Mad, Bad, and Sad: A History of Women and the Mind Doctors

by Lisa Appignanesi

  Freud had learned other lessons too. For all his own high-handedness and the patriarchal bullying that he himself draws attention to in his analysis of his teenage hysteric–offspring of a father who ‘offers’ her to the husband of his own mistress–Freud’s talking treatment is humane when compared to that experienced by Augustine at the Salpêtrière. Candidly an experimental subject for her doctors, Augustine undergoes a series of interventions which are both exploratory and intended as teaching means. The hysterics at the Salpêtrière were routinely given a number of drugs to calm the fits they seemed to produce in growing numbers the longer they stayed in the epileptics ward and remained under Charcot’s care. Inhalations of valerian or amyl nitrate or ether, ovarian compressors, baths, application of various metals, magnets, hypnosis in front of an audience, including pressing on the ‘hysterogenic’ zones so as to produce symptoms, electricity, the highly addictive chloral–all are used as research tools and to awaken sensation and mobility, or to suppress agitation, attacks, insomnia, and a host of other symptoms. Alongside these, and probably as effective as forms of treatment, were two particularly Charcotian specialities, subcategories of the curative powers of sheer medical attention: photography, and the public Charcotian lecture at which patients were encouraged to perform their condition, in and out of hypnosis.

  Augustine became a model patient and, like all bright young women, learned from her peers and teachers in the hospital. In Regnard’s photographs and according to Bourneville’s notes, she produces all four stages of the hysterical attack as Charcot defined them, though most often separately. Bourneville records that in 1876 she suffered 1097 attacks; the following year there were more, and then fewer again the year after, though more complete attacks. Perhaps Augustine had consciously or unconsciously learned all the necessary stages. To begin with there is the ‘aura’, the lead up to the fit. This can consist of a seething pain in the right ovary, and is quickly followed by the sense of a ball rising from stomach to throat to form a knot, all accompanied by palpitations, agitation, speeding heart, difficulty in breathing, rapid eye movements. Sometimes, warned by these indicators, the hysteric, like an epileptic, will lie down. Then comes the loss of consciousness, the fixed stare.

  In a photograph labelled ‘Beginning of Attack’ Augustine lies belted and tied to the bed by a straitjacket, her mouth wide in a scream. There follow all the stages of what became the ‘typical’ Salpêtrière attack. Charcot himself described Augustine as a ‘classic’ example, in part, perhaps, because she came to him before the height of his fame and seemed too young and innocent to be putting on what became the hysterical style.

  First there was the epileptoid phase or ‘tonic rigidity’, which mirrored epileptic behaviour. Augustine’s muscles contract, her neck twists, the heels turn out, her arms swing round wildly several times in a row, then her wrists reach towards each other while the fists gyrate outwards. She grows rigid, lies immobile, plank-like, eyes directed at space, unseeing.

  Next came the circus-like acrobatics of the ‘clonic spasms’ or grands mouvements, also known as le clownisme–so very camera-worthy. This was followed by the representation of emotional states such as love, hate, fear, known as attitudes passionnelles. Here Augustine enacts seduction, supplication, erotic pleasure, ecstasy and mockery in a series worthy of silent film. Hallucinations often accompanied this stage. Augustine hears voices, is terrified, in pain, sees blood, rats; and when she slips into the delirium which marks the final stage of an attack these hallucinations often take on the shape of her rapist, lover or family. She pleads, says the scarf around her throat is choking her, refuses to drink, howls her pain. At the end, there are tears and laughter, both of which Charcot saw as a release before the patient comes back to herself.

  Bourneville documents Augustine’s narrative of her dreams, as well as those which come in her ‘provoked sleep’, including her wonderful aside when she doesn’t want to talk about them: ‘you think you’ve dreamed when you’ve only been hearing people speak’. He notes the relationship between menstruation and fits, though also underlines, like a good scientific observer, that there is no regular pattern to discern. Prejudice would have come up with a link: the new science is more meticulous, though still hopes some causal relationship will occur. He notes her vaginal secretions after her voluptuous dreams on ether during which she enacts a sexual scene she writes down graphically for the doctor. There is a seductiveness in her postscript which suggests a kind of collusion between doctor and patient: he is allowed in on her secret life, may even have helped her with the imaging of it, but the crowd in front of whom she sometimes performs her hysteria is not: ‘I’ve ended up saying everything you asked of me and even more. I would speak more openly if I could, but I fear doing it in front of everyone.’ Bourneville notes this, perhaps in a willing suspension of disbelief that the doctors haven’t themselves provoked Augustine’s dreams.

  As she gets better towards the end of December ’78, three years after her arrival, she begins to work as a nurse–a pattern Pinel had pioneered at the Salpêtrière years before and that we are to see again in the ‘transmission’ of psychoanalytic knowledge. In this later version, patients become practitioners, having learned the procedures through what might be called a training illness as much as a training analysis. In her new uniform, Augustine looks sedate and respectable. Some four months later, however, she suffers a relapse and is back in Dr Charcot’s service. Her behaviour is violent and she has to be placed in a cell. Even Charcot, it seems, cannot now hypnotize her into sleep.

  In July, she takes the opportunity of a large public concert in the hospital to make her escape. She is caught on the Boulevard de l’Hôpital, just as she’s getting into a carriage. During what seems to be a scuffle she trips and cuts herself. Back in the hospital, she climbs on a chair to see the crowd, falls off and breaks her kneecap. Only after a month can she walk again. Three weeks after the ability returns, Augustine flees once more, this time dressed as a man. The gender change is not insignificant. As a man, she can flee, can shake off her hysterical paralysis, which is a gendered, sexually linked inability to move unless the will of the hypnotist propels her. Since her escape, Bourneville tells us, Augustine has been living with her lover–a man she met at the Salpêtrière. He doesn’t tell us whether this person is a doctor, some kind of assistant, or another patient. We are told only that when she suffers another relapse, she goes to another hospital, the Charité, before once more returning to her lover.

  After that Augustine disappears from history. But she reappears as myth. She becomes the very ‘type’ of the young belle époque hysteric–beautiful, capricious, extravagant, sexually provocative, mysterious, attuned to the camera, capable of masquerading as a boy and, of course, masquerading sleep and paralysis in order to please her doctors. Léon Daudet, who attended Charcot’s lectures, satirizes her and her kin as well as the whole Charcotian establishment in his novel Les Morticoles, where the hospital becomes the equivalent of a music-hall, the Folies Hystériques. In a more romantic vein Augustine returns, after the horrors of the First World War, as a muse for the Surrealists, who see her heightened sexuality, her disarray of the senses, her delirium and excess as the ideal of femininity, one which could, prophet-like, speak truths through madness.

  HYSTERIA’S HISTORY

  Immediately after Charcot’s death in 1893, and despite his international reputation, the new generation at the Salpêtrière turned against the Maître’s diagnosis of hysteria. This may have in part been due to the now increasingly recognized professionalization of the patients, whom the younger doctors saw as making a mockery of their serious anatomical science. The rumour mills had it that the Salpêtrière was (inadvertently) courting the hirelings of ‘magnetizers’ or latter-day mesmerists, the kind of women who also made up the ranks of somnambulists, mediums and the popular hypnotists of theatrical spectacle. Here were jobs for aspiring working-class girls who had a talent for ‘sleep’ and who moved between mus
ic-hall and hospital stage with ease. These were women, some said, who could teach Charcot himself something about paralysis by suggestion; and if the medical, let alone the social, ranks had been more open, could have trained as hypnotizing doctors.

  Freud, a man of this next generation, did not agree with the rebels against Charcot. The theatricality of convulsive fits, at once erotic and religious, may have been a particular displacement of the gestures which were part of the Republic’s love affair with boulevard spectacle. Hysteria would be enacted differently elsewhere. But the underlying logic of psychological distress finding itself converted into bodily symptoms, something Charcot came increasingly to see in the 1880s, was important. As Freud explained in his obituary of the Napoleon of nervous illness, what hysteria revealed was a whole new way of reading the human mind, which could express what it wasn’t aware of through physical symptoms:

  if I find someone in a state which bears all the signs of a painful affect–weeping, screaming and raging–the conclusion seems probable that a mental process is going on in him of which those physical phenomena are the appropriate expression. A healthy person, if he were asked, would be in a position to say what impression it was that was tormenting him; but the hysteric would answer that he did not know…If we enter into the history of the patient’s life and find some occasion, some trauma, which would appropriately evoke precisely those expressions of feeling–then everything points to one solution: the patient is in a special state of mind in which all his impressions or his recollections of them are no longer held together by an associative chain, a state of mind in which it is possible for a recollection to express its affect by means of somatic phenomena without the group of the other mental processes, the ego, knowing about it or being able to intervene to prevent it.

  Through Charcot and the hysterics, the unconscious begins to be theorized. With Freud, and the other researchers into the human psyche in which this turn of the century is increasingly rich, it takes on a key role in understanding both madness and ordinary everyday behaviour.

  Hysteria, however, as a florid set of expressions in bodily form of mental problems–conversion hysteria, as Freud named it–ceased to be an illness prominent amongst Western women. As a diagnosis, it migrated with the First World War into the ‘war neuroses’ from which so many soldiers suffered, their blindness or muteness or paralysis an expression of the trauma of battle. Since then, conversion hysteria has all but disappeared. Certain psychoanalysts and therapists may still occasionally use the nomenclature for women who are dramatic, desperately seductive and alternately self-destructive, but the floridly dramatic symptoms its turn-of-the-last-century sufferers presented have largely gone. Increasingly, the complex set of bodily symptoms that had been hysteria was confused with the ‘histrionic’.

  The condition’s component parts remain, however, alongside more contemporary patterns of symbolizing and diagnosing distress. Anorexia could easily be considered one of those component parts: Freud long saw it as one of the features of hysteria in adolescent girls, part of a number of disoriented appetites. So, too, did Charcot. For him, hysterics always functioned outside the norm: either they were in a state of lethargy and somnolent, or they suffered from insomnia; their organs functioned super-fast or slowed to the point of disappearance; their need to eat was exaggerated into what he calls bulimia, or reduced to abstinence. So-called dissociation or multiple personality disorder is one of the hysteric’s other aspects.

  The Diagnostic and Statistical Manual of Mental Disorders (DSM), the hymnbook of current psychiatry, no longer lists hysteria. Instead, it takes the fragmentation of the historic condition further and gives it nomenclature which fits more smoothly into the medical and behaviourist preferences of our own turn of the century: ‘factitious illness disorder’, ‘dissociative disorder–conversion type’, ‘psychogenic pain disorder’. It also lists a ‘histrionic personality disorder’ which medicalizes behaviour many would consider common, particularly in adolescents. This is characterized as a pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

  –[The individual] is uncomfortable in situations in which he or she is not the center of attention.

  –Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior.

  –Displays rapidly shifting and shallow expression of emotions.

  –Consistently uses physical appearance to draw attention to self.

  –Has a style of speech that is excessively impressionistic and lacking in detail.

  –Shows self-dramatization, theatricality, and exaggerated expression of emotion.

  –Is suggestible, i.e., easily influenced by others or circumstances.

  –Considers relationships to be more intimate than they actually are.

  For once, the recommendation is that drugs are not indicated, unless this histrionic disorder is tied in with other conditions, such as depression. People who suffer from the disorder, mostly women, can be highly successful, we are told. They are more prone to come for treatment (being attention seekers) than those suffering from other kinds of personality disorder, and tend to do so when romantic attachments have gone awry.

  Your and my favourite adolescent, be warned: your life is a psychiatric diagnosis.

  Hysteria is one of those conditions that is reinvented for different times and has a cultural malleability almost as dramatic as Augustine herself. Elaine Showalter in her Hystories has argued that in the 1990s the United States had become ‘the hot zone of psychogenic diseases, new and mutating forms of hysteria amplified by modern communications and fin de siècle anxiety’. She lists amongst these new hysterical syndromes which often convert psychic problems into physical ills or use external sources as evidence for them: chronic fatigue syndrome, multiple personality, recovered memory and satanic ritual abuse.

  The very malleability of hysteria might make us suspect the science-laden certainties with which the DSM names its component parts, let alone the possible cures. After all, hysteria’s long and florid history stretches back to the Egyptians and the Greeks. Initially based on the idea that the womb, or uterus, was a free-floating entity which could leave its moorings when a woman was dissatisfied, to travel around the body and disrupt everything in its passage, hysteria was thought to be able to produce any number of symptoms, both physical and mental. The wandering womb in search of gratification could make skin go numb (anaesthesia), engender fits, muteness, paralysis and, of course, that choking breathlessness of ‘globus hystericus’ when it lodged in the throat. In the Timaeus, where he explores origins and the relations between the sexes, Plato noted: ‘The womb is an animal which longs to generate children. When it remains barren too long after puberty, it is distressed and sorely disturbed, and straying about in the body and cutting off the passages of the breath, it impedes respiration and brings the sufferer into the extremest anguish and provokes all manner of disease besides.’

  With Christianity, some have contended, hysteria took on a supernatural configuration and became a sign of demonic possession: convulsions, muteness, fits–all became signals of concourse with the devil. Trial and punishment or exorcism were the only remedies. Only with the Renaissance did hysteria come back within the scope of medicine. In the late seventeenth century, when nerve-based theories began to be propounded, Thomas Willis proposed a medical model in which the condition was caused by an excess of animal spirits which travelled from brain through nerves to various body parts. George Cheyne gave it a dietary trajectory. Certain of the doctors of the eighteenth century linked it with hypochondriasis, the vapours, and a generalized ‘neurosis’. William Cullen, the inventor of the term ‘neurosis’, placed its causes solidly, though not solely, back in the genitals, and saw it as a condition linked with an excess of sexuality which failed to find its completion in childbirth–hence its incidence among young widows:
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  Observations of the dead bodies of patients labouring under hysterics, shew that in most of them the ovaria are affected. These are liable to a turgescence, which gives an irritability to the system; and hence a want of veneral pleasure is assigned as a very common cause of the disease. I will readily allow, that this turgescence, by producing such an irritability, may sometimes excite it; but I cannot consider it as a general cause, or hysterics would be a much more rare distemper. We may here observe, that though the seminal evacuation may in our sex prevent the attack of hysterics, it will not have that effect in females, for this reason: that by it the male purpose of the male economy is fulfilled: not so for the females; they are also destined for the breeding and bearing of children; and hence evidently we are to account for our diseases attacking young widows.

  Cullen may conceive of women’s sexuality as rampant, but–unlike many of the medical reporters on the condition–he also finds hysteria in men, if less often, and is unclear whether hysteria may not also be a version of dyspepsia. Following him, Pinel in his Nosography comments on the vagueness and over-generality of the category. This means that he is forced back to a primary observation of cases. He notes two: one is of a girl whose menstruation is not yet regular.

  This seventeen-year-old is healthy and ruddy of colour: for no attributable reason she falls suddenly into a kind of ‘mania’–or what he would rather describe as a sequence of extravagant behaviours which consist of talking to herself, jumping about, tearing off her clothes and throwing them in the fire. This lasts for some five months, then stops during the summer, perhaps because of many trips to the countryside which are followed by the oncoming of menstruation. Three months later the hysteria erupts again: the girl manifests a disgust for her ordinary activities, weeps for no reason, is sombre and taciturn. Soon enough there is loss of speech, spasmodic choking and a sense of strangulation accompanied by an engorgement of the salivary glands, then abundant salivation as in someone who has taken mercury. The girl’s mouth, at this point, won’t open and the rest of her body is rigid, the pulse almost inaudible, the breathing very slow. There is constipation, but the urine is clear. For three or four days the patient stops eating altogether, and then eats voraciously. Everything seems normal once more–before the whole cycle begins again. During this time the girl’s periods stop for five months. Pinel sends the patient to the country for breathing in the open air, exercise and healthy food. And recommends marriage. Once this had taken place, he notes, and her wishes were satisfied, the patient recovered.