracted syphilis between 1880 and 1890 which showed that 4 9/10 per cent had developed general paralysis by 1912.
22 . D.K. Henderson, "Cerebral Syphilis," American Journal of Insanity 70(1913),282
23 . Charles P. Bancroft, "Is There an Increase Among the Dementing Psychoses." American Journal of Insanity 71(1924-15),59-73. D.K.Henderson, American Journal of Insanity 70(1913)282."Mott asserts... that owing to the increased strain of living and owing to the conversion of a rural into an urban population, syphilitic affections of the nervous system are greatly on the increase."
24 Salmon, Thomas, "General Paralysis as a Public Health Problem," American Journal of Insanity 71(1913-4),44
25 . Adolf Meyer, "Differential Diagnosis of General Paresis," American Journal of Insanity 71(1914-15),51-58
26 . Harry C. Solomon,”The value of treatment in general paresis” Boston Medical and Surgical Journal, 188(1923),635
27 .Harry C.Solomon Boston Medical and Surgical Journal 188(1923)636 cited observations that that treated cases lived only half as long as untreated cases and also urged against treatment.
28 . H Goldsmith, "A Plea for Standardized and Intensive Treatment of the Neurosyphilitic and Paretic," American Journal of Psychiatry. 82(1925),251-61,
29. Henry Head and E.G. Fearnsides,"The clinical aspects of syphilis of the nervous system in the light of the Wassermann reaction and treatment with neosalvarsan," Brain 37(1914), 134.
30 . H. Goldsmith, op.cit., 256
31 . William A. White and Smith Ely Jelliffe, Modern Treatment of Nervous and Mental Diseases, (Lea & Febiger, Philadelphia and New York,1913),249
32 .See for example, E.C. Spitzka, Insanity, Its Classification, Diagnosis and Treatment,(New York, Bermingham & Co. 1883), 195 ""The patient claims to be the most powerful, the richest and ablest man in his community, He can raise the asylum with his little finger, he has trunks filled with gold in every city in the Union, he is married to all the handsome women in the world, can speak all the living and dead languages, has the best-developed sexual organs extant, and is the intimate friend of every contemporary great man, sometimes himself Napoleon, Caesar, Shakespeare, Grant, Buffalo Bill, and every other celebrity in one person, and the fortunate owner of numerous patents." Spitzka goes on to itemize the extravagant list of "possessions" of a paretic former stock-broker.
33.Joel T. Braslow, "Effect of Therapeutic Innovation on Perception of Disease and the Doctor-Patient Relationship: A History of General Paralysis of the Insane and malaria Fever Therapy, 1910-1950," American Journal of Psychiatry, 152(1995)660-65.
34 .Harry C. Solomon, op. cit., 635
35 I.J.Furman,"Treatment of General Paralysis," Archives of Neurology and Psychiatry, 12(1924),359-69 .
36. Mortimer Williams Raynor, "Remissions in General Paralysis." Archives of Neurology and Psychiatry 12(1924), 419-425.
37 .New York Neurological Society: Proceedings of joint meeting with Philadelphia and Boston Neurological Societies, November 14,1911, "Use of Salvarsan in Syphilis of the Nervous System," Journal of Nervous and Mental Diseases, 39(1912),180-86
38 .Archibald Church and Frederick Peterson, Nervous and Mental Diseases,(Philadelphia and London, W.B.Saunders Company,1911),818
39 Albert Neisser,On Modern Syphilotherapy with particular Reference to Salvarsan, translation of a 1911 article, (Baltimore Johns Hopkins Press 1945),22.
40 .Walter F. Shaller and Henry G. Mehrtens, "Therapy in Neurosyphilis with Particular Reference to Intraspinal Therapy," Archives of Neurology and Psychiatry, 7(1922),89-97 "...every case of cerebrospinal syphilis improved...Patients with paresis, as a whole, did poorly." Franklin G. Ebaugh, "The Treatment of General Paresis by the Intracistern Route," Archives of Neurology and Psychiatry 7(1922),325-31."The clinical results of intercisternal therapy have been disappointing.". H. McKusker, "Some observations on Cistern Puncture," Journal of Nervous and Mental Diseases 53(1921),453.
41 . H. Goldsmith, op. cit.,253 "It has only been in recent years that spinal puncture has become general and attended by very few untoward results. I can remember when any medicine to be injected intravenously was attended by preparations equal almost to that of a major operation and spinal puncture was approached wit fear and trembling."
42 .D.K. Henderson,”Cerebral Syphilis,” American Journal of Insanity, 70 (1913),282.
43 .Magda Whitrow, "Wagner-Jauregg and Fever Therapy," Medical History, 34(1990), 294-310.
44 . James G Kiernan, "Variola and Insanity," American Journal of Neurology 2(1883)365-72.
45 .Julius Wagner-Jauregg, "The History of the Malaria Treatment of General Paralysis," American Journal of Psychiatry 102(1945-6),577-82
46 H. Houston Merrit, Raymond Adams, Harry C. Solomon, op. cit.,397
47 .E.Mattauschek and A. Pilcz, "Aweite Mitteilung uber 4134 katamnestisch verfolgte Falle von luetischer Infection," Ztschr.f.d.ges.Neurol.u.Psychiat. 15(1913)608 as discussed in H. Houston Merrit, Raymond D. Adams and Harry C. Solomon, op. cit.,,396
48 .Julius Wagner-Jauregg,"The History of the Malaria Treatment of General Paralysis," American Journal of Psychiatry 102(1945-6),580
49 .Whitrow, "Wagner-Jauregg and Fever Therapy," Medical History 34(1990),294-310. incident reported on p.304-5.
50 . Magda Whitrow "Wagner-Jauregg and Fever Therapy," Medical History 34(1990),306.
51 . H. Houston Merrit, Raymond Adams, Harry C. Solomon, op. cit.,.397.
52 .J.R. Driver,J.A. Gammel,L.J. Darnosh, "Malaria Treatment of Central Nervous System Syphilis, Journal of the American Medical Association 87(1926),1921 cited in Bunker,"Recent Treatment of General Paralysis,”
53 . A.L. Lestchinsky, "Treatment with Malaria Inoculation in Paresis," abstract in American Journal of Psychiatry 86(1929-30), 589..
54 . H. Houston Merrit, Raymond Adams, Harry C. Solomon, op. cit..397.
55 . Magda Whitrow "Wagner-Jauregg and Fever Therapy," Medical History 34(1990),310
56 .Henry A. Bunker Jr. "Recent Methods in the Treatment of General Paralysis,"American Journal of Psychiatry. 85(1928-9), 681-94,
57 .H. Houston Merritt, Raymond Adams, and Harry C. Solomon, op. cit..406
58 Joel T. Braslow, "Effect of Therapeutic Innovation on Perception of Disease and the Doctor-Patient Relationship: A History of General Paralysis of the Insane and malaria Fever Therapy, 1910-1950," American Journal of Psychiatry, 152(1995),660-65.

Edward M. Brown History of Psychiatry, Volume 11, December 2000, 371-382.

Emotional Trauma and the Development of the Idea of Neurosis in the United States: 1865-1930

2009-01-01T08:28:00.000-08:00

Between the 1860s and the 1920s American psychiatrists expanded their nosology to include a new category - the neuroses. They also expanded their ideas of what counted as an acceptable medical explanation of psychiatric disorders to include what are now known as dynamic psychological explanations. The history of these developments has usually been told in terms of the introduction and acceptance of Freud's ideas.l The same story can also be told in terms of rivalry between two nineteenth century professional groups-asylum superintendents and neuroiogists-who later realigned to form the twentieth century profession of psychiatry.2 In addition, however,this

story can be told in terms of an emerging social and professional awareness of a puzzling syndrome of physical and mental symptoms which followed railway accidents in civil life and artillery shelling during World War I. Professional efforts to explain this syndrome and social conflict over its significance, resulted, it can be argued, in the construction of the idea that certain types of traumatic environmental events are causally linked with certain specific emotional symptoms. The concept of the traumatic emotional disorder gave legitimacy to the diagnosis of neurosis by demonstrating that "nerves" were more than a matter of a weak nervous system or poor heredity.

Prior to the late nineteenth century the psychiatric symptoms of soldiers might be diagnosed as due to nostalgia, that is, homesickness or to insanity but they were not attributed to the effects of battle.3 Psychiatrists did recognize moral causes of insanity such as fear and grief as well as physical causes such as fevers and blows to the head but they had not developed a causal model in which "trauma" mediated between circumstance and symptom. It can be argued that industrialization and the advent of industrial warfare created the social conditions which allowed this model to be constructed. It was not simply that people experienced emotional pain as the result of railway accidents or artillery shellings but that they held corporations and nations responsible for this suffering that gave rise to debate. Looked at from this point of view the history of the neuroses in the United States it is not simply an episode in the history of psychoanalysis nor in the history of the development of the psychiatric profession but a consequence of this debate over social responsibility for injuries.

RAILWAY SPINE

Controversy over responsibility for injuries began when passengers started filing damage claims against railway companies.Such claims were a significant source of litigation in England by 1860 and they grew in significance throughout the industrializing world as railroads expanded during the late nineteenth century. Indeed, litigation against railroads became one of the most prominent expressions of the discontents engendered by the process of industrialization. There were a number of reasons for this. Railway corporations were among the most visible of the impersonal corporations which were coming to dominate economic and social life. Railways accidents were frequent, terrifying and highly publicized instances of the capacity of industrial technology to maim and kill. Moreover, railway passengers did not confront the same obstacles to litigation as industrial workers.4

In 1866 the English surgeon John Eric Erichsen opened the medical debate over the emotional consequences of accidents with his On Railway and other Injuries of the Nervous System, which was Published in the United States the following year. 5 What concerned Erichsen was the spectacle of doctors disgracing the profession by disagreeing in court over claims made by accident victims. Erichsen noted that while "nineteen-twentieths of all railway or other accidents that are referred to surgeons" provoked no diagnostic controversies, there were many controversies over that small percentage of cases where "the relation between alleged cause and apparent effect may not always be easy to establish."6 To resolve these legal controversies Erichsen first argued that the problematic cases were sufficiently similar to constitute a syndrome, his description of which is worth citing at length:

at the time of the occurrence of the injury the sufferer is usually quite unconscious that any serious accident has happened to him.... When he reaches his home, the effects of the injury that he has sustained begin to manifest themselves. A revulsion of feelings takes place. He bursts into tears, becomes unusually talkative, and is excited. He cannot sleep, or, if he does, he wakes up suddenly with a vague sense of alarm. The next day he complains of feeling shaken and bruised all over, as if he had been beaten,.. After a time, which varies much in different cases, from a day or two to a more, he finds that he is unfit for exertion and week or unable to attend to business. He now lays up, and perhaps for the first time seeks surgical assistance. 7

After presenting 39 case examples, Erichsen went onto explain this syndrome pathoanatomically. He argued that the symptoms of what he called "concussion of the spine" were "in realty due to chronic inflammation of the spinal membranes and the cord." Cerebral symptoms, such as "headache, confusion of thought, loss of memory, disturbance of the organs of sense, [and] irritability of the eyes and ears," were indirect expressions of the spinal process.8 This was not,at the time, an implausible theory, and given popular sentiment about railway accidents, it was an easy one for many to accept. Indeed while Erichsen insisted that "concussion of the spine" occurred in a variety of accidents, the growing frequency and importance of railway litigation led virtually everyone to refer to Erichsen's discovery as "railway spine."

Throughout the 1870s railway spine reigned without competition as the diagnosis used by plaintiffs seeking damages for emotional symptoms following railway accidents. It was, by all accounts, a highly successful legal strategy. 9 The success of the diagnosis of railway spine, however, provoked harsh criticism. Erichsen's ideas were vulnerable to such criticism for several reasons. First, while Erichsen had aimed at improving the precision of medical testimony, the diagnosis of railway spine was sufficiently all-inclusive and vague that claims were easy to make. That Erichsen interpreted the clinical findings as due to an inflammation of the spinal cord, for which there was no treatment,implied a poor prognosis and consequently resulted in what many felt were exorbitant awards. Moreover the fact that victims of railway spine did not die meant that no patho-anatomical findings were available to support the diagnosis. Finally when accident victims were observed to recover after their claims were
settled, critics lost patience and cried malingering. As was frequently noted:
The truth [was] that when juries find the medical evidence is
conflicting, not being able to judge for themselves as to the
merits of the case,they almost always decide in favor of
the claimant.(an accident victim had) merely to go to bed, call
in a couple of sympathizing doctors, peruse Mr. Erichsen's
...work on Railway Injuries [and], go to court on
crutches...[to be assured a] jury would give large damages.10

JAMES JACKSON PUTNAM AND RAILWAY SPINE IN THE UNITED STATES

The concept of concussion of the spine had few medical defenders. In the United States the National Association of Railway Surgeons published so many articles disputing the validity of railway spine in its official journal that one writer was led to suggest that "the destruction of belief in the so-called "railway spine" [was] the causa vivende" of the association.11 Not only railway surgeons criticized Erichsen. As R.M. Hodges noted in a paper presented to the Boston Society for Medical Improvement in 1880, Erichsen's work was "universally thought to present the subject in stronger colors than it deserves; to show an undue partiality for the public, and to be altogether too severe on the railroad companies."12

Nonetheless not everyone, not even all doctors, were distressed by the social consequences of accident litigation. In 1880 the prominent Boston neurologist James Jackson Putnam. for example, noted that "from a social standpoint" successful litigation stimulated railway authorities to be more careful to avoid accidents. He added that railway travel was safer in Europe and noted that, since the passage of stringent liability laws in Prussia in 1871, the cost in fines was no greater than paid in the United States by one railroad following a single accident.13 Consistent with these views on the value of successful litigation in promoting railway safety, Putnam also supported a view railway spine similar to Erichsen's. He argued that "such injuries... act...indirectly by causing minute haemorhages into the cord or its membranes" and he defended Erichsen's view that even such "definite lesions" might not manifest themselves immediately after the accident.14

Putnam's views on neuropsychological consequences of accidents are of particular interest for two reasons. First they reflect role that controversy over these accidents played in the construction of the psychiatric category of the traumatic emotional injury. They also provide a glimpse of Putnam's own dramatic evolution from a hostile opponent of the psychological to a leading exponent of psychoanalysis. Educated in Germany, Putnam was an influential proponent of a thorough going somaticism in the years after the Civil War. At a meeting of the American Neurological Association in 1876, for example, when George Miller Beard presented a series of experiments which tested "how much could be done in the way of effecting cures in cases of rheumatism, neuralgia sleeplessness, and various forms of chronic diseases by exciting in patients a definite expectation," Putnam replied that he "had never seen any evidence that cure had been effected by mental means in cases where actual disease existed."15 By 1909, however, Putnam was ready to enthusiastically welcome Freud, when the latter gave a series of lectures at Clark University, and by the time of his death in 1918, Putnam had become Freud's most influential American
disciple.

While in 1880 Putnam's views on railway spine resembled Erichsen's, by 1883 they had changed dramatically. He no longer argued for the presence of minute hemorrhages in the cord but instead urged doctors, to search cases of apparent railway spine "carefully for the presence of functional symptoms which may be grouped under the term hysteria."16 This shift in opinion marked Putnam's first step on his way from somaticism to psychoanalysis. While he attributed this new opinion to his own observations, he also emphasized the influence of Jean Martin Charcot and Herbert W. Page in changing his interpretation of these observations. As Putnam noted, "there are few kinds of disease with regard to which the interpretation of evidence is of so much importance as compared with the simple accumulation of evidence as in the case of the so-called concussion of the spine."17

Page's "exceedingly valuable book," as Putnam referred to it, had been published only months before Putnam announced his new interpretation of cases of concussion of the spine. Presenting 234 cases of his own, Page argued that Erichsen had been misled by symptoms due to "injury to the extra-spinal muscular, and ligamentous structures" and had erroneously attributed "nervous symptoms" to a lesion of the spinal cord. Putnam was particularly impressed by Page's demonstration that the frequency of favorable outcomes in these cases was greater than his knowledge of serious disease would lead him to expect and that sprains and "reflex functional disorders" could simulate real organic diseases.18 Page explained this simulation by adopting a psychosomatic position. He argued that what he called "nervous shock" was a real disorder which could be produced by fear or alarm, but that it had a such better prognosis than concussion of the spine. Erichsen's syndrome, he explained, was produced by "neuromimesis," an involuntary process, which allowed a functional and curable disorder to mimic an incurable structural lesion.19

Although Page's motives for writing were certainly colored by the fact that he was a surgeon working for the London and North-Western Railway Company, his influence on Putnam was great because his views represented a compromise between Erichsen's views, which he so ably discredited, and the views or those who saw railway spine as nothing but compensation seeking. Putnam's eagerness to read Page as relatively sympathetic to accident victims is shown in his insist~ence that Page did not regard "rapid improvement after the settlement of legal claims ...(as) proof that the patient's symptoms were imaginary or assumed, an inference, (that) Putnam felt (was) often unjustly drawn."20 Interestingly Putnam ignored the fact that Page argued that with repetition functional disorders or mimicries could be brought on or terminated voluntarily. "Herein lies the explanation," Page wrote, "of those happily timed convulsions which occur when it is most important that you should see them..." as well as the "disappearance of mimicries" when the matter of compensation was settled.21

In spite of Page's somewhat idiosyncratic terminology, Putnam was able to respond as immediately and enthusiastically as he did because of the close parallel between Pages ideas and contemporary neurologic thinking about the functional interpretation of the symptoms of hysteria. The idea of the functional nervous disorder had a continuous history going back to Thomas Willis and William Cullen in the seventeenth and eighteenth centuries, but its significance as an explanatory concept had been eclipsed in the nineteenth century by enthusiasm for clinico-pathological explanations of nervous disorders.22 During the late nineteenth century, however, as Kenneth Levin has shown, efforts to explain all neurological symptoms pathoanatomically were blocked by the inability of neurologists to find lesions that would explain hysteria. 23 Some neurologists, like Putnam and Jean Martin Charcot, responded to this apparent failure by arguing that hysteria was a true, though functional, nervous disorder. Some functional cases, Putnam pointed out, "can be proved beyond the possibility of deception to be examples of that important neurosis hysteria a term which thanks to the labors of Charcot and his pupils, has vastly outgrown its old and vague meaning, and is constantly acquiring a mare precise and practical s;significance."24

This practical significance was particularly apparent in cases of railway spine. A functional diagnosis like hysteria because it was considered to have relatively good prognoses, offered the courts a way to acknowledge the legitimacy of many injury claims while limiting the damages awarded. Because hysteria was generally regarded as a disorder of women its symptoms were, however, thought of as being as unreliable as the women who complained of them. In court cases, as Putnam noted, "the admission of the diagnosis of hysteria is liable to throw a weapon for ridicule and disparagement into a skillful lawyer's hands."25 Hodges argued in 1880 that three fourths of the cases that he was familiar with were "really or probably deceptions.26 Putnam responded to concerns about malingering in several ways. He presented the case of a young woman whose injury did not occur in a railway accident and the case of a "large, powerful, and robust" railway fireman who developed hysterical symptoms following injury for which he was not filing a legal claim. He also reported several cases of accident victims who were unaware of their insensitivity to pain over one half of their bodies.27 This discovery of hysterical hemianasthesia was particularly important to Putnam because even if it was not a strictly objective finding, it was at least unlikely enough to be feigned, to have medico-legal value. It's discovery was also important enough as support for arguments for the legitimacy of the disease character of hysteria that Charcot cited Putnam's contribution;

While these controversies over hysteria were going on, a second psychosomatic disease--neurasthenia-- also came to be associated with the emotional effects of accidents. Unlike hysteria, it was rapidly accepted as a genuine disease. Originally described in 1863 by the American neurologist George Miller Beard, neurasthenia presented with a great variety of unrelated and vague physical symptoms, such as headaches, impotence, indigestion and exhaustion. It was understood physiologically as due to a lack of nerve force and was successfully treated somatically with electrotherapy, rest and overfeeding. Like hysteria neurasthenia was understood to have psychological causes. Following Beard it was most often explained as due to the stresses of advanced civilization.28 Neurasthenia was readily accepted because Beard's explanation of it as a physiological disorder due to the stresses of advanced civilization fit the expectations of many people who were anxious about the consequences of industrialization. Because neurasthenia was understood in this way, it was relatively easy for people to accept the idea that it might be caused by the terror of railway accidents.

By the end of the nineteenth century, neurologists had established a rough medical consensus that fright following accidents led to genuine, if not terribly serious, disturbances of the nervous system. Traumatic hysteria and traumatic neurasthenia successfully replaced railway spine as the accepted diagnoses for this condition. Erichsen's concept of concussion of the spine had only a few quixotic defenders such as S.V. Clevenger, who hoped to revive the concept by changing its name to 'Erichsen's Disease.'29 By the beginning of the twentieth century the courts too began to accept the utility of the concept of the traumatic nervous disorder, as a tool in resolving conflicts over responsibility In industrial accidents. With the advent of Workers' Compensation laws in England and the United States in the early twentieth century these diagnoses were applied not only to railway passengers but also to industrial workers.While there were special problems involved in establishing claims for emotional
injuries under worker's compensation laws, the legitimacy of such
claims was not a major source of controversy. 30

SHELL SHOCK AND WORLD WAR I

By the beginning of the twentieth century traumatic emotional disorders had acquired a limited role in accident litigation and workers compensation settlements and played a significant role in persuading some somatically oriented neurologists, like Putnam, of the importance of emotions In the formation of neuroses. Experience with traumatic emotional disorders during and after World War I contributed further to the acceptance of the neuroses. Martin Stone
has argued that in Britain "shell shock" rather than Freud's writings was critical to the expansion of the psychiatric enterprise to include the neuroses.31 In the United States the idea of unconscious mental
processes had achieved sufficient acceptance before 1917 that wartime experience played only a catalytic role in the more general acceptance of this idea.32 The perceived prevalence of these disorders during the war and the apparent success of the American Expeditionary Force in treating them helped persuade many Americans that neuroses were common treatable disorders. At the same time as Americans were using experience with shell shock to promote optimism about the neuroses, however, they were beginning to see large numbers of ex-servicemen who were not recovering from their wartime experiences. The sight of these veterans whose neurotic symptoms did not dissolve as expected after the war reopened the question of who was responsibility for this form of suffering.

Preparation for the treatment of shell shocked soldiers by the American Expeditionary Force began in May 1917 when Thomas Salmon, with the approval of the war department and the support of the Rockefeller Foundation, went to England to study British treatment methods first hand.33 In December of that year he was appointed Director of psychiatry for the AEF. Salmon was well suited for the task of creating an organization to care for the expected wave of wartime psychiatric casualties. While serving in the public health service between 1903 and 1912 he had been responsible for screening immigrants for insanity and had become quite concerned about the threat these immigrants posed to the mental health of the nation. In 1912 he left that position to become director of the National Committee for Mental Hygiene. The National Committee had been founded in 1910, two years alter Clifford Beers, a former mental patient, had published his influential book A Mind That Found Itself. Beers hoped to use this book to establish a national movement to improve the conditions of the hospitalized mentally ill. Influenced by the prominent psychiatrist Adolf Meyer, however, the National Committee shifted its focus to an educational program aimed at preventing mental illness. As director of the National Committee Salmon devoted his statistical talents to surveying the mental institutions and calling attention to what he saw as the growing problem of mental illness.34 Even before traveling to England Salmon had gathered considerable information about the occurrence of mental illness in the military. He noted, for example, that the prevalence of mental disorders among the troops on the Mexican border In 1916 was three times that in New York State. 35

By the time Salmon came to England controversies over "shell shock" had largely been resolved. The term was originally used to describe soldiers who developed neurological symptoms during battle in the absence of signs of physical injury. The term derived from the initial belief that these symptoms were due to changes in the nervous system produced by the sudden changes in atmospheric pressure produced by exploding shells. Initially, the victims of "shell shock," like those of railway spine, were caught up in controversy over whether they suffered from a form of brain damage or were merely malingering. The serious and ultimately unacceptable social implications of labeling thousands of soldiers either cowards or insane gave advocates of functional and psychological notions of traumatic emotional disorders an opportunity to promote the socially more useful
compromise suggest;on that shell shock was a real disorder, but one which could be readily treated by psychological means.36 By the time the United States entered World War I both the British and the French had agreed that the most effective way to return soldiers to battle was to treat them close to the front and return them to the trenches quickly. Two broad psychological interpretations of these symptoms had developed. The first stressed the role of suggestion and was treated by counter suggestion. Soldiers who could not speak, for example. were painfully stimulated until they screamed, thereby demonstrating that they could speak. The second stressed the role of psychological trauma and conflict and was treated with the abreaction of painful memories.

Salmon and other leaders of the American effort to deal with Psychiatric casualties of the war quickly adopted British psychological views on the war neuroses and their treatment. This was in part due, of course, to the fact that Salmon studied British efforts first hand but also to the fact that ideas about unconscious or subconscious mental processes had achieved a substantial foot-hold in the United States before the war. By the turn of the century a
virtual psychotherapeutic school had developed in Boston around Putnam, the neurologist Morton Prince and the psychologist William James. Widespread interest developed after 1906. In that year Pierre Janet, who was viewed as a representative of the "school established by Charcot," delivered an important series of lectures on "The Major Symptoms of Hysteria" at Harvard University and Morton Prince published his The Dissociation of a Personality, which brought the subject of multiple personality before a wide audience. By July 1907 seventy-nine papers and ten books were listed in the Index Medicus under the heading "psychotherapy" --a heading which had first appeared only in May 1906. In 1909, Freud, who thought his ideas would be anathema in the United States, was surprised by the warm reception he received when he spoke at Clark University.37

Salmon returned from England with the view that "whatever the unknown physiological basis, psychological factors are too obvious and too important in these cases to be ignored."38 While he accepted the commonly held view that the uniquely terrible conditions of the fighting made World War I the first war in which the traumatic neuroses were observed, his emphasis was on the vulnerability of individuals not the conditions of fighting. He rejected the term "shell shock" because by 1917 the evidence clearly showed that only a small number of cases occurred in the presence of shell fire. He held that the largest group of cases consisted of individuals who were exposed to conditions no different from those which hundreds of their asymptomatic comrades experienced. These cases, he added, resembled 39 Salmon also supported those seen in civil practice in most respects his psychological view by pointing to the high ratio of officers to men among the "shell shocked," the rarity of war neuroses among prisoners and the wounded, and the success of psychological treatments. Because Salmon adopted a psychological point of view he could also accept the controversial distinction between malingering and hysteria, insisting that the hysteric unconsciously deceived himself about his disability.40

Along with the psychological orientation of his British mentors, Salmon also accepted the British view that the most effective treatment must occur close to the front where every effort could be made to return the soldier to the fighting. Salmon insisted that such treatment not only promised to increase the manpower available for the war effort but also to reduce morbidity from the war neuroses. While he accepted that fact that relatively few men could be returned to the front and consequently the results of treatment might be disappointing to the military, he rejected the idea of simply discharging all cases of she:l shock. That, he argued, would encourage the use of neurosis "as a way out."41

Salmon!s ideas about treatment were based on his opinion that "the Psychological basis of the war neuroses (like that of the neuroses in civil life)...(was) an elaboration, with endless variations, of one central theme, escape from an intolerable situation in real life to one made tolerable by the neurosis."42 Sidney Schwab, L. a theoretically inclined American neurologist, grounded similar views on the vulnerability of shell shocked soldiers on Freud's idea of defense and British ideas on the instinct of self-preservation. He argued that even normal individuals erect neurotic defenses to protect themselves from psychological as well as physical trauma.43 What was critical was the individual's vulnerability. For Schwab the war demonstrated that "any soldier under given circumstances would develop a neurosis... (but that) the potential neurotic not only developed a war neurosis under less intense traumatic environment than the normal soldier, but ...was less capable of cure."

AFTER THE WAR

American involvement in the war was brief and the operation or the "forward treatment" strategy even briefer. Nonetheless Americans were proud of both their success in screening out potential psychiatric casualties and in treating those which occurred. After the war Americans asked what lessons could be learned from wartime experience with the neuroses. Views such as Salmon's about the nature of the war neuroses were widely held. Such views of the dynamics of the war neuroses led to optimistic predictions of post war recovery and did not prepare Americans for the problems of chronic shell shock. Because Salmon regarded neuroses as an "escape" from intolerable c;circumstances, he concluded that "with the end of the war most cases, even the most severe, will speedily recover, those who fall to being constitutionally neurotic.''44 E.E. Southard also insisted that ''in a period of not over two years after the war experience is over these men should get back to their normal emotivity..."45 Fredrlck W. Parsons commanding Officer of Base Hospital No. 117, which served as the primary treatment facility for the war neuroses noted that
"practically all" cases treated at his hospital recovered. Parsons, however, anticipated post war problems with chronic shell shock even as he reassured his readers that:

a war neurosis which persists is not a creditable disease to have, as it indicates in practically every case a lack of the soldierly qualities which have distinguished the Allied Armies, and it will not be a serious problem. The population of the United States will easily absorb the few scores of unrecovered cases that will exist after the expiration of six months of peace, and no one should be permitted to glorify himself as a case of "shell shock."46

The apparent success of the AEF in preventing and treating war neuroses allowed doctors to draw a number of morals for the treatment and prevention of civilian neuroses from their experiences with the wartime variety. The lesson for post war America, Schwab concluded, was that "an individual who has failed to adjust himself to the demands of civil conflict implied in the struggle for existence and to the economic social stresses, through the compromise of a neurosis, must be regarded as a citizen soldier for whose concern the community is responsible."47 Norman Fenton, who regarded war neuroses which persisted or recurred as like bad habits, warned parents and teachers that "through neglect or unwise attitudes ... (they might) be partially responsible for the genesis of such symptoms in children."48

Austen Fox Riggs, who established a successful residential center for the treatment of the neuroses in Stockbridge Mass. before the war,for example, also drew a moral for post war civil life from his optimistic understanding of the psychodynamics of the war neuroses. For Riggs shell shock was due to a soldier's failure to recognize that fear was not "synonymous with cowardice," but a normal reaction to danger and an "occasion for courage." Given enlightenment on matters such as this, Riggs was quite sure that in "complicated neuroses of ordinary civil life" as well as war neuroses, the patient could find "the will to get well, ready to apply itself" to the problem of adjustment.49

The war neuroses were, however, not as easily treated as Riggs' optimistic rhetoric would have suggested. Paul Fredrick Slocum, a graduate of Yale and a first lieutenant, for example, was dazed and suffered from severe pain in his neck following exposure to an explosion during the war. Riggs diagnosed him as suffering from a war neurosis when he treated him for six weeks in 1920. In spite of this Slocum spent at least the next decade unsuccessfully seeking treatment alone and compensation for his symptoms. 50 Lieutenant Slocum was not alone his protracted struggle with the effects of the war. Norman Fenton's followup of ex-servicemen treated at Base Hospital 117 showed that in 1919-1920 forty percent were still disabled by symptoms and that in 1924-5 twenty percent remained so. Salmon expressed concern that "misdirected sympathy or ...misdirected harshness,...frequent transfers from hospital to hospital with consequent varied diagnostic notions...(contributed to) the fixation of symptoms."51 Fenton, however, also suggested that social factors played a role in recovery, noting that individuals with clerical and professional backgrounds made much better adjustments than those who worked in agriculture, mining and transportation. He interpreted this in terms of the greater intelligence of the former. 52 Douglas Thom's observations on how ex-servicemen sought out treatment, however,suggested that social and economic factors, particularly in the difficult years immediately after the war, may have played a greater role than intelligence. He noted that the majority of such patients "returned to their homes after the war and for a longer or shorter period adjusted themselves to the old environment." Subsequently, "accident or illness to the patient, possibly some sickness in the family or financial loss, more likely unemployment or domestic difficulties...act(ed) as the exciting cause of a so-called nervous breakdown. It is during this period of social and economic maladjustment that the individual makes first contact with one of the ~numerous agencies interested in the ex-serviceman."53

Some reacted to the unexpected prevalence of neurotic ex-servicemen by insisting that provisions made to provide for their care were contributing to their neurotic disability while others insisted that these provisions were inadequate. To provide for the care for ex-servicemen after the war, Congress, in 1917, amended the War Risk Insurance Act, a law which had been passed to provide insurance for commercial shipping in wartime. Congress took this approach rather than utilize the pension system which was developed after the Civil War because, in the words of a contemporary observer,that "patchwork of pensions (was) based on gratuities and political favor rather than on a sense of social justice and mutual obligation, (and was) universally recognized as a failure."54 In order to avoid such corruption the amendment to the War Risk Insurance Act provided for optional life insurance and universal compensation in the case of disability. The compensation provision resembled the workmen's compensation laws which had been passed in many states during the previous decade. Soldiers would be compensated only for injuries incurred during the war and the War Risk Insurance Bureau was empowered to establish this service connection and the degree of disability. To make the operation of this Bureau fair and practicable all service men were assumed to have been able bodied at the time of their admission to the service.The provisions of this amendment created special problems in cases of neurosis.

The presumption that American soldiers were mentally healthy at induction was justified by the fact that the psychiatric service of the American Expeditionary Forces had established an elaborate and extensive program of screening recruits for mental disorders including the neuroses. They hoped that this screening would reduce the number of wartime psychiatric casualties; and after the war, they took pride in the overall success of their efforts. Nonetheless, even before the war was over, some neuropsychiatrists were expressing bitterness about the terms under which they had to treat neurotic soldiers. Pearce Bailey, a neurologist with considerable prewar experience with railway spine, for example, noted that:

In our army the task of the cure of patients is difficult by reason of the sweeping application of the principle of compensation for disability. ...Legally, no disorder can have preexisted in a person accepted for military service. As far as the neuroses are concerned, this law puts it beyond the power of medical officers to throw any doubts into the mind of the patient that he will surely be compensated if he persists in his long enough. 55

That compensation was payable only for disability directly connected with service meant that benefits were payable to a relatively small number of men. Immediately following the war there was little difficulty in establishing service-connection, but with each passing year this connection became more and more difficult to establish, Particularly for tuberculosis and neuropsychiatric diseases.This resulted in considerable litigation to establish service connection as well as disability.

In 1921 Senator Walsh of Massachusetts proposed legislation to eliminate the delay and annoyance created by "requiring the disabled soldier to prove that the disease from which he is suffering was contracted in the line of service." What particularly concerned Walsh was the disabled veteran who had sent proof that he was suffering from tuberculosis or a neuropsychiatric disease to Washington only to be told that: "The burden is upon you to prove that the disease was contracted while in the service of your country." He felt that requiring proof of service connection had been responsible for much of the "complaints, dissatisfaction, and disappointment" with the War Risk Insurance Act. Walsh felt that his legislation was justified by the fact that so many ex-service men suffered from tuberculosis and nervous and mental diseases. After all he asked rhetorically, "Where did they acquire these diseases?" "Surely," he concluded." the young manhood that you and I knew and grew up with were not so generally and promiscuously afflicted with tuberculosis or nervous or mental diseases.''56 When it finally passed Walsh's legislation contained the
first departure from a strict requirement of service-connection, It provided that a veteran with active tuberculosis or a neuropsychiatric disease causing a disability of 10 per cent or more, developing within two years after separation from service, would be considered to have acquired his disability in service." 57 In 1924 the World War Veterans Act extended the date of this presumptive service connection to January 1, 1925.58

It is not necessary to review the obvious influence of veterans politics on the passage of Walsh's legislation. It is sufficient to note that the passage of Walsh's legislation indicated that the problem of shell shock was not going to evaporate after the war as Salmon's psychological formulations had led people to believe. More generally the passage of Walsh's legislatlcn demonstrates how difficult it is to separate the relationship between trauma and emotional disorders from social and politlcai processes. Traumatic emotional disorders continue to be a source of social conflict as recent debate over post traumatic stress disorder among Vietnam veterans and the victims of childhood sexual abuse makes clear. With the perspective provided by the history of railway spine and shell shock it should also be clear that such conflict is to be expected because claims of emotional injury inevitably raise questions of responsibility. This perspective should also help us to see that the process by which our understanding of traumatic emotional disorders is shaped cannot be completely understood without taking social conflict into consideration.

1.John C. Burnham, Psychoanalysis and American Medicine,l894-1918:Medicine, Science and Culture (New York:International Universities Press,1967); Nathan Hale, Freud and the Americans:The Beginnings of Psychoanalysis in the United States.1876-1917, (New York: Oxford University Press,1971)

2. Edward M. Brown, " Neurology's Influence on American Psychiatry," http://members.home.net/edwardmbrown1/historyofpsychiatry.html

3 .George Rosen, "Nostalgia: A Forgotten' Psychological Disorder,"
Psychological Medicine,5(1975) 340-355.

4 .Edward M. Brown, "Regulating Damage Claims for Emotional Injuries
before the First World War," Behavioral Sciences and the
Law,8(1990)421-434.

5.Wolfgang Schiveibusch, The Railway journey: The Industrialization of
Time and Space in the 19th Century, (1977, University of California
Press), Esther Fischer-Homberger, "Railway spine und traumatische
Neurose-Seele und Ruckenmark," Gesnerus, 67 (1971)96-111

6 .John Eric Erichsen, On Railway and other Injuries of the Nervous
System (1867, Philadelphia: Henry C. Lea) p. 19.

7.Ibid. p.74. 8

8.Ibid.pp.88-91.

9. J.Burry and E.W. Andrews. "Medico-legal Aspects of Some Injuries of
the Spinal Cord," Journal of the American Medical Association
11(1888)841-884.

10. R.M. Hodges, "So-Concussion of the Spinal Cord,"Boston Medical and
Surgical Journal 104(1881)388. Hodges quotes: James Syme, "Compensation for Railway Injuries," Lancet, 3an. 5, 1867

11. A.J.S., "Railway Spine," Railway Surgeon, 1 (1894-95)255-6.

12. R. M. Hodges "Suckled Concussion of the Spinal Cord," Boston
Medical and Surgical Journal, 104(1881)388.

13 .Proceedings of the Boston Society for Medical Improvement, Boston Medical and Surgical Journal,102(1880)132-135.

14 .Proceedings of the Boston Society for Medical Improvement, Boston
Medical and Surgical Journal,102(1880)133.

15 .George M. Beard, "The influence of the mind in the causation and
cure of disease and the potency of expectation," Journal of Nervous and
Mental Diseases,3(1873)430-31.

16 .Putnam, J.J., Recent investigations into the pathology of so-called concussion of the spine. Boston Medical and Surgical Journal, 109(1883)217-220.

17. Ibid. p.217.

18. Ibid. p. 218

19 .Herbert W.Page, Injuries of the spine and spinal cord, without apparent mechanical lesion, and nervous shock, in their surgical and medico-legal aspects. (London: J& A. Churchill,l883) pp.203

20 .Putnam,"Recent Investigations..." 1883,p.217

21. Page, Injuries of the spine. . .,1883. p. 203-4.

22. Jose Lopez Pinero, Historical Origins of the Concept of Neurosis, (Cambridge,Cambridge University Press, 1983).

23 .Kenneth Levin, Freud's Early Psychology of the Neuroses, (Pittsburgh, University of Pittsburgh Press, 1975).

24. J.J. Putnam, "The Medico-Legal significance of hemianaesthesia after Concussion Accidents," American Journal of Neurology (1884)507.

25. Ibid.

26. R.M. Hodges,"So-Called Concussion of the Spinal Cord," Boston Medical and Surgical Journal,104(1881)361-2

27 . G.L. Walton, "A case of Hysterical Hemianaesthesia," Boston Medical and Surgical Journal, 111(1884)558-559; J.J. Putnam, "Recent Investigations into the Pathology of so-called Concussion of the
Spine," Boston Medical and Surgical Journal,109(1883)217-220.

28 .Charles Rosenberg, "The Place of George Miller Beard in American Psychiatry,"Bulletin of the History of Medicine,36(1962),245-259.

29. S.V.Clevenger, "Legal Aspects of Spinal Concussion," Journal of the American Medical Association 15(1890)629-634.

30. E.M. Brown, "Regulating Damage Claims..."

31. Martin Stone. "Shell Shock and the Psychologists,” in William P. Bynum, Roy Porter, and Michael Shepherd (eds.), The Anatomy of Madness, (London and New York: Tavistock Publications, 1985),pp. 242-271,

32 .John Burnham, Psychoanalysis and American Medicine , (International Universities Press, New York,1967) p.44.

33. Earl D. Bond,Thomas W. Salmon: Psychiatrist, (W.W.Norton &Co.,New York,1950) p.83.

34.Norman Dain,Clifford W. Beers: Advocate for the Insane (Pittsburgh: University of Pittsburgh Press, 1980) 165-228 .

35. Bond. p.83

36. Edward M. Brown, "Between Cowardice and Insanity: Shell Shock and
the Legitimation of the Neuroses in Great Britain." in E.Mendelssohn, M.R.Smith and P.Weingart (eds.), Science. Techhnology and the Military, (Dordrecht:Kliuwer Academic Publishers, 1988) pp. 323-345

37 .John C. Burnham, Psychoanalysis and American Medicine.; Nathan Hale, Freud and the Americans; Edward M. Brown, "The Influence of Neurology on American Psychiatry,l865-1915." http://members.home.net/edwardmbrown1/historyofpsychiatry.html

38. "Neuropsychiatry," Norman Fenton and Thomas Salmon (eds.) U.S.
Army in the World War,Vol.X, (Washington:Government Printing Office,1929) p.505.

39. Ibid. p.505

40. Ibid.

41. Ibid.p.512

42. Ibid. p. 506.

43. .Sidney I. Schwab, "Influence of War upon concepts of Mental Disease and Neuroses," Mental Hygiene,

44. "Neuropsychiatry, " Vol X, p. 511

45. quoted in Norman Fenton, Shell Shock and its Aftermath (St Louis: C.V. Mosby Co., 1926) p.148.

46. quoted in Mental Hygiene, 3(1919) 131-132

47. Schwab,"Influence of War...," p.667

48.Fenton, Shell Shock and its Aftermath, 1926 p.162

49. Austen Fox Riggs. Just Nerves, (Houghton Miflin Company, Boston,
1922) pp.47-~1.

50. Slocum v.United States, 2 F. Supp.8.pp.8-11.

51. Fenton, Shell Shock and its Aftermath, 1926 p.155.

52. “Neuropsychiatry" Vol.X p. 461-2

53 Douglas A. Thom. "The Patient and His Attitude Toward His Neurosis,"Mental Hygiene, 6(1922)241-2.

54 .Samuel McCune Lindsay, "Soldier' Insurance Versus Pensions," The American Review of Reviews,
(1917) 401-402.

55. Pearce Bailey, "War Neuroses, Shell Shock and Nervousness in Soldiers,"Journal of the American Medical Association 71 (1918)2148-2153.

56. Congressional Record, July 20,~921, pp.4105-6.

57~ William Pyrle Dillingham, Federal Aid to Veterans:1917- 1941, (University of Florida Press, Gainesville, 1952) p.43 58

58.Roger Burlingame, "Embattled Veterans," Atlantic Monthly, Oct., 1933

p.393.

Edward M. Brown

Neurology's Influence on American Psychiatry: 1865-1915

2009-01-01T08:27:00.000-08:00

Prior to the middle of the nineteenth century psychiatry was clearly identified with the asylum and with the humane care of the most disturbed members of society. Between 1865 and 1915, however, this began to change and psychiatry began to assume its twentieth century form. During this period the profession became more scientific and simple concern with humane care became suspect. Psychiatrists also began to show more interest in less severely disturbed patients who might be treated outside of the confines of an asylum. Furthermore, the treatment of these patients in particular came increasingly to be understood in psychological terms as the ground was laid for the explosive development of twentieth century psychotherapies. In the United States it is clear that these changes did not simply evolve out of the older asylum psychiatry but were the result of the catalytic action of a new medical specialty--neurology-- on the practice of caring for the mentally ill. In Europe, largely through the influence of Wilhelm Greisinger, psychiatry and neurology were more or less united after 1860. In the United States, by contrast, asylum superintendents were both well organized and isolated from the mainstream of medicine. What this meant was that newer perspectives were assimilated in the course of conflict and competition between two professional groups. Neurologists stimulated the assimilation of these newer perspectives by advocating a more scientific approach to patients, criticizing the quality of asylum care, treating patients previously unnoticed by psychiatrists and importing a new psychological point of view from Europe. While asylum superintendents at first bitterly resisted the intrusion of these new specialists into their territory, in time they came to adopt a point of view quite similar to that of the neurologists. By the first World War this process was largely complete and psychiatry was well on its way toward assuming its twentieth century form. This chapter will trace, in greater detail, the events outlined above. It will focus on developments in the United States because they serve both as a demonstration of how the intellectual and social shape of professions change and as an example of how such changes are brought about through conflict between social groups.1
Before the Civil War the practice of psychiatry occurred almost exclusively within the walls of asylums. The wave of reforming optimism which swept over the United States in the early nineteenth century resulted in the construction of a number of these institutions. By 1844 the superintendents of thirteen asylums were ready to form the Association of Medical Superintendents of American Institutions for the Insane (AMSAII) and establish the American Journal of Insanity. While this association was the first organization of medical specialists in the United States, it was quite different from those which followed it. As the name of the association suggests its members were not primarily interested in a class of patients, as was true of pediatrics, or with diseases of a particular organ system, as with opthalmology, but with the administration of a particular institution. This administrative slant was so pronounced, in fact, that even assistant asylum physicians were excluded from membership in AMSAII. As early issues of the American Journal of Insanity demonstrate, concerns with asylum management rather than scientific studies of insanity dominated the early meetings of the association. Some superintendents wrote about the consequences of religious revivals, mental hygiene and medico-legal subjects but these issues always remained marginal to the day to day problems of caring for severely disturbed patients. Concerns with the quality of asylum care during the first half of the nineteenth century resulted both from the humanitarian impulses of the early superintendents and a need to legitimize asylum care in a society where hospitals were seen chiefly as places to die. The narrowness of these concerns, however, made members of AMSAII vulnerable to criticism that they had isolated themselves from important scientific developments in medicine.2
By the end of the Civil War some of the early optimism which had led to the founding of the insane asylum was beginning to fade. Foreign born patients appeared more difficult to treat, chronic patients were accumulating and asylums were beginning to become overcrowded. Nonetheless asylum superintendents were still confident about their approach to patients and, indeed, some physicians were beginning to apply the principles of asylum care to the treatment of alcoholics by creating specialized inebriate asylums.3 At the same time, however, a new group of professionals was organizing itself and preparing both to claim expertise in the treatment of the insane and to advocate a radically expanded vision of the idea of mental illness and health. The new professionals called themselves neurologists and with their claims to a truly scientific understanding of the nervous system in health and disease they both challenged the hegemony of the medical superintendents and opened the way to a transformation of the field of psychiatry.
The American Neurological Association was established by eighteen physicians at a meeting in New York City in 1875 and the Journal of Nervous and Mental Diseases was designated as their official organ in the following year. In contrast to AMSAII which was founded out of the real need of asylum superintendents to discuss common problems, the ANA was founded in the faith that recent scientific studies of the nervous system would soon change the treatment of nervous diseases sufficiently to justify their new specialty. These early neurologists drew their confidence in their scientific understanding of the nervous system from several sources. In Europe advances were being made in the development of a localizing neuropathology. The older theories of phrenology had not only been put to rest but discoveries such as Broca's delineation in 1860 of a speech area in the brain opened the prospect that the true functions of the brain would soon be outlined. The concept of the reflex arc developed in the first half of the nineteenth century by Bell, Magendie and Hall had also created the possibility that the basic physiological processes of the nervous system would soon be understood. Indeed some such as Carpenter and Laycock in England attempted to use the concept of reflex action to explain "higher" mental functions and such pathological phenomena as somnambulism and trance. While these developments were occurring in Europe, some Americans were also contributing to the scientific foundations of the new specialty of neurology. During the Civil War, S. Weir Mitchell, who was later to be one of the leaders of American neurology, and his colleagues William W. Keen and George Read Morehouse had an opportunity to observe a vast number of peripheral nerve injuries. These observations were carefully recorded and formed the basis for subsequent publications including Mitchell's internationally renowned Injuries of the Nerves and their Consequences.4
While neurologists could use these specific scientific developments to give substance to their claims of scientific expertise, they were also eager to wrap themselves in the broad banners of positivism and scientism, which were so popular at the time, and to draw on models that had been successful in other areas of science. Some such as Edward Spitzka studied in Germany and brought back the conviction that new scientific methods would soon lead to great breakthroughs in neurology. Others were eager to present themselves to the public as scientific critics of such popular "delusions" as spiritualism.5 Virtually all of them drew heavily on contemporary theories of evolution, particularly those of Spencer, and popular ideas about the conservation of energy. This strong identification with the values of science contrasted sharply with the moral and religious tone of many asylum superintendents. It was also in terms of these differences in style, rather than specific scientific differences, that the conflicts between the neurologists and the asylum superintendents expressed themselves.
In practice many of the bold scientific claims of the neurologists were, however, no more than programatic. While some neurologists were among the first to introduce lectures on nervous and mental diseases into medical school curricula, late nineteenth century American medical schools offered very little support for research careers. What research neurologists did was usually privately funded, on a small scale and largely clinical. To make a living these new specialists generally found themselves in office practice in American urban centers such as Boston, New York and Philadelphia. Unlike the opthalmologist, whose clearly superior skills and narrowly focused specialty allowed comfortable referral relations with the general practitioner, the neurologist, like the pediatrician and the gynecologist, defined his speciality quite broadly. This put the specialist in neurology in direct competition with the generalist. Freud, whose practice in the 1880s resembled that of his American counterparts, also reflected their experience when he wrote that:
On the one hand the prospects in the treatment of... (organic nervous) disorders... were never promising, while on the other hand, in the practice of a physician working in a large town, the quantity of such patients was nothing to the crowds of neurotics whose number seemed further multiplied, by the manner in which they hurried, with their troubles unsolved, from one physician to another.
Because many of the neurotics to whom Freud refers were likely to agree with their family physicians that their complaints were "only nervousness," neurologists faced the difficult task of convincing the public to take these complaints seriously and to insist on neurologic treatment.6
In order to win serious consideration for the nervous patient, neurologists had to present nervousness in medically acceptable terms. Because the suffering of these patients could not be explained in terms of anatomically discrete neuropathological lesions they turned to physiological ideas, particularly that of the functional disorder. While such physiological thinking had less prestige, at the time, than anatomical explanations, it still had greater medical legitimacy than what would now be called psychological explanations. The latter were seen as "spiritual" and more appropriate for the theologian or novelist than the doctor. The awkwardness of such physiological thinking about patients' complaints is, perhaps, suggested by the title of W.B. Carpenter's popular book Mental Physiology; while the lengths to which this style of thinking could be pushed can be seen in Freud's Project for a Scientific Psychology. When, in the 1880s, the great neurologist Charcot turned his attention to hysteria and treated it as a functional disorder, however, the physiological approach succeeded in establishing the nervous patient as medically ill.7
Perhaps the first successful proponent of the notion of functional nervous disorder was the American neurologist George Miller Beard. In 1869 Beard announced his discovery of what was to become--even more so than hysteria-- the typical functional disorder of the age: neurasthenia. Without special training in neurology, Beard made his discovery while using a form of "general electrization" he had learned from a lay practitioner. Placing the electrodes on his own hands, Beard gave a mild electrical massage to all the muscles of the patient's body and he repeated this process daily for weeks or months as necessary. What he found was that two-thirds of his patients recovered from a wide variety of complaints such as fatigue, dyspepsia, headaches and nervousness. Viewing electricity as a kind of tonic, traditionally associated with vital nervous energy, he reasoned that all of these patients suffered from a lack of nerve force which his treatment restored. "Nervousness," he proclaimed, " is really nervelessness." He argued that this lack of nerve force was the result of a specific functional nervous disorder that he called neurasthenia and in the years following his initial publication he became a tireless advocate of the importance of this condition. 8 Beard's physiological explanation of neurasthenia in terms of nerve force as well as his apparent ability to cure this illness had great appeal. Not only were some relieved to learn that they suffered from something real, but others were reassured to learn that their "symptoms, which for a long time had kept them in a state of alarm, if not despair, lest they might be precursors of incurable disease of the brain or spinal cord" could be treated. Beard's theory also had special appeal for affluent patients, who were of particular interest to neurologists in private practice. By drawing on contemporary notions of evolution, this theory suggested that the victims of neurasthenia were most likely to be highly successful as well as highly refined people. The highly developed "nervous organization" of such "brain workers" it was argued, made them especially sensitive to the stresses of advanced civilization. Because Beard explained the protean manifestations of neurasthenia by calling on three central ideas of the period-- the reflex theory, the electrical nature of the nerve impulse and the law of conservation of energy, he also left little doubt about the scientific status of those who treated it.9
While the diagnosis of neurasthenia and Beard's explanation of it achieved international standing, which they maintained into the twentieth century, Beard's treatment was soon eclipsed by the more comprehensive rest cure. This treatment was developed by S. Weir Mitchell who, like Beard, had established an office practice after the Civil War. Drawing on his observation that "complete rest and plentiful food" allowed exhausted soldiers to return to the front, he tried the same approach in 1874 with Mrs. G. a "lady of ample means, with no special troubles or annoyances, but completely exhausted by having had children in rapid succession and from having undertaken to do charitable and other work to an extent for beyond her strength." When he discovered that she could not tolerate complete bed rest he added passive massage to the regimen and was delighted by her recovery. Soon he added electrotherapy, over-feeding and seclusion of the patient from her family to the treatment. This treatment, particularly his insistence on secluding the patient from her family, showed considerable insight into the family dynamics surrounding invalids. Mitchell nonetheless was consistent in emphasizing the somatic aspects of the rest cure-- even calling his book describing the cure Fat and Blood. This treatment, like the concept of neurasthenia, achieved international popularity-- even Freud spoke highly of it. It also provoked one of Mitchell's patients, the noted feminist Charlotte Perkins Gilman, to write 'The Yellow Wallpaper' a stinging satire in which she suggests that the rest cure nearly drove her crazy.10
With diagnoses like neurasthenia and treatments like the rest cure achieving significant popularity, a new type of medical practitioner, the nerve doctor, was emerging. In Europe a sharp split betweem this new specialty and the older form of practice, which centered around the asylum, was largely avoided. In Germany, for example, the influential Wilhelm Greisinger assumed the chair of Psychiatry and Neurology at Berlin in 1865. By uniting psychiatry and neurology with the prestige of a university chair as well as his slogan "psychological diseases are diseases of the brain," Greisinger established a tradition that left little room for the kind of interprofessional conflict that marked the American scene. In France the great neurologist Charcot worked at that country's largest asylum, the Salpetriere; and In Austria, while Freud pursued his office practice with nervous patients, his mentor, Meynert, held a chair at the University and conducted a program of research on localizing neuropathology.11
In the United States the absence of a strong university medical school tradition and the presence of a well organized association of asylum superintendents left those neurologists who wanted to emulate their research oriented European counterparts isolated from the most interesting patients. During the late 1870s and early 1880s this situation contributed to one of the most bitter conflicts in the history of American psychiatry. Having established a national association of their own in the early 1870s, American neurologists were soon ready to launch an organized critique of the dominant branch of the psychiatric profession. The New York Neurological Society, which represented the core of the national association, fired the first volley in 1878 by submitting a formal petition to the New York State legislature demanding an investigation of the asylum system of that state. When the legislature's committee on public affairs absolved the state's hospitals the following year, the neurologists claimed there had been a whitewash. After this initial clash, however, momentum built and soon led to an alliance between the neurologists and members of the National Conference of Charities and Corrections which was a group of charity reformers concerned with placing public welfare on a more "scientific" footing.
By 1880 this coalition of neurologists, charity reformers and a few reform minded asylum superintendents were ready to form the National Association for the Protection of the Insane and the Prevention of Insanity (N.A.P.I.P.I.). Dedicated ( in George Miller Beard's words) to "obtaining universal recognition of the fact that it is no disgrace to be crazy," this organization provided a forum for neurologists to continue their attack on the management of American asylums. They pointed to the growing isolation of asylum superintendents from new developments in medicine, the seemingly excessive preoccupation of the superintendents with the physical plants of their asylums, the superintendents' lack of scientific training and the paucity of scientific research done in asylums. They also joined with English psychiatrists in complaining about the use of mechanical restraints on insane patients in the United States. Because asylum care in the 1870s had deteriorated from what it had been thirty years earlier, some of the neurologists' criticisms were well taken. The thrust of these criticisms, however, was aimed not so much at the specific abuses as at establishing the ideal of "science" as the norm of good psychiatric care. Because asylum superintendents did not take this criticism passively, what evolved was an intense war of words between a group of self-proclaimed advocates of the ideals of science and a group that considered itself uniquely qualified to provide humane care for the insane. In this context asylum superintendents were assailed as "despots," "autocrats," "reactionaries," and "businessmen who had lost interest in medicine and science," while the superintendents expressed their contempt for "outside meddlers," "soft headed humanitarians," and "neuropaths."12
The conflict between the neurologists and the asylum superintendents was not, however, limited to the question of asylum reform. The assassination of President Garfield by Charles Guiteau in 1882 provided another arena in which both groups could attempt to demonstrate the superiority of their professional perspectives. By providing an opportunity for the most outspoken members of the two groups to line up on opposite sides of the question of guilt versus insanity, Guiteau's trial probably gave the public more insight into the conflicts within the profession than into the accused's mental state. John Gray, who was superintendent of the Utica Asylum in New York and editor of the American Journal of Insanity (which he owned), took the position that Guiteau was sane because he "had been motivated neither by uncontrollable rage nor by the torrents of insane compulsion...(but instead)... thought, reasoned and controlled his actions." Guiteau's claim that he killed the president out of inspiration was dismissed by Gray as after-the-fact rationalization and his long history of strange behavior as egotism. The star defense witness, the neurologist Edward Spitzka, argued that Guiteau was insane because his crime was "the result of a morbid project rather than a delusion strictly speaking." This broad definition of what counted as insane behavior was supported by Spitzka's view that Guiteau's long history of strange behavior was due to a "congenital malformation of the brain." With testimony like this Spitzka no doubt demonstrated his familiarity with the latest European scientific theories, especially the popular theory of hereditary degeneration. Nonetheless Gray's narrow interpretation of criminal responsibility prevailed. Guiteau was convicted and hung-- perhaps inevitably considering public sentiment about the assassination. Within a few years the neurologists' position seemed increasingly plausible and few doubted Guiteau's insanity.13
Not long after the Guiteau trial the sharp controversies between the neurologists and the asylum superintendents died down almost as abruptly as they had begun. By the mid 1880s the NAPIPI was dead and with it the chief instrument of the neurologists attack. In part this was due to the death of some of the most active leaders of the organization. In part it was due to a split between the neurologists and the lay members of NAPIPI, some of whom were hostile to all medical experts. It was also, no doubt due to the fact that the asylum superintendents slowly began to reform their organization. By 1892 AMSAII had broadened its membership to include assistant asylum physicians and at the same time, in a significant symbolic gesture, they changed the name of the organization to the American Medico-psychological Association. Of particular interest is the fact that in 1894 the distinguished neurologist S. Weir Mitchell was invited to address the newly renamed association. Mitchell initially refused the invitation, perhaps not wanting to rekindle the controversies of the 1880s. The invitation was renewed; and when he spoke,Mitchell did not pull his punches. He repeated many of the same criticism that had been made in the early 1880s and told his audience:
You were the first specialists and you have never come back into line... You soon began to live apart and you still do so. Your hospitals are not our hospitals; your ways are not our ways... I am strongly of the opinion that... the belief that no one could, or should, treat the insane except the special practitioner has done us and you and many of our patients a lasting wrong.
While some of Mitchell's criticisms were unjust because he seemed to be unaware of changes that had occurred in the care of the insane, the American Journal of Insanity published a remarkably mild response. Clearly the members of the American Medico-psychological Association were confident enough in their own progressive reforms that they were willing to listen to their critics.14
Another reason that the neurologists may have moderated their criticism of their asylum based colleagues was that they had achieved a degree of success in establishing themselves as experts in the care of the mentally ill. What this meant, in part, was establishing the value of the non-asylum treatment of the insane. Because of the great popularity of asylum care in the early nineteenth century and the wide acceptance of the view that isolating the insane from the harmful influences of their environment was an important ingredient in successful treatment, non-asylum care had no formal place in American medical theory or practice. In an influential paper on "The Non-asylum Treatment of the Insane" published in 1879, the neurologist William A. Hammond argued "that the medical profession is, as a body, fully capable of treating cases of insanity as cases of any other disease, and that in many instances sequestration is not only unnecessary but positively injurious." According to Hammond, neurologists, and even some general practitioners, were better able than asylum superintendents to recognize cases of insanity during their early and treatable phase. With the exception of "those who refuse food, who have homicidal or suicidal tendencies, or delusional or morbid impulses, which prompt them to the destruction of property or other acts of violence," he argued, they were also quite able to treat them at home. Because twentieth century definitions of mental illness are so different than those of the 1870s it is difficult to understand Hammond's point without considering a specific case. For example:
M.g., a lady thirty years of age, and a widow for three years, consulted me on February 20th, 1877, for what was considered to be incipient insanity, and an affection in all probability, requiring, it was feared, incarceration in a lunatic asylum. The patient was quiet and orderly in her demeanor, and so far as her friend's accounts went, entirely sane, except on one point of fear of contamination, which was exhibited by mental distress, and the practice of washing her hands without there being obvious cause for doing so...
Treating her with a mixture of a mild cathartic, a bromide and opium, he reported that within three to four months her mental strength was improved and she was better able "to contend with the ridiculous notions which govern her." By advocating the non-asylum treatment of a case of "incipient insanity" such as this Hammond was redefining the place of asylum care in psychiatry and enlarging the field of "out-patient" treatment that Beard had begun to stake out with his concept of neurasthenia. By the beginning of the twentieth century many asylums (which were often called hospitals by then) had established out-patient departments.15
By the 1880s the field of non-asylum treatment was well established and a significant number of neurologists could make a living treating neurasthenics as well as patients such as the one described by Hammond. Perhaps the most important condition that neurologists treated, however, was hysteria. Both because hysteria mocked neurologists' efforts to explain it in terms of their localizing neuropathology and because it responded to such distinctly "unmedical" treatments as hypnosis, suggestion, and psychoanalysis, it opened the way for some neurologists to broaden the field of psychiatry by developing a psychological point of view. Traditionally viewed as a disorder of women, hysteria had long been the bane of physicians' lives. As Reynolds put it in a standard medical text, " The employment of the word 'hysterical' may sometimes be found indicative of the state of mind of the practitioner rather than that of the patient's health." Viewed in terms of twentieth century categories, the hysterical woman's symptoms have recently been described as a covert rebellion against her limited oportunities in life. For nineteenth century neurologists, however, hysteria was interesting because so many of its symptoms resembled those produced by genuine neurologic lesions. Paralysis, ataxia, abnormal movements, dysasthesias, and seizures could all be found. If the power of neurologic diagnosis was to be established, hysterical imitations had to be distinguished from the real thing. Even the great English neurologist Hughlings Jackson was interested in the difference between hysterical seizures and epilepsy. For Jackson as well as many of his counterparts in Europe and America, however, hysteria itself was of little interest after the process of differential diagnosis was complete. According to Jackson's influential doctrine of concomitance "mental symptoms...are, strictly speaking, only signs to physicians of what is going on or what is going on wrongly in a part of a patient's material organization." From this point of view the protean and perplexing symptoms of hysteria offered little promise of neurologic insight.16
Not all neurologists, however, followed Jackson's lead. Particularly in France, under the influence of Jean Martin Charcot, neurologists began turning their attention toward hysteria as a condition worthy of study in itself. Beginning his career as Medicin de l'Hospice de la Salpetriere in 1862, Charcot had used his "museum of living pathology" to delineate numerous neurologic syndromes. When he turned his attention to the study of hysteria in the late 1870s he was generally recognized as one of the world's leading neurologists. With Charcot studying hysteria, others could not easily ignore it. Charcot was important not only because of his prestige but also because he presented his views in terms that were readily acceptable to late nineteenth century neurologists while at the same time opening the way for others to go beyond his findings to develop a psychological point of view toward hysteria and other nervous disorders. For Charcot the fact that hysteria 'left no material trace that can be discovered' and therefore resisted efforts to explain it in terms of localizing neuropathology was of less importance than the fact that it was "governed, in the same way as other morbid conditions, by rules and laws." In his hands, for example, hysterical seizures appeared to proceed through distinct and readily observable stages. While observations like this later came under severe criticism, they were important at the time because they allowed neurologists to see hysteria as a genuine disease. Charcot's understanding of hysteria was also readily accepted by neurologists because it was consistent with their belief that only materialistic explanations could be regarded as truely scientific. For Charcot the dominant idea in the etiology of hysteria was hereditary predisposition. Drawing on the popular theory of hereditary degeneration, he generally established the presence of such a predisposition by giving the patient's family history, where psychic disturbances, organic nervous diseases and more or less diffuse diseases of other kinds in relatives were mentioned.17
In spite of his strong somatic bias, Charcot's studies on hysteria opened the way for the development of a psychological point of view in at least two ways. The first of these was his legitimation of hypnosis as a tool of neurological research. Since the late eighteenth century regular physicians had largely avoided using hypnosis. Efforts to explain its effects in material terms, that is in terms of a magnetic fluid, had been consistently unsuccessful and medical discourse had no place for "spiritual' explanations. Consequently during the nineteenth century, with exceptions like James Braid in England, hypnosis was largely the property of irregulars such as spiritualists and magnetic healers. Even in the 1870s neurologists who attempted to employ hypnosis ran the risk of being regarded as charlatans. When Charcot started to use hypnosis to study hysteria in 1878 this began to change. Only after 1882, when Charcot's findings with hypnosis were accepted by the Academie des Sciences, which had rejected similar findings three times in the previous century, could other neurologists begin to investigate hypnotic phenomena in earnest.18
One reason that Charcot's understanding of hypnosis was readily accepted was that, like his understanding of hysteria, it was quite consistent with the dominant scientific mores of the time.Viewing hypnosis as only "an artificially produced morbid condition--a neurosis" which "disclose(d) itself almost always on soil predisposed by hysteria," he regarded its potential as a treatment as quite limited. Nonetheless, others, notably Charcot's rival Bernheim, extended the territory established by Charcot by arguing that hypnotic phenomena could be found in normal people as well as in hysterics and by demonstrating the therapeutic potential of hypnotic suggestion.Still others such as Janet, Breuer and Freud built on Charcot's work, using hypnosis to establish their remarkable hypotheses about the presence of an unconscious mental life. With this work psychological theory and psychological treatment were well on their way to being established as part of the field of psychiatry.19
Charcot also created an opportunity for neurology and psychiatry to incorporate the psychological in to their domain through his consideration of the role of trauma in the etiology of hysteria. While regarding hereditary predisposition as central to his understanding of this disorder, he did grant that "a thorough acquaintance not only with the disease, but also with the conditions under which it is produced will... (be seen)... as useful from the fact that nervous disorders often ensue without any traumatic lesions and simply as a result of ...psychical nervous shock." It is of interest that Charcot's consideration of traumatic, that is to say, emotional factors resulted from his study of male hysterics-- particularly those men who were the victims of a puzzling nervous disorder often referred to as "railway spine." Because women were expected to be emotional it was easy to see their hysteria as simply due to an inherited nervous weakness. The possibility, Charcot noted, that "a firemen of a locomotive, for instance, never before emotional, at least in appearance, may as the result of a railroad accident... become hysterical just like a woman-- this (had) never entered into the imagination of some people." While Charcot regarded the terror that such a fireman might have experienced as only an "agent provocateur" that released the disposition to disease, the fact that he acknowledged that emotions might result in hysteria in such apparently robust individuals clearly weakened the explanatory importance of heredity. In the hands of other neurologists, most notably Charcot's student Freud, the importance of traumatic factors could be expanded to the point of virtually replacing heredity as the dominant idea in the etiology of hysteria-- for women as well as men. The fact that such traumatic factors also appeared to be treatable through new psychological means also contributed to an important wave of therapeutic optimism among neurologists.20
With this significant work occurring on the continent of Europe, Americans could not completely ignore hysteria, hypnosis and the developing psychological point of view. Among those claiming expertise in caring for the mentally ill, neurologists were among the first to import these new ideas and approaches. While some neurologists were interested in European developments in the 1880s and 1890s, widespread interest did not develop until after 1906. In that year Pierre Janet, who was viewed as a representative of the "school established by Charcot," delivered an important series of lectures on "The Major Symptoms of Hysteria" at Harvard University and another series of lectures on psychotherapeutics at the Lowell Institute. The year before, the Swiss neurologist Paul Dubois' book, The Psychic Treatment of Nervous Disorders, (for a time regarded as the bible of psychotherapeutics), had been translated. By July 1907 seventy-nine papers and ten books were listed in the Index Medicus under the heading "psychotherapy" -- a heading that had first appeared only in may 1906. The psychological ideas of Bernheim, Dubois, Janet and especially Freud, were, however, not imported without controversy. At the opening of the twentieth century controversies among neurologists about the legitimacy of psychological ideas and treatments had, in fact, clearly upstaged lingering disagreements between neurologists and those working in psychiatric hospitals. While most hospital-based psychiatrists had little use for the new ideas, reformers saw the new psychological approach as a way to revitalize their work. Indeed, the combination of increasing conflict among neurologists and a progressive rapproachment between psychologically oriented neurologists and reform minded hospital psychiatrists contributed greatly to establishing the boundaries of the field of psychiatry that have prevailed through most to the twentieth century.21
Disagreements among neurologists over hypnosis, suggestive therapeutics and especially psychoanalysis took on a somewhat regional character. While Boston neurologists were relatively eager to import the new approaches, neurologists in other cities such as Philadelphia imposed a virtual quarantine to prevent their spread. Perhaps a lingering sympathy for transcendentalist philosophy made Bostonians particularly receptive to the results of hypnotic experiments and even psychical researches. In any event between 1890 and 1909 a loosely knit group of psychologists, philosophers, neurologists and even men associated with psychiatric hospitals--the so-called Boston school-- cooperated to develop a sophisticated psychological approach to mental disorders. The two neurologists in this group, Morton Prince and James Jackson Putnam, deserve special mention. Prince began his medical career treating diseases of the nose and throat but switched to the study of nervous diseases in the early 1880s. A visit to Charcot (with his ailing mother) and another trip to study with Bernheim firmly established his interest in hysteria and hypnosis. By 1890 his own research allowed him to publish a paper on "Some of the Revelations of Hypnosis: Post-Hypnotic Suggestion, Automatic Writing and Double Personality." Accepting Bernheim's view of hypnosis as a normal phenomena, Prince used this technique less as a therapy than as a tool to conduct a series of original researches, particularly on the subject of multiple personality.Prince's importance, however, was perhaps less as an original researcher than as a publicist for the importance of psychological issues. In 1906 he founded the Journal of Abnormal Psychology, which was highly influential in introducing professionals to this area. In the same year he also published The Dissociation of a Personality, which was, perhaps more than any other single early twentieth century work, responsible for exposing the American public to the mysteries of the subconscious.22
To understand the role of the profession of neurology in introducing the psychological point of view into psychiatry, however, it is perhaps more useful to consider less original thinkers than Prince, Janet, or Freud. From this point of view those neurologists who gave up a firm commitment to somaticism to accept the psychological ideas of others are of particular interest. Here the best known American example is James Jackson Putnam. Educated in Germany like such ardent materialists as Spitzka, Putnam was a highly influential proponent of the somatic point of view in the years after the Civil War. At a meeting of the American Neurological Association in 1876 when George Miller Beard presented a series of experiments which tested " how much could be done in the way of effecting cures in cases of rheumatism, neuralgic sleeplessness and various forms of chronic diseases by exciting in patients a definite expectation," Putnam replied that he "had never seen any evidence that cure had been effected by mental influences in cases where actual disease existed..." By 1909, however, Putnam was ready to enthusiastically welcome Freud, when the latter gave a series of lectures at Clark University, and by the time of his death in 1918 Putnam had become the leading American advocate of psychoanalysis. Freud's charisma notwithstanding, Putnam's own career clearly must have been critical in producing such a radical transformation. Certainly his friendship with members of the Boston "school" such as William James and Morton Prince played a role as did Putnam's own philosophic interests.23
Two features of Putnam's neurological career, however, should also be mentioned. First, Putnam studied not only in Germany but also in England with Hughlings Jackson. While Jackson's principle of concomitance kept him from directly pursuing psychological investigations, his dynamic and evolutionary approach to nervous function bears some striking similarities to Freud's dynamic psychology. Indeed Putnam remembered Jackson teaching that "when the hierarchy of (cerebral) functions... suffers derangement at any part... the attempt at a reestablishment of some sort of equilibrium is always such that the new arrangement tends to safeguard itself..." One wonders whether Putnam's exposure to this style of thinking prepared him to find Freud's dynamic explanations in terms of energy, regression and defense more congenial. In any event, the fact that Freud's style of theorizing in terms of dynamic and evolutionary concepts was generally familiar to neurologists must have allowed them to take his ideas seriously even when they did not agree with him.24 To understand Putnam's willingness to accept a specifically psychological etiology for hysteria it is important to note that Putnam, like Charcot, had considerable experience with traumatic neuroses like "railway spine." Because such patients often suffered from apparently trivial injuries and because they often developed symptoms only some time after the accident their compensation by railway companies was the subject of considerable controversy. In examining these patients Putnam had to distinguish between hysteria, as a genuine disorder, and deliberate simulation. Perhaps his success in doing so allowed him to take hysteria seriously and prepared him to accept Freud's emphasis on traumatic factors in the etiology of hysteria. The experiences of other neurologists with traumatic neuroses may also have prepared them for Freud's theory of the traumatic etiology of hysteria. In any event neurologists did find that theory a comfortable way to understand Freud and continued to ascribe it to Freud long after he had changed his views.25
Perhaps the greatest effect of the new European ideas on American neurology was not as a source of hypnotic experiments or explanations for traumatic neuroses but as a source of effective treatments. As practitioners, neurologists were always aware of the importance of such treatments in attracting patients. While electrotherapy and the rest cure continued to suffice for some neurologists, their limitations were well known by the turn of the century. Indeed even in the 1890s there was some willingness to understand these treatments in psychological terms. At the same time Europeans were developing several kinds of psychotherapy and claiming dramatic results. Hypnosis itself could be used therapeutically. Bernheim, who saw hypnosis as only an extreme form of the normal suggestive influence of one person on another, advocated using suggestions to directly correct symptoms. Those who found such suggestive therapeutics deceptive and perhaps unethical could turn to Dejerine or Dubois who advocated using moral appeals and reasoning to persuade patients to get better. And, of course, there was Freud and his "psycho-analysis." After Janet's visit in 1906 and Freud's in 1909, competition between the advocates of these various approaches intensified.26
There were, however, other sources of competition as well. Particularly in Boston at the turn of the century Christian Science, the New Thought Movement and the Emmanual Movement were all successful in attracting patients to religious healers. Such competition with religious movements was not altogether new to neurologists. In the 1870s, for example, Beard and Hammond devoted considerable energy to demonstrating that materialist explanations of trance phenomena were superior to the supernatural explanations offered by the quasi-religious movement known as "modern" spiritualism. What was new at the turn of the century, however, was that the new psychotherapies were not so easily distinguished from their religious counterparts. Janet, for example pointed out the similarities between Dubois' "medical moralization" and Christian Science; the Emmanual Movement actually used friendly neurologists to develop their approach.27 The New York neurologist C.L. Dana summed up the situation: "After all, the question is not whether we should use psychotherapeutics, hypnotism or suggestion; we as neurologists are confronted with the fact than an enormous number of mentally sick people are running around and get their psychotherapeutics from the wrong well."28
While some neurologists were actively developing and promoting the new forms of psychotherapy, others saw these new treatments as a threat to neurology . For them the psychological point of view undermined the identity of the profession. While one neurologist saw Freud and Dubois as contradicting one of neurology's fundamental beliefs because he got the impression "that neither one of them believes that there is ever a physical foundation for nervous disorders," another neurologist worried that enthusiasm for psychoanalysis and psychotherapy would deprive neurologists of those basic diagnostic skills that gave the profession its claims to expertise.29 Still a third said that he was "in favor of psychotherapy but such as he can practice without labeling it or calling the attention of his patients to it and saying to them "Here I am a practitioner of psychotherapeutics." "I am a neurologist, he added, "I am not going to call myself a psychotherapeuticist any more than I would call myself an electrician."30 What this meant was that somatically oriented neurologists might adopt such techniques as suggestion, that could be incorporated into their familiar mode of practice, while rejecting more elaborately systematized methods such as psychoanalysis. Even such a staunch somaticist as the Philadelphia neurologist Francis X. Dercum could claim that "suggestion as an adjuvant may, in skillful hands, aid in the most unmistakable manner in bringing about a recovery." On the other hand he added, "psychanalysis (sic)... is a cult, a creed, the disciples of which constitute a sect. To be admitted to its brotherhood it is merely necessary that he should be converted to the faith, not that he should be convinced by scientific proof, for none such is possible."31
The split among neurologists over psychotherapeutics in general and over psychoanalysis in particular widened during the second decade of the twentieth century. Some neurologists were not only troubled by the sectarian character of the psychoanalytic movement but by what they saw as Freud's exclusive concern with sexual factors in the etiology of nervous disorders or as one of them put it,"this eternal harping on sex as if it were the only thing in life."32 One focus of these differences was the Journal of Nervous and Mental Diseases. Because this journal published the proceedings of the American Neurological Association it was virtually the official journal of that organization even though it was privately owned by its editor Smith Ely Jelliffe. After Jelliffe's "conversion" to psychoanalysis in the early years of the century an increasing proportion of the journal's articles were devoted to psychoanalytic subjects. By 1913 a number of neurologists, feeling that there was literally not enough room in that journal for their organic approach and that of the psychoanalysts, rebuffed Jelliffe and founded a new journal--The Archives of Psychiatry and Neurology. After this dramatic event organically and psychologically oriented neurologists continued to grow further apart. For neurologists interested in psychotherapy and psychoanalysis this did not result in professional isolation, however, because while some neurologists were rejecting the psychological point of view, hospital based psychiatrists were increasingly coming to accept it.33
The rapproachment between hospital based psychiatrists and neurologists had been going on since the 1890s. The fact that psychiatrists emphasized their scientific credentials and their interest in disease processes made the differences between the two professions less apparent. Not only were some neurologists running psychiatric hospitals and hospital psychiatrists caring for "extra-mural" patients but they were even participating in the same professional organizations. The Boston Medico-Psychological Society, which was founded in 1880 by asylum psychiatrists, for example, admitted neurologists to membership in the 1890s and in 1901. changed its name to the Boston Society for Psychiatry and Neurology.34 While the new psychological approaches had little to offer most institutionalized patients, they did offer the possibility of some cures and this appealed to reformers hoping to cast off psychiatry's custodial image. Some efforts to introduce psychotherapy and psychoanalysis into psychiatric hospitals were made. As William Alanson White noted, however, the effect of such treatments was more easily measured in improved staff morale than in increased patient well being. Of greater importance to the relationship between psychiatry and neurology was the fact that after the turn of the century psychiatrists were increasingly anxious to reach beyond institutional walls and no longer limit their activities and responsibilities to the institutionalized mentally ill. After 1910 the mental hygiene movement, with its emphasis on preventing mental disorders, gave this change in psychiatry its rationale. Adolf Meyer's ecclectic "psychobiology," which stressed understanding individual patients through a complete account of their biographies, gave these changes a theoretical foundation. Neurologists interested in psychotherapy could now find a more comfortable home in the newly expanded field of psychiatry.35
By the time of the First World War, then, the boundaries of the field of psychiatry had been radically altered. The nineteenth century distinction between asylum superintendent and nerve specialist had been obliterated. Neurologists were no longer concerned with the nervous patient but rather with the diagnosis and treatment of organic disorders of the nervous system. Psychiatry, while not completely abandoning its commitment to the institutionalized mentally ill, had expanded its claims of expertise to cover a broad domain beyond the walls of the hospital. Late nineteenth century neurologists had catalyzed this change in psychiatry in several ways. By insisting that psychiatrists adopt a more scientific posture toward their work they had stimulated reforms that allowed the profession to achieve a degree of credibility in the twentieth century. By legitimizing the care of the nervous patient they had opened up a new field into which twentieth century psychiatrists were able to move. By introducing psychological theories and psychological treatments they had given psychiatry the tools it needed to broaden its claims of expertise. In stimulating this broad expansion of psychiatry late nineteenth century neurologists may not have succeeded in demonstrating that it "is no disgrace to be crazy" but they did contribute to the astonishing willingness of twentieth century Americans to see themselves has having psychiatric problems.

1 . Jacques M. Quen, "Asylum Psychiatry, Neurology, Social Work and Mental Hygiene:An Exploratory Study in Interprofessional History," J. Hist Beh.Sci. 13 (1977):3-11 presents a similar argument to that presented in this paper.He adopts a broadly interprofessional focus, while this paper focuses more narrowly on the dynamic influence of the new profession of neurology. 2 .Gerald Grob, Mental Institutions in America: Social Policy to 1875 (New York: The Free Press, 1973). Nancy Tomes, A Generous Confidence: Thomas Story Kirkbride and the art of asylum keeping, 1840-1883, (Cambridge U.K.: Cambridge University Press, 1984). For a discussion of types of medical specialty see; Bonnie Blustein, "New York Neurologists and the Specialization of American Medicine," Bull. Hist. Med. 53, no.2 (Summer 1979): 170-183. Among those early superintendents who wrote on non-asylum related issues were: Isaac Ray, Mental Hygiene (Boston:Ticnor and Fields, 1863); Isaac Ray, A Treatise on Medical Jurisprudence of Insanity (Boston: Charles C. Little and James Brown, 1838); Amariah Brigham, Remarks on the Influence of Mental Cultivation and Mental Excitement Upon Health (Boston : March Capen and Lyon, 1832) 3 . Edward M. Brown,"What Shall We do with the Inebriate: Asylum Treatment and the Disease Concept of Alcoholism in the Late Nineteenth Century," Journal of the History of the Behavioral Sciences,21(1985):48-59. 4 . Russell N. DeJong, A History of American Neurology (New York: Raven Press, 1982), pp.37-41. A. Earl Walker, "The Development of Cerebral Localization in the Nineteenth Century," Bull. Hist. Med. 31, no.2 (March-April 1957): 99-121. Franklin Fearing, Reflex Action: A Study in the History of Physiological Psychology (Cambridge, Mass.: MIT Press, 1970), p.237.S. Weir Mitchell, Injuries of Nerves and Their Consequences (Philadelphia: Lippincott, 1872) 5 .Edward M. Brown, "Neurology and Spiritualism in the 1870s," Bull.Hist.Med. 57,(1983):563-578. 6 .T.H. Weisenberg, "Neurologic Teaching in America," Trans.Sect.Nerv.and Ment. Dis. AMA(1908):11-15.For a discussion of research done by neurologists see: Bonnie Ellen Blustein, Preserve your love for science: life of William A. Hammond (Cambridge U.K.:Cambridge University Press, 1991) . Stephen Young Wilkerson, "Mind Over Body:James Jackson Putnam and the Impact of Neurology on Psychiatry in Late Nineteenth Century America," Unpublished Ph.D.dissertation (1978), Duke University.Sigmund Freud, An Autobiographical Study (New York :W.W.Norton, 1963),p.29. 7 .Kenneth Levin, Freud's Early Psychology of the Neuroses (Pittsburgh: Univeristy of Pittsburgh Press, 1978),pp.16-63.
William B. Carpenter, Principles of Mental Pathology (London:C. Kegan Paul & Co., 1879).Sigmund Freud, The Origins of Psychoanalysis (New York:Basic Books, 1954), pp. 347-446. 8 .Charles Rosenberg, "The Place of George Miller Beard in American Psychiatry," Bull.Hist.Med.36 (1962):245-259. Edward M. Brown, "An American Treatment for the 'American Nervousness': Beard and Rockwell's General Electrization," Presented to the American Association for the History of Medicine, May 1980. 9 .Young amd middle aged men worried especially about developing general paresis or tabes dorsalis both of which were, at the time, fatal and of unknown etiology. George Miller Beard, A Practical Treatise on Nervous Exhaustion (New York: Wm. Wood & Co.,1880)pp.87,115.Barbara Sicherman,"The Uses of a Diagnosis: Doctors,Patients, and Neurasthenia," J.Hist.Med.and All.Sci.32(1977):33-54. 10 .S. Weir Mitchell, "The Evolution of the Rest Treatment," J.Nerv.Ment. Dis. 31(1904):369.Sigmund Freud, The Standard Edition of the Complete Psychological Works,Vol.1 (London: The Hogarth Press, 1966),pp.36,55.Sigmund Freud, The Standard Edition of the Complete Psychological Works, Vol.2 (The Hogarth Press, 1966),p.267.
Charlotte Perkins Gilman, "The Yellow Wallpaper," in The Charlotte Perkins Gilman Reader, ed. Ann J. Lane (New York: Pantheon books, 1980), pp.3-20. 11 .Erwin H. Ackerknecht, A Short History of Psychiatry (New York and London: Hafner Publishing Co., 1968), pp.64-73. 12 .Bonnie Ellen Blustein, "'A Hollow Square of Psychological Science':American Neurologists and Psychiatrists in Conflict," in Madhouses, Mad-Doctors and Madmen, ed. Andrew Scull( Philadelphia: University of Pennsylvania Press, 1981),pp.241-270.Albert Deutsch, "The History of Mental Hygiene," in One Hundred Years of American Psychiatry, ed. J.K. Hall (New York: Columbia University Press, 1944),pp. 325-366. Barbara Sicherman, The Quest for Mental Health in America:1880-1917 (New York:Arno Press,1979) Gerald N.Grob, ed., National Association for the Protection of the Insane and the Prevention of Insanity (New York:Arno Press, 1980),p13. Gerald N.Grob, Mental Illness and American Society, 1875-1940 (Princeton:Princeton University Press,1983) 13 .Charles E. Rosenberg, The Treal of the Assassin Guiteau (Chicago and London: University of Chicago Press,1968), pp.95-97,161-162. 14 .Sicherman, The Quest for Mental Health, pp. 249-256. 15 .William A. Hammond, "The Non-Asylum Treatment of the Insane," Neurologic Contributions 1, no.1 (1879): 1-22. William A. Hammond, "Mysophobia," Neurologic Contributions 1, no.2 (1879): 40-54. 16 .Currently the best introduction the historical study of Hysteria is Mark S. Micale, Approaching Hysteria, Disease and its Interpretations, (Princeton: Princetion University Press, 1995).J.Russell Reynolds, "Hysteria," in A System of Medicine, ed. J. Russell Reynolds (London: MacMillan and Co., 1872)c p. 82. Carroll Smith-Rosenberg, "The Hysterical Woman: Sex Roles and Role Conflict in the Nineteenth Century," Social Research 39 (1972): 652-78. Owsei Temkin, The Falling Sickness (Baltimore and London: The Johns Hopking University Press, 1971), p.352. 17 .Edward Shorter, From Paralysis to Fatigue: A History of Psychosomtic Illness in the Modern Era (New York: The Free Press,1992) pp.166-200.Michael R. Trimble, Post-Tratumatic Neurosis; From Railway Spine to Whiplash (New York: John Wiley and Sons,1981) p.42. Jan Goldstein," The Hysteria Diagnosis and the Politics of Anticlericalism in Late Nineteenth-Century France," Journal of Modern History 54(1982)209-239.Levin, Freud's Early Psychology, p.43. Ilza Veith, Hysteria: The History of a Disease (Chicago and London: University of Chicago Press,1965) pp.228-247.J.M. Charcot and Pierre Marie, "Hysteria Mainly Hystero-Epilepsy," in A Dictionary of Psychological Medicine, Vol. 1, ed. D. Hack Tuke (Philadelphia: P. Blakiston, Son & Co.,1892), p.628l Ola Andersson, Studies in the Prehistory of Psychoanalysis (Stockholm: P.A. Novstedt and Soner,1962) p.38. 18 .Brown, "Neurology and Spiritualism". Henri F. Ellenberger, The Discovery of the Unconscious (New York: Basic Books, 1970), pp.83-101. 19 . J.M. Charcot and Gilles de la Tourette, "Hypnotism in the Hysterical," in A Dictionary of Psychological Medicine, ed. D. Hack Tuke (Philadelphia: P. Blakiston, son & Co., 1892) p.606. 20 .Mark Micale, "Hysteria Male/Hysteria Female: Reflections on Comparative Gender Construction in Nineteenth-Century France and Britain," in Marina Benjamin (ed.) Science and Sensibility: Essays on Gender and Scientific Enquiry, 1780-1945, (London: Basil Blackwell, 1991) Edward M Brown, "Between Cowardice and Insanity:Shell Shock and the Legitimation of the Neuroses in Britain during World War I," in ed. Everett Mendelsohn et al. Science, Technology and the Military, Volume xii/2,(Dortrecht: Kluwer Academic Publishers, 1988),323-345. Andersson, Prehistory, p.39. Sigmund Freud, "Heredity and the Aetiology of the Neuroses (1896)," in Early Psychoanalytic Writings, ed Philip Rief (New York: Collier Books, 1963), pp. 137-50. Jean Martin Charcot, Clinical Lectures on Certain Diseases of the Nervous Stysem, Trans. E.P. Hurd (Detroit: Davis, 1888), pp.100-101. 21 .John Chynoweth Burnham, Psychoanalysis and American Medicine, 1894-1918: Medicine, Science and Culture (New York: International Universities Press, 1967), pp.47-83. Anonymous editorial, "Professor Janet's Visit to Boston and Psychotherapeutics," Bost. Med. Surg. J. 155 (1906):622. E.W.Taylor, "The Attitude of the Medical Profession toward the Psychotherapeutic Movement," Bost. Med. Surg. J. 157 (1907) 845.
22 .Nathan G. Hale, Jr., Freud and the Americans: The Beginnings of Psychoanalysis in the United States (New York: Oxford University Press, 1971) pp.116-150. Morton Prince, Psychotherapy and Multiple Personality: Selected Essays, ed. Nathan G. Hale, Jr.(Cambridge: Harvard University Press, 1975).Otto Marx, "Morton Prince and the Dissociationof a Personality," J. Hist.Beh. Sci. 6 (1970): 120-130. Michael G. Kenny, The Passion of Ansel Bourne: Multiple Personality in American Culture (Washington D.C.:Smithsonian Institution Press,1986), pp.129-160. 23 .Nathan G. Hale, "Introductory essay," in James Jackson Putnam and Psychoanalysis, ed. Nathan G. Hale (Cambridge: Harvard University Press, 1971), pp.1-67.George M. Beard, "The Influence of the Mind in the Causationa and Cure of Disease and the Potency of Expectation," J.Nerv.Ment. Dis. 3(1867):430-1.Russell G. Vasile, James Jackson Putnam:From Neurology to Psychoanalysis (Oceanside, N.Y.: Dabor Science Publications,1977). 24 .Kenneth Dewhurst, Hughlings Jackson on Psychiatry (Oxford: Sanford Publications,1982), p.122.E.Stengel, "Hughlings Jackson's Influence on Psychiatry," Brit.J.Psychiat. 109(1963):348-55. 25 .Wilkerson, "Mind Over Body," pp.233-276. James J. Putnam, "Recent Investigations into the Pathology of So-called Concussion of the Spine," Bost.Med.Surg.J.109 ((1883):217-220. Anonymous Editorial,"Railway Spine," Bost.Med.Surg.J. 109 (1883):400. Burnham, Psychoanalysis and American Medicine, pp.180-3.Edward M. Brown,"Regulating Damage Claims for Emotional Injuries Before the First World War,"Behavioral Sciences and The Law,8(1990):421-434. 26 .Burnham,Psychoanalysis and American Medicine, pp.67-83.Hale, Freud in America, pp.225-50. 27 .Brown, "Neurology and Spiritualism". Pierre Janet, Psychological Healing, Vol.1 (London:George Allen and Unwin, Ltd., 1925), pp 99-109. Elwood Worcester, Samuel McComb and Isador H. Coriat, Religion and Medicine: The Moral Control of Nervous Disorders (New York:Moffat,Yard & Co., 1908). 28 .American Neurological Association, reported in J.Nerv.Ment. Dis. 35(1908): 783. 29 .Burnham, Psychoanalysis and American Medicine, p.79. 30 .American Neurological Association, reported in J.Nerv.Ment. Dis. 35(1908):784. 31 .Francis X. Dercum, Rest suggestion and other Therapeutic Measures in Nervous and Mental Diseases (Philadelphia: P. Blakiston,Son & Co.,1917), pp. 276,353. 32 .Burnham,Psychoanalysis and American Medicine, p.122. 33 .James B. Mackie, "The Journal of Nervous and Mental Diseases: The first 100 Years; III. 1902-1944. The 42 year Editorship of Smith Ely Jelliffe, A Practical Mystic," J.Nerv.Ment. Dis. 159(1974):307.John C.Burnham, "The Founding of the Archives of Neurology and Psychiatry or What was Wrong with the Journal of Nervous and Mental Diseases," J.Hist. Med. 36(1981):310-24. 34 .Sicherman, "The Quest for Mental Health," p.263. 35 .Grob, Mental Illness, pp. 112-18,121,144-178.

An American Treatment for the 'American Nervousness': George Miller Beard and General Electrization

2009-01-01T08:26:00.000-08:00

George Miller Beard won his place in American psychiatry through his promotion of neurasthenia as a nervous disorder. Understood vaguely as an inadequate endowment of nerve force to meet the demands of advanced civilization, this so-called disease was diagnosed in patients with a vast array of complaints including fatigue, “nervousness,” indigestion, headaches, impotence, and neuralgia. Efforts to understand how Beard arrived at this broad conception have focused on cultural and intellectual influences on his career as a neurologist.1 The role of his career as an electrotherapist in defining the concept of neurasthenia has not, however, been emphasized. 2

Beard began his medical career in 1866 as an electrotherapist and it was while developing the method he called “general electrization” that he drew together that vast array of symptoms under the label of neurasthenia. General electrization was, then, instrumental in the development of Beard’s conception of neurasthenia, which as he formulated it was virtually identical with the whole field of functional nervous disorders-- except for hysteria. As such this somatic therpy can be seen as playing a role in deliniating an area of investigation that would later be interpreted psychologically.
The treatment itself, like animal magnetism, involved an elaborate ritual and a belief in a more or less mysterious fluid--in this case electricity. Whele derived from a popular American tradition of electrization, it, like neurastheia, was given an acceptable somatic explanation and became an established component of late nineteenth century neurological practice. In what follwos I will describe the development, contexst and influence of this treatment.
George Miller Beard was born in 1839 in Connecticut, attended Yale, served in a non-specialist medical capacity during the civil war and received his medical degree from Columbia University in 1866. Ambitious, often bombastic and open to unorthodox ideas, he was a controversial figure during his life. Edward Spitzke, a highly regarded German trained neurologist, refered to him as the “P.T. Barnum of medicine” and in 1876 his paper 'The Influence of the Mind in the Causation and Cure of Disease and the Potency of Expectation' was severely criticized by his fellow neurologists.
Beard’s interest in the medical application of electricity began while a student at Yale where he used it to obtain relief from persistent indigestion and nervousness--two complaints for which his patients would later also find it of value. In 1866, just out of medical school, he began a practice of electrotherapeutics with his friend A.D. Rockwell.
Electrotherapy was then undergoing a revival. It had known a great vogue in the late eighteenth century; even Benjamin Franklin had tried it, though without much success. In the early nineteenth century, partly due to an association with animal magnetism and partly due to unreliable techniques, it had fallen into some disrepute and had been practiced largely by popular healers and quacks. Beginning in 1849 in Europe, Duchenne, Remak and a number of other prominent neuroloists had been perfecting a means of applying electric current to neuralgias, paralyses and other local affections. This 'local electrization' allowed for the more precise study of the effects of the electrical current and avoided undesirable systemic effects. it was these developments which had returned the attention of the established medical community to the healing possibilities of electricity and created the revival that Beard and Rockwell joined.
By the civil war this European work had begun to enter the United States. In 1858 Garratt, reporting on travels to the continent, presented these recent developments in an enormous and somewhat forbidding manual. By 1869 there was sufficient interest for William A. Hammond to translate a major German work. Nonetheless in the United States as in Europe popular electrotherapists had continued to practice largely uninfluenced by the work of Duchenne and the others.
One of these was William Miller. A man of seventy at the end of the civil war, he had been practicing electrotherapy for thirty five years. In 1866 he befriended Beard and Rockwell and was under his influence that they began their electrotherapy practice. Called doctor only by courtesy, Miller had developed a thriving practice in New York City. Impressed by his 'evident honesty,' and good results, Beard and Rockwell found him to be a 'thorough master of the method he invariably used.' It is reasonable to assume that they were heavily influenced by him. During the next two years as they developed their method of general electrization they practiced in the same building as Miller and treated a steady stream of patients sent by him.
While we know nothing of Miller’s ideas and little of his practice, other American electrotherapists did publish during the period before the civil war. Common to these writers was an idea of nervous fluid and electricity as virtually identical, both often associated with a principle of vitality. Disease was often seen as due to a lack or disequilibrium of nerve force, and electricity was seen as restoring the healthy state. Since both mesmerism and electrization were regarded by some as due to similar if not identical fluids, it is not surprising to find one author who prescribes them interchangeably and another who bases his electrotherapy practice on a version of animal magnetism known as electrobiology. In any event, the hallmark of pre-civil war practice was the wide variety of conditions to which electricity was applied. Among the conditions for which good results were reported were: paralysis, rheumatism, asthma, indigestion, liver complaints, sciatica, nervous complaints and nervous headaches.
Beard and Rockwell’s general electrization undoubtedly owes something to this earlier electrothrapeutics. In the first place, simply getting referrals from Miller exposed them to the same variety of complaints that Miller treated. In addition, they went “again and again” to study his method. The rationale of their treatment in terms of nerve tonic bears a clear resemblance to earlier notions of the relationship of nerve force, electricity and vitality. The aim of general electrization also resembled the earlier electrotherapeutics rather than the recent European practice. This aim was to “bring every portion of the body under the influence of the electric current.”
The treatment itself involved an elaborate ritual. Patients would come to the doctor’s office for ten to twenty minute sessions. They would sit facing a more or less imposing generator. Both men and women would disrobe except for underclothing which would be loosened in such a way that free access could be had to the entire surface of the body. The cathode was placed under the coccyx or under the feet and the positive pole in the form of a damp sponge or the operator’s hand was moved over the head, neck, shoulders, trunk, extremities and, in the case of impotence, the penis as well. Interestingly, Beard and Rockwell recommended passing the current through the operator;s hand. This though criticized by Garrat, had been Miller’s technique for thirty-five years. As the treatment might be painful and as many of their patients were highly sensitive, having the current pass through the operator’s body allowed for the kind of individualized treatment that Beard and Rockwell regarded as critical. For example, with especially sensitive patients, the treatment might begin with the application of the doctor’s hands but no current at all. This would allow the doctor a palapable reading of the patient’s response to the idea of the treatment. In any event this individualized and highly intimate treatment proceedure, once begun, would be repeated daily or at least every other day for months.
One of Beard’s cases, reported in 1866, three years before he first used the term neurasthenia, will suggest the kind of patient they treated and the way this treatment influenced theirperception of patients:
A pale-lipped, sad-eyed lady came panting into our office and almost fell down in the sette before she could begin to tell her story. So exhausted was she with the exertion of ascending one flight of stairs, that her speech was at first only in broken utterances, and we very naturally surmised that she was laboring under some organic derangement of the heart. But the history of the case seemed to point unmistakably toward anoemia as the prime source of all her unpleasant symptoms. She was troubled with great depression of spirits, Amenorrhea had existed for nine months.
The patient was so hysterical that the first application was given with difficulty. She could endure but the slightest current. Whenever its strength was much increased faintness was at once produced. This extreme susceptibity was, however, speedily overcome, and after the first week, she could bear a current of ordinary severity without the slightest discomfort. Applications were made every other day for a month, at the end of which time the improvement was most satisfactory. The menses returned after seven or eight applications. A few days ago she came briskly up the stairs, and with a light elastic step, and with a smiling rubicund countenance. All her cardiac symptoms had disappeared, her breating was natural, and her whole appearance was that of a person in the hey-day of youthful vigor.
In the late 1860s, while developing general electrization, Beard and Rockwell began a campaign to promote and legitimize the treatment. It was a good time to promote a new treatment such as theirs. Neurology as a medical specialty was being born in America and its practitioners, like Beard and Rockwell, worked not in asylums but in private ofices among the urban “comfortable classes.” Here they saw, and were to a certain extent in competition for, patients with vague and often chronic complaints of the sort that general electrization was designed to treat. That there was a need to legitimize the treatment can be seen in the fact that Rockwell was refused an opportunity to address the New York Medical Society on the grounds that electrotherapy was advocated only by quacks.
Beard and Rockwell pursued this campaign in a series of papers some of which were republished as a book and then expanded into the impressive looking Practical Treatise on the Medical and Surgical Uses of Electricity. With some lack of gratitude their first objective was to distinguish themselves from such irregular parctitioners as Miller. In these papers Miller is referred to with respect, but only incidentally. Of other American electrotherapists they wrote:
In our country at least the practical applications of this agent [electricity] has fallen into the hands of uneducated and unscrupulous practitioners who know little of the human sysyem and still less of the agent they employ. Empirics and charalatans versed in no art except that of robbing the unfortunate have thus far had the field mostly to themselves…
Garratt, whose cautious and practical book had reported on twenty years of experience as well as introducing European work, was dismissed as 'verbose and mystic.' Such rhetorical excess must have been intended to convince their readers that they were rescuing the field for scientific medicine.
An equally important objective of this campaign was to identify themselves with the European tradition associated with Duchenne and Remak, while claiming their own work as a genuine innovation. The very name of their treatment, general electrization, would have called to mind Duchenne’s local electrization. Comparing the tow they wrote that, “ While it is true, as is commonly supposed that galvanism and faradization are specially indicated in certain forms of paralysis it is also true that they are still morevaluable in general nervous debility whether it manifests itself in the shape of dyspepsia, chorea, neuralgia, anemia or amenorrhea.” In another place they add that parealysis is among the “least tractible of the various diseases that present for…” electrization. At the same time they promoted their discovery that electrization, used generally, “is a tonic of vast and varied powers.” Others had failed to perceive this tonic property of the curent because they had either applied it only locally or had failed to persist in its application in the face of discouragement. Readers were, it seems, to see their treatment as a logical thouugh original extension of accepted electrotherapeutic practice.
In 1869 Beard published 'Neurasthenia or Nervous Exhaustion' in the Boston Medical and Surgical Journal. While this paper is well known as his first use of a term which would have wide influence on late nineteenth century neurology, it can be seen in the context of his career as an electrotherapist as his most effective effort to popularize and legitimize his treatment. He indicated here that his “atention was first drawn to this morbid condition quite early in [his] professional life in the cultivation of the department of neurology and electrotherapeutics…” Although the expressed intent of this paper was merely to coin a name for a commonly observed phenomenon, what it did in effect was to attribute the array of symptoms for which general electrization worked so well to a single neurological disease-- neurasthenia. Much of the paper was devoted to praising the treatment and it recorded that twenty out of thirty of
Beard’s neurasthenics were either cured or much improved by it. As a disease due to a want of nerve force neurasthenia was suitabley treated by nerve tonics and Beard concluded that, among those tonics, general electrization was “preeminent.” For Beard as an electrotherapist this identification of his treatment with such a disease could only have helped distinguish him from empirics and charalatans.
During the next few years Beard and Rockwell changed the name of their original proceedure, which involved induced current, to general faradization. They also developed a new proceedure, central galvanization, in which direct current was applied primarily to the head and spine. Beard increasingly identified with the rising specialty of neurology; he sold his share of their electrotherapy treatise to Rockwell and devoted his energies to writing about neurasthenia, or as he came to call it the “American Nervousness.” As a neurologist he continued to use general electrization and to encourage others to do so. It becam, however, only one of many treatments in a complicated gegimen and this has tended to obscure its unique role in the deliniation of the concept of neurasthenia.
The reaction to general electrization itself was ambivalent, though most of the negative reaction appears to have been to Beard and Rockwell’s style, rather than to the treatment itself. A review in 1868 suggestd that Beard and Rockwell had been less than scientific, doubted that their claims were warranted and referred the reader to a translation of a French report in the same issue. That some change in attitude may have occured is suggested by the fact that Rockwell, though interestingly not Beard, was a charter member of the American Neurological Association and presented a paper on electrization at its first meeting 1875. What influence their Practical Treatise, which appeared in 1871, had on this is hard to say. Certainly its form resempled European treatises, even if it continued to be, in large measure, an advertisement for their version of electrization. Nonetheless it was translated into German and ten additions appeared over the next forty years. In 1876 the Journal of Nervous and Mental Diseases, the official journal of the American Neurological Association, devoted a long review to the second edition of ther treatise. It did not question the rationale, method or results of the treatment, though it did look askance at the authors denigration of experimental science and worried that their enthusiastic promotion of electrotherapy might lead to sectarianism
In germany personal reactions to the authors were apparently less important. Fischer reported good results with their method and maintained that constitutional illnesses like 'nervous dyspepsia, neurasthenia, anemia, chlorosis, hypochondria and hysteria' should be treated with general electrization while local diseases werre indications for local electrical treatment. Erb, in a text that Freud among others used, credits Beard and Rockwell with the development of general electrization and notes that he also got good results with it.
The reaction of patients is more difficult to determine except through the fact that the treatment remained popular for many years. One case cited by Beard does suggest the role that belief in the tonic properties of electricity as well as his charisma played in the treatment.

The patient was a twenty-nine year old physician who was chronically underweight and suffered and sick headaches, fatigue, poor appetite. After the first treatment he felt temporarily enlivened and exhilarated… returning after two days he felt no special benefit, but had gained one half pound. This change, however slight as it was, encouraged him. He watched and studied his symptoms, and carefully ascertained his weight from day to day, not as a hypochondriac at all, but as a scientific man, inspired not by any special faith in the remedy but by a desire to test for himself the tonic effects of general electrization. He continued to gain weight…The improvement in his general condition has gone hand in hand with [this].

Whatever the reaction to Beard and Rockwell’s often bombastic style the treatment became standard for functional nervous disorders. This is not surprising in that they had effectively camoflaged any associations between their treatment and early nineteenth century electrotherapeutics and, in presenting the treatment as a nerve tonic had used a somatic vocabulary acceptable to doctors and patients. In addition it is reasonable to assume that general electrization was helpful to many nervous patients. One sign of the treatment’s acceptance was its role in S. Weir Mitchell’s rest cure. In 1876 Mitchell gave as the pillars of his treatment isolation from family, strict bed rest, overfeeding, massage and electrization. He cited Beard and Rockwell and considered electrization a tonic--albeit for muscles. As a component of the rest cure general electrization was assured an even wider acceptance, though not as the preminent treatment for neurasthenia that Beard had once claimed it to be.
Serious doubts about electrization did not begin to appear until the 1890s. After Beard’s death in 1883, Rockwell continued reediting and republishing their treatise until 1903, maintaining throughout that electrization worked as a tonic. Moses Allen Starr, a somatically oriented neurologist, did not question the rationale of the treatment but in 1892 reported that he found its results disappointing. In 1889 Moebius in Germany wondered if the success of electrotherapeutics was due to ‘’suggestion’’ initiated by the elaborate apparatus, the mysterious nature of the treatment and the stimulation of the faith of the patient. In 1895 Freud referred to electrization as a 'pretense treatment' and gave a perceptive psychological rendering of Elizabeth von R’s response saying that she 'took a liking to the painful shocks' and that 'the stronger these were the more they seemed to push her own pains into the background.' Even J.J. Putnam, who had been critical of Beard’s psychological approach in 1876, wondered if electrization, whil still useful in treating neurasthenia, didn’t act by suggestion.
General electrization then, only began to lose ground with the somatic model which had supported it. It survived into the twentieth century only where the somatic approach to functional nervous disorders persisted and cannot be seen as a forerunner to any psychotherapy. Nonetheless during its brief preeminence as a nerve tonic it focused George Miller Beard’s attention on that cluster of symptoms that he called neurasthenia. In doing so, like animal magnetism, it pointed to an area of investigation which would be interpreted psychologically.

Presented to the American Association of the History of Medicine, Boston 1980

Review: Madness, Religion and the State in Early Modern Europe: A Bavarian Beacon, by Mark Lederer. New York: Cambridge University Press, 2006.

2009-01-01T08:06:00.001-08:00

Students of the history of psychiatry have usually been uncomfortable writing about the early modern period because the categories used to describe mental states were often religious rather than secular and scientific. This has, David Lederer suggests, left the false impression of a radical disjunction between medieval and modern ideas about madness. Describing what he calls "spiritual physick," Lederer shows that while ideas and practices in the sixteenth and seventeenth centuries were certainly very different from ours, one can see them evolve, if one looks closely enough.
This book started as an effort to reconstruct the operations of cult shrines in the Duchy of Bavaria dedicated to the treatment of madness. Using the manuscript miracle books from two shrines, Lederer has mined biographical information about sufferers, including symptoms, attempted cures and votive offerings. Lederer uses this material to demonstrate how early modern people thought, not only about why they were suffering but also what they needed to do to obtain relief. He shows, for example, how people sought relief for a patient's suffering by promising to make a pilgrimage.
In addition to describing the operations of these shrines, the book also provides a broader view of "spiritual physick" in society. Because he focuses on a particular time and place, he is able to present a complex description of the relations between church, state and popular beliefs. During this period, he notes, Europeans perceived themselves to be in the midst of both a material and spiritual crisis. Among the responses to this, aimed at uniting society, Bavarian authorities proselytized for the use of confession and even criminalized noncompliance with a yearly requirement. Requirements like this meant that "religion and government interwove into the same coarse sackcloth [57]." Despite the repressive motives of secular authorities confession achieved huge popularity through its consoling function.
In the seventeenth century the pendulum swung and authorities sought to secularize responses to madness. Again Lederer's focus on a particular locale allows him to show that this was not a simple process. In Bavaria, with increased secular authority over the regional church, religious explanations for psychic suffering fell under attack. Ironically, in responses to possession and exorcism, moderate clergy played a significant role in this, not by challenging the epistemological framework that allowed for the possibility of demonic intervention, but by arguing legalistically for other possibilities, such as insanity. The efforts of secular authorities to develop uniform procedures for burials ran into considerable popular opposition because of profound religious concerns about burying suicides in hallowed ground. By contrast the general population, while still holding religious views of madness, were quite willing to avail themselves of government efforts at institutional confinement, when it allowed them to avoid the burdens of home care.
Lederer's tightly focused account succeeds admirably in conveying the complex evolution of the care of the mentally ill in a particular time and place. I would only warn more "general readers" that some background in European history of the period is needed to put this account in context.

Edward M. Brown, Brown University, Providence RI

Review: Allan Young. The Harmony of Illusions:Inventing Post-Traumatic Stress Disorder. Princeton, NJ: Princeton University Press, 1997 (first paper

2009-01-01T07:16:00.000-08:00

The concept of psychological trauma arose in the nineteenth century in the context of litigation over railway accidents. In the twentieth century its history has been tied to wars and more recently to concern over sexual abuse. Throughout, the interests of various groups in issues of responsibility, compensation and punishment have made thinking clearly about psychological trauma difficult. Since 1980, however, when the American Psychiatric Association formally included the diagnosis of Post-Traumatic Stress Disorder (PTSD) in the third edition of its Diagnostic and Statistical Manual (DSM-III), the notion that psychological trauma is caused by memories has acheived the status of fact. In the spirit of Ludwig Fleck, Allan Young’s valuable book attempts to trace the perceived timelessness of this fact to a “harmony of illusions.”
Young is an anthropologist and the core of this book is the field work he did in 1986-7 at a U.S. Veterans Administration unit for the diagnosis and treatment of Viet Nam veterans suffering from PTSD.The book is divided into three sections; the first two discuss aspects of the history of the concept of psychological trauma and the third is devoted to Young’s anthropological work. A lot of recent psychiatric research and treatment has been staked on the view that memories of trauma cause symptoms and that remembering heals. Each section of this book takes aim at this proposition from a different vantage point. Young’s fundamental concern is with the difficulty knowing, in an particular case, whether there is a causal link between the memory of a “traumatic” event and an individual’s current symptoms, or whether this link has been constructed after the fact to make narrative sense of troubling and mysterious symptoms.
The first chapter is devoted to retelling the history of the concept of psychological trauma in the nineteenth century. Young argues that while some nineteenth century ideas about psychological trauma gave memory an important role, others did not. In the second chapter he reinterprets the career of the anthropologist and neurologist W.H.R.Rivers, who has served several recent authors as an emblem of enlightenend treatment of shell shock during World War I. By a close reading of Rivers he shows that Rivers believed “that, in most cases, it is not the traumatic memory that produces the physical and emotional symptoms of the war neuroses…but rather the reverse: the symptoms account for the memory.” (p.83)
The second section of the book traces the development of DSM-III and the construction of the diagnosis of PTSD. Intruigingly, Young points out that while the authors of DSM-III were determined to root out all causal attributions in its classification scheme, the diagnosis of PTSD managed to have a causal theory central to its definition. The story of the political and socal forces that resulted in this anomaly is a fascinating one.
In the third section of the book Young describes the unit for the diagnosis and treatment of PTSD where he did his field work. He demonstrates how institutional and personal motives drive and sustain a particular understanding of a set of psychiatric symptoms. His demonstration, through transcripts of therapy sessions, of how “ideology,” or the theories of therapists shape the meaning given to the thoughts and actions of participants in therapy is particularly valuable.
Young does not discuss sexual abuse or the debate about false memories. While this is a loss, it does allow him to keep his focus on the more fundamental questions of the construction of diagnoses and the uses of casual attributions. This is a book that should be read by anyone interested in the history of psychiatry as well as those interested in the cultural history of the United States.

reviewed by Edward M. Brown M.D., Clinical Associate Professor of Psychiatry, Brown University

Review: Nancy Tomes, A Generous Confidence: Thomas Story Kirkbride and the Art of Asylum-Keeping, 1840-1883

2009-01-01T07:14:00.000-08:00

Writing about the history of psychiatry has often resembled a battle of ideologies. While early historians of the field were content to trace the advance of science and civilization in the treatment of the menally ill, revisionists, who have seen psychiatry as a nexus of social, political and economic issues, attempted to turn these earlier ' whig' interpretations on their head. Michel Foucault, perhaps the most prominent revisionist, candidly expressed his motives for entering into the fray: For me, it was a matter of this: if, concerning a science like theoretical physics or organic chemistry one poses the problem of its relations with the political and economic structures of society, isn't one posing an excessively complicated question" Doesn't it set the threshold of possible explanations impossimbly high? But on the
other hand, if one takes a form of knowledge [savoir] like psychiatry, won't the
question be much easier to relolve, since the epistemological profile of psychiatry
is a low one and psychiatric practice is inked with a whole range of institutions,
economic requirements and political issues of social regulation? Couldn't the
interweaving of the effects of poewr and knowledge be grasped with greater certainty
in the case of a science as 'dubious' as psychiatry.* Animated by views such as this, revisionists fashioned an image of psychiatry which focused on the relationship of psychiatry to society-at-large and emphasized its social control functions over its therapeutic pretentions.
At one time, anyone attempting to write about the history of psychiatry was tempted to be drawn into the battle between the whigs and the revisionists. As Nancy Tomes wisely noted at the beginning of her book, however, both of these views tend to reduce psychiatry to one sterotype or another. What was missing from both whig and revisionist interpretations was a careful study of the daily practice of psychiatry and not simply what the published record showed that psychiatrists and others may have said. It was precisely Professor Tomes' intellient effort to look at the daily life of psychiatrists and patients at the Pennsylvania Hospital for the Insane during the nineteenth century that made A Generous Confidence one of the most enriching works in the history of psychiatry at the time it was published. Many books have since been published in a similar spirit, but Tomes' book was certainly one of those that pointed the way.
By taking a close look at the life of Thomas Story Kirkbride, who was the superintendent of the Pennsylvania Hospital for the Insane from its founding in 1841 until his death in 1883, she was able to open a window on the treatment of the mentally ill which made simple stereotypes more difficult to maintain. In doing this she was fortunate that the records of the hospital were unusually well preserved, but her resourcefulness in using these records cannot be overstated.
We are also fortunate that in choosing to write about Kirkbride, Tomes selected one of the most influential American psychiatrists of the period. This choice allows a study of one man and his institution to reflect, quite convincingly, the rise and decline of asylum treatment of the insane. In addition to managing his asylum, Kirkbride was also a founder and leading member of the Association of American Superintendents of Asylums for the Insane [the forerunner of the American Psychiatric Association]. His writings about asylum architecture were highly influential in an ear that took the moral influences of asylum design very seriously. His biography is also of interest because, as a leading advocate of 'moral treatment' who remained professionally active into the 1880s, he lived to see and struggle against the severe criticism which this treatment received in the 1870s. Because of Tomes' approach, however, the reader is not only able to form a picture of the controversies which swirled around asylum practice but also of tensions within the asylum. Especially interesting are her discussions of the various ways patients resisted Kirkbride's efforts and her portrayals of particular patients such as Wiley Williams, who shot kirkbride in the head, and Ebenezer Haskell, who made a cause celebre of his contention that he had been unjustly committed.
Perhaps the most interesting feature of this book is Tomes'' discussion of Kirkbride's efforts to 'cultivate his patron's generous confidence' in asylum treatment. Arguing that the rise of the asylum corresponded with changes in families' willingness and ability to care for disturbed members, Tomes overcomes the dichotomy between views of the asylum as merely controlling disturbed members of society or simply providing care for patients. Families wanted both control and care for their relatives and Kirkbride attempted to convince them, in both his rhetoric and his practice, that his institution would provide them with what they wanted. Particularly illuminating in this regard is Tomes' discussion of Kirkbride's preoccupation with architectural details. while previous historians wrote off such preoccupations as reflecting merely managerial concerns, Tomes shows, quite convincingly, that Kirkbride was able to use his descriptions of thephysical structure of the asylum to convince families that it was an institution that they could trust. Through her use of asylum records and letters, she is also able to show that Kirkbride's practice was often quite effective in restoring patients to health. Tomes' ability to convey how it was that moral treatment healed is a particularly rewarding feature of this book.
Well indexed and annotated and complete with helpful photographs and an appendix with a statistical profile of the asylum, this is an eminently readable book. More than that it is a book which has been important in helping us transcend earlier battle lines and arrive at a more accurate picture of asylum treatment in the nineteenth century.
This is a revision of a review originally written in 1985. Edward M. Brown *Michel Foucault, Power/knowledge: Selected Interviews and other Writings 1972-1977,
edited by Colin Gordon [New York, 1980, p 108

Review: Healing the mind: A history of psychiatry from antiquity to the present, Michael H. Stone, (New York, W.W. Norton, 1997)

2009-01-01T07:12:00.000-08:00

As someone who teaches the history of psychiatry to psychiatric residents, I have long hoped to find a single textbook to spare me the chore of putting together a syllabus each year. Given the the tremendous explosion in historical studies of psychaiatry over the last thirty years, however, it has seemed unlikely that anyone would be able to produce a comprehensive and accessible history to replace Zilboorg’s History of Medical Psychology. It was, as a result, with skepticism as well as hope that I turned to Michael Stone’s Healing the Mind .

The book is well designed and will be useful to some psychiatrists. It contains many short sketches of great and not so great contributors to the field. These are clearly written and the name of each individual is printed in a wide margin alongside the sketch. If you are curious about Friedrich Scheidemantel, Henrik Sjöbring or Sacha Nacht, you will find them along, of course, with Freud and Pinel. One of the nicest features of this book is that it has numerous small pictures of the people mentioned in the text as well as classic pictures of patients. Psychiatrists lecturing on their research will find this book useful in providing material about early workers in their field as well as material for entertaining slides.
Unfortunately it will not be very useful in teaching history to young psychiatrists. While the subtitle of the book “A History of Psychiatry from Antiquity to the Present” leads one to expect a broad survey, more than half of its 435 pages are devoted to the period after nineteen-sixty. As a result the first half of the book is quite sketchy while the second half reads like a series of literature reviews. More serious, however, is the fact that Stone seems unaware that there there has been and continues to be a lively debate about how to interpret psychiatry’s history. While the book has a thirty-two page bibliography, works by Michel Foucault, Roy Porter, Jan Goldstein, Elaine Showalter and John Burnham are not included. This is not to suggest that this book does not rely on secondary sources. Indeed there are so many refernces to Zilboorg, Alexander and Selesnick and Hunter and Macalpine that these are referred to simply as “Z.,” “A.&S.” and “H.& M.”
There is constant tension in teaching history to young psychiatrists between their desire to translate everything historical into familiar terms and the importance of showing them that studying history can help them acheive a critical distance from which to reflect on their work. In this regard Stone’s book clearly leans toward showing how the remote or strange can be understood in terms of the familiar. Expressions such as “ an example of self-mutilation still viewed as demonic possession,” or “this view comes closer to our modern conceptions,” jump out irritatingly from too many pages.
Because psychiatry has, as Michel Foucault once said, a “low epistemological profile,” it has provided a particularly good opportunity for historians to demonstrate how social, economic and political forces influence theories and practice. Stone is not interested in this angle of vision. His book does not shed much light on the growth of psychiatric institutions or their place in society. This is a book about psychiatrists and their ideas. Unfortunately it is not a very searching or critical one. His discussion of DSM III, for example, gives the reader no idea of the controversies that surrounded this fundamental change in psychiatric thinking about diagnosis.
Psychiatrist will be able to use this book as a reference in certain limited circmstances, but they won’t learn much about the scholarship that has made the history of psychiatry such a rich field of study.

reviewed by Edward M. Brown
Journal of the History of the Behavioral Sciences, Volume: 34, Issue: 4, Date: Autumn(Fall) 1998, Pages: 391-392

Review: Jean-Charles Sournia, A History of Alcoholism, Oxford, Basil Blackwell, 1990, 8vo, pp. xix, 232, illus., L 25,00.

2009-01-01T07:10:00.001-08:00

Jean-Charles Sournia is both an eminent French historian and Vice President of the French Government's Commission on Alcohol. A history of alcoholism is the English translation of his ambitious attempt to chronicle how attitudes toward the excessive consumption of alcohol have changed through time. Both the structure of this book and its point of view reflect the author's dual perspective. While the first two sections of the book present a more or less narrative account of the history of the subject up to 1950, the third section largely an explication of enlightened late twentieth century views. Sournia is well aware of the limitations of these views. Nonetheless he writes both as an historian and as an advocate of what he regards as humane non-judgmental contemporary approaches to the problems of excessive drinking.
A history of alcoholism is inevitably a history of the shifting boundary between moral and medical or scientific attitudes toward excessive drinking. As Roy Porter comments in his introduction to Sournia's book, many recent historians have adopted a skeptical and even hostile stance toward the motives behind efforts at "medicalization." Sournia does not engage in this kind of analysis. His book is not, however, an argument for the power of medicine either.While Sournia accepts the idea that alcoholism is a disease, he insists that it is not a "disease like any other." Had it been, he argues, Western society might have come to terms with it. Sournia does accept the popular contemporary view of alcoholism as complex bio-psycho-social problem. This vantage point has the virtue of allowing him to see medical history against the background of the social, economic and political factors involved in controlling the production and consumption of alcohol.
The first section of the book covers the nineteen centuries before 1850. While necessarily sketchy, it is broad in scope. Among many other things, Sournia briefly mentions a number of drink-related incidents in the Bible, pauses to speculate on the role of alcohol in the death of Alexander the Great, sketches the spread of distilled drinks through Europe, and indicates the views of early medical writers such as Rush and Trotter. If a theme ties this overview together it is Sournia's observation of the limited role medical thought played in early approaches to excessive drinking.
In his second section Sournia looks much more closely at the period from 1850 to 1950. He begins with a chapter on Magnus Huss, who coined the word alcoholism in 1849 and whose work ushered in the era of intensive medical scrutiny of excessive drinking. Following this he wisely chooses to treat the complex ideas and events of the period both thematically and chronologically with separate chapters on drinking habits, medical ideas, temperance efforts and the interaction between late nineteenth century medical thought and the tremendous anxiety that was felt over the role of alcohol in corrupting Western society.
The final section of his book is devoted to recent efforts to acheive an adequate understanding of and treatment for alcoholism. Here his book reads, at times, less like history and more like a review of the literature on enlightened approaches to the many problems created by alcohol. His review of late twentieth century views is judicious and balanced though some doctors might take issue with him on certain points. American readers might also feel that he doesn't give sufficient credit to the tremendous impact of self help groups such as Alcoholics Anonymous.
Sournia's ability to cover a great span of time coherently and lucidly, as well as to consider variations between different countries and religions is truly remarkable. Because of its comprehensive scope and attention to detail this book will serve as a useful orienting reference for those planning to make more detailed studies in the history of alcoholism. As a French historian he understandably pays more attention to his own country than to others, but this should be a benefit to readers of this English translation. While his identification with the currently popular bio-psycho-social point of view leads him to make a number of unhistorical judgments as, for example, when he dismisses nineteenth century biological theories as "simplistic," it also allows him to insist on the complexity of the unsolved problem of excessive drinking. Overall the combination of Sournia's commitment to humane, non-judgmental approaches to alcohol related problems with his scholarly, lucid, and well translated, prose make this a book well worth reading.
Edward M. Brown
Brown University, Providence R.I.

Review: Ben Shephard, A War of Nerves: Soldiers and Psychiatrists in the Twentieth Century, [Harvard University Press, 2001]

2009-01-01T07:07:00.001-08:00

During the 1970s American lobbying by psychiatrists and veterans succeeded in elevating Post Traumatic Stress Disorder to the status of a category in the DSM III. Efforts on the part of advocates for abused women and children have further established PTSD in our minds as a timeless phenomenon. Research over the last twenty years has buttressed this view with reams of biological data. However, in spite of these recent events, at least one important historical question remains. Why has psychological trauma, as a medical problem, been discovered, disappeared from sight, and then been rediscovered, several times?
Some, like Judith Herman in her book Trauma and Recovery, have argued that this periodic disappearance phenomenon of trauma has been due to willful forgetting-- a repression of the phenomenon analogous to the repression some think of as a part of it. It has been hard to adequately challenge simplistic, tendentious and mythic interpretations such as Herman’s because of the scope and complexity of the history of traumatic phenomena over the last century.
Ben Shephard’s A War of Nerves: soldiers and Psychiatrists in the Twentieth Century succeeds admirably, however, in doing just this. Shephard maintains his focus by limiting his story largely to the Anglo-American military from World War I through Vietnam. He has little to say about France or the Soviet Union, but his chapters on German war experience are among the most interesting in the book.
Shephard sets out to counter what he calls the “bipolar” view that emphasizes William Rivers work during World War I and the emergence of PTSD during Viet Nam but ignores the “important historical fact that the problem of war neurosis was comparitively well handled during the Second World War.” Llooking beyond case histories, Shephard tries to consider the multiple ways soldiers and psychiatrists have responded to the stresses of war in the twentieth century. Indeed the subtitle of his book aptly emphasizes the struggle of individuals rather than the visissitudes of an abstract diagnostic category.
As a journalist Shephard has a wonderful eye for detail. The numerous anecdotes about individual soldiers and psychiatrists enliven the narrative considerably. While he is always sensitive to the moral contradictions involved in treating soldiers in order to send them back to war, he balances this with his acknowledgment of the legitimacy of concerns about maintaining manpower on the front lines. He is also well aware of the irony that while treatment has sometimes increased disability, the threat of punishment has at times helped soldiers get over their symptoms.
Because Shephard narrative is so rich his argument is hard to reduce to a simple statement. What he clearly recognizes is that damage claims can be exaggerated and fabricated as well as minimized and denied. For those who want to consider the complex history of psychological trauma in the twentieth century this book is a great place to start.

Edward M. Brown

Review: Jack D Pressman, Last resort: psychosurgery and the limits of medicine, Cambridge History of Medicine series, Cambridge University Press, 1998

2009-01-01T07:04:00.001-08:00

With the introduction of chlorpromazine in 1954, the reputation of lobotomy as a psychiatric treatment plummeted, becoming, by the time of the film One Flew Over the Cuckoo’s Nest, a symbol of psychiatric barbarity. In seriously attempting to put the history of this recently failed treatment, as opposed to a more remote example such as bloodletting, in its social as well as medical context, the late Jack Pressman took the risk of being called an apologist for psychiatry’s abuses. He has however, wonderfully avoided both bashing psychiatry and whitewashing the historical record by writing both “an intensive case study of the rise and fall of” of a treatment and “an extended musing on how we tell our stories of triumph and failure in science.”

One could give numerous examples of Pressman’s “musings on how we tell our stories.” Consider for one the priority dispute between John Fulton, the influential Yale physiologist, who claimed that his work on lobotomies on chimpanzees critically influenced Egas Moniz, the Portuguese neurologist, who won the Nobel Prize in 1949 for introducing lobotomy as a treatment for psychiatric patients. For Pressman the story of this priority dispute emphasizes a traditional narrative of scientific discovery. Pressman accepts the view that Fulton did not deserve recognition for priority. What makes his chapter on priority interesting, however, is that Pressman retells the story to show how Fulton’s insistence on the importance of his work on chimpanzees contributed enormously to legitimizing lobotomy by giving the procedure a veneer of scientific credibility as well as the imprimatur of Yale science.
Many of the chapters in this book attempt similar reworkings of accepted versions of the lobotomy story. Perhaps the most significant of these is Pressman’s detailed study of the records of patients who underwent lobotomies at McLean Hospital in Massachusetts. Since I was familiar with the story of Walter Freeman taking an ice pick to the brains of many indigent patients in state hospitals, reading Pressman’s account of thoughtful psychiatrists deciding which affluent patients in this elite hospital would receive the benefit of lobotomy made it easier to see a parallel between the practice of lobotomy and the treatment of severely ill psychiatric patients in the 1990s. Far from whitewashing lobotomy, Pressman’s approach provided an historical lens through which to see my own work more critically.
In addition to reconstructing clinical decision making practices at a single hospital, Pressman also puts the lobotomy story in the context of the evolution of the treatment of severely mentally ill patients in the United States in the twentieth century. One limitation of this is that he has nothing to say about treatment in other countries. Limiting himself to one national context is, however, a wise choice because it allows him to demonstrate social and intellectual synergies that otherwise would have gotten blurred. Of particular interest is his demonstration of how Adolf Meyer’s notion of psychobiology, the most influential psychiatric philosophy in the United States in the first half of this century, provided an intellectual rationale for the practice of lobotomy. Given psychobiology’s previous reputation as providing fertile soil for the growth of psychoanalysis, Pressman’s observation of its role in supporting the ultimate biological treatment gives the reader a new understanding of just how eclectic psychiatry was in the mid-twentieth century.
Last Resort is a fine book that deserves a wide readership. Unfortunately the author’s penchant for repeating his arguments again and again makes the book longer than it needed to be and will probably put off one group who would benefit from reading it--clinical psychiatrists. For historians, however, it is, as the author hoped it would be, both a detailed case study and a fascinating musing on how we tell stories.
Gerald Grob’s introduction spells out how much we have lost by the untimely death of this talented historian.

reviewed by Edward M. Brown, History of Medicine,

Review: Harry Oosterhuis, Stepchildren of Nature: Krafft-Ebing, Psychiatry and the Making of Sexual Identity, [University of Chicago Press, 2000]

2009-01-01T07:01:00.000-08:00

Most English speakers know little about the Viennese psychiatrist Richard von Krafft-Ebing [1840-1902] beyond the facts that he was the author of Psychopathia sexualis and one of the founders of scientific sexology, who coined such words as sadism and masochism. Most often he is treated as a footnote in the history of psychoanalysis.
Harry Oosterhuis’s profound reading of published as well as unpublished sources does more than establish Krafft-Ebing’s place in the evolution of twentieth century ideas about sexual identity. It also provides a cogent and convincing alternative to Foucault’s view that concepts of sexual identity were simply imposed by doctors ‘from the top down.’ While Krafft-Ebing was a great classifier, he didn’t simply reduce his patient’s lives to symptomatic expressions of pathology.
Oosterhuis begins with the simple observation that Krafft-Ebing often quotes his patients directly and at length and that even when not directly quoting them, he still manages to give voice to their view of their distress. While Krafft-Ebing was certainly a psychiatrist of his times in his views about the role of heredity in sexual deviance, Oosterhuis makes it clear that he also listened closely to his patients and was influenced by their opinions.
In doing so Krafft-Ebing participated in transformation of attitudes about sexuality. In the early nineteenth century what mattered about sexuality was whether it contributed to reproduction. By the end of that century what mattered was a person’s sexual experience and identity. Not only did homosexuality become a category opposed to heterosexuality, but heterosexuality became more that having babies. It came to mean having sexual pleasure with a person of the opposite sex.
Because homosexual acts were illegal in Austria, Krafft-Ebing first became involved with cases of sexual deviance through his forensic work, where he examined many working class offenders. Acheiving some fame, he opened a private practice and began to see individuals from his own social background for consultations. Confronted with these patients, in a voluntary, private setting, Krafft-Ebing, like others in the history of psychiatry, could not help but recognize something of their humanity. Because his hereditarian theory provided no way for him to think about these people, he published their stories more or less as told to him.
Some of these patients insisted that they did not suffer from an illness, that they were perfectly happy and that their only problem was legal persecution. Others wrote to him saying that they had found it very helpful to read the stories published in his book, that they could see themselves in his case histories. Through Oosterhuis’ eyes, Psychopathia sexualis, begins to seem like a nineteenth century chat room, a space where anonymous discourse allows for the shaping of new identities.
All of this, as Oosterhuis makes clear, simply does not fit the model of the medicalization of sexual deviance given to us by Michel Foucault. In Krafft-Ebing’s work one can begin to see a negotiation between psychiatrists and patients about the scope and meaning of classificatory systems.
This vision of the negotiation of diagnostic catagories between psychiatrists and patients represents a profound revision of one of the principles that has influenced the history of psychiatry over the last thirty years. As such Oosterhuis’s meditation on the life and and work of Richard von Krafft-Ebing has broad significance and deserves a wide readership.

Edward M. Brown

Review: Motherless Brooklyn, Jonathan Lethem, [Vintage Books, 1999]

2009-01-01T06:59:00.001-08:00

Ever since Emile Zola wrote about the Rougon-Macquart family in the late nineteenth century novelists have used psychiatric ideas to give their works greater verisimilitude. The twentieth century was indeed awash with the influence of psychoanalysis. Now that Freud has been succeeded by the neo-Kraeplinians it appears that a new kind of psychiatrically inspired character has been born.
In Motherless Brooklyn, a spoof of a hard-boiled crime story, the narrator-detective suffers from Tourette’s syndrome. This provides the author, Jonathan Lethem, with an opportunity to engage some wonderful word-play. On being introduced to a hoodlum named Matricardi, for example, the narrator says, “I thought mister catch your body mixture bath retardy whistlecop’s birthday and didn’t dare open my mouth.” There are a lot of italics in this novel. Beyond this the narrator-detective’s ticcing and swearing allows him to acheive a valuable degree of invisibility because so many other characters think that because he is obviously crazy he must be stupid too.
Lethem also tries to use Tourette’s as a metaphor, writing, for example. “Conspiracies are a version of Tourette’s syndrome, the making and tracing of unexpected connections of a kind of touchiness, and an expression of the yearning to touch the world, kiss it all over with theories, pull it close. Like Tourette’s, all conspiracies are ultimately solipsistic, sufferer or conspirator or theorist overrating his centrality and forever rehearsing a traumatic delight in reaction, attachment and causality, in roads out from the Rome of the self.”
While this is a very entertaining novel, the ticcing of the narrator seems nothing more than a device for allowing the author some literary room to play. The narrator learns about his disorder casually, when someone hands him a book on the subject. Throughout, however, he speaks as an expert on Tourette’s. He speaks about himself as if he were presenting a case history. The acknowledgement to the books of Oliver Sacks seems appropriate, though Sacks writes about his characters with more compassion.
Is this the legacy of neo-Kraeplinian psychiatry to literature. It’s enough to make one nostalgic for the pat symbolism of psychoanalytically inspired fiction.

Edward M. Brown

Review: Adam Haslett, You Are Not A Stranger Here, [Doubleday, New York, 2002]

2009-01-01T06:55:00.000-08:00

As reviewers of Adam Haslett's collection of nine short stories have repeatedly noted these stories are beautifuly, masterfully written. I am mentioning them on this page because they are also important stories for psychiatrists to read. Just a list should give an idea of what I mean.
'Notes to my Biographer' is the story of a manic father visiting his gay son, told by the manic father. It is hard to recall the last time I have read a story told by a manic narrator, without the author intervening to explain the meaning of what is being said. In 'The Good Doctor' a young psychiatrist visits a deeply traumatized woman. His efforts to reach out to her, guided by the best precepts of our field, are so clumsy and ineffective that the story acheives a tragic dimension. How little psychiatrists understand of the meaning of their conversations with others? How presumptious we are in think that we do understand?
Some of the stories have homosexual themes. 'The Beginning of Grief' relates the efforts of a teenage boy to find comfort, following the deaths of his parents, in a violent homosexual encounter. 'Reunion' allows a man dying of AIDS to relate the story of his last days. In both of these I felt a profoundly uncomfortable sense of being in the skin of the protagonists, and a better understanding of what it is like to live lives different from mine.
Depression, suicide and madness are also Haslett's themes. 'My Father's Business' is a zany but poignant story composed of typescripts of the 'anecdotal sociology' project of a patient in a psychiatric hosptial who wants to know how people became interested in philosophy. It offered me a haunting reflection on madness, philosophy and living.
What provides hope in these stories is the capacity of the doomed, or at least the damaged, to give each other comfort. In 'Devotion' Haslett allows us to trace the strands that knot the lives of a brother and sister together. In 'Wars End' a profoundly depressed, suicidal man finds comfort in reading to a boy dying of a horrible skin disease. In 'The Volunteer' an awkward teen-aged boy with a depressed mother finds the caring of a mother in a psychotic woman, who finds the love of a son in him.
This brief summary should convey why this book might be of interest to psychiatrists. Beyond his fine writing, I am grateful to Adam Haslett for writing about these themes without cant, jargon or reductionism. In an era of psychobable, it is no mean achievement to write simply and to convey something of experience that we as psychiatrists are often to blinkered to see.

Review: Joel Braslow. Mental Ills and Bodily Cures: Psychiatric Treatment in the First Half of the Twentieth Century. Berkeley: University of Californ

2009-01-01T06:53:00.001-08:00

In 1977 Charles Rosenberg noted that most historians “have always found therapeutics an awkward piece of business” and “and on the whole, they have responded by ignoring it.” If this statement has been true for medicine in general, it has been even more true for psychiatry. After reading “Mental Ills and Bodily Cures,” it will be harder to ignore this awkward piece of business any longer. This book a concise, clearly written and closely argued series of essays on biological treatments in psychiatry, from hydrotherapy to lobotomy. It does more, however, than present the history of psychiatric treatments. As a psychiatrist I must confess that this book made me distinctly uncomfortable as I found myself reflecting on the effects of the biological treatments that I prescribe. Joel Braslow, a psychiatrist as well as a historian, has written a book that is not merely critical of some past practices but raises questions about contemporary practice as well.

Braslow has not, however, written an anti-psychiatric rant; I wouldn’t have felt so uncomfortable if he had. He understands and explains the medical and scientific literature surrounding the treatments that he describes. More than that, he doesn’t accept generalities about treatments, but writes about specific doctors and patients. Using case records and verbatim typescripts of case conferences from several California state hospitals, he allows us to virtually hear what doctors and patients are saying about treatment. Braslow is frank, but also balanced in his opinions. This is not a book about perpetrators and victims.
Braslow theme is “the power of biological therapies to alter the way in which doctors perceive both their patients and the doctor-patient relationship.” He does not accept the comforting view that psychiatrists treat diseases, syndromes or even disorders that are simply “out there.” Instead he insists that the use of any particular treatment actually structures what psychiatrists count as signs and symptoms of illness. It also structures the quality of the relationship between psychaitrist and patient. He supports this controversial position by developing a typology of how treatments influence the perceptions of psychiatrists as well as their relationships with patients. It matters, he says, whether we use treatments to control behavior, cure disease or ease suffering.
He argues, for example, that hydrotherapy was prescribed to control disorderly behaviors not to cure an illness. While doctors insisted that hydrotherapy was a treatment and not a punishment, patients often received this “treatment” against their wills. As a consequence patients had very different opinions of what it meant to receive hydrotherapy than did their psychiatrists. Braslow uses both hospital records and the proceedings of a governmental investigation to present these differing opinions. By contrast malaria therapy was given for a specific, laboratory confirmed, disease, general paresis. This disease had been a common cause of dementia and death for over a century when malaria therapy finally offered hope of a cure. Patients not only consented to this treatment, at times they requested it, and were even allowed to refuse it. In this case hospital records dramatically demonstrate how physicians’ attitudes towards patients became more respectful after the introduction of this treatment.
In addition to these treatments Braslow also devotes a chapter to sterilization, electroshock therapy and lobotomy, as well as a chapter about the influence of gender on decisions to perform lobotomies. In each chapter his analysis stays close to the psychiatrist and patient. Writing about steralization he argues that a belief in eugenics was not the only ingredient in making decisions, psychiatrists also had to believe the treatment had medical value. Electroshock therapy was used both a therapeutic discipline aimed at behavior and a therapy of despair aimed at releiving psychic pain. Lobotomy, while arguably the most destructive of these treatments, ironically also had the strongest scientific credentials. While psychiatrists performed lobotomies in response to incorigible behavior, they were convinced that they were treating diseased behavior. Astonishingly, but perhaps not surprizingly, Braslow also shows that psychiatrists also found reasons lobotomize women much more frequently than men. Using evidence from case records he argues that what counts as incorigible behavior depends on gender role expectations..
“Mental ills and Bodily Cures” is a book that historians will certainly profit from reading. I believe it will stimulate controversy as well as research on the awkward business of therapy. Hopefully it will also be book that psychiatrists will read and be disturbed by.

Edward M. Brown, Journal of the History of the Behavioral Sciences, 2001

Review: Eric Caplan, Mind Games: American Culture and the Birth of Psychotherapy, [University of California Press, 1998]

2009-01-01T06:50:00.000-08:00

The question of why Freudian ideas were so broadly and easily accepted in the United States during the twentieth century remains an important historical puzzle. Eric Caplan’s consice and lucid book Mind Games approaches this puzzle by by describing crucial features of the American cultural landscape in the thirty years leading up to Freud’s epochal visit to Clark University in 1909. Much of the territory he covers has been visited previously by Nathan Hale and John Burnham among others. What distinguishes Caplan’s book from others is detail with which he describes what he calls the 'discrete nodal points at which medicine and culture acutally intersect.'

Mind Games is in fact a series interconnected essays on railway accidents and the concept of psychological trauma, somatic treatments for neurasthenia and other functional nervous disorders, the Mind Cure Movement, medical controversies over psychotherapy, and the Emmanuel Movement. For someone relatively familiar with this terrain, the depth of Caplan’s research periodically provides rewarding nuggets of new information. Who was Thomas Jay Hudson, the author of that odd little book The Laws of Psychic Phenomena, that I picked up in a used book store years ago? Some of his chapters --particularly those on 'Railway Spine,' and the Emmanuel Movement--really do illuminate events that are usually glossed over. I hadn't appreciated, for example, just how vigorously the prestigious neurologist and influential Freudian, James Jackson Putnam, had opposed the Emmanuel Movement.
Caplan has an eye for irony. His chapter on Railway Spine, for example, demonstrates how 'conservative' railway surgeons, invested in decreasing railway liability for accidents, played an important role in developing the 'progressive' idea of psychological trauma. Occassionally he is also very insightful. The fact that 'mental medicine' emerged in reaction to the restrictions imposed by the 'somatic style' in neurology and psychiatry on the doctor patient relationship is perhaps well known. By drawing attention to the the somatic style itself as a product of late nineteenth century preoccupation with specific diseases, however, Caplan is able to suggest that the emergence of mental medicine represented a reemergence and transformation of early nineteenth century concerns with individualized treatments.
Caplan's book succeeds in providing a readable account of one piece of the puzzle of why the United States has been so receptive to psychotherapy. It is a book that psychiatrists and patients as well as historians should read.

Edward M. Brown

Notes on Nostalgia [Unfinished]

2009-01-01T05:16:00.000-08:00

By the waters of Babylon, there we sat down, yea, we wept, when we remembered Zion [Psalms 137:1].

Like the fugue states described by Hacking, nostalgia was a 'transient' psychiatric disorder that was recognized and treated for a time and then disappeared [Hacking, 1998]. From the late seventeenth through the late nineteenth centuries, what we might call homesickness was a disorder that doctors and patients took quite seriously. Like shell shock and PTSD a diagnosis of nostalgia could result in a soldier being discharged from the army. Like anorexia nervosa, nostalgia occasionally resulted in death. It was a serious disorder, as long as social and intellectual circumstances provided a lens for seeing it. When those circumstances changed, nostalgia, like hysteria in the late nineteenth century, evaporated. Below are some notes about the history of nostalgia. They are intended to be suggestive, not to explain the strange career of this transient disorder.
As early as 1569, a Swiss officer reported that one of his cadets had succumbed to homesickness [Anderson, 1984, 156]. Incidents of homesickness were described in medical literature at least as early as the seventeenth century, given different names in various languages--maladie du pays in French, Heimweh in German, el mal de corazón in Spanish. As early as 1634, 44 cases, characterized by deep despair, were described among Spanish conscripts serving in Flanders.
In 1678 Johannes Hofer [1669-1752] coined the name nostalgia, from Latin roots, to refer to 'the pain a sick person feels because he is not in his native land, or fears never to see it again' [Rosen, 1975, 30]. This neologism was so successful that people forgot its origin. Moreover, its original technical meaning has been lost as it has entered everyday language. As Starobinski has pointed out, this trajectory was not unique. It also happened with the term 'melancholy' and is perhaps happening with 'schizophenia' [Starobinski, 1966, 96]. At the time, however, Hoffer used the term to refer to two cases:
The first was a young man who had come from Bern to Basel to study. After a period of dejection he developed a low grade, continuous fever, anxiety and palpitations. His symptoms worsened and death appeared imminent. When the student heard that plans were being made to send him home, in spite of the gravity of his symptoms, he grew calmer. After several miles on the road from Basel, his complaints abated noticeably, and before reaching Bern he had recovered [Rosen, 1975, 30-1].
The second was a young peasant woman, who was brought to the hospital, unconscious, after a fall. On waking she refused all food and medication and constantly moaned, "I want to go home." After a few days, despite her weakness, her parents took her home, where she recovered completely [Rosen, 1975, 31]
Hoffer explained such cases with the psychosomatic theory that nostalgia was a disorder of imagination which could result in death. When one dwelled on images, such as those of one's native land, the vital spirits, which flowed through the nerve fibers in which images were stored, deepened these channels and increased the flow through this region of the brain. As a result there was a decreased flow of vital spirits in other regions of the brain. This resulted in an increased preoccupation with images of one's home, as well as an indifference towards one's immediate surroundings. The process was self prepetuating. Vital spirits were not available to stimulate appetite or digestion, resulting in a reduction in the quality and quantity of these spirits. As the vital spirits were exhausted, bodily functions weakened and death ensued. [Rosen, 1975, 32].
While a twentieth century reader might take Hofer's nostalgia as an anticipation of attachment theory, in the eighteenth century it was regarded as a slur [Starobinski, 1966, 98]. J. J. Scheuchzer, perhaps for patriotic reasons, explained cases of nostalgia with in a purely mechanical way. A Swiss, Scheuchzer tried to combat the theory that Swiss soldiers in foreign service, suffered from a strange kind of weakness which might even be considered cowardice. In 1705 he argued that when his countrymen descend into lowlands, the delicate fibers of their skin are compressed, their blood is forced into the heart and brain, its circulation is slowed and if the individual's body cannot resist these deleterious effects, anxiety and homesickness supervene [Rosen, 1975,33-34].
During the eighteenth century nostalgia was generally accepted as a mental illness. William Cullen classified it as a species of false or defective appetite along with bulimia, polydipsia and satyriasis. In England it was considered a disease of foreigners, particularly the Swiss on foreign service. "In England," Arnold wrote, " whatever may be the partiality to our native land... we know nothing of this passionate aattachment that leads to this sort of Insanity" [Macalpine & Hunter, 1982, 499].
Although Hofer's initial cases were drawn from civilian practice, during the eighteenth century, attention increasingly focused on the military significance of nostalgia. For any European country that went to war the recruitment of soldiers on a large scale was a problem. Only hunger would tempt most peasants, who comprised the mass of the European population, to join an army. As a result kidnapping, deception and impressment were used to fill the ranks. Voltaire's Candide, published in 1759, during the Seven Years War, provides a satirical, but apparently not overly exaggerated, depiction of the use of deception to lure a recruit into the Prussian army. When more enthusiastic volunteers could be found they were usually exiles from other countries. Continental armies, for example, included many Irish and Scottish Catholics opposed to English rule [Rosen, 1975, 37-8].
In Britain press gangs provided men for the Royal Navy by seizing seaman returning home from long voyages. Living and working conditions in the Royal Navy were terrible. Cramped quarters, poor scanty food, indescribable sanitary conditions together with severe and rigid discipline were all the impressed men could expect. It is not surprising to find men in such circumstances falling into profound despair, and suffering depression, anxiety and all the other features of nostalgia [Rosen, 1975, 38].
In 1787 Robert Hamilton [1749-1830] described a case of a soldier suffering from nostalgia, who received sensitive and successful treatment:

In the year 1781, while I lay in barracks at Tinmouth in the north of England, a recruit who had lately joined the regiment,...was returned in sick list, with a message from his captain, requesting I would take him into the hospital. He had only been a few months a soldier; was young, handsome, and well-made for the service; but a melancholy hung over his countenance, and wanness preyed on his cheeks. He complained of a universal weakness, but no fixed pain; a noise in his ears, and giddiness of his head....As there were little obvious symptoms of fever, I did not well know what to make of the case...Some weeks passed with little alteration...excepting that he was evidently become more meagre. He scarcely took any nourishment...became indolent...He was put on a course of strengthening medicines; wine was allowed him. All proved ineffectual... He had now been in the hospital three months, and was quite emaciated, and like one in the last stage of consumption...[Macalpine & Hunter, 1982, 499-500]
On making my morning visit, and inquiring, as usual, of his rest at the nurse, she happened to mention the strong notions he had got in his head, she said, of home, and of his friends. What he was able to speak was constantly on this topic. this i had never heard of before...He had talked in the same style, it seems, less or more, ever since he came into the hospital. I went immediately up to him, and introduced the subject; and form the alacrity with which he resumed it.. I found it a theme which much affected him. He asked me, with earnestness, if I would let him go home. I pointed out to him how unfit he was, form his weakness to undertake such a journey [he was a Welchman] till once he was better; but promised him, assuredly, without farther hesitation, that as soon as he was able he should have six weeks to go home. He vevived at the very thought of it... His apeitite soon mended; and I saw in less than a week, evident signs of revovery...[Macalpine & Hunter, 1982, 499-500].

During much of the eighteenth century much of the medical literature on nostalgia was German. At the beginning of the nineteenth century nostalgia became a matter of considerable concern to French doctors, especially those associated with the armies of the First Republic and the Napoleonic Empire. The large heterogeneous armies raised by the leveé en mass comprised numerous conscripts from remote regions, who were regarded as highly susceptible to the dreaded mal du pays. The military camps to which these conscripts were brought were poorly organized and equiped, and almost half the troops were inactive. Cases of nostalgia, which sometimes occurred as epidemics, were less frequent when the armies was victorious and more frequent when they suffered reverses. The seriousness with which the condition was taken can be seen in an action taken in 1793 by the deputy minister of war, who suspended all convalescent leaves, except in cases "where the patient suffered from nostalgia, or maladie du pays" [Rosen, 1975, 39-40].
The acceptance of nostalgia as a serious military disorder contributed to its stature in civilian practice. Early in the nineteenth century, for example, doctors warned that children who were sent out to nurse would be especially vulnerable to the disease [Roth, 1991,8-9].In 1841 Jean-Baptist-Felix Descuret published the following case in his La Médecine des Passions:

Eugène L., born in Paris, was sent to a wet nurse in the Amiens area and brought back to his family when he was two years old. the strength of his limbs, the firmness of his flesh, his coloring, the vivacity and gaiety of his character, everything indicated that he had been well cared for and that he was a vigourous child. During the fifteen days that his nurse remained at his side, Eugène continued to enjoy the most robust health; but as soon as she left he became pale, sad and morose. He was unresponsive to the caresses of his parents and refused all the food that had pleased him the most just a few days before.

Struck by this sudden change Eugène's mother and father summoned Hippolyte Petit who, recognizing the first symptoms of nostalgia, recommended frequent walks and all the childish distractions that abound in Paris. These techniques, ordinarily so effective in such cases, failed completely, and the unhappy little boy, who was becoming weaker all the time, remained for whole hours sadly immobile, his eyes turned toward the door through which he has seen departing the woman who had acted as his mother. Called again by the family, the practitioner declared that the only way to save the child was to have his nurse return immediately and take the boy away with her again. When she arrived, Eugène erupted with cies of joy; the melancholy imprinted on his face was soon replaced by the radiation of ecstasy and, to use one of his father's expressions, from that moment he began to revive. Brought to Picardy the following week, he stayed there about a year enjoying the best of health. During his second return to Paris Dr. Petit progressively separated the nurse from the child, first for a few hours, then for a whole day, then for a week, until he was used to being without her. This tactic was corwned with complete success [Roth, 1991, 5-6]. .

Descuret called little Eugène's disturbance "nostalgia from affection." With this label the author emphasized the psychological, or what would have been termed the moral, etiology of the disease. Other physicians placed a greater emphasis on the physical aspects of such maladies. Eugène's first impressions had been in Picardy; it was not only his affection for his nurse but his attachment to the environment around Amiens that had made the return to Paris a threat to his health. In this case, what descuret called the child's "memory of the heart" was too faithful to its first oblect. Separation was experienced as violent deprivation [Roth, 1991,7].
Eugène had been sent to a wet nurse in the countryside, a custom not unusual for a middle-class child in the early nineteenth century, although this does not mean that sending a child away to nurse was uncontroversial during this period. At least since the Enlightenment mothers had been urged to nurse their own children, yet it seems that at least forty percent of children born in Paris in the mid-1800s were placed with rural wet nurses. In the case of Eugène, the child seemed to suffer no ill effects from his two years in the countryside. On the contrary, he was a vigorous two-year-old, a fact that must have made his decline into lethargy even more frightening to his parents [Roth,1991,8].

Debate During the 1820s and 1830s
During the early decades of the nineteenth century, and especially in the 1820s and 1830s, there was an impotant increase in medical writings on nostalgia, and the disease attracted considerable medical attention, discussion and intervention. Although not many medical writings concentrated on nostalgia as a childhood illness, almost all identified the origins of the disease in the first affective connections to people and places in the child's world. Doctors believed that attachment to one's earliest memories was so frequently the core of this disorder because the first impressions on the brain were permanent. Eugène's attachment to his lost nurse renderd him morose, pale and unresponsive to any pleasures his parents could provide. In the nineteenth century these signs were suggestive of melancholia. Nostalgia was distinguished from melancholia by the specificity of its object, and rapidity with which it developed. As a disorder that was considered to be potentially fatal, doctors looked for postmortem changes in patients who died from nostalgia. Finding such changes on occasion gave support to the view that emotional states can result in organic changes. [Roth, 1991,9].
Forgetting could be protection against nostalgia, but no doctor thought it wise to forget one's origins completely. How could physicians understand this desease, which seemed to be the result of "our finest natural sentiments," but which could spred to others and be fatal?"

By the 1850s nostalgia was losing its status as a particular disease and coming to be seen rather as a symptom or stage of a pathological process. It was considered as a form of melancholia and a predisposing condition among suicides. This was not surprising, the psychiatrist Brierre de Boismont argued in 1856, "if one considers the mass of strangers who come to seek their fortune in Paris, and who so frequently find only poverty, isolation and despair." After coming to Paris from Brittany, the heroine of Balzac's Pierrette, for example, suffers from nostalgia, leading finally to death from consumption [Rosen, 1975, 43-4].

A Revival in the American Civil War
While nostalgia was in decline as a diagnostic category in the mid-nineteenth century, it experienced a revival in the American Civil War. After insanity, nostalgia was the second major disgnostic category used in the Civil War era to describe what we would think of today as a stress disorder. The official records of noninfectious diseases in the federal army during this war reveal 5,213 cases of and 58 deaths from nostalgia among white troops from May 1861 to June 30 1866. The record for 'colored troops' reveals 334 cases of nostalgia and 16 deaths [Anderson, 1984, 157].
In A Manual of Instructions for Enlisting and Discharging Soldiers the Union Army instructed medical officers that:
Nostalgia is a form of mental disease which comes more frequently under the observation of the military surgeon… Considered as a mental disease,-- and there can be no doubt that the primary phenomena of this state are mental,-- it belongs to the class Melancholia. The extreme mental depression and the unconquerable longing for home soon produce a state of cachexy, loss of appetite, derangement of the assimilative functions, and, finally, disease of the abdominal viscera,-- in fact, the objective phenomena of the typhoid state… As Nostalgia is not unfrequently fatal, it is a ground for discharge if sufficiently decided and pronounced [Dean, 1997, 129]

Early in 1863, assistant surgeon general Dr. Dewitt C. Peters also described nostalgia as a 'species of melancholy.' He then elaborated on the symptoms:

'First, great mental dejection, loss of appetite, indifference to external influences, irregular action of the bowels, and slight hectic fever. as the disease progresses it is attended by hysterical weeping, a dull pain in the head, throbbing of the temporal arteries, anxious expression of the face, watchfulness, incontinence of urine, spermatorrhea, increased hectic fever, and a general wasting of all the vital powers. The disease may terminate in resolution, or run on into cerebral derangement, typhoid fever, or any epidemic prevailing in the immediate vicinity and frequently with fatal results [Anderson, 1984, 157].'

Military doctors attempted to predict who was likely to develop nostalgia. 'Young men of feeble will, highly developed imaginative faculties and strong sexual desires' were considered the most obvious group at risk . A second group at risk were 'married men who for the first time were absent from their families' [Anderson, 1984,158]. For example, a middle-aged soldier, who was an intelligent, well read, competent mechanic from a happy family, quickly became disenchanted with military life. 'He would sit for hours with his face in his hands and his elbows on his knees, gazing out upon the mass of men and huts, with vacant, lack-luster eyes. We could not interest him in anything. We tried to show him how to fix his blanket up and give him some shelter, but he went back to work in a disheartened way and finally smiled feebly and stopped.' His mind seemed to be fixed on his wife and cinldren. When he first arrived he ate his rations, but then he began to reject them. In a short time he was delirious with hunger and homesickness. ' He would sit in the sand for hours imagining that he was at his family table, dispensing his frugal hospitalities to his wife and children...' Shortly after this, he died [Anderson, 1984, 159].

Other factors were also considered. A military surgeon, J. Theodore Calhoun argued that, 'the very existence of nostalgia, presupposes a state of mental depression, extremely favorable to the contraction of the disease' [Anderson, 1984, 158]. Some saw nostalgia as the result of what was called 'crowd poisoning.' According to this view men from the country were more susceptible to nostalgia because of their early life in the pure atmosphere of fresh air and sunlight. Those coming from the city were not as easily affected by the 'poisonous effluvia' generated by crowded camps [Anderson, 1984, 1957-8]
Dealing with cases of nostalgia was an important concern for miliatary doctors during the Civil War. One tactic was to accuse soldiers suffering from nostalgia of moral turpitude and a lack of patriotism and courage. Some argued that a generous furlough policy might be useful. Others thought that idleness provoked 'home sickness.' They insisted that if a soldier were ' hard at work all day,...he will have a relish for his rations, and will sleep soundly all night, having little time to think of home'. Battle activity and preparation for battle were also seen as curing many individuals. Calhoun insisted that the 'Battle of Chancellorsville cured ... [a whole] regiment [of nostalgia] and it has since enjoyed as good health as any in the division' [Anderson, 1984, 160-1].

During the American Civil War nostalgia was not only a diagnosis made by doctors but a way that soldiers thought about the mental deterioration of their comrades. In a letter describing prisoners of war one soldier, for example, wrote, "They became homesick and disheartened. They lost all interest in everything, and would sit in the same attitude hour after hour day after day, with their backs against the wall and their gaze fixed on the floor at my feet... they were dying of nostalgia." Or as another soldier wrote, "Homesickness, the most pitiless monster that ever hung about a human heart, killed them. It killed as many in our army as did the bullets of the enemy" [Dean, 1997,129].
Terror struck soldiers, in large numbers, claimed to suffer from nostalgia. During an evacuation by boat authorities noted that "it was found impossible to prevent the flocking on board of many whose only complaint was nostalgia [Dean, 1997,130]. Soldiers who wanted to avoid combat were tempted to fake nostalgia, claiming to their commanders and doctors that they suffered from being so far away from home. However these malingerers were betrayed by their complaints: true nostalgics would conceal their disease, withdrawing into lethargy without disclosing the origins of their suffering [Roth, 1991, 13]
Although reports of nostalgia went up in the second year of the war, reaching 2,057 cases and 12 deaths in the year ending June 30 1863. After 1863 the number of cases declined [Anderson, 1984, 157]. A number of explanations for the waning of this diagnosis might be suggested. It has been suggested that a change in the type of men selected for service or a more realistic view of the duration of the war may have been responsible for the decline in number of cases [Anderson, 1984, 157]. Another possibility is that the meaning of nostalgia changed and came to be viewed as a sign of weakness. As a letter from a veteran put it, "These new fellers ARE GENERALLY a homesick set. The toughening process affects them rather severely" [Dean, 1997, 130].

The Disappearance of Nostalgia
By the 1870s interest in nostalgia as a medical category had all but vanished. Those who saw it as disappearing saw this as the result of progress. As one author declared, "Le mal de pays, already rare in our time, is destined to disappear before the progress of hygiene and civilization." Perhaps better education had made people "more capable of struggling against this disease." Or, perhaps, the development of steam engines, regular mail and telegraph lines prevented people from being so completely separated from home [Roth, 1991, 19-20].
In 1875 Charles Lasègue, by contrast, argued that it was impossible to say whether there was a decline in the incidence of the disease because nostalgia had never signified a "pathological unity" in the first place. As a member of the young profession of psychiatry he argued that the army doctors responsible for much of the writing on nostalgia were not real experts on "troubles intellecutels." "The asylums of convalescents, …he wrote, "are a homeland for no one, and yet how many sick people have found a cure there?"[Roth, 1991, 21]
As nostalgia was being eliminated as a medical concern in the 1870s, psychiatrists were beginning to direct their attention toward hysteria. While Lasègue had complained that hysteria was the "waste paper basket of medicine where one throws otherwise unemployed symptoms," he had spent years working to clarify the use of that diagnosis. As interest in nostalgia declined, Lasègue's colleague and rival Jean Martin Charcot began to focus the attention of French psychiatry on hysteria. If nostalgia was erased by the developents of industrialization and centralization, these same aspects of historical change were said to be responsible for the exhaustion of the nerves defined as neurasthenia [Roth, 1991, 22-3].
Nonetheless most saw the decline of this serious disease was a good thing, but some lamented the loss of the feelings for home that gave rise to the illness [Roth, 1991, 29-30]. Of course the phenomenon of nostalgia did not disappear with its demedicalization. [Roth, 1991, 7].

Anderson, Donald Lee & Anderson Godfrey Tryggve. 'Nostalgia and Malingering in the Military during the Civil War,' Perspectives in Biology and Medicine, 28 [1984] 156-166.

Dean, Eric T. Shook Over Hell: Post-Traumatic Stress, Vietnam, and the Civil War, [Cambridge MA, Harvard University Press, 1997].

Hacking, Ian. Mad Travelers: Reflections on the Reality of Transient Mental Illnesses, [Charlottesville Va., University Press of Virginia, 1998].

Macalpine, Ida & Hunter, Richard. Three Hundred Years of Psychiatry, [1982]

Rosen, George. “Nostalgia: A ‘Forgotten’ Psychological Disorder,” Clio Medica 10/1[1975]28-51.

Roth, Michael. 'The Time of Nostalgia: Medicine, history and normality in 19th-century France,' Time & Society, 1[1992]271-286.

Starobinski, Jean. 'Le Concept de Nostalgie,' Diogène, 54[1966] 92-115.

Edward M. Brown

Biography: James Jackson Putnam (Oct.3 1846-Nov. 4, 1918)

2008-12-31T08:36:00.000-08:00

A neurologist, he was born in Boston, Mass., the son of Charles Gideon, a physician, and Elizabeth Cabot (Jackson) Putnam. He was a brother of physician Charles Pickering Putnam. He graduated from Harvard College in 1866 and Harvard Medical School in 1870. After completing an internship at the Massachusettes General Hospital he studied neurology in Leipzig, Vienna, and London, where he was influenced by Carl Rokitansky, Theodor Meynert and especially by John Hughlings Jackson.

Putnam was one of the pioneers of neurology in the United States. After returning from his European studies in 1872, he started one of the first neurological clinics in this country, at the Massachusettes General Hospital. Because of a lack of hospital facilities at that time he established a neuropathological laboratory in his own home. In 1874 the Harvard Medical School appointed him Lecturer on the Application of Electricity in Nervous Diseases, a title which reflects the infant status of the field of neurology at the time. In the same year Putnam was one of the seven charter members of the American Neurological Association, and he served as its president in 1888. He was also a founder of the Boston Society of Psychiatry and Neurology. By 1893 he had risen to the rank of Professor of Diseases of the Nervous System at Harvard--a position which he held until 1912, when he was made Professor Emeritus.
During a career that spanned nearly 50 years he published over one hundred papers on clinical and pathological neurology. Early in his career he did experiments on localization of brain functions with Henry P. Bowditch, a professor of physiology at Harvard. Most of his neurologic work focused on disorders of the spinal cord and peripheral nerves. His first significant publication, in 1881, was the earliest adequate discription of parasthesias in the hands. He wrote important papers on neuritis, particularly neuritis due to lead and arsenic poinoning. He also spoke out on social issues, notably, in 1879, defending the place of women in medicine.

While he was severely critical of functional or psychological explanations of nervous symptoms during the first decade of his career, his views changed radically over the years. This change in attitude appears to have been influenced by his extensive experience giving medico-legal evidence in in cases of traumatic neuroses. Between 1890 and 1909 Putnam cooperated informally with psychologists, philosophers and psychiatrists, including William James, Josiah Royce and Hugo Munsterberg, to develop a sophisticated, scientific psychotherapy. The first published evidence of Putnam's changing views was an 1895 paper titled "Remarks on the Psychical Treatment of Neurasthenia." In 1906 Putnam published the first clinical test of psychoanalysis in an English-speaking country, concluding that Freud's claims were stimulating but exaggerated.

While some physicians like Putnam "flirted" with psychotherapeutic techniques around the turn of the century, psychotherapy didn’t explode into the American consciousness until 1906 with the Emmanuel Movement. The Emmanuel Movement, a church-based initiative in the progressive spirit of the social gospel and supported by leaders of the Boston medical community, promised to treat (free of charge) psychoneurotic patients. The ministers at Emmanuel Church were so successful in their treatments, and demand across the country was so great, that physicians feared they had committed professional suicide. They turned-coat and, with much effort, effectively ended the movement. Putnam was among most visible and vocal of the physicians both in his initial support for the movement and in his later repudiation of it.

In recent years Putnam's pioneering work in establishing neurology as a medical specialty in the United States has been overshadowed by interest in his role in establishing the psychoanalytic movement in this country. His serious involvement in psychoanalysis began during Freud's visit to Clark University in 1909, where the two men had a chance to talk at length. In the last decade of his life Putnam wrote over thirty papers on psychoanalysis and related topics. Putnam's stature among neurologists secured a hearing for Freud's views within the profession and his reputation for sound scientific judgement and unimpeachable integrity played a crucial role in the American acceptance of psychoanalysis.

For articles on Putnam: Dictionary of American Biography, 1935, v.15,p.282-3; E.W. Taylor, Archives of Neurology and Psychiatry 3(1920)307-314;Ernest Jones, "Obituary" in James Jackson Putnam, Addresses on Psychoanalysis (1921);Nathan G. Hale, "Introduction," in Nathan G. Hale (ed.), James Jackson Putnam and Psychoanalysis, (1971).

Edward M. Brown

Biography: Albert Deutsch (23 Oct. 1905-21 June 1961)

2008-12-31T08:34:00.000-08:00

An historian and journalist, he was born in New York City. Raised on the lower east side, Deutsch was the fourth of nine brothers and sisters in a poor Jewish family that had recently emigrated from Latvia. At the age of five, following an accident, his right eye had to be enucleated. He was largely self educated. Before finishing high school, he left home and traveled around the United States, working as a longshoreman, a field hand, and a shipyard worker. While on the road, he continued his education in public libraries around the country.
By the early thirties he had returned to New York where he found work doing archival research. In 1934 while surveying documents for a proposed history of the New York State Department of Welfare, he found records on the public care of the mentally ill. Recognizing the social as well as historical value of these records he submitted a written proposal for a history of the public care of the mentally ill in America to Clifford Beers the founder of the National Committee for Mental Hygiene. He worked under contract with the Committee for two years to complete The Mentally Ill in America (1937), a 530 page scholarly social history of the care of the mentally ill from colonial times to the present. Remarkable because it was written by someone without a college education or any direct training or experience in psychiatry, this book immediately established Deutsch's reputation as the most important historian of American psychaitry up to that time.
Between 1936 and 1940 while employed at the New York Department of Welfare as a Research Associate, he wrote, with David Schneider, The History of Public Welfare in New York State,1867-1940 (1941). In 1938 he was elected to the newly formed "Innominate Club," which later became the New York Society for the History of Medicine, where he presented many scholarly papers on the social history of psychiatry and medicine. In 1942 he published an important paper, "Historical inter-relationships between medicine and social welfare" in the Bulletin of the History of Medicine. In 1944 he contributed scholarly papers on the history of the mental hygiene movement and military psychiatry during the American civil war to One Hundred Years of American Psychiaty, a volume commemorating the centennial of the American Psychiatric Association.
In 1941 Deutsch began to write a daily column for the newspaper PM. Deutsch used this column to speak out on a wide range of contemporary social issues related to health care. In 1945 his columns criticizing the maltreatment of psychiatric patients in veterans hospitals led the House Committee on Veterans Affairs to demand that he name his news sources. He refused and was voted in contempt of Congress. Later the committee rescinded its action and many of Deutsch's suggestions for improved treatment were adopted by the Veterans Administration. In 1945 and 1946 the American Newspaper Guild's gave him its Heywood Broun citations for this series of articles. In 1947 the New York Newspaper Guild honored him for "the most distinguished and effective humanitarian crusading in American journalism."
In 1948 he gathered together a series of articles on mental hospitals written for PM and published them, as well as numerous photographs, as The Shame of the States, a powerful indictment of state hospital care in America. The following year he won the Lasker Award "for his outstanding contribution to the advancement of mental health through his journalistic efforts." In 1958 he he was made an Honorary Fellow of the American Psychiatric Association.
In addition to PM, Deutsch published articles various popular magazines including The New York Times Magazine, Colliers, The Woman's Home Companion, The Saturday Evening Post and The Reader's Digest. When PM closed he wrote breifly for other New York newspapers. In 1949 he gave up daily newspaper work in order to explore social problems more deeply. In 1950 he published Our Rejected Children, a book on juvenile delinquency. In 1955 he brought out another crusading book on the need for police reform, The Trouble With Cops.
Deutsch was married once and divorced. He died in England while attending an international research conference convened by the World Federation for Mental Health.

Works about Deutsch include: an obituary in The New York Times, 20 June 1961; M. E. Kenworthy, "Albert Deutsch," American Journal of Psychiatry, 118 (1962):1064-1068; Jeanne L.Brand, "Albert Deutsch: The Historian as Social Reformer," Journal of the History of Medicine and Allied Sciences, 18 (1963):149-57; George Mora, "Three American Historians of Psychiatry: Albert Deutsch, Gregory Zilboorg, George Rosen," in Edwin R. Wallace,IV and Lucius C.Pressley (eds) Essays in the History of Psychiatry,(1980); George Mora, "Early American Historians of Psychiatry," in Mark S. Micale and Roy Porter, (eds.) Discovering the History of Psychiatry,(1994).
In addition to his books and popular articles Deutsch published scholarly articles including: "Dorthea Lynde Dix: Apostle of the Insane," American Journal of Nursing, 36(1936):987-997; and "The cult of curability, its rise and decline," American Journal of Psychiatry, 92 (1936):1261-1280; "Historical inter-relationships between medicine and social welfare," Bulletin of the History of Medicine, 11(1942): 485-502.

Edward M. Brown

Biography: Johann Christian Reil (1759-1813)

2008-12-31T08:30:00.000-08:00

Reil was one of the most famous medical theorists of his time. Born in an East Frisian parish house, he studied medicine rather than theology, against his father's wishes, and received his medical degree in 1782. He had a private practice until 1788, when he was then appointed professor of medicine at Halle, where he became one of the most sought-after physicians. His wide ranging research activities brought him a chair at the new Univeristy of Berlin in 1810. He knew Fichte, Schleirmacher, Goethe, Humboldt and Gall and was an enthusuastic disciple of the philosopher Shelling. During the Napoleonic war he was in charge of army hospitals on the left bank of the Elbe, where he died of typhoid in 1813.
Reil intended physiology to serve as the foundation of medicine and in 1795 he founded the Archiv für Physiologie and remained its editor until his death. He used this journal to promote the reform he felt was necessary in physiology. Following Kant, he argued that physiology had failed to observe the boundaries of human knowledge. Specifically he thought the problem lay with the concpet of Lebenskraft or life force. He offered his monograph "Von der Lebenskraft," as the lead article in his new journal to discuss just this problem.
His first systematic consideration of various forms of psychological disturbance came in his book Fieberhaste Nervenkrankheiten (Feverish nervous illness, 1802), where his interest in mental illness was due to the fact that derangement often accompanied fevers. At this point Reil thought of mental illness as a disruption of the normal functioning of the powers of the soul: consciousness, understanding, reason, imagination, and sensibility, which he glossed explicitly in Kantian fashion. He accorded the soul, however, only phenomenal existence-- what it really might be remaining totally unknown. The entire direction of his analysis of the powers of the soul implied that though they were called psychic they could ultimately be reduced to forces of the nervous system. The powers of the soul, he insisted, stood in an exact relationship to the operations of the nervous system.
In 1803 he published Rhapsodien über die Anwendung der psychischen Curmethode auf Geisteszerrüttungen (Rhapsodies on the Application of Psychological Methods of Cure to the Mentally Disturbed), perhaps the most influential work in the shaping of German psychiatry before Freud. The model of mind that he developed in the Rhapsodieen went considerably beyond Kantian boundaries. With the Rhapsodieen,Reil dramatically shed his materialistic interpretation of living nature and adopted a radically contrary stance. According to Robert Richards Reil's introduction to the philsopher Friedrich Schelling's romantic idealism fundamentally reoriented his understanding of the root causes of mental illness. In the light of this new philosophical conception, Reil came to regard insanity as stemming from the fragmentation of the self, from an incomplete or misformed personality, and from the inability of the self to construct a coherent world of the nonego-all of which resulted from the malfunctioning of self-consciousness, that fundamentally creative activity of mind postulated by the romantic philosophers.
In the Rhapsodieen, Reil again proposed a medical and quasi-physiological interpretation of mind, identifying mental powers quite closely with underlying forces of the brain and nervous system. "The brain," he argued, "may be conceived as a synthetic product of art, composed of many sounding bodies that stand in a purposeful relationship (that is, in rapport) with one another" (RU, p. 46). Any change in the brain's components from external sources would then change the orchestration of the whole. The ordering of these relations of the parts of the soul's organ is grounded in a determined distribution of forces in the brain and the whole nervous system. If this relationship is disturbed, then dissociations, volatile character, abnormal ideas and associations, fixed trains of ideas, and corresponding drives and actions arise. The faculties of the soul can no longer express the freedom of the will. This is the way the brain of a mad person is produced.
Reil now conceived of the nervous system as an integrating force designed to achieve a "natural purpose," precisely the conception of organic activity rejected in his earlier "Von der Lebenskraft."If psychological manipulations were successful, then the underlying nervous connections would be properly readjusted and the rational operations of
mentality restored (see RU, p. 150).It would be a mistake, though, to think of Reil as introducing, via the mind, an indirect means of altering the pathological brain. In his construction, brain and mind became inextricably joined. Indeed, not
worrying about theoretical problems of the mind-body relationship, he treated them as virtually identical, as if mind were completely instantiated in the nervous system. Hence, an altered mind was an altered brain.
In the Rhapsodieen, Reil distinguished three chief forces of the soul, whose disruption could produce pathology. These were self-consciousness,prudential awareness,and attention. He devoted most of his effort in the Rhapsodieen to the analysis of a force now considered the most crucial for understanding pathologies, that of self-consciousness. "The essence of self-consciousness," Reil held, "seems chiefly to consist in joining the manifold into unity and assimilating the representations as one's own." When self-conscious action falters, when pathology of the ego strikes, then personality fragments and the world becomes incoherent. Some people will not be able to distinguish real objects from phantoms of their imaginations.When the faculty of prudential awareness, which keeps mental focus fixed on an object or project, becomes weakened, then attention shifts with the wind and patients live in another world. As the quote accompanying the Katzenclavier indicates Reil as drawing the patient's attention back from that other world, by mobilizing his/her prudential awareness.
(This note is derived from Robert Richard's The Romantic Conception of Life: Science and Philosophy in the age of Goethe, (University of Chicago Press, 2002)251-288.

Katzenclavier

2008-12-31T08:29:00.000-08:00

I can't resist sharing an account of what is one of the most bizarre treatments I have read about. Johann Christian Reil (1759-1813), the very influential German psychiatrist, who first used the word psychiatry in 1808, describes the use of the Katzenclavier-- a piano made of cats. After voicing the instrument with suitable animals, they would "be arranged in a row with their tails stretched behind them. And a keyboard outfitted with sharpened nails would be set over them. The struck cats would provide the sound. A fugue played on this instrument--particularly when the ill person is so placed that he cannot miss the expressions on their faces and the play of these animals--must bring Lot's wife herself from her fixed state into prudential awareness." We have made progress
in the last two centuries!

Five Easy Pieces: Essays on Practicing Psychotherapy

2008-12-31T08:20:00.000-08:00

The five essays were written in the early 1980s as I was starting out in the practice os psychotherapy. I was trained by psychoanalysts and had read and reread a lot of Freud's works. Starting out in practice I found myself wondering what I was presuming to do and why I was doing it the way I was. I was very uncomfortable viewing the people who came to talk to me through the theoretical lens provided by psychoanalysis. I was more than a little overwhelmed by the contrast between the power of their immediate distress over the circumstances of their lives and the meagre resources I felt that I had to help them. The first essay was written while I was teaching an undergraduate course called "Reading Freud" at Brown Univeristy with Professor Giles Milhaven. We asked students to read selections from Freud's writings and then respond to them from their personal experience. "The Medical Frame" was intended as my response to Freud. It was inspired by an undergraduate course I had taken with David Bakan, who, as I recalled, described having seances in which he tried to communicate with Freud. "The Medical Frame was my attempt at such communication.

#1 The Medical Frame

2008-12-31T08:19:00.001-08:00

THE MEDICAL FRAME: A Phenomenological Inquiry

Edward M. Brown, M.D.

The dream might be described as a substitute for an infantile scene modified by being transferred onto a recent experience. The infantile is unable to bring about its own reviva1 and has to be content with returning as a dream.

--Freud: The Interpretation of Dreams

Transference is an acting out of the reality of the unconscious.

--Lacan

[Freud's] first interest was in hysteria [ . ] He spent a lot of time listening, and while he was listening, there resulted something paradoxical [. . .], that is a reading. It was that while listening to hysterics that he read that there was an unconscious. That is something he could only construct, and in which he himself was implicated; he was implicated in it in the sense that, to his great astonishment, he could not avoid participating in what the hysteric was telling him, and that he felt affected by it. Naturally, everything in the resulting rules through which he established the practice of psychoanalysis is designed to counter act this consequence, to conduct things in such a way as to avoid being affected.

--Lacan at Yale, November 24, 1975

I would like to take this opportunity to discuss some implications of the psychoanalytic situation. In doing this I will rely on my own experiences as a psychoanalytically oriented psychotherapist and my efforts over the last three years to re-read a substantial portion of Freud's writings as closely as possible. I refer to the psychoanalytic situation and not psychoanalysis because my approach involves taking the terms of psychoanalytic theory and temporarily suspending them so that I can take a fresh lock at the experiences of the participants in this unique form of human conversation. While concepts like transference, countertransference, defense mechanisms and `the unconscious are critical to my work, what I would like to suggest is that the psychoanalytic situation, as Freud constructed it generates certain enlightening experiences which precede, and perhaps transcend any conceptual fix that we may put on them. My aim then is to suggest a way to look at the psychoanalytic situation, independent of psychoanalytic theory, as an epochal contribution to our efforts to understand people.

That Freud was a physician and that he developed the psychoanalytic method as it is called, in an effort to treat neurotic patients is an obvious but also a critical point of departure in considering the psychoanalytic situation. This is so because the treatment that he created is, in some very important ways, quite paradoxical. As a physician he elicited a history from his patients but, unlike a physician, he listened to this history not as an index of pathology but as a text to be judged in terms of its internal consistencies or lack of them. His patients came with the expectation of having their disease removed or at I east suppressed, but instead found themselves receiving interpretations of the most puzzling features of their story. The psychoanalytic situation was paradoxical in that it maintained the medical definition created by the collaboration of a helpseeker and a helpgiver while, at the same time it aimed, not to cure, but to make sense or to understand. In its efforts to make sense, this treatment was then not so much a treatment in the traditional medical sense, but rather what I would call, an exploration.

Such an exploration is founded on what Freud called the fundamental rule. Simply put this is an instruction to the patient to say whatever is on his mind. It seems to me, however, that the fundamental rule must be seen at least implicitly as a set of rules involving the thorough structuring of both the analyst's and the patient's roles in their conversation. Not only is the patient to say whatever is on his or her mind, but the analyst is to listen with "free floating attention." In addition, they agreed to meet regularly for fixed periods of time and to have the patient pay the analyst (or in some other way indicate that he is receiving something of value). Crucial in this is also the implication that nothing more than these conversations would transpire between these two people; that is, neither would have a-stake in the other's life. These simple if austere rules structure the exchanges between analyst and patient rather like the rules of a chess game, albeit asymmetrically, and thereby constitute a structure in which the exploratory process of psychoanalysis occurs. This exploration does not occur, however, in a vacuum but in a medical setting. This setting is not at all ambiguous but clearly defined by a sick patient consulting a knowledgeable doctor in search of a cure. Degrees, symptoms and theories render this setting meaningful and thereby reassure both participants that as a doctor and patient they do know what to expect from one another. In this way the medical setting disguises the exploratory process as a medical procedure and thereby allows the exploration to go on silently but inexorably.

Exploration as I am using the term is not a conscious and deliberate process. Insofar as they have attempted to delineate rules and techniques for exploration they have reduced it to something akin to a surgical procedure. Indeed the surgical metaphor is a popular one for Freud and other analysts. It is perhaps easier to say what exploration is not than what it is. Exploration is not anything that the analyst does to the analysand or anything that either does to themselves. To borrow some terms from Professor Naomi Schor, exploration might be described as the process by which both participants become aware of fragments among all the details of their conversation. What I mean by this is that as the psychoanalytic process goes on, certain words, dreams, laughs, details no longer seem to "fit." They begin to seem that belong in another time or place. which the analyst and analysand lay hold of these details, and begin to perceive them as fragments, process of exploration.

I have contrasted exploration with everything that is medical about the psychoanalytic situation for two reasons. First exploration is not a process which involves technique, surgical or otherwise. While Freud put great emphasis on the interpretation of resistances, he also stressed the free floating attention of the analyst, and I do not see why one could not add the analysand. It is to this free floating attention that certain details begin to seem recurrent and somehow out of place. Surprise and wonder are the emotions associated with exploration, The second reason to distinguish the exploratory from the medical is that the medical involves all that is known and reassuring about the psychoanalytic situation while exploration opens onto the unknown and uncertain.

The medical definition of this situation is not, however, merely an unnecessary impediment to exploration, but acts rather as a frame. The medical frame prescribes certain conventional expectations on both participants. Patients have problems and symptoms for which they seek help. Doctors are kindly and helpful. Patients receive therapy at an appointed hour and pay regularly for this service. Doctors understand their patients and proffer interpretations at intervals . In the psychoanalytical situation this medical frame is much more tenuous than in other medical situations. There is no physical examination, no pills, no anesthesia-to remind the participants of the meaning of the situation. And so in the psychoanalytic situation it should not be too surprising that this frame quite regularly dissolves or nearly does at any rate. These moments (and sometimes weeks or months) when the frame dissolves, or is at least threatened with dissolution, are moments when both participants lose their bearings. Without the medical frame the significance of their situation becomes uncertain and terrifying possibilities are suggested. These are moments of crisis and they are also moments of the most profound psychoanalytic understanding.

I should qualify this perhaps melodramatic description by saying that ordinarily with a seasoned analyst, and a merely neurotic patient, such crises are muted. However, with patients called borderline, that is to say patients who more easily lose hold of the frame, and who more desperately challenge the - analyst's grip on the frame, the crisis may indeed become terrifying for bath participants. Nonetheless, in principle at least, a crisis involving the potential loss of the medical significance of the psychoanalytic situation threatens every analysis.

Let me give you an example where the medical frame was perhaps more threatened for the patient than for the doctor, but which in any case suggests the kind of thing that I am talking about: A woman came to talk to me about her "problem" the first twenty minutes crying uncontrollably. I felt helpless and confused as she would not respond to my requests to tell me what the trouble was. Finally she blurted out:

"I wasn't really fall ing apart. I had heard that a friend's therapist had given her an extra appointment, and I wanted to see if you would give me one. When you hesitated I thought you wouldn' t, and I panicked.- That's just what my mother would have done. Try to make you feel guilty. God I 've tried all these years to be different from my mother. She ' s so hysterical, manipulative and guilt provoking Now I see that I'm Just like her."

One of the difficulties of locking at an example like this, or any example from psychoanalytic practice, is that we can lock at it post facto, that is, from the point after the patient offered her reassuring interpretation. More often it is the analyst's interpretation through which we psychoanalytic situation. When this point of view with an elaborate theoretical rationalization for the interpretation it gives the distinct impression that operates somewhat like Sherlock Holmes by pure logic. Leaving aside this patient's interpretation, my interest the twenty minutes during which she cried and I and confused. At that point I would had become quite blurred. This very controlled woman had given into an impulse to ask for something that she could not see as treatment and she had “lied” to get it.. In my office the next day she was humiliated at confessing what she had done. During those twenty minutes I did not know what she was feeling and had some doubts about being able to find out. My helplessness and confusion at times bordered on panic with such thoughts as "My God, what am I going to do if she never stops crying?" I could reassert the medical frame with such thoughts as ''it is unlikely that this is a psychotic decompensation. I t is more likely a transference reaction. " Such thoughts were reassuring but as the time passed- - and twenty minutes can be a very long time to look at someone crying uncontrollably--such reassuring thoughts alternated with my more anxious ones. When she finally did respond, she was contrite but evasive saying in effect, "it wasn't me who lied and manipulated to get the extra hour of your time but the ghost of my mother." We were both relieved to have this interpretation and in fact we were able to talk quite profitably about her unsuccessful struggles to be different from her mother. This interpretation, however, focused our attention on the phone call of the previous day, and not on the twenty minutes during which she cried and I felt helpless. After all she might have said the same thing without crying, or she might not have cried "uncontrollably,'' but made a greater show of trying to describe what was bothering her. There was something about those twenty minutes, those tears, and my feeling of helplessness which didn't fit. There was something about those twenty minutes that was just a bit uncanny, something about the details of that exchange which felt like a fragment broken off from some other time, some other relationship and transferred whole into the present . We made nothing of this at the time but a certain uneasiness crept into this treatment as I began to wai t for the next time the medical frame would dissolve, and the meaning of our situation would slide into another domain.

Experienced analysts, while they may feel helpless and confused at moments such as I have described, are not altogether surprised by their occurrence. In fact while there might be some question as to the proper way to understand experiences such as this, their role in psychoanalytic understanding has been pointed to for a long time. Indeed one of the oldest psychoanalytic myths dating from the prehistory of the discipline involves such a moment. I am referring to the case of Anna 0. and Jones' report that this treatment ended with Breuer fleeing in panic from his hysterically pregnant patient. While the drama of that moment certainly exceeds the one that I have presented, and while the truth of the story is open to serious question, that myth points to the broken medical frame as central to psychoanalytic experience. That moment when Doctor Breuer fled his patient involved a misunderstanding. This misunderstanding was the fact that Anna's pregnancy no longer called for or generated a medical response. Breuer, helpless and confused, not knowing what response this pregnancy should call forth, or perhaps knowing and dreading that response e, could think only of protecting himself, his marriage and his reputation. Another such misunderstanding in the his tory of psychoanalysis was, as we have discussed, the case of Dora. Here the question is whether a medical frame or a treatment ever existed at all. Dora was of course referred against her will for reasons that had little to do with her welfare. In reading Freud's account of this case, one can only wonder how much interest he had in treating this reluctant patient. Nonetheless, when Freud lost his chance to demonstrate his theories, we can [eel some sympathy for this victim of spite, as well as some appreciation for Dora's secret pleasure at having triumphed over Freud and her father. The most remarkable feature of this case is that out of this debacle Freud developed perhaps his most important clinical concept-transference.

Transference, as Freud came to articulate it, involved the repetition of certain childhood experiences in disguised form in adult relationships. Experience, as Freud used it in talking of transference, was not, however, a simple phenomena. Experience involved an element of wish or fantasy, this being most characteristically sexual and an element of trauma. Freud used the term psychic reality to describe this compound of wish and trauma, and it is this psychic reality which is understood to be repeated in transference. But what is this psychic reality? What is this compound of internal state and external event? It is my view that to understand what this psychic reality is and to understand what transference is we must put aside the concept of transference and look almost with the eye of a stranger or perhaps an archaeologist at those misunderstandings that gave rise to the concept of transference. This is what Freud did after all. We would have to think of the case of Dora not as an instance of transference, but as a moment when the medical frame dissolved, when the medical and, for that matter, all other familiar meanings of the situation would not contain the experience of these two people. Such a moment occurs with some regularity in the psychoanalytic situation. It occurs in other human situations as well--moments of intense love or hate between two people--but it was Freud's specifically new contribution to create a situation where this moment, which I must describe as uncanny, can be used to increase our understanding of people. What is uncanny in these situationsis the feeling that we are losing hold of those signposts of this reality, what I have called the medical frame, and are somehow in the presence of another reality. Before I give you the impression that I am speaking of something utterly mysterious and demonic, let me give you another example from the patient that I mentioned earlier.

One day after she had been in treatment for about a year,this woman happened to see me on the street and at that moment experienced a powerful tingling sensation all over her body and a palpitation of her heart. When she discussed this with me at our next session I suggested that it sounded like the kinds of feelings that a pubescent girl might have if she were to form a crush on an older man. She was greatly relieved to hear this and expressed gratitude {or my help in clarifying her feelings. In our next session she began by asking me to say more about the same subject. Not having more to say at this point I asked her what her thoughts were. At that point she fell into an angry sullen pout and refused to speak for the rest of the session. She slumped down in her chair, crossed her arms and stared at me intently. Every effort that I made to encourage her to speak only intensified the feeling of an angry silence. I was extremely uncomfortable and found myself wishing that I could get up and leave. Although I did not leave--a tribute to the residual but critical power of that very medical frame--toward the end of the session I could not resist the urge to tell her what I was feeling--something which might well be regarded as poor psychoanalytic technique. I said, "I canunderstand how your father might have ignored you because I I've been sitting here wanting to leave the room. " She responded immediately by saying, "You finally tell me how you feel about me and it's bad." Since my remark was not at all calculated but had emerged out of my discomfort, her remark left me feeling guilty. I felt that I had hurt her terribly by saying that I wanted to leave the room. After all I was her doctor. When she returned to our next session she was no longer pouting but was curious to understand what had happened the session before. She related that in suggesting that she had a crush on me she felt that I was demonstrating that I really cared about her. How else could I have understood so clearly what she was feeling. When I refused to answer her question at the opening of the next session she was crushed. She felt that she had gotten her hopes up but that now she could see that I really did not care for her. After my remark at the end of the session she had remembered that she had pouted with her father in just this way when she was twelve years old. In fact she could remember that very posture--slumped down in the chair with her arms folded across her chest.

Here, then, is a second instance of a misunderstanding between this woman and myself. Working within a psychoanalytic tradition I did not flee the situation as Breuer did. Having Freud's concept of transference to hold on to, I was less likely than Freud in the case of Dora to take her assaults personally. Nonetheless the medical frame, including the concept of transference can only provide a measure of protection against such distinctly nonmedical responses as wanting to abandon my patient. In fact, what is most important about this narrative is that I felt like abandoning her as I had felt helpless and confused in my previous example. I will get back to this in a minute, but first let me say that I am tempted to suggest that such feelings are somewhat under my control by using an expression such as "I allow myself to feel thus and so . . ." The £act of the matter is that I wanted to leave her sitting there in the worst way and if I allowed myself to feel that way, it is à strange way to use the word allow. It was only two closed doors and the weight of internalized psychoanalytic tradition which kept me sitting there. But it was critical that I did sit there and feel that way. In any other intense love hate relationship between myself and another person I probably would have gotten up and left. And I should add that on other occasions it is equally critical that patients do come to sessions regardless of how they feel and do not leave them no matter how much they may wish to. As I suggested before, for the process of exploration to occur, all that is necessary is that we sit and talk to one another. Indeed telling this patient that I wanted to leave the room was, from the point of view of exploration as opposed to that of technique, perfectly all right. The only question that it ought to have raised was why I felt so guilty.

Why had I felt so guilty? The answer is simple: I wanted to abandon her. But why abandon her, why get up and leave the room? After all she was just a patient and if I sat through this unpleasant hour I would get paid my fee and do something more pleasant the next hour. My feelings were far more intense than a purely medical frame would account for. What these questions suggest is that this exchange between this patient and myself was quite anomalous, it did not really make sense in terms of our medical work together. In the welter of details of the treatment situation this experience stood out, like a fragment broken off in another time and place and found here, out of place, amidst the present reality of our medical relationship. What is more when we began to look at this fragment (and I should say that we did look at this session as a fragment often referring to it as "that session"), we could see that it fit with other fragments of these small details in themselves but also somehow out of place. For example, we could see a relationship between this second example and the first example that I presented. In both situations we sat face to face for excruciatingly long periods of time with me feeling somehow responsible for her feeling badly and yet helplessly unable to do anything about this. Her comments at the end of my second example began to place these fragments. That she could remember sitting slouched and cross armed facing her father at age twelve suggested that this episode was a piece of the past somehow alive in the present.

This, however, raises an additional question: "If we could see this as a piece of the past alive in the present or as a fragment broken off and found among the details of the present, then what kind of a piece of the past was this?" Again I would like to return to my examples without looking at them through the lens of the concept of transference. There was a moment in the course of my experience with this patient when psychic reality became manifest, even palpable between us. There was a moment when it was impossible to tell how much of what was going on was a matter of her frustrated wish and how much was a matter of real trauma. There was a moment when her wish for my affection and my refusal to give it were so intertwined that we could not tell where the pain of that moment came from. While my example can be explained in terms of transference and countertransference, what is important to the exploration that I am discussing, is that this moment be experienced in all of its confusing reality.

It is this moment of confusion and uncertainty, an uncanny sense, at times, that we are being lived by a demon, or as Freud spoke of it, by a memory that is of paramount importance to psychoanalytic understanding. While we may label such an experience in terms of transference and counter-transference, after the fact; if we react to such an experience with labels instead of confusion we only thwart the exploratory process by reasserting the medical frame. What the psychoanalytic situation , with its rule that we only sit and talk, does is to create a situation where two people can experience all the helplessness and confusion of an intensely loving and hating relationship. We can experience what Freud called psychic reality. After such an experience memories such as my patient's of sitting cross armed and slouched with her father may help to place this experience, but without the experience such a memory would be sterile.

In the course of my work with this patient these experiences between us became landmarks. She was able to point to similarities between these experiences and confusing episodes with other men and she increasingly could remember episodes with her father as also being similarly confusing. She had been assuming that quiet men like her therapist and her father were strong men. Similarly, she would fall in love with quiet men and when they would flee her demanding petulant behavior she would assume that they had not loved her all along, not that they might be overwhelmed by her behavior. Her pride was of course hurt by this and she approached each new relationship with mere selfdefeating determination to find out if she were loved. Because the psychoanalytic situation allowed us to experience this piece of psychic reality without it running its course, she could begin to see the uncertainty in other situations and men as less powerful.

The psychoanalytic situation is an unusual human situation in that it allows two people to be involved in an intense loving and hating relationship with one another in such a way that this relationship can be experienced in all its uncanniness. Such experiences led Freud to develop the concept of transference but this a concept cannot be a substitute for these experiences in developing psychoanalytic understanding.

#2 Breaking the Frame

2008-12-31T08:18:00.000-08:00

BREAKING THE FRAME: A Phenomenological Inquiry

Edward M. Brown, M.D.

In a previous paper I described certain moments which occur in the course of a psychotherapy where the doctor and the patient lose hold of the medical significance of their relationship and an opportunity is created for new meanings to define that relationship. Such moments, as I suggested, do not result from the application of therapeutic technique but have rather the quality of unsettling, and even uncanny, breakdowns in the deliberate pursuit of the therapy process. Since writing that paper I have had several additional opportunities to experience such moments and I would like to take this opportunity to share two of them with you as well as to present some reflections on these experiences. As we all know psychotherapy involves us in a dual relationship with our patients. On the one hand, as mental health workers, we attempt to apply what techniques we have to bring about a healing process. On the other hand, as individuals with histories of our own we are inevitably drawn into intensely personal involvements with the people we are trying to help. Certainly it was one of Freud's signal contributions to recognize that this personal dimension can be used to foster the healing we desire. It is also true, however, that these-two dimensions, the personal and the healing, do not simply support one another but at times conflict in significant ways.

Of particular interest to my theme are the ways in which our commitment to healing inhibits our ability to see how our personal histories influence our feelings about our patients. This, of course, is an aspect of the problem which has been addressed in psychoanalytic writings under the heading of countertransference. The dilemma that we face is that it is both necessary but, at times, blinding to see our patients through the 'medical frame' as objects of our healing efforts. It is all too easy, as I have found, to conceal uncomfortable personal feelings about our patients behind a reassuring image Of ourselves as benevolent healers. When we do this it is often necessary, as I hope my examples will show, for our patients to break the 'medical frame' and insist that we acknowledge our more personal feelings about them. The importance of this is greater than the mere technical caveat that we should 'be aware of our feelings.' It also points to the unsettling view that our patients may often have a more reliable sense of the significance of our feelings for their therapy than we ourselves do. After all, they know that we are people, and not merely mental health workers; and they also know that their actions affect other people even if they have never been able to be clear as to what these effects are. Moments when our patients break the 'medical frame' and insist that we look at our personal feelings about them, then, can be seen to suggest a 'negative' image of the therapy process . In this image it is not our patients' resistances and defenses which stand out but rather our difficulties in understanding them. The importance of this image lies in its ability to remind us that psychoanalytic healing can never be divorced from personal understanding.

In order to be clear let me present an example: B. is a twenty year old woman who took leave from college a couple of months before consulting me. At the time she was overweight and lethargic. She spent most of her time in bed and had done nothing about finding a job. She had left school because she had been unable to do her school work. If she couldn't work to please an admired professor, she told me, she couldn't work at all. She came from a middle class family and reported no major traumas in growing up. She spoke with affection about her mother but with contempt about her father. He was, in her eyes, a failure at work and a defensive, petty tyrant at home. I liked her, in part, because she was so conscientious about the work of therapy, and found myself feeling a benign fatherly affection for her. These feelings troubled me some; but, as so often happens with warm feelings toward patients, I did not view them as intensely problematic. She did well and in a few months was feeling better, working and losing weight. She warned me, however, that this was not the outcome that she was locking for because she felt that she was now working for me as her admired therapist. After we had worked together for about four months she came to a session at which she announced that though she wanted to talk she could not. As the session proceeded she writhed around in her chair without looking at me. I found myself amused by her conscientious efforts to make herself talk.

Toward the end of the session she looked up and noting my amusement asked pointedly, "Why are you smiling?" Feeling embarrassed myself at having my amusement revealed, I adopted the posture of kindly doctor and wondered about her embarrassment. I was reminded of my daughter 's humiliation when, a few days earlier, she discovered me smiling at her fumbling efforts to paint a wall and I said to my patient, "Are you embarrassed by my smiling?" She responded angrily, "That's not the point," but was not able to tell me what the point was before the session ended. At the beginning of our next session she again asked me why I had been smiling. At this point it seemed that I could not continue to assume a medical stance by inquiring about her feelings without further aggravating a growing misunderstanding. It also seemed clear that I did not know why I had been smiling and so I decided to answer her question as straightforwardly as possible. I do not recall exactly what I said though it had something to do with my kindly interest in her conscientious efforts to make herself talk. After some time she interrupted me by saying, ''You were being patronizing. " Alas she was right and I acknowledged that. I felt embarrassed by what felt like a faux pas but she did not press the point further. Instead she went on to talk about other things. As she did so I found myself thinking about what had transpired between us. As I did I felt less guilty about my patronizing attitude and I began to see how accurately it reflected her effort to lock like a helpless child. After some time I asked her whether she thought it was so surprising that I should feel like a kindly father given her exaggerated expressions of helplessness. She thought that I had a point. At our next session she began to talk about other men who treated her in a fatherly way and began to wonder how her actions might evoke such treatment.

Looking back on this example, it is clear enough that I was far too complacent about my affectionate feelings toward this woman. She had warned me, in what she had said d about her father, that I could not expect to remain simply an admired therapist forever. That I was not more troubled by these affectionate feelings perhaps reflects their congruence with my image of an ideal medical relationship. When she called these feelings into question, then, she was calling into question my image of myself as her doctor. It is in this sense that I would say that she broke the 'medical frame.' Her reasons for doing this are, of course, open to a number of interpretations. Ordinarily these interpretations would focus on her ambivalent feelings toward patronizing men. While I would not quarrel with such interpretations, they seem to me to neglect an important dimension of the therapy process. After all, it would have been less risky for B. to have accepted my bland but sympathetic statement that she was embarrassed by my smiling. In challenging me as she did, B. was not only trying to see if I would act as defensively as her father might have in such a situation but also to get me to acknowledge that our relationship was a good bit more problematic than I was willing to see. Looked at in this light, B.'s actions represented an effort to overcome my resistance to seeing that I was really treating her-as others had. In our ordinary view of the therapy process, of course, I would have come to appreciate this on my own or perhaps with the help of a supervisor or a colleague. In that view, I might then have asked her, for example, how she thought I felt seeing her writhe around helplessly in her chair. In presenting this example, however, I want to suggest not only that this ideal scenario does not always occur but also that a view of the therapy process which does not take into account our patient's active efforts to get us to understand them is incomplete.

Of course, not all patients challenge me as B. did. With most, in fact, I am able to remain comfortably in my role as their doctor and still understand them sufficiently to help alleviate their distress. The importance of examples such as the one I have presented lies in their ability to reveal a - 'negative'-image of the therapy process. In this image our patients come to therapy hoping to understand themselves by discovering how they affect another human being. For this to occur requires courage on their part and trustworthiness on ours. With enough of both of these ingredients some patients will attempt to recreate with us a facsimile of certain troubling relationships from their histories. When they are willing to do this we must be willing and able to enter into and to reflect upon these dramatic recreations. This, as I have found, is easier said than done. With B., for example, my complacency
about my affectionate feelings toward her kept me from acknowledging that these feelings were also a part of another drama going on between us. It is this resistance to seeing ourselves as a part of this 'other drama' which brings patients to break the 'medical frame.' Complacency is, however, not the only motive that we as therapists have for this blindness. At times acknowledging our role in our patient's drama requires that we accept aspects of our own histories which we may find distasteful. When this occurs our patients may have even more difficulty breaking the 'medical frame' than did B.

My second example is of this type: K. is a twenty-seven year old woman who has been in psychotherapy with me for three and a half years. Her complaints have centered around episodes of panic (for which she has steadfastly refused to take medication), more or less debilitating phobias and severe inhibitions in pursuing her career and developing relations with men. After much work we were able to understand her complaints in terms of her feelings about her mother and father. Her father is an aggressive businessman, who K. had often seen physically abuse her brothers, particularly at moments when they attempted to emancipate themselves from his domination. In contrast he never abused K. and frequently encouraged her ambitions. K.'s mother is an extremely fearful housewife with many phobias. Initially, K.'s description of her mother was positive but as our work progressed she became more critical of her mother's failure to - protect her children and herself from K.'s father. In her early years K. identified with her mother and became a very 'good' but rather fearful and self-righteous child. During adolescence she began to feel increasingly ambitious and while still in high school decided to pursue a career Her first episode of panic occurred around this time and shortly after she and her mother had watched helplessly as her father beat up one of her brothers. With the help of a psychiatrist, this episode was contained and K. was able to go on to college where she did well academically, had several women friends, but had virtually no contact with men. Her second episode of panic occurred while working at her first job and contemplating an ambitious move to-a new city. This brought her to see me. We were able to understand this and subsequent episodes of panic as reactions to feelings of ambition. At such times she was terrified that she was a homosexual. We were able to understand this as a fear that her ambition would destroy her attractive feminine attributes and transform her into a person like her father. In this context, her phobias seemed ways of limiting her ambitions by closing off various career options. Her difficulties forming relationships with men seemed related to her inability to fee! ambitious and attractive at the same time and her refusal to adopt the submissive stance taken by her mother.

Such understanding was, however, of little help to K. In fact, she seemed to resent and depreciate my interpretations while at the same time acknowledging that they made sense. She would repeatedly say, in effect, "These interpretations don't do me any good. I'm still frightened and I 'm afraid that you' 11 run out of interpretations and I'll wind up a hopeless agoraphobic . " In the face of this lament I became discouraged and frustrated by what I saw as her passively waiting for my interpretations to cure her. What I saw as passivity she saw as feelings of helplessness in the face of her seemingly intractable fears and feelings of hopelessness in the face of the evident lack of success of our work. She angrily pointed out her many efforts to overcome her fears and I had to acknowledge that these were at times quite heroic. We had reached an impasse and we remained in this impasse for many painful months. She consulted with two other psychiatrists but refused to switch therapists. In spite of her often keen appreciation of my limitations she seemed to feel that if I could not understand her then perhaps no one could. She also refused medications because she felt that they would only further isolate her from feeling like a whole human being.

Our impasse began to develop into a crisis when she learned that she would soon lose her job because of a reorganization of the company she worked for. She had no alternatives but to look for another job or return to live with her parents as a hopeless invalid. As we discussed this she made it clear that she wanted to look for a job that was better than the one she had but not so much better that she would be overwhelmed by panic. Nonetheless, her panic mounted and I tried to cope with this by discussing our understanding of the roots of her difficulties. One day she once again began our session by talking about her panic and her conviction that she was an agoraphobic. I commented that such a label only expressed her feelings of hopelessness and I reminded her of our understanding of her dilemma. At this instant she said angrily, "If that's your diagnosis, I'm not staying," and walked out of my office. I was confident that she would return but, nonetheless, felt confused, anxious and guilty. When she returned she explained that she had heard me saying, in effect, ''There 's nothing more that I can do for you--so fly to San Francisco [for a job interview that she had rejected as too ambitious] and have your nervous breakdown." As I heard this I felt that I must have sounded like a father saying to his child, ''There's nothing more that I can do to teach you to swim--so go on the high board and jump."

Following this session I began to reflect on what it was that K. wanted from me in a way that I had not done before. I began to see similarities between my relationship with K. and my relationships with other women in my life. In my helplessness was I insisting that she be strong and denying that she might be frightened at the same time? Certainly I had done this with other women. But if this were true, wasn't it possible that I was treating K. in a way that really did resemble the way her father had treated her? Was I saying, in effect, that she had to be either strong like me or weak like her ` mother? Was I, like her father, perhaps leaving no room for ambition and fear to coexist? These were troubling thoughts because I had, for so long, shared K.'s dislike for her father as a violent and domineering man and because I prided myself on being such an understanding doctor.

Before I had too long to spend on these reflections, however, K. called for an emergency session. She had a job interview the next day. She had no confidence. She was panicked. Once again I felt helpless and I recited our understanding of her dilemma. She said that made her feel hopeless. We sat silently for a long time as I recalled my reflections of-the previous few days. Finally I said, ''I think that what you want is someone to acknowledge that this interview is very frightening for you but also that you have got what it takes to do it--that both are true." We ended that session without much more being said. At our next session K. was as close to jubilant as I have ever seen her. "I've got the job,'' she exclaimed, "I was confident. What you said in our last session really helped. Seeing that I could be frightened without losing all of my confidence allowed me to play the interview by ear." It felt as though our impasse had ended.

In this example, once again, you can see that my failure to understand my patient led her to insist that I reconsider my feelings. Of course, she did not do this as directly as B. It is not necessary, however, to say that she was aware of doing this to see that her dramatic actions would have had that effect on all but the most insensitive of therapists. After all for a woman who had never threatened to quit therapy before and had stuck with it through some very dark hours, her gesture of walking out in the middle of a session was a very powerful protest indeed. She broke the 'medical frame,' then, by threatening to disrupt our healing relationship itself. In doing this, she shattered lay image of myself as a kindly doctor with a difficult patient and left me feeling simply like a man trying to understand what had gone wrong with a relationship he valued. In this frame of mind I could see, for the first time, ways that my feelings toward K. resembled my feelings toward certain important women in my life. More specifically, I came to see that the more helpless I felt in my efforts to help her the more I ignored just how frightened she really was. I did this, it seems in retrospect, through my continued repetition of 'our understanding.' It was as if I were saying, "With this interpretation you can do anything--so you have no reason to be afraid." My resistance to looking at this, as I have already suggested, grew out of my reluctance to see any similarity between myself and her father. If I had taken her misunderstanding of my 'diagnosis' as 'sending her to San Francisco to have a nervous breakdown,' simply as reflecting her feelings toward me as a symbol of her father, I would, however, have missed the point. She prevented me from making this additional interpretation by breaking the 'medical frame. ' Only without this frame was it possible for me to accept the distasteful thought that I, like her father, sometimes see women as being either strong or frightened, but not both.

In both of these examples I have chosen to look at my patients not as people with 'disorders' coming to see a doctor for treatment. This usual image of the therapy process is, of course, a legacy of the medical origins of psychoanalysis. It is a useful image for several reasons. It gives patients a socially sanctioned reason to seek out therapists. It allows therapists to construct theories and to communicate with each other about the many puzzling things they observe in their consulting rooms. It also serves to reassure patients and therapists alike that what transpires between them has a healing intent. The psychoanalytic situation is, however, more than simply a healing situation or perhaps I should say psychoanalytic healing is a peculiar enterprise which is not readily reduced to medical terms. Psychoanalysts have been aware of this in developing their concepts of transference and more particularly of countertransference. What has not received sufficient attention, at least to my knowledge, however, is just what it is that makes this enterprise so peculiar. In focusing on examples where patients break the 'medical frame' I have tried to suggest a 'negative' image of the therapy process. I have done this not to deny our usual image but hopefully to complete it. In this 'negative' image we can see patients coming to therapy not because they are sick but to understand themselves. The understanding that they seek is peculiar in that it involves not a diagnosis of their disorder but rather a reflection of their effect on another human being. In seeking this kind of knowledge, they choose a medical situation in part because of the reputation of doctors as trustworthy people. Our trustworthiness is important because they know, all too well in many instances, that people have many ways of deceiving one another. Trustworthiness is not enough, however, because therapists, like other people, also have many ways of deceiving themselves.

The problem that patients face, then, in this 'negative' image, is how to unravel their therapists' self-deceptions in order to get the accurate reflections they sock. In my examples I have suggested that one way that they do this is by breaking the 'medical frame.' Of course, they are not always forced to this extreme tactic. From Freud on a substantial tradition has developed in which therapists attempt to unravel their own self deceptions. This is the significance of the concept of countertransference. As my examples have shown, however, patients cannot always rely on their therapists for this good work. Where complacency or distasteful thoughts about ourselves come into play, self-deception is always possible. Were the psychoanalytic situation merely one where patients come for treatment, they would have no more recourse than a patient under anaesthesia or perhaps a patient who has been given a toxic drug. What the 'negative' image of the therapy process highlights, however, is that the psychoanalytic situation is not a medical one in which an expert manipulates a disease. What this image allows us to see more clearly, I hope, is that psychoanalytic healing cannot be divorced from personal understanding and that this understanding requires our patients' good work as well as our own.

#3 Tacit Agreements

2008-12-31T08:17:00.000-08:00

Tacit Agreements

Edward M. Brown, M.D.

In earlier presentations I have attempted to conceptualize the psychotherapeutic process in terms of an idealized model of psychoanalysis as a human encounter structured by Freud's Fundamental Rule. This approach led me to emphasize certain intriguing moments which might be called misunderstandings. This concern with idealized models, however, always operates in tension with my awareness that in daily life of a psychotherapist such misunderstandings while highly instructive are actually quite rare. This fact has led me to wonder how I might conceptualize psychotherapeutic practice in a way that would do justice to the diversity of human encounters that I actually participate in.

The strategy that I would like to adopt in confronting this problem grows out of a recognition that any attempt to conceptualize psychotherapeutic practice must take into account the fact that such practice always involves the meeting of two intentions--the patient's and the therapist's. Most efforts to formulate theories of psychotherapy, including my own, suffer from the fact that they are written by therapists and therefore emphasize the intentions and the point of view of the therapist. One obvious means of-avoiding this limitation -- asking patients why they seek psychotherapy-- has limitations of its own. In the first place patients may not have a clear understanding of their reasons for seeking psychotherapy and in many instances may simply repeat versions of the mental health theory (or ideology if you will) that are current in their social class and circumstance. A more important limitation, however, is that the patient's point of view like the therapist's represents only half of the story while an adequate understanding of psychotherapy practice involves coming to grips with the meeting of two people.

My approach to this problem draws on recent descriptions of one of the earliest forms of modern psychotherapy practice--the magnetic cure. For a relatively brief period following the Napoleonic Wars a school of psychotherapy grew up especially in France, which was based on the ideas of animal developed earlier by Mesmer and Puysegar. What is of interest to me about this form of treatment is the fact that it often involved a kind of bargaining between the patient and the magnetizer. According to Ellenberger’s account, "during has somnambulic sleep, the patient would foretell the evolution of his symptoms and prophesy the exact date of his definitive cure. He would also prescribe his own treatment. It was by no means an easy task for the magnetizer to find a right compromise with the demands of the patient without exposing himself to being maneuvered by him." J.P.F. Deleuze who was the most articulate theorist of magnetic practice approached this therapeutic situation with a set of explicit rules which are worth recounting. The first of these was "that one must magnetize only to cure and not just for amusement or for experimental reasons;" and the second was that "the treatment must be stopped as soon as the patient is cured." Without going into the significance of these rules in their early nineteenth century French context, I would
like to point out that these rules structured magnetic practice by placing clear limits on the actions of the magnetizer. These limits provided the framework in which the bargaining of the somnambulist and the magnetizer occurred and in a way facilitated finding the “right compromise” that Ellenberger refers to.

This early modern psychotherapy, the magnetic cure, then, can be seen as a rule structured bargaining which resulted in a compromise which both the somnambulist and the magnetizer could regard as a cure. Viewed in this way I would like to suggest that the magnetic cure can be regarded as a model for all psychotherapy practice. This model has several advantages for me: 1) it allows me to consider the intentions of the patient and the therapist independently, 2) it allows me to make statements about psychotherapy practice which do not depend on a particular therapist's theory, 3) it allows me to take into account the variety of psychotherapy practice in terms of the various bargains people strike, 4) it allows me to consider the outcome of psychotherapy as guided by rules which can be made explicit in the way that Deleuze made his rules explicit, 5) it allows comparing psychotherapies by comparing the rules that govern them.

Such an approach must begin with a statement of patient's intentions. Given my position as a practicing psychotherapist my view of these has obvious limitation. Nonetheless I would like to indicate certain
common intentions that I have observed. For example patients come to psychotherapy
1) to grieve. In my practice this commonly results from the break-up of a marriage or a love affair.
2) to have a love relationship. In my experience, as a man, these are usually women. One such patient was a homely, shy suspicious young woman while another was a fifty-two year old woman whose husband had recently left her.
3)...seeking a better parent than they had while growing up. Again, in my experience, this is usually a father. One such patient had a father who was an ambitious, abusive alcoholic while others describe fathers who were cool, aloof and distant.
4...seeking support and confirmation for their grievances with a world they feel has treated them badly. One woman, for example, who was a victim of gynecological malpractice, came to psychotherapy, in part, to find a doctor who would confirm her view that doctors are thoughtless and cruel. -
5)...looking for permission. This commonly involves permission to leave a marriage or to return to one. It has also, on occasion, involved permission to lead an "alternative life-style,"
6)...looking for an intermediary who will help them negotiate a separation from their parents. This is obviously a common intention among college students and other young adults.

This list could be extended but it should be sufficient to suggest the kinds of intentions and the kinds of people I am talking about. Because I have generated this list from my own practice it is colored not only by the kinds of people that I see but also by the assumptions through whichI see them. Most notably it is based on my assumption that people come to psychotherapy looking for a particular kind of human relationship. Because I practice a ‘talking cure’ based on this assumption the kinds of intentions I have listed are those which stand out to me. Were I to practice in a different manner with different assumptions I would, no doubt, have constructed a different list. What is important about this list, however, is not how it might compare with other lists generated from other kinds of practices but how these intentions differ from my own. It is this difference between the intentions of patients and therapists which results in bargaining. And it is this bargaining, which, while present in all medical practice, becomes central in psychotherapy practice.

Patient's intentions may be expressed rather explicitly or quite covertly. They may function tacitly within the therapy, that is, without ever being discussed, or they may become the object of open and extended discussion. A homosexual man looking for permission for his way of life was relatively explicit in expressing his intentions. After a few sessions in which he tested me to discover that I was neither a homosexual nor unduly critical of homosexuality we were able to talk rather like a knowledgeable father and an adolescent son about the dilemmas of homosexual life. I didn't feel that he was looking for a better father than his but only for a more knowledgeable one whose authority he could use for the permission he wanted. I refer to his intentions as relatively explicit not because we ever discussed them as such but rather because I had relatively little difficulty in seeing what they were. In fact our agreement to talk like father and son remained tacit and as I will discuss later this was an important dimension of our psychotherapeutic work.

More interesting and challenging from the point of view of the therapist, at least, are those patients whose intentions are covert and actively concealed. Such patients characteristically present with symptoms that therapists, over the years, have learned to interpret in various ways. Most often therapists will be able to discern these covert motives and much work among psychoanalytic psychotherapists is directed at just this goal. At times, however, these intentions may remain covert throughout the psychotherapy work even though the work may be more or less successful. When this occurs it is not always possible to attribute it to unusual efforts on the part of the patient to conceal his motives but may just as well be due to the therapist's inexperience or ineptitude. What is important, however, from my point of view, is that successful work does occur even when patient's motives remain unclear. With one man, for example, I can remember spending a year talking about things which made little sense to me and continually wondering how it was that I was helping him. Nonetheless he gave up drinking, returned to his marriage and expressed considerable gratitude for my help. Again it seems that we did our work through a tacit agreement which, in this case, even I was unable to understand.

Therapists intentions are both simpler and more difficult to characterize. On one level therapists aim to do therapy, uncover unconscious motives, treat psychopathology and cure their patients. Other motives are, however, also at work. Clearly therapists work to make a living. Some enjoy the power they have in relationships with "sick" people. Others enjoy the intimacy they find in psychotherapeutic conversations while still others hope to prove theories, as Freud did with Dora. These intentions, like those of patient's, may be either explicit or covert. And at times such motives may prove to be a real detriment to psychotherapeutic work. What is more remarkable, however, is that successful psychotherapeutic work can tolerate a vast array of therapists motives just as it can tolerate a vast array of patient's motives.

This fact--that psychotherapeutic work can occur in the face of a vast array of patient and therapist's motives--is worth examining more closely. Psychoanalytic theorists argue that this is so because the psychotherapeutic process makes such motives conscious and thereby allows them to be dealt with directly. While I would not argue with the view that psychoanalytic psychotherapy may make unconscious motives conscious, as a psychoanalytic psychotherapist myself, I cannot help but feel that this explanation does not do complete justice to actual psychotherapy practice. Certainly the existence of other successful modes of psychotherapy, which do not aim to explore unconscious motives, argues against the psychoanalytic point of view. Deleuze's successful magnetic cures might be taken as an example of this. Other theorists, such as Frank, argue that hope, expectation and other non-specific placebo factors do much of the work of psychotherapy. While, again, I cannot argue that hope and expectation do not play an important role in psychotherapeutic work, I find this explanation incomplete because it does not take into account the variety of quite different relationships which are formed by therapists and patients.

In order to account for those aspects of psychotherapeutic practice which these theories do not deal with, I would suggest that successful psychotherapeutic work proceeds through the negotiation of tacit agreements such as those I have mentioned in my examples. The homosexual man I have described and I arrived at a tacit agreement to talk as a knowledgeable father and an adolescent son. While in this instance, I was aware of this agreement--and I am quite sure that he could have acknowledged it had I asked him to--it was not necessary for either of us to have this awareness for our work to proceed. All that was necessary was that we act out the agreed upon relationship in much the way people have always acted out healing rituals. Indeed, I believe, that had our tacit father-son relationship become too much a matter of focal awareness it would have impeded our work in much the way self-consciousness often makes dancing, singing or other performances more difficult.

Before characterizing the notion of tacit agreements further, I must distinguish it from two related concepts--the corrective emotional experience and positive transference. Tacit agreements differ from corrective emotional experiences in that they do not involve deliberate role playing on the part of the therapist. In fact it is important to understanding the concept of tacit agreements to note that, in my work, at least, they occur in the context of psychotherapy that is governed by a set of rules that can be characterized as psychoanalytic in a rather orthodox sense. Other psychotherapies, governed by different rules, may also generate tacit agreements. What is important, however, is that psychotherapy be governed by rules. The artificiality of the corrective emotional experience is simply not necessary.

The concept of the positive transference as an important factor in successful psychotherapeutic work is closer to the idea of tacit agreement than is the corrective emotional experience. Like tacit agreements, positive transference occurs spontaneously. As a concept, however, positive transference has always been described as adjunct to the most important work of psychoanalysis. because psychoanalytic theorists have always placed such a premium on understanding, they have explained “the relationship,’ from its place in the therapist’s theory. Transference, positive or otherwise, is always something the patient has or does and which the therapist tries to understand. The therapist’s feelings toward his or her patient must theretore be dealt with separately. Tacit agreements involve both participants in a therapy fully and completely and neither of them has a privileged position from which to understand these agreements.

In attempting to discuss tacit agreements directly I must return to Deleuze’s magnetic cure as an exemplar. The key elements in the magnetic cure, for my purposes, are: 1)that the patient prescribes his own cure, 2) that it is not an easy task for the magnetizer to find the right compromise with the demands of the patient., 30 that Deleuze operated in accordance with a set of rules. What I would like to suggest is that modern psychotherapies, because they operate through tacit agreements, can also be characterized by these three elements. That Deleuze worked with somnambulists who were presumed to be "asleep" while we work with patients who are presumed to be gaining greater self awareness should not be an obstacle to comparing our therapies with his. After all Freud's notion of the unconscious was based on the belief that we are all somnambulists even when we are wide awake.

That patient's prescribe their own cure may be only another way of stating the obvious fact that patients come to therapy with their own intentions. We may hope that they will use the therapy to achieve greater self-understanding but this does not prevent them from using the therapy to achieve quite different aims. The reason that we do not fully appreciate this fact is that we seldom ask patients what they got out of the therapy and when we do, we do not consider these statements to be as important as our understanding of the therapy. I recently heard a patient of Stuart Flerlage's present her version of their eleven years of work together. This woman, who had received an amazing amount of bad treatment at the hands of other people throughout her life, seemed to be saying, if I heard her correctly, that what was important to her about her treatment with Dr. Ferlage was simply that he treated her with kindness and respect. Flerlage, no doubt, could have said a great many astute psychoanalytic things about her treatment. It is not clear, however, that what he might have said about that treatment would have been any more valid than what she said. What is clear is that they managed to work out a tacit agreement in which he could do his psychotherapy and she could have the kindness and respect that she wanted. While this may not seem like prescribing the cure in just the way that Deleuze meant it, the fact that this woman had consulted several therapists before Flerlage and rejected them because they did not show her sufficient kindness and respect, suggests that she knew exactly what she wanted.

Finding the right compromise with the demands of the patient is also a key element in modern psychotherapies as it was in the magnetic cure. Ordinarily this is not much of a problem. For Flerlage, for example, it was probably not especially difficult to give his patient the kindness and respect that she wanted. But what about patients who want love. It is certainly true that this is what some patients want. It is also true, for me, at least, that I am not in business to love people. Nonetheless it is clear that some patients do manage to become involved with me in ways that allow them to feel loved. Perhaps I even love them. For this to happen a "right compromise'' must be found. What has struck me about those relationships in my practice that I would characterize as loving, is that the patients in these relationships with me have never asked me to declare my love and they have never asked me to demonstrate my love except in ways that are within the limits of my role as their doctor. By restraining themselves in this way they allow our loving relationship to remain tacit and in this way they also allow our relationship to remain a healing one.

The importance of this restraint in achieving a "right compromise" can be seen through a painful experience with a patient who would not accept my love tacitly. At the close of a year of successful psychotherapeutic work she suggested that she wanted to end the therapy so that we could get together as friends. When I indicated that I would not become involved with her outside of our therapy sessions, she insisted that she knew that I cared about her and that I was betraying her by my refusal to be her friend. Of course she was right. I did care about her and I had, no doubt, expressed this in many ways. Because she was unwilling to allow this caring to remain tacit and because she was unwilling to look at her motives for breaking our tacit agreement she left the therapy feeling hurt and betrayed. The fact that this can be understood, correctly, I believe, as a repetition of earlier experiences of betrayal, should not obscure the fact that our inability to find a "right compromise" as well as our inability to understand why we could not do this resulted in a failure of our work. The fact that I might have been able to anticipate and avert this outcome also should not obscure the fact that many therapies do proceed successfully by allowing similar caring feelings to remain tacit.

The third feature of the magnetic cure, Deleuze's rules, are, I believe the most important though, perhaps, the most difficult to demonstrate in relation to our work. Modern psychotherapy, like the magnetic cure and all human relationships, is governed by rules. That Deleuze was explicit about some of the rules governing his work is a tribute to his clearsightedness. Freud also stated some of the rules governing psychoanalysis quite clearly--most notably the Fundamental Rule and the Rule of Abstinence. That neither of these men stated all of the rules governing their work is obvious. That both were unaware of many of the rules that governed their work is also likely. This does not alter the fact that both the magnetic cure and psychoanalysis were self-consciously structured as therapeutic relationships. Unfortunately the rules governing the magnetic cure were not incorporated into a tradition and taught from generation to generation. Even in Deleuze's lifetime people began to use somnambulism not to cure but for religious insight and simply for entertainment. Deleuze's call that the magnetic cure be used only for healing was not heeded and his treatment lost its healing significance. Fortunately Freud created a tradition-largely an oral tradition, I believe-- and this tradition has allowed his cure to remain a therapy. What is learned through this tradition with its supervision, training analyses, conferences and a great deal of informal discussion is that structured set of rules which constitute psychoanalytic treatment. Training in other forms of psychotherapy also serves to transmit rules which govern other forms of therapeutic relationships. That these rules are largely implicit, and would require an anthropologist to spell them out, is a tribute to the complexity of therapeutic relationships but it is also a tribute to the divorce between theory and practice in our scientific culture.

The importance of these rules, in the context of the tacit agreements that I am discussing, is that they allow patients and therapists with differing intentions to find the "right compromise" and thereby avoid being maneuvered. Lacan, in an unusually lucid passage, points to the importance of this fact in the creation of psychoanalysis when he notes that Freud found himself "implicated in it (the unconscious) in the sense that, to his great astonishment, he could not avoid participating in what the hysteric was telling him, and that he felt affected by it. Naturally, everything in the resulting rules through which he established the practice of psychoanalysis is designed to counteract this consequence, to conduct things in such a way as to avoid being affected." The difficulty with this passage as well as my earlier description of the magnetic cure is that they suggest that the rules function only to protect the therapist from being affected or maneuvered. Since therapists also have intentions, which may not be consistent with their patient's, these rules must also serve to protect patients if they are to be of value. Freud's rule of abstinence is an example of this function of the rules and our current understanding of the prohibition against therapists having sexual relationships with patients is a current version of the same kind of protection.

While rules which protect patients from being maneuvered has an obvious ethical dimension, it also has a therapeutic dimension as well. If the kinds of tacit agreements that I have described are important for a healing process to occur, they must have limits. Much has been written about the power that therapists have over patients and the limits this power places on the validity of the "findings" of psychoanalysis. Since I am not particularly concerned about the validity of psychoanalytic "findings" this dimension of the therapists power is not of great interest to me. What does seem important--is that only when a therapist's power is limited by rules can patients enter into relationships based on what I am calling tacit agreements. When a therapist violates these rules by breaking confidentiality or by becoming sexually involved, for example, tacit agreements of the sort I am discussing become impossible and therapy no longer occurs.

When the rules of the therapeutic encounter are observed, therapists and patients are able to bargain and agree on a way of talking with one another that in some ways meet the patients demands without involving the therapist in more than he or she is willing to give That the agreement reached, and the bargaining as well, are tacit is due to the fact that what is at stake is often so personal or so forbidden that making it explicit would destroy the illusion that patient and therapist are talking merely as patient and therapist. What this would do is to destroy what I described in an earlier paper as the "medical frame." This frame is necessary, in our culture, at least, because strangers such as doctors and patients are not allowed to have intimate relationships without becoming intimately involved. While loving relationships are often helpful to people, healing realtionships are defined, again, in our culture, as relationships between strangers. If healing is to occur in psychotherapy, then, the medical frame must be maintained and therapy relationships must be allowed to remain tacit.

While therapists have an obligation to maintain the medical frame, patients do not. This brings me to those important moments when tacit agreements fail. At these moments, which I have described in two earlier papers, tacit agreements are broken and the "medical frame" threatened. At these moments therapist and patient are not able to find the "right compromise" and their bargaining threatens to break down. This occurs, I believe, when the wishes or intentions of therapists and patients are incompatible. It is a tribute to Freud that he gave us ways to understand these breakdowns in the therapy process and to turn them to therapeutic advantage. In my earlier papers I attempted to describe how these breakdowns occur and how they can be understood. It must be noted, however, that this is not always possible as the example I cited earlier of the woman who wanted to form a friendship with me demonstrates.

Having said all this you may object that I am not describing good psychotherapy but only the prevalance of unanalyzed transference cures in my practice. Perhaps this is true. If it is true then I must add that many of these so-called transference cures have been quite beneficial and lasting . Because I believe this to be true I must also say that the concept of transference cure has done us a great disservice distracting us from understanding what goes on in many therapy relationships. I hope thatt he notion of tacit agreements will contribute to such understanding.